Hi! ^\m- f PAIN PAIN ITS ORIGIN, CONDUCTION, PERCEPTION AND DIAGNOSTIC SIGNIFICANCE RICHARD J. BEHAN, M.D 6e :.«OHMEB ASSOCIATE PROFESSOR OF PHYSICAL DIAGNOSIS, WESTERN PENNSYLVANIA MEDICAL COIiEC y! (university of PITTSBURGH); FORMER ASSISTANT SURGEON AND PATHOLOGIST, ST. FRANCIS* HOSPITAL, PITTSBURGH; MEMBER A. M. A., DEUTSCHE GESELL8CHAFT FUR CHIRURGIE, ETC.; FORMER VOLUNTEER ASSISTANT IN CLINICS OP PROF. H. SCHLES- INGEB, VIENNA, AND GEHEIMRAT PROF. BIER BERLIN. WITH ONE HUNDRED AND NINETY-ONE ILLUSTRATIONS IN THE TEXT AND MANY DIAGNOSTIC CHARTS NEW YORK AND LONDON D. APPLETON AND COMPANY J921 Copyright, 1914, 1920, by D. APPLETON AND COMPANY Printed in the United States of America IT IS WITH THE GREATEST OF PLEASURE THAT I DEDICATE THIS BOOK TO ONE WHO HAS EVER BEEN AS A FATHER TO ME AND TO WHOM I OWE THE MOST OF WHAT I AM TO MY UNCLE MALACHY O'DONNELL r !7 /9t^- PEEFACE During many years I have been impressed with the necessity of a thorough understanding of pain phenomena in the making of a diagnosis. Pain is universal, and is present in practically every disease, and in most diseases it is the one symptom which first attracts the patient's attention and causes him to become aware of some change in his physical well-being. The patient then comes to the physician, who, unless he is well versed in the inter- pretation of pain phenomena, may be at a loss to interpret the symptoms which are presented to him. To do so he needs to know not only the various factors to which a certain pain may be due, but also the reasons why it should be produced and the different diseases giving rise to pain of similar character and loca- tion. To understand thoroughly these latter factors the physician must needs be versed in all the essentials and components of which a pain consists, its causes, character, varieties, its localizations and the changes induced by its presence. It was with the idea of supplying easily accessible informa- tion along these lines that I undertook the composition of this book. To those, who, like myself, have felt the need of such a book, I offer it with the hope that it may be of some help to them. To make it as complete as possible has been my endeavor, and to do so I have thoroughly searched the literature and culled from it all that I thought might be of use. I believe credit has been given in all cases to the authors of my references, but if, through vii viii PREFACE an unintentional oversight, this has been neglected, I beg that my attention may be called to it so that it can be remedied. It is with the gTeatest pleasure that I express my thanks to Dr. T. L. Disque, Dr. Wm. H. Glynn, Dr. E. C. Stuart, who so kindly granted me the use of an abundant material from his surgical service; to Goldsmith of Vienna, who reviewed the anatomical section of my work ; to Dr. Frankel of the same city, who reviewed my gynecology section; to Dr. Smith Ely Jelliffe, who has reviewed the entire work ; to Mr. Sander of Vienna ; and Dr. Frenzel and Dr. Powers of Berlin ; to Miss Esther Hrubesky of Berlin, who has aided me in revising my proofs and illustrations. R. J. Behan. CONTENTS CHAPTER I GENERAL CONSIDERATION OF SENSATION ' PAGB Sensation in Lower Animals ....... 1 Reaction of Animals to Pain 3 General Consideration of Sensation ..... 4 Properties of Sensation ........ 7 Centers for Sensory Perception and the Sense Organs . . 8 Sense Perceptive Organs ........ 11 Stimuli ........... 12 Interpretation of Sensation ....... 13 CHAPTER II THE NATURE OF PAIN Definition ....... Metaphysical Consideration of Pain Memory Centers for Pain .... Causative Factors in the Production of Pain . Apparatus for Receiving and Conducting Pain Pain and Mental States ..... Relation op Pain to Other Sensations Conveying Channels for Sensations 18 20 24 25 28 30 31 35 CHAPTER III DISTRIBUTION OF THE SENSATION OF PAIN Distribution of the Sensation of Pain . ... 40 CHAPTER IV PERCEPTION OF PAIN SENSATION Analgesia 61 Anesthesia 63 Hyperalgesia 67 iz CONTENTS Tenderness Paresthesia PAGE 70 73 CHAPTER V CLASSIFICATION OF PAIN Subjective Pains Emotional pains Hysteria Hypnosis Habit pains . Monomania pains Occupation neuroses Objective Pains Central objective pain Peripheral objective pain 74 76 76 80 80 80 80 82 82 83 CHAPTER VI CLASSIFICATION OF PAIN (Continued) Peripheral Objective Pains Propagation of pains Character of the pain Persistency of pain Time of the pain . Sensitiveness to pain Individual susceptibility CHAPTER VII THE INTENSITY OF PAIN Factors upon Which Intensity Depends The stimulus Sensitiveness of the patient Centric increased irritability . Irritability of the nerves Extent and number of nerve fibers involved Factors Modifying Pain Production Psychical factors . Physical factors Estimation of the Intensity of Pain Blood-pressure elevation Motor reflexes Complaints of patient compared with his susceptibility Vasomotor signs .,,,,,, 89 89 108 109 110 111 112 114 114 115 115 115 115 115 115 116 120 120 122 123 124 CONTENTS xi PAGE Dilatation of the pupil . 125 Amount of morphine necessary to overcome pain . 125 Appearance of patient . . . 125 Patient's description . . 128 Mechanical factoi-s . . 129 Conditions Associated with Severe Pain . 132 Respiratoiy system . . 134 Circulation . . . 134 Loss of equilibrium . . 134 Trophic changes . . . 134 Preprotective functions . , . . 135 Elevation of temperature . . 135 Method of Recording Pain , , . 135 CHAPTER VIII PAIN IN* DISEASES OF THE NERVES, BRAIN, AND CORD Affections of the Nerve Terminals and Nerve Trunks Etiology ....... SjTiiptoms ....... Duration of neuralgia ..... Diagnosis of neuralgia ..... Types of neuralgia according to localization Central Nervous System ..... Anatomy ....... Origin of headache ..... Headache in disease of the brain and meninges Leptomeningitis purulenta .... Brain tumor ....... Diagnosis of headache in diseases of the brain and meninges Differential diagnosis ....... CHAPTER IX DISEASES OF THE SPINAL CORD 140 142 143 146 146 147 172 173 175 178 180 182 190 195 Cord Conditions "Which Cause Pain . Meningeal apoplexy .... Hematomyelia ..... Caries of the vertebral canal Tumors of the spinal cord and vertebrae Acute spinal meningitis Pachymeningitis spinalis hypertrophica . Myelitis ...... Poliomyelitis of children Syphilis of the meninges and of the cord Multiple sclerosis , , , . , 208 209 210 210 211 212 212 212 212 213 213 3rii CONTENTS PAGE Syringomyelia ......... 214 Tabes doi-salis ......... 214 Neurasthenia ......... 215 Hysteria 216 Traumatic neuroses ........ 216 General summary ......... 216 CHAPTER X PAIN IN THE TISSUES Muscular Tissues 218 Voluntary Muscles 219 Myositis 219 Acute polymyositis ........ 220 Myositis hemon-hagica ........ 221 Mj'Ositis fibrosa ......... 221 Myositis ossificans ........ 221 Myalgia . .221 Involuntary Muscles . • 222 Colics 222 Fatty Tissues 224 Adiposis dolorosa ......... 224 CHAPTER XI BONE PAINS— THE OSTALGIAS General Considerations 226 Types op Pain 227 Continuous pains . . . . * . . . . . 227 Intermittent pain ......... 227 Diurnal variation of the pains ...... 228 Character of Bone Pain ........ 228 Localized Bone Pain ......... 228 Periosteal lesions ......... 229 Traumatism 229 Fracture 229 Contusions .......... 230 New growths ......... 230 Septic involvement ........ 231 Generalized Bone Pain ........ 232 Osteomalacia ......... 232 Diseases of the hemopoietic system . . . . . 233 Sarcoma and carcinoma ....... 233 Myeloma, lymphadenoma ossium, and chloroma . . . 233 CONTENTS xiii PAGE Osteitis deformans ........ 233 Leontiasis ossea ......... 233 Spurs 233 Differential Diagnosis op Bone Pain ..... 233 Joint Pains — Arthralgia ........ 234 Classification ......... 234 Radiation of joint pains ....... 236 Intensity of the pain ........ 236 Symptoms .......... 236 Diagnosis of inflammatory joint pains ..... 239 Hip joint 240 Tension pain of intra-artieular hip-joint abscess . . . 244 CHAPTER XII THE CIRCULATORY SYSTEM Pain Caused by Changes in the Blood Pains from increase in blood supply Pains from diminution in blood supply Arterial Diseases Causing Pain Inflammation ...... Increase of blood pressure Intermittent claudication .... Erythromelalgia ...... Embolism and thrombosis of the mesenteric arteries Aneurysm ....... Diseases of the Veins Causing Pain Inflammation of the veins .... Thrombosis ....... Varicose veins ...... 247 247 248 249 250 251 251 252 253 254 255 255 256 256 CHAPTER XIII THE GLANDULAR TISSUES The Glands 257 The Mammary Gland 257 The Adrenals .......... 259 The Mesenteric Glands 261 The Thymus and Thyroid 261 CHAPTER XIV REGIONAL PAIN The Head 262 Sense of pressure in head ....... 264 Head pain .......... 265 Diagnosis of headache .,.,,.., 281 xiv CONTENTS PACE Pain in the Back 296 Lungs 300 Heart and aorta ......... 301 Stomach 301 Intestines 302 Liver and gall-bladder ........ 302 Kidney 302 Pancreas, spleen, etc. ........ 303 Anemia and chlorosis ........ 304 Pain in the Limbs 304 Pain in the Abdomen 307 Chest Pain 310 Clavicular Pains 310 Neck Pains 312 Summary ........... 312 CHAPTER XV THE SIGNIFICANCE OF PAIN IN DISEASE OF THE EYE Etiology 317 Localization of Pains ........ 318 The eyelids 318 Surroundings of the eye ....... 322 Conjunctiva and cornea ....... 322 The iris and ciliary body ....... 325 Sclerotic coat ......... 327 Choroid, retina and optic nen'e ...... 328 Glaucoma .......... 329 Panophthalmitis ......... 330 Asthenopic disordei-s ........ 330 CHAPTER XVI PAIN IN DISEASE OF THE EAR External Ear 332 External Auditoey Canal ........ 333 Tympanum 335 Middle-ear Disease . ........ 335 Middle-ear Catarrh ......... 339 Otosclerosis 339 Labyrinth .......... 339 Keferred Pain 340 CONTENTS XV CHAPTER XVII PAIN IN DISEASES OF THE NOSE PAGE The Sensory Nerves of the Nose ...... 341 Diseases "Which Produce Pain and Their Manner of Production 342 Nasal Stenosis .......... 342 Empyema ........... 343 Headache from Disease of the Sphenopalatine Ganglion . 345 Tumors 347 Diagnosis . 348 CHAPTER XVIII PAIN IN DISEASES OF THE THROAT Pain in Diseases op the Pharynx ..... i. 351 Pain in acute diseases ........ 351 Pain in chronic diseases ....... 354 Pain in the Larynx ......... 356 Pain in acute affections ....... 357 Chronic processes ......... 358 CHAPTER XIX ABDOMINAL PAIN Classification 360 Subjective Pain 360 Objective Abdominal Pain ....... 360 Inflammations of the Peritoneum ...... 364 Tumors of the Peritoneum ....... 367 Nature of Pain from Adhesions 367 Nature of Pain in Hernia 371 CHAPTER XX PAIN IN ABDOMINAL VISCERAL DISEASE History 377 Location of Pain ......... 383 Transference of Pain 38f ZVl CONTENTS CHAPTER XXI DIAGNOSIS OF ABDOMINAL PAINS Nature of Various Abdominal Pains • Examination for Pain .... Localization of pain .... Localization of organ producing pain Lesions causing epigastric pain Pain due to functional processes . Pain due to intestinal diseases Abdominal tenderness .... Posture in Abdominal Diagnosis Forms of Abdominal Pain Functional pains ..... Care in diagnosis ..... Conditions Associated with Abdominal Pain Spasm and rigidity of muscles Visceromuscular reflex .... Toxemia ...... Indicanuria ...... Polyuria ...... Relationship of hysterical to abdominal pain Abdominal incisions . . '. . Post-operative abdominal pain Pain refeiTed to extra-abdominal regions Absence of pain ..... PAGE 390 394 394 395 396 400 401 403 406 408 409 410 413 413 413 414 414 414 414 415 415 416 416 CHAPTER XXII PAINS OF THE ALIMENTARY TRACT Lips .... Cheeks . . . Teeth Tongue Salivary Glands Pharynx and Tonsils Esophagus 418 418 419 421 422 423 424 CHAPTER XXIII THE STOMACH Areas of Referred Pain Caused by Stomach Disorders Pain in Gastric Areas Character of gastric pain ..... Time and manner of its appearance 427 429 429 430 CONTENTS Relationship to ingestion of food . Duration of pain . . Previous attacks ..... Associated symptoms .... Pain reflected or referred to gastric areas Lesions of Stomach Causing Pain . Displacement of the stomach (gastroptosis) Gastralgia or gastromyalgia . Hyperchlorhydria .... Pyloric or cardiospasm Acute dilatation of the stomach . Acute gastritis ..... Chronic gastritis ..... Gastric erosions ..... Gastric ulcer ..... New growths of the stomach Perigastric adhesions .... Referred Pains Confused with Those of Gastric Origin XVH PAGt 430 430 431 431 431 431 431 431 434 436 439 440 442 442 442 455 459 461 CHAPTER XXiy INTESTINAL PAIN General Considerations . . 463 Etiology of pain .... . 463 Location of pain . 469 Type of pain .... . 470 Manner of onset .... . 471 Relation of the position of the patient to the pain . 472 Relation of the ingestion of food to the pain . 472 Duration of pain ...... . 473 Result and history of the pain . 473 Tenderness ..... . 474 Symptoms associated with the pain . 474 Lesions of the Intestines Causing Pain . 476 Enteralgia ' . 476 Pain due to functional disturbances . 477 Type of pain in colic . . 483 Inflammation of the bowel . 484 Ulcers of the intestine . . 487 Distention of the bowel . 491 Adhesions . 491 Obstruction of the intestine . . 492 The rectum ..... . 505 The anus . 509 xviii CONTENTS CHAPTER XXV THE APPENDIX PAGE Varieties of Appendiceal Pain 516 Tenderness in Appendicitis ....... 529 Symptoms Associated with Pain Production in Appendicitis . 535 Differential Diagnosis ........ 537 CHAPTER XXVI THE LIVER, GALL BLADDER AND DUCTS General Considerations ........ 540 Nerve supply ......... 540 Pain op the Liver . . . . . . . . . 545 Character of the pain ........ 545 Relation to the ingestion of food and drink .... 545 Relation to the movement of the body ..... 547 Position of the body ........ 547 Relationship to other diseases and processes .... 548 Time of appearance of pain ...... 549 Neuralgia .......... 550 Pains due to the disturbance of the liver substance proper . 550 Gall Bladder 562 General etiology ......... 562 Diagnosis .......... 563 Diseases causing pain ........ 568 Gall-duct Pain . 572 Etiology 572 Location of pain ......... 573 Character of pain ......... 573 Associated symptoms ........ 576 Differential diagnosis ........ 577 CHAPTER XXVII THE PANCREAS General Considerations 580 Nerve supply ......... 581 Structure of the pancreas ....... 582 Peritoneal covering ........ 583 Relationship to other parts ....... 584 Character of pain ......••. 585 Location of pain ......... 585 CONTENTS xlx PAGE Tenderness 586 Position of the patient .... • . 587 Diseases of the Pancreas Causing Pain . 587 Pancreatitis ...... , . 587 Pancreatic calculi .... . . 580 . . 591 Cancer of the pancreas • . 591 CHAPTER XXVIII THE SPLEEN General Considerations 593 Anatomy . 593 Nerve supply ..... . 593 Position of patient ..... . 596 Tenderness . 596 Factors influencing pain . 596 Disorders of the Spleen Producing Pain . 598 Displaced or movable spleen . 598 Congestion ....... . 599 Perisplenitis ...... . 600 Abscess of the spleen . 601 Infarct . 601 Rupture of the spleen . 602 Tumors of the spleen ..... . 602 Cysts of the spleen ..... . 602 CHAPTER XXIX THE KIDNEY General Considerations Nerve supply Etiology of kidney pain Character of renal pain Localization of kidney pain Tenderness . Factors influencing production of pain Absence of pain in kidney lesions Symptoms associated with pain phenomena Pain in diagnosis of kidney lesions Differential Diagnosis of Kidney Diseases Causing Movable kidney Renal infarction . Hematuric nephralgia . Inflammation of the kidney Pain 604 601 605 607 607 615 617 618 618 619 620 620 626 629 629 XX CONTENTS PACE Perinephritis 637 Rupture of the kidney ........ 641 Tuberculosis of the kidney ....... 642 New growths ......... 644 Pyelitis 647 Hydronephrosis ......... 653 Renal calculus ......... 655 CHAPTER XXX THE URETER, BLADDER AND URETHRA The Ureter 670 The Bladder 672 General considerations ........ 672 Bladder affections causing pain ...... 683 The Urethra .......... 695 Urethral caruncles ........ 695 Calculus .......... 696 Rupture of the urethra ....... 696 Transfen-ed pain in urethral disease ..... 696 Pain on urinating ........ 696 CHAPTER XXXI THE MALE ORGANS OP GENERATION The Testicles 698 Epididymis, Vas Deferens, and Seminal Vesicles . . . 699 The Prostate . 700 Congestion and inflammation ...... 700 Lesions .......... 701 Hypertrophy . . . . . . . . . 701 Tumors of the prostate ....... 702 Tuberculosis ......... 702 Associated symptoms ........ 702 The Penis , ' . 703 Urethritis 703 Inflammation of the prepuce ...... 703 Inflammation of Cowpei''s glands ...... 703 CHAPTER XXXII PAIN IN THE FEMALE GENITALIA General Considerations 705 Anatomy .......*•• 705 Nerve supply ......... 705 CONTENTS xxi PAGE Diagnosis of pelvic and hysterical pain .... 709 Varieties of pain ..... . 712 Character of uterine pains . 716 Diagnosis of the pelvic diseases . 722 Uterine Pain .... . 724 Character of uterine pains . . 724 Neuralgia .... . 726 Displacement of the uterus . . 726 Functional disorders of the uterus . 728 Inflammation of the uterus . 740 New growths of the uterus . . 743 Fallopian Tubes . 744 Tubal conditions causing pain . 744 Extrauterine pregnancy . 746 Ovary . 747 Local point of pain . 748 Causes of pain .... . 748 Neuralgia of the ovary . 749 Displacement of the ovary . . 749 Hernia of the ovary . . 749 Hyperemia of the ovary . 749 Abscess of the ovary . . 751 Tuberculosis .... . 752 Enlarged uterus .... . 752 Relationship of ovaries and parotids 3 . 752 Cysts of the ovary . 753 The Vagina . 755 Nerve supply . 755 Affections causing pain . . 755 Sexual connection . . 756 CHAPTER XXXIII PAIN IN THE CHEST The Thoracic Walls The skin Muscles, fascia and nerves Nerve and muscle pain . Bone pain . Pleural pain Referred and Reflected Pains of the Thoracic Walls Localization of pain on the chest wall Pains w^ithin the Thorax The pleura ..... 760 760 762 762 764 764 76^ 767 769 769 xxii CONTENTS CHAPTER XXXIV HEART DISEASE PAGE General Considerations 773 Nerve supply of the heart 774 Diagnosis by means of location of referred pain . . . 774 Intracardiac lesions as causes of pain 782 Angina Pectoris 783 Etiology .......... 783 Character of the pain in angina pectoris .... 784 Location of the pain ........ 785 Local tenderness ......... 787 Associated symptoms ........ 787 Disease of the Pericardium ....... 788 CHAPTER XXXV THE RESPIRATORY ORGANS The Lungs 790 General considerations ........ 790 Diseases of Thoracic Organs Causing Pain .... 795 Acute bronchitis ......... 795 Pneumonia .......... 797 Tuberculosis ......... 800 The Mediastinum 802 BIBLIOGRAPHY 805 INDEX 869 LIST OF ILLUSTRATIONS FIG. PAGE 1. — Right cerebral hemisphere seen from the outside . . 9 2. — Inner surface of right cerebral hemisphere .... 9 3. — Schematic illustration showing how the various sensations are transmitted from the periphery to the brain cortex and from thence to the two brain centers .... 23 4. — Diagi-am showing how changes in the cell metabolism may produce changes in the irritability of the cell and a de- parture in its reaction to external stimuli, either making it more or less sensitive to peripheral irritation . . 27 5. — Areas of epicritic and protopathic sensibility ... 38 6.^-Effect of injury to the pain-conduction paths in the cord . 39 7. — Unilateral complete lesion on one side of the cord producing a narrow band of anesthesia on the same side at the level of the lesion and a broader zone of anesthesia on the opposite side slightly below the level of the lesion ... 39 8. — Cross section of the spinal cord ..... 40 9. — Diagram showing intraspinal course of sensory fibers . . 43 10. — Course of the different sensory (peripheral) fibers, according to Head . . . . . . . . .44 11. — Cutaneous sensoiy nerve supply to the lower limbs. (After Toldt.) 49 12. — Cutaneous distribution of peripheral nerves. (After Fowler.) 50 13 and 14. — Cutaneous nerve supply, showing the distribution areas of the different plexuses. (Toldt.) .... 51 15. — Distribution areas of the nerves (from lumbar plexus) distrib- uted to the anterior surface of the thigh and abdomen . 52 16. — Distribution of the nerves derived from the sacral plexus . 53 17. — Dorsal nerves ......... 54 18. — Cord zones according to Kocher ...... 55 19. — Cutaneous areas related to spinal cord segments and cutaneous distribution of nerves ....... 56 20. — Areas of anesthesia and paralysis corresponding to affected vertebra3 ......... 57 21. — Distribution of the lumbar segments according to Thorbum 57 22. — Distribution of lumbar and sacral segments as outlined by Starr 57 zziii xxiv LIST OF ILLUSTRATIONS FIG. PAGE 23. — Relationship of the segments of the spinal cord and their nerve roots to the bodies .and spines of the vertebrje . 58 24. — Cord zones and areas of maximum tenderness according to Head 59 25. — Cord zones and areas of maximum tenderness according to Head 59 26. — Cord zones and areas of maximum tenderness according to Head 59 27. — Areas of anesthesia on leg due to depressed fracture of skull 64 28. — Method of eliciting hyperalgesia . . . . . . 67 29. — Areas of analgesia in "hysteria ...... 78 30. — Method of pain production in inflammation ... 85 31, — Varieties of pain : Origin and transmission ... 89 32. — Scheme showing how the different varieties of pain may arise and how the different musculo-sensory reflexes may occur 90 33. — Varieties of pain: Origin and transmission ... 91 34-36. — Case illustrating upward reference of pain ... 99 37. — Hand pressing on the abdomen, very characteristic of colic, i.e., of the uterus or intestine ..... 126 38. — Position assumed in uterine colic, intestinal colic, and distended urinaiy bladder ........ 127 39. — Lacing shoe position ........ 128 40. — Pain on hyperextension of the body ..... 129 41. — Pain on going upstairs ....... 129 42. — Marking code of Dr. Harris 136 43. — Figures showing the application of the marking code of Dr. Harris ......... 137 44. — Areas of neuralgic pain ....... 148 45. — Brachial plexus ......... 151 46. — Areas of distribution of nerves derived from the brachial plexus ......... 152 47. — Areas of distribution of nerves derived from the brachial plexus ......... 152 48. — Distribution areas of the cutaneous nerves of the upper limbs 154 49. — Areas of distribution of the different cords of the brachial plexus ......... 155 50. — Distribution of sensory disturbances in a lesion of the fifth cervical nei've ........ 156 51. — Area of distribution of pain in lesions of the sixth and seventh cervical nerve ........ 156 52. — Distribution of sensory disturbances in lesions of the cervical plexus ......... 157 53. — Area of anesthesia in a lesion of the first dorsal nei-ve . . 157 54. — Method of eliciting pain in brachial neuralgia . . . 158 LIST OF ILLUSTRATIONS FIG. 55. — Method of eliciting the points of tenderness in intercostal neuralgia ......... 56. — Cutaneous distribution areas of small and greater sciatic 57. — Method of eliciting pain in sciatica 58. — Distribution of the plantar nerves 59. — Pain in skin over back and shoulder due to disease of shoulder joint ...... 60. — Obturator and accessoiy obturator 61. — Pain areas in the head 62. — Pain areas in the head 63. — Figure illustrating the places where induration takes pi 64. — Locations of the principal headaches 65. — Locations of the principal headaches 66. — Occipital headache .... 67. — Fronto-temporal headache . 68. — Temporal headache .... 69. Frontal view of Head's zones . 70. — Lateral view of Head's zones . 71. — Lateral view of Head's zones 72. — Posterior view of Head's zones . 73. — Figure showing the modifications of pain in the lumbar by change of position . 74. — Pain areas in trunk and lower extremities 75. — Pain areas in breast and abdomen 76. — Pain areas in neck, chest, clavicular region and abdomen 77. — Pain areas in the back .... 78. — Pain areas in spinal column 79. — ^Pain areas in back ..... 80. — Posture assumed in earache 81. — Scheme of innervation of abdominal \ascera 82. — Figui'e shelving the anterior distribution of the ninth, tenth, eleventh and twelfth dorsal nei-ves 83. — Anterior view of abdominal zones with corresponding 84. — Posterior view of abdominal zones 85. — Areas of local tenderness, when the inflammation of the appen- dix, gall bladder, and Fallopian tube and ovary has spread to the peritoneum and has produced a localized peritonitis 86. — Posture of abdominal protection present in peritonitis . 87. — Position in abdominal colic, assumed on lying 88. — Position in abdominal colic, assumed on sitting . 89. — Areas of referred pain as given by Head .... 90. — Nervous supply of the stomach ...... 91. — Location of the pain symptoms in a ease of hyperchlorhydria 92. — Pain radiation ......... 93. — Location of pain in acute gastritis ..... XXV 164 167 168 169 235 240 263 264 266 278 279 280 280 281 291 292 293 294 298 308 309 311 313 314 315 335 379 385 395 396 404 406 407 407 427 428 435 436 441 xxvi LIST OF ILLUSTRATIONS FIG. PAGE 94. — Location of pain in gastiic ulcer ..... 443 95. — Sites of tenderness in gastric ulcer, ulcer of pylorus and ulcer of duodenum . . . . . . . . 446 96. — Sites of tenderness in gastric ulcer, posterior view . . 446 97. — Hyperalgesic zones in cancer at cardiac end of stomach . 456 98, — Point of tenderness and the area of pain in a case of peri- gastric adhesions ........ 460 99. — Anterior \'iew of areas of referred pain in intestinal diseases 466 100. — Posterior view of areas of referred pain in intestinal diseases 466 101. — Points to which pain is referred in lesions of different parts of intestinal tract ........ 467 102. — Pain areas in colonic colic ....... 481 103. — Pain areas in intussusception ....... 498 104 and 105. — Areas of pain in diseases of colon .... 500 106. — Irritation at external sphincter referred to skin over coccyx . 510 107. — Cutaneous and muscular distribution of eleventh and twelfth thoracic nerves ........ 515 108. — Areas supplied by the posterior branches of the eleventh and twelfth thoracic nerv^es ...... 520 109. — Areas of pain referred from the appendix .... 521 110 and 111. — Areas of cutaneous hyperalgesia in appendicitis cor- responding to the eleventh dorsal area of Head . . 522 112. — Reflected pain in appendicitis. Triangle of cutaneous tender- ness .......... 523 113. — Reflected pain in appendicitis. Small area of cutaneous ten- derness occasionally present ...... 523 114. — Reflected pain in appendicitis. Rounded patch of cutaneous tenderness in lumbar region ...... 523 115. — Location and radiation of sympathetic reflected pain in appen- dicitis 524 116. — Location and radiation of sympathetic reflected pain . . 524 117. — Areas of hyperalgesia in the eleventh dorsal visceral segment due to appendicitis of the catarrhal type . . . 525 118. — Areas of increased sensitiveness to pain and to touch in appen- dicitis ......... 526 119-121. — Pain in the left side in appendicitis .... 528 122. — Areas of referred pain in liver diseases : Anterior view . 541 123. — Areas of referred pain in liver diseases : Posterior view . 541 124. — Areas of refeiTed pain in liver diseases: Lateral view . . 542 125. — Relationship of ner\'e supply of liver to cerebrospinal and sym- pathetic systems . . . ... . . . 543 126. — Area of greatest tenderness in diseases of the gall bladder and appendix ........ 564 127. — Method of eliciting gall-bladder tenderaess .... 565 128. — Radiation of gall-bladder pain as given by Schmidt . . 566 LIST OF ILLUSTRATIONS xxvii FIG. PAGE 129. — Nerve supply to pancreas .... , . . 581 130. — Distribution areas for pain due to pancreatic lesions . -. 582 131. — Relation of pancreas' to posterior abdominal wall . . 583 132. — Pain areas in disease of pancreas ..... 590 133. — Points of pain and tenderness in diseases of the spleen . 595 134. — Points of pain and tenderness in diseases of the spleen . 595 135. — Method of palpating for splenic tenderness . . . 596 136. — Location of the kidney ....... 597 137. — Areas of referred and reflected pains in diseases of the urinary apparatus ......... 609, 138. — Nerves involved in refeiTed pain from kidneys . . . 611 139. — Distribution of cord zones (according to Head) and of ner\'es ......... 613 140. — Areas of reflected hyperalgesia, in tenth, eleventh and twelfth dorsal, and first lumbar visceral segments (according to Head) 614 141. — Method of palpation in eliciting tenderness in the kidneys , 615 142. — Position assumed in kidney disorders, ureteral and kidney colic, lumbago, uterine and tubal adhesions and drag on back, enteroptosis, especially after removal of corset . 617 143. — Area of hyperalgesia in congestion of kidney . . . 631 144. — Areas of hyperalgesia in congestion of kidney associated with liver congestion : Anterior A-iew ..... 634 145. — Areas of hyperalgesia in congestion of kidneys associated with liver congestion : Posterior view ..... 634 146. — Area of hj'peralgesia in kidney and liver congestion . . 635 147. — Area of hyperalgesia in nephritis ..... 636 148 and 149. — Areas of tenderness present in renal tuberculosis . 643 150. — Areas of distribution of anterior spinal nerves . . . 660 151. — Areas of distribution of posterior spinal nerves . . . 660 152. — Head zones of hyperalgesia usually associated with kidney lesions : Anterior \dew ....... 661 153. — Head zones of hyperalgesia usually associated with kidney lesions : Posterior ^^ew ....... 661 154. — Area of cutaneous hyperalgesia in severe renal colic in which the stone was in the ureter ...... 662 155. — Pressure made upon ureter in endeavor to obtain local ten- derness ......... 663 156. — Toumier's points of pressure in kidney and ureter lesions . 664 157. — Relationship existing between pain and other sensations arising in the urinary bladder ....... 673 158. — Pain areas associated with diseases of bladder . . . 674 159. — Relationship of rectal tenesmus to vesical tenesmus . . 675 160. — Areas of refen-ed pains usually associated with disease of urinary bladder ........ 676 PAGB xxviii LIST OF ILLUSTRATIONS FIG. 161. — Referred pain in disease of bladder ..... 677 162. — Referred pain in disease of bladder . . . . . 677 163. — Referred pain in disease of bladder ..... 677 164. — Referred pain in disease of the bladder due to involvement of the pudic nerve ........ 679 165. — Areas of cutaneous tenderness in disease of the epididymis . 699 166. — Areas of distribution of the tenth and eleventh dorsal segments, and the first, second and third sacral segments on the right side ......... 701 167. — Nerve supply of female genitalia ...... 706 168. — Area of distribution of cord segments involved in uterine, ovarian, and tubal diseases ...... 714 169. — Points of tenderness as elicited by Donald and Licklej'^ in ovarian, tubal, and uterine diseases .... 720 170. — Areas of hyperalgesia in a woman two months pregnant . 736 171. — Phenomena accompanying tubal disorders .... 738 172. — Areas of referred i^ain in a case of labor .... 740 173. — Areas of cutaneous distribution of the thoracic segments . 761 174. — ^Points at which the intercostal nerves become superficial . 763 175. — Location of tenderness in various diseases of the chest and abdomen ......... 765 176. — Location of hyperalgesic zones and the areas of pain in cardiac and aortic lesions ....... 775 177. — An area of hyperalgesia corresponding to portions of the sec- ond, third and fourth dorsal zones .... 776 178. — Areas of cutaneous and deeper hyperalgesia in a case of acute dilatation of the heart, accompanied by acute distention of the liver ......... 777 179. — Hyperalgesic area in a case in which the myocardium is prob- ably in a state of intoxication .... 180. — Areas of pain in a case of mitral and aortic regurgitation 181. — Area of sensory disturbances in a case of angina pectoris 182. — Communication between spinal accessory and vagus 183. — Emergence of the spinal accessory from imder the sterno- mastoid ........ 184. — Conducting paths for impulses from the heart 185. — Points of emergence of the dorsal nerves (anterior) 186. — Areas of hyperalgesia in a case of diaphi-agraatic pleurisy 187 and 188. — Areas of referred pain in pleurisy . 189 and 190. — Figures showing, on the left side, the areas of distri- bution of pain in a case of diaphragmatic pleurisy with effusion; on the right, the areas before the effusion ap- peared ......... 796 191. — Some of the areas of pain and tenderness in cardiac and pul- monary disease ........ 801 778 779 785 786 787 788 791 793 794 PAIN CHAPTER I GENEEAL CONSIDEEATION OF SENSATION To those who are interested in the study of disease, it is scarcely necessary to emphasize the value of the correct apprecia- tion of pain as a symptom. The importance of its interpretation must be obvious. Almost ninety per cent, of all diseases either begin with, or have, pain as a prominent symptom at some time during their course. Therefore, a correct diagnosis can hardly be made without an intensive study of the various forms of pain. Sensation in Lower Animals. — We may, therefore, take up with profit a consideration of sensation, of which pain, as a psycho- logical entity, is but a part. In fact, to gain a comprehensive idea of pain, it is necessary to begin our studies with those organ- isms in which sensation emerges from that simple state in which all stimuli are responded to by reflex protoplasmic movements, of which the organism has no perception. This movement according to Loeb would be the result of che- motropism. All protoplasm is attracted by certain substances and repelled by certain other substances, the attraction and repul- sion depending upon the construction of the protoplasm and the stress of its need or avoidance of the constituents of which the other body is composed. Such a state we find in the ameba. In a higher organism, as the medusa, an aggi'Cgation of cells possesses the same threshold of irritability for certain substances and thus they respond to irritation by coordinated motion and this seems to be due to the presence or absence of certain ions in the stimu- 1 2 GENERAL CONSIDERATION OF SENSATION lating substance. (Na ions start or incrcacc rhythmical contrac- tions; Ca diminish the rate or inhibit such contractions.) Or should the cells all not come into contact with the exciting factor, the one coming into contact can transmit its stimulus to other adjacent cells and in them produce a similar reaction to its own. This propagation by contraction is better exampled in the Ciona intestinalis, where as a means of communication a set of cells are specially differentiated so that they can better and more quickly carry stimuli from one structure to another. In other words, conduction is their function. These cells arrange them- selves into special groups, etc., and form what is termed the nerv- ous system. But in the lowest forms of life the nervous system is not a necessity, but only an auxiliary in the life economy of the animal, as demonstrated by Loeb. He removed the central nervous apparatus of the Ciona intestinalis and found that it still responded to a mechanical stimulus of one group of muscles by contraction of other groups, but that this response was much slower than when the central nervous system was intact. From this he conduced that while the central nervous system was not absolutely necessary (in this animal) still it served a useful pur- pose in that the stimuli were conducted more quickly and that therefore the threshold of response was greatly lowered. In the earthworm, which is composed of segments, each segment has its own special nerve supply. Forward motion in this animal is due to the alternate action of the longitudinal and the circular mus- cles. Friedlander found that removal of its central nervous sys- tem had no effect on the coordination of progressive motion. This is explained by Loeb, who says that when the forward piece is elongated and attempts to shorten itself by contraction of the longitudinal muscles, the skin of the aboral piece is stretched and that this stretching produces a stimulus to the longitudinal mus- cles of the posterior piece which then contracts and causes the animal to move forward. Thus at this stage of biologic advance- ment, motion is not the result of sensation, but is only a reflex of a very simple nature. In animals of a higher order the same stimulus exists, but the stimulus of origin is in some cases far REACTION or ANIMALS TO PAIN 3' removed from the stimulus of effect. The conduction from place of origin to point of effect being through nerve paths, the motion is still the result of a reflex, and this reflex either causes the ani- mal to move to or draw away from the source of the stimulus either as it is beneficial or destructive to its economy. When it does so withdraw or when it responds to excitor stimuli by rapid and irregular motion, are these an indication of a disagreeable sensation or of pain ? Reaction of Animals to Pain.— Many have assigned to the lower organisms the same pain sensation as that possessed by man. The reason assigTied for this hypothesis is that reactions take place to injurious stimulation, by various reflex movements, and that these reflex movements are the motor manifestation of pain. This interpretation is contested by IS^orman ("American Journal of Physiology," Vol. Ill, p. 271, 1899), who states that in many animals, ranging from the simple worm to the higher vertebrates, such as fish, he has cut off segments of the body and otherwise insulted the integrity of the structure, without, in some instances, producing any movement at all, or, if movement occurred, with- out producing any which was greater than that caused by ordinary and slight stimuli. He maintains that the movement of an ani- mal is not due to impulses caused by the sensation which we desig- nate as pain. Should excessive reflex movements be produced, they are the result of an excess of stimuli, not necessarily destruc- tive. His experiments were varied and numerous. In one in- stance, he cut an earthworm in two ; and while the posterior part performed very rapid twisting and squirming movements, the anterior half simply elongated and went on crawling, the same as before the experiment. Is it possible that pain would be felt in the posterior part, and that the anterior segment, in which the main ganglia are located, would be free of pain ? l^orman elaborated his experiments further. He cut in half a leech, which was swimming in the water, and observed that both segments continued their motion without interruption. Starfish and crabs, as well, showed no reaction to division. He cut away the posterior part of the abdomen of a bee, while it was engaged in sucking 4 GENERAL CONSIDERATION OF SENSATION honey, without any interruption to its activity. He also men- tions the fact that sharks may be cut and operated upon without the slightest movement on their part. Experiments of this nature tend to show that one must ascend rather high in the vertebrate scale before true pain phenomena make their appearance. In fact, it is only in mammals that this sensation is developed to its highest degree. In our study of pain, therefore, we must bear in mind that motor response to an irritant is not always an indi- cation of pain, but is only a reaction to stimuli (not necessarily sensory). However, before proceeding further in our considera- tion of pain phenomena we shall study sensation and its attributes. General Consideration of Sensation.^ — Sensation itself is the perception of an impression conveyed to the brain as the result of the activity of some peripheral sense-organ. These sense-organs may give rise to both subjective and objective sensations. Sub- jective sensation is the result of activity of those forces of the body which are concerned with its integrity and well-being. It gives rise to hunger, satiety, nausea, thirst, physical or mental depression, or exhilaration, joint sensation, and the like, and may be called an organo-protective sensation. It also produces the feeling of fatigue and exhaustion. Objective sensations primarily depend, for their perception, upon the presence of external re- ceptors, such as those of sight, touch, smell, hearing, taste, tem- perature, etc. Therefore, in order to have sensation, that is, to be capable of perceiving and interpreting stimuli, and of classi- fying them under certain empirical divisions as belonging to one domain or another of feeling, it is first necessary that our sense- receptive organs be intact, the sense-conveying organs normal, the sense-interpreting centers active and the associative memory cen- ter (consciousness) intact. Should the latter be disturbed, as oc- curs during certain mental diseases, anesthesia, etc., sensory stim- uli, irrespective of their character, either will fail to be perceived, ' Feeling is the impression which sensory stimuli arouse in consciousness. An example from IMeyer is that we perceive that ice gives rise to a cold sensation, which in turn causes an unpleasant feeling. To be properly influenced, i. e., to be influenced so that the resulting feeling properly represents the combined results of the sense perceptions, requires that one be in a proper receptive state, i. e., anger or disagree- able emotions destroy the pleasure created by pleasing sounds or beautiful combina- tions of color. GENERAL CONSIDERATION OF SENSATION 5 or, if they are, will be greatly modified. Since we speak of con- sciousness it may be well to briefly consider it. It has been de- fined as the ability, power, faculty, or mental state of being aware of one's own existence, thoughts, feelings, actions and sensations, whether intellectual, moral or physical (Sudduth, 472), and must be present to take up and correlate the different stimuli reaching the brain from the periphery. Consciousness has been divided into two classes: (a) subjective and (b) objective. Subjective consciousness tells us of things which originate in the mind (we shall have occasion to use this concept later in our study of hysteria). Objective consciousness tells us of things perceived through the senses. Of the senses we distinguish two varieties, the internal and the external. The internal senses are those which are concerned with the well-being of the organism, and the relation of the dif- ferent parts, one to another. They include muscle sense, joint sense, hunger sense, etc. The external senses are those which are concerned with the interpretation of external objects, and in- clude, generally speaking, touch, smell, sight, hearing, taste, mus- cular and temperature sense. Each of these senses has a complete nerve apparatus of its own, consisting of sense-receptive, sense- conveying, and sense-perceptive organs. The sense-receptive or- gans are the terminal filaments of the sensory nerves. The sense- conveying organs are the axis cylinders of the sensory ganglia cells (the nerves) and the sense-perceptive organs are the sensory cor- tical cells. We now have the apparatus; all that is lacking is the force. The question now arises, what is this force, and what varieties of stimuli produce the changes which give rise to sensation ? The two most prominent hypotheses are that the stimulus is of a chemical or electrical nature or is a mechanical force in the form of vibra- tion. The chemical hypothesis is that the external stimuli produce some chemical change in the cell, which reaction is propagated into other adjacent cells until it reaches the perceptive center. Engelman (377) advances the idea that the impulse which cre- ates sensation is of an electrical nature, but does not exactly de- 6 GENERAL CONSIDERATION OF SENSATION fine what he means by electrical nature. By many, however, it is held that all sensation is the appreciation of arrested motion (vibration), this motion being the result of a mechanical, a chem- ical or an electrical contact. It is the motion of the ether mole- cules upon the retina which produces the "formation or decom- position of certain substances and it is the chemical processes of the formation and decomposition of these substances which deter- mine light and color sensations" (Loeb, 104 C, p. 291); the mo- tion of the air molecules upon the drum membrane of the ear which "causes vibration in endings of the auditory nerve by which new molecules are brought into contact with each other and sound is produced" (Loeb); the impact of the odoriferous parti- cles upon the olfactory nerve terminals in the mucous membrane of the nose which creates smell (chemical action). ,For taste, it is essential that the sapid substance shall come in contact with the taste-buds of the tongue (chemical action); for touch, that matter must come in contact with the nerve terminations in the skin. Thus we see that all sensation depends upon contact, and that contact gives rise to motion. This motion is in the form of vibration (molecular), and the sensation produced depends upon the sense- organ against which the vibration impinges. Each terminal sense- organ takes up only the vibrations produced in a particular me- dium. For instance, in the normal state, sound is perceived only when the air is in vibration against the cochlear apparatus; light depends wholl}^ upon the vibration of the ether upon the retina; smell upon the impingement of minute physical particles upon the olfactory terminals, etc. It is also of great interest to know that the sense perception of these organs in man is limited to the perception of vibrations which lie within certain limits. For example, the human ear is unable to hear if the vibration is below two per second, or greater than thirty-three thousand per second. Thus man is unable to hear the calling of a whale, be- cause the tone of the whale's voice vibrates only two per second; as he also frequently is unable to hear the humming of a swarm of gnats, a sound which is produced by a vibration of about thirty- five thousand per second. SENSORY PERCEPTION AND THE SENSE-ORGANS 7 The adequate stimulus, according to Loeb, loc. cit., p. 181, is transmitted from the receiving station to the perceiving station by means of ions, the exact nature of which is not known. He claims that whenever the progress of the ions is blocked in the central nervous system an increase in their concentration will occur, and that this must be followed by physical or chemical alterations of the colloids. It may also happen that too fre- quently repeated stimuli will leave a disorganizing action on the colloids and that this disorganization is interpreted by the organ- ism as pain. Properties of Sensation. — Sensation possesses the following properties: quality, intensity, and duration. (1) Quality gives us an idea as to the cause of the sensation. For instance, the quality of the sensation of sound is entirely dif- ferent from that of the sensation of taste, and it is this difference which enables us to correctly determine the source of origin (whether from a peripheral sense-organ of taste, hearing, smell, etc.). It also enables one to distinguish variations in the same sensation. (2) Intensity enables us to distinguish differences in the strength of stimuli producing the same sensation, and indicates, also, the receptive state of the organism to the sensation. At cer- tain times pain is much more acutely felt. This is due to the fact that at these times the organism is weaker, being either re- duced by exhaustion or disease, and therefore it is more acutely affected by all irritative stimuli. (3) Duration of a sensation depends, first, upon the inten- sity, and second, on the rapidity of the impulse. If the impulse is very intense, the sensation in the sense-perceiving centers persists for some time after the stimulus has ceased. For example, if a bright light is placed before the eyes, the sensation of light per- sists for some time after the light stimulus ha-s been removed; also if we gaze at a bright light and then close the eyes, the sensation of light still continues for a few seconds. The rapidity of the repetition of stimuli also influences the duration of the sensation. If the stimulus is repeated too frecjuently, we find that a continu- 8 GENERAL CONSIDERATION OF SENSATION ous instead of an interrupted sensation is felt. This is due to the fact that the sense perception of all stimuli persists for a short time after the stimulus has ceased to exist. Thus, if the stimuli follow each other at short intervals, the sensation is that of a con- tinuous stimulation. At times, remissions in sensation occur, and are due to fatigue of the central sense-perceiving center. Centers for Sensory Perception and the Sense-Organs. — It has been observed by Goltz, H. Munk and others (Tigerstedt's "Physiology," p. 651), that in the dog the destruction and removal of the motor region and the cortical layers adjacent thereto cause a variety of derangements of sensation and of mo- tion. These cortical layers, then, must in some manner be con- cerned with the perception of sensation. It has been found that if the entire cortical area for the posterior extremity is removed the muscles of the opposite leg can no longer execute finely graded movements; that for some days after the operation a complete insensibility in this extremity exists; and that a certain blunt- ness of sensibility becomes permanent. With still more extensive destruction, the finer movements of the hand and foot are permanently arrested in the monkey, and for some time after the operation the sensitiveness of the paws is somewhat reduced, so that the animal reacts only to very painful stimuli. In fact, the sensitiveness of the hand and foot becomes permanently so slight that a severe pinch produces no reaction at all (Mott). On the other hand, Schaffer has found that a monkey which does not react at all to a painful pinch im- mediately notices a slight tactile stimulus applied to the para- lyzed extremity. The monkey from which Goltz had removed the entire motor region of the left hemisphere took no notice of the gentle tactile stimuli applied to the right extremity. Stronger pressure stimuli were always felt. INIotor sensations were also somewhat diminished. From this it will be observed that generally, except in the case mentioned by Schaffer, in which pain sensation was lost but tactile sensation was present, it will be found that, in case of destruction of the motor area, the sensation in the skin over General Sensation Touch Vision Hearing Fig. 1. — Right Cerebral Hemisphere Seen from the Outside. General Sensatiorl Vision Smell Fig. 2. — Inner Surface of Right Cerebral Hemisphere. Figures 1 and 2 show the areas of sensory distribution according to Tiger- stedt (p. 654), modified from Flechsig. Dots indicate sensory areas. Areas where dots are thickest are the regions where most of the sensory pathways end. 10 GENERAL CONSIDERATION OF SENSATION the paralyzed part will also be reduced for touch, but present for pain. This might be accounted for on three hypotheses: (1) that the impulse which would produce pain is so intense that it spreads over a considerable area of the cortex, and is communi- cated to parts which are not destroyed and which still have the power of pain perception; or (2) that, owing to the strength and volume of the impulse, it is transmitted to the cortical area in the opposite hemisphere, and is there perceived; (3) that the center for pain sensation is not in the cortex, but lies proximr.l to it in one of the forwarding structures of the sensory apparatus^, namely, in the optic thalamus. The first supposition gives weight to the argument that it is the extent of the cortical reaction which produces the relative sensations, either of touch or of pain, a small area giving rise only to touch, a large area to pain. This possibly can be explained from the inhibitory action of the cortex, the destruction of a small area being not sufficient to abolish the in- hibitory impulses sent from the cortex to the optic thalamus and their acting as controls over the sensory perceptions. It has been found that general sensation and touch are lost by destruction of the central and parietal convolutions, paracen- tral lobules, and possibly the posterior part of the frontal convo- lutions, and that, for the most part, the sensory area consists of post central and parietal convolutions (Leszynsky, 498; May, 397, p. 793). Many sensory fibers enter the post central convolution. Some also enter the precentral convolution. The first and second frontal convolutions also receive some fibers; they chiefly are, however, sensory fibers connected with the cerebellar system. Upon destruction of these areas, the different sensations are differently affected, namely: (1) pain sensations suffer least, because a wider area is required for their destruction; (2) pres- sure and temperature sensations are somewhat reduced, but by no means abolished; (3) power of localization is profoundly affected; (4) motor sensations are much disturbed. The areas for sensation are probably bilateral in their loca- tion. Mills claims that they are also found in the limbic and SENSE PERCEPTIVE ORGANS 11 quadrate lobes. While Dana admits that this is possible, he also holds that the motor areas are also sensory (Church and Peterson, 506, p. 307). The sensorimotor area, in the optic thalamus (the so-called associative memory center of Loeb), is probably a depot for memory of sensation as it passes on its way to higher centers, in the limbic or c^uadrate lobes. According to Horsley (ibid., p. 162), the different cell areas for motion and sensation are superimposed in strata. ^Nlost super- ficially the tactile sense, then the muscular sense, and finally the pure motor sense elements are found. It appears that in these areas the granular cells are the active agents in sensory percep- tion, since lesions in this cell layer cause disturbances of touch, pressure, localization, muscular sensibility (sense of passive posi- tion and of movement), and, less frequently, of pain and tem- perature. This disturbance occurs in the opposite side of the body, and, when a limb is involved, the sensation is first lost in, and is last to return to, the distal portion and outer margin (W. Page, May, 397, p. 796). The small pyramidal cell layer may also be concerned indi- rectly in pain production, since these cells are atrophied in dementia, and may, therefore, be indirectly associated with sensi- bility; because it has been found that sensibility varies almost directly in proportion to the mental development of the individual, and that the pyramidal cells vary directly in proportion to the mentality. It has also been claimed that the cerebellum is the seat of all pleasure and pain activities (F. Courmont, "Le Cervelet et ses Fonctions"), and also of those connected with the emotions (Marshall, p. 25). ^Modern anatomical research, however, has shown that the cerebellum is the chief central organ for the senses of equilibrium, muscle tonus, and orientation in space. And al- though it is preeminently a sensory organ, the cortex being a sensory cortex, it is not such for pain, for light touch, heat, or cold. Sense Perceptive Organs. — Recently the sense-organs, the stimulation of which causes sensation, have been divided into 12 GENERAL CONSIDERATION OF SENSATION three classes: (1) the visceral sense-organs of the internal organs and their derivatives, (2) the extroceptor, or somatic, sense-organs, which receive the impressions from the outer world, and (3) the proprioceptors, which receive impressions from the muscles, ten- dons, etc., and report to the sensory area the exact position of the body and the relationship of parts to each other. The researches of Head, Holmes, and Sherrington have served to show that the constituents of sensation are extremely complex. So far as the visceral receptors are concerned, we know very little about them. There are chemical, touch, heat, and cold receptors, and undoubtedly receptors which have to do with the forces of gravity. Most of these receptors Head has placed within his pro- topathic system. They belong, phylogenetically speaking, to old systems; are almost automatic, and for the most part are passed over to the autonomic sympathetic nervous system. Their spinal representations are present largely in the lateral processes of the cord. Their central paths are not as yet definitely determined. The extroceptor or somatic sense organs are divided b}- Head into the epicritic and protopathic systems. The ability to dis- tinguish light touch (cotton wool), two points of a compass (at small intervals varying with the part), and to discriminate slight variations in temperature, are held by Head to be specific and in- dividual entities. Together they constitute his epicritic system. Their spinal, medullary, thalamic, and cortical distributions have been fairly well defined. To the protopathic system on the other hand belong the faculties to distinguish ordinary touch, deep pressure, extremes of heat and cold. Finally, according to Sher- rington, there exists another system, the proprioceptive. Its re- ceptors are found in many places in the body, chiefly in the ten- dons, muscles and bones, and also most characteristically in the labyrinth. Its chief sensations are those connected with the orientation of the body in space; the vestibular nerve being its chief cephalic ganglion and the cerebellum its chief central organ. Stimuli. — The stimuli necessary to produce a sensory-reaction may be mechanical, chemical, thermal or electrical. Any of these. INTERPRETATION OF SENSATION 13 when applied in normal quantity, and with normal force, produces a normal reaction; but when applied with excessive intensity, all are capable of stimulating the specific pain receptors. Interpretation of Sensation. — If we consider for a moment the embryological development of the human body, we find that the external organs of sensation develop pari passu with the in- ternal organs, but that the external ones are practically without function until the fetus is born. During the period of intra- uterine existence, the external senses are lying dormant, but as soon as the fetus is born, and feels the touch of air upon its sur- face, it has entered upon a new life, and one vast complex of sensations reaches it from every side. Embryologically the vestib- ular system develops very early. These sensations are for three purposes: (1) to provide pro- tection for the organism; (2) to provide for its development; and (3) to provide for its reproduction. We find that in general everything which reacts unfavorably to the organism causes dis- tasteful and disagreeable sensations. These, when of a peculiar quality and intensity, give rise to the sensation which we term pain. It is also found that everything which acts or aids in the growth, development and reproduction of the organism causes pleasure. Between the two extremes of pain and pleasure there exists a neutral state, where, because of the weakness of sensory stimulation or perception, a state neither of pleasure nor of pain is produced. This we term the state of indifference. Therefore, we may be said to have three states of sensory mental activities, namely, pain, indifference, and pleasure. Definition of Pain. — Pain is distinctly a mental interpre- tation, and cannot be strictly defined. It is the interpretation of some abnormal and generally harmful process which is occurring in the organism. It cannot be classed as a sensation, but rather is the result of the perception and interpretation of sensation by the mind. Our consideration of pain will naturally lead us into a discussion of its antithesis, pleasure, since the two are inti- mately connected in their perception and in their interpretation. Both are the result of mental activity. 14 GENERAL CONSIDERATION OF SENSATION Mental Activity. — According to many authors, three divi- sions of mental activity have been assumed: intellect, or the faculty of thought; sensibility, or the faculty of feeling, and voli- tion, or the faculty of voluntary action. This is manifestly a purely artificial division. While we are primarily interested with the second division, it is my purpose to show that it is intimately bound up with the first (intellect). I shall also point out that the intellect can, by the exercise of memory, recall to mind the ob- jective sensations classified as pain, and, by making them perti- nent to the moment, cause them to appear real, as if experienced at the time. In other words, intellect is able to produce, without any objective means, the sensation of pain. This class of pain- sensation, which seems to appear without any definite causative factor, is frequently called subjective pain. The crudest mental impressions consist of the primary sensa- tions of touch, sight, hearing, taste, smell, and temperature, which are objective, and muscle sense, joint sense, hunger sense, etc., which are subjective. These, when carried to and interpreted by the brain, result either in pleasure sensation, neutrality, or pain; and as a result of these mental interpretations there arise certain mental states, such as joy, sadness, pleasure, and happiness, which in turn may give rise to mental activities, such as anger or its converse. Mental States. — I do not mean to say that all sensation must definitely be interpreted either as painful or as pleasant, in- asmuch as there are sensations which are neither painful nor pleasant. These are referred to as neutral sensations. For in- stance, the sight of a tree may be neither pleasant nor painful^ but the recollection of certain facts associated with that particu- lar tree may recall, at the sight of it, certain thoughts that induce a painful or rather unhappy emotion; and here it is well to dif- ferentiate emotion, which is a mental state, from pleasure-sense or from pain, which are but sensations. Ideas or thoughts may give us pleasure, but it requires an external stimulus to arouse the pleasant sensation that may accompany thought, such as is found in reading, in listening to sounds which are pleasant when INTERPRETATION OF SENSATION 15 grouped in the form of harmony, in hearing beautiful ideas well expressed, or in seeing wondrous productions of blended colors in the form of a beautiful landscape. Therefore, the use of the word pleasure should be restricted, I think, to the mental state following upon pleasant or agreeable sensations, which, in turn, should be called pleasure-sensations. Thus we have the emotional condition of pleasure and of its converse, displeasure. Mental Resultants. — From every mental state, certain de- rivatives arise; for instance, anger is often evolved from dis- pleasure, while pleasure gives rise to elation. It is the affective state which we are in that colors our perception and guides our acts; and it is particularly fitting, in this connection, that physi- cians should bear in mind that the fundamental cause of an ill- behaved, crabbed disposition very often is to be found in the elementary sensations coming from the periphery, acting as ex- citors to a possibly already overwrought and abnormal nervous system. How easy it is, on this hypothesis, to account for the sour and surly disposition of the dyspeptic, or the forbidding as- pect of the chronic sufferer! They are worthy of our kindest con- sideration, for their disposition and their evil manners are often due to causes over which they have little control. Relation of Pain and Pleasure to Mental States. — Ac- cording to Marshall, pleasures and pains are but differential quali- ties of all mental states. To this I must take exception, for, to my mind, they are but interpretations of sensations which are perceived as arising in the periphery. It would seem more fitting that pleasure, when applied to sense perception, should be spoken of as pleasure-sensation. For in- stance, a cool bath taken on a warm day gives rise to a pleasant sensation and at the same time produces pleasure; but thoughts of an absent one, or of some joyous past event, may give pleasure, while at the same time we have no pleasant sensation. Next it behooves us to ask, can both pleasure-sensation and pain be perceived at the same time, and, if they are not perceived and factors which ordinarily produce them are present, is their non-perception due to the fact that they neutralize each other? 16 GENERAL CONSIDERATION OF SENSATION It is inconceivable that two such opposites as these could exist in consciousness at the same time; and it is entirely improbable that, should such a state exist, their contra-action would produce a con- dition of neutrality, which is the result of two active, equal and opposing forces. For instance, the distress which comes from an ulcerated stomach or an irritated sore cannot be neutralized by the physical pleasure derived from epidermic sources. We experi- ence either pleasure or pain; there is no halfway stop where the one counteracts the other, giving rise to a state neither of pleasure nor of pain, but of neutrality. Yet, in some cases a transition from pleasure to pain-sensation may occur, for it is found that sensations which ordinarily are interpreted as pleasant may, from frequent repetition and excessive stimulation, become painful, as in pericementitis, in which at first a pleasant sensation is pro- duced on lightly pressing the teeth together, but which, if the pressure is continued or increased, results in pain. Another ex- ample is priapism, in which the distention, which at first is pleas- ant, if continued, soon becomes painful. Gentle friction over the body, especially over the nape of the neck, is pleasant (to most people); yet, if the friction becomes excessive, and the nerve- endings are irritated, the pleasant sensation is transformed into a painful one. Again, a harmonious play of colors is soothing and pleasant to the eye; but let the colors be exceedingly brilliant, the pleasant sensation is transformed into a disagreeable and painful one. Another example may be deduced from the sense of hear- ing. We all know how pleasant to the ear are the tones of a harp; but change them into the shrill notes of the siren and we almost shriek with pain, or rather let us say distress. Yet, if now we modify the vibrations and reduce them in number, the distress disappears; and the sound, while neither painful, nor pleasant, may become pleasant if we place among its components some half tones which increase the fullness and volume. These are examples of sensations changing from pleasant to painful, and then back again from painful to pleasant. The changes which bring this about are the result of variations in the force and rapidity of the impulses impinging on the nerve ternainals, INTERPRETATION OF SENSATION 17 The change from a neutral state to one of pain may not be acute, but rather a gradual increase in unpleasant sensation un- til the threshold for pain perception is past and the patient has the sensation of pain. This transition from pleasure sensation to that of pain occurs on the application of heat or cold or on the application of pressure to a part. In the latter the pressure may at first be so light that it is not perceived; then it may become stronger and be felt as touch; then again stronger and be felt as a definite sensation of pressure. Finally it may become still stronger and then be felt as pain. Certain laws have been deduced from the transitional inter- pretation of impulses from pleasure to pain, of which the two following are taken from IMoher ("Psychology," p. 225), who says that: (1) Pleasure is an accompaniment of the spontaneous and healthy activity of our faculties, and pain is either the result of their restraint or of their excessive exercise, (2) Pleasure increases with increasing vigor in the opera- tion, up to a certain normal medium degree of exertion, and pro- gressively diminishes after that stage is passed. Farther on, pleas- ure disappears altogether, and beyond this line pain takes its place. Whether this interpretation is correct is not yet apparent. If the receptors for light and sound, for example, have specific pain receptors, which have a definite threshold value and only react when the intensity of the stimulus has reached a definite point, then the older hypothesis that assumes that pleasure passes into pain fails. By bearing in mind the analogies in skin sensibility, it would appear that such specific receptors are probably present, and recent studies of sensation tend to show that they are pres- ent and are independent of others of a lower threshold value. Should this principle hold true for the sensory systems through- out, epicritic and protopathic, our conceptions of pain and its re- lation to pleasure will be markedh' altered and simplified; we then may discard much of the metaphysical speculations regarding the relations of pleasure and pain. These, however, will be discussed more fully in another chapter. CHAPTER II THE NATURE OF PAIN Definition. — Various definitions of pain have been given by- different authors. Meade says that pain is an indication of inter- ference with the power of nutrition of the organism; pleasure, of the elevated power of nutrition of the organism. Oilman thinks that the source of all pleasure is the renewal, on the part of the nerves, of the activity that has already become familiar to them, while pain has its source in the violation of nervous habitude. Meynert and Oilman think that the effective working of the psychic functions is the cause of pleasure, while any obstacle to these functions is the cause of pain. Sidney E. Mezes says that pleasure is attention without difficulty or obstruction, while pain is attention with difficulty. This applies to mental pleasure par- ticularly, as close attention with deep thought is pleasant, while obstruction to this attention and thought, due to internal conflict, distress of mind, or other causes, is painful (Bianchi, p. 346). Bianchi further says that whenever there is internal emotion, or exteriorization, in response to the needs of life, there is pleasure; when the movement is hindered or obstructed, there is pain. The aspect theory, as held by C. D. Strong (473), regards pain as the highest degree of displeasure, and holds that the pain of a cut or of a burn can always be anal}'zed into a tactile or tem- perature sensation, on the one hand, and a feeling of displeasure on the other. Kulpe evidently was the inspiration for this idea, for he is quoted by Strong as saying that "the characteristic fea- ture of pain is not the sensational quality, which is never absent, but the feeling of the disagreeable, of which pain is the highest degree." On the other hand, Lehmann does not entirely lose sight of the sensational element of pain when he says: "A feel- ing, whether of pleasure or of pain, never occurs apart from a 18' DEFINITION 19 sensation, however weak, and in every case where such an isolated feeUng is supposed to have been observed, the sensational element has merely been overlooked." Meyers (122, p. 744) says that pain is a beneficent reaction, through the nervous system of altered structure or disordered function, against threatening forces. Dunglison, in 1857, defined pain as "a disagreeable sensation which scarcely admits of defi- nition "—truly a very indefinite definition. Quain (471), not more clear, said that " it is the representation in consciousness of a change produced in a nerve center by a special mode of excita- tion." Sudduth says that "pain is a mental state, an element of consciousness, due to the perception of an injury to the body or to the feelings." By this definition it is seen that Sudduth holds that there must be a condition of mental aptitude, otherwise it is not possible to decide as to whether or not an injury is painful. Schopenhauer turns to scholastic philosophy and the intro- spective method of deduction, for he believes that "pains are positive and pleasures are negative experiences; pleasures are due to the absence of pain, and the intensity of one is often in propor- tion to the other feeling that preceded it." Another definition, of the same character, is given by Spinoza, who says that "pleas- ure is an emotion whereby the body's power of activity is in- creased or helped, and pain is an emotion whereby the body's power of activity is diminished or checked. Therefore, pleasure in itself is good." (Spinoza's "Improvement of the Understanding.") As one retreats farther into the past, it will be seen that the physical properties of pain were not perceived, and that only a metaphysical interpretation was taken into consideration. The early Celts and Teutons had a mythological representation of disease, called Hela, a ghastly form who received all who died of disease into her residence, Niflheim. In this were the Hall Elidnir (pain), her bed, Koer (disease), and the table, Hungur (Allen, 510). Cicero described pain as a disagreeable .move- ment in the body (35); Gambuus called it a disagreeable sensa- tion which the mind would rather not experience; while Sauvage spoke of it as a disagreeable sensation originating from any lesion 20 THE NATURE OF PAIN of nerve fibers (5). Valentine (507), Wundt (508) set forth the idea that too great an intensity of stimuH may cause pain; Erb held that every increase of sensory stimuli is capable of producing pain as soon as it attains a certain intensity; Eulenburg (509) states that it is a gradual increase in the feeling which accom- panies every sensory process. From the preceding, we see that there are two ideas underly- ing the various definitions for pain; the one physical and the other metaphysical. The older writers dwelt upon its psychological as- pect, namely, that it is a disagreeable sensation, while the modern thinkers add that the disagreeable sensation is the result either of lessened nutritive activity in the cell (receptive or perceptive), or is the indicator of the reaction against whatever tends toward the destruction of the organism. Universality of Pain. — As an evidence of the universality of pain, we find words expressing it in all languages; and as evidence of the antiquity of its existence, we find that the word expressing it is practically the same in all languages having a common origin. In the English language, the name is probably derived from the Middle English, and is a term used to convey the idea of suffer- ing. This, in turn, like a similar expression found in all modern languages, was probably derived from the Latin poena, which means a punishment, and no doubt originated in the Greek word irolva, also meaning a punishment or penalty. Metaphysical Consideration of Pain. — Is pain a "sensation" or a "feeling"? Meyer believes that pain consists of two com- ponents, i. e., sensation and feeling. The perception element is paramount, when, for instance, if pressure be made on the finger the sensation of touch would be experienced, then pressure, and then pain would be experienced. The latter is a feeling qualify- ing or superimposed upon touch. Therefore, he asks, is pain a true sensation or is it only a perception and interpretation of a sensation to which the conscience has, from past experience, learned to give the name pain? For instance, is it possible for us to know what pain is unless we have been informed at one certain time of the sensation which we were then at that time experi- METAPHYSICAL CONSIDERATION OF PAIN 21 encing. If we adopt such an interpretation we must regard pain as a "feeling." We have been considering pain as a sensation. This, according to Marshall ("Pleasure and Pain," p. 25), is un- tenable, for the following reasons: A sensation must have a receptive, a conducting, and a per- ceptive organ and (1) Xo center for pain has ever been defined or located.^ (2) Xo special means for pain production are present, as in the case with other sensations. (3) Pain is aroused by the most varied stimuli, while sensa- tions are aroused by well-defined and limited stimuli, which must be exerted upon a Special sensory-perceptive apparatus. (4) Sensations are themselves both painful and pleasant; therefore, pain and pleasure are but attributes of sensation; and cannot exist by themselves as separate sensations. For instance, heat, cold, taste, smell, hearing, and sight may all be painfully, as well as pleasurably, perceived. (5) Pain may exist in the intellect without any peripheral cause, but in this case it generally acts as a qualifying factor in emotion, which is a mental state. It is extremely difficult to say whether an abstract idea can or cannot be painful. Perhaps the most we can say is that it is either agreeable or disagreeable. (6) An argument sometimes advanced against pain being a sensation is that we can draw up in imagination a representation of sensation without its actual presence; but we cannot, by any stretch of imagination, conjure a picture of a pain, but must al- ways associate it with some sensation, such as touch, heat, cold, etc. Xewer research has shown that Marshall's position is abso- lutely untenable, but we shall for a moment discuss its merits and demerits, with the hope of adding light to the whole subject. With regard to Marshall's first proposition, that no center for pain has ever been defined or located, it may be said that while, as a rule, physiologists and psychologists do not limit pain perception to a particular region of the brain, they hold a rather unanimous belief • At the present time, however, most physiologists hold that the pain center is located in the optic thalamus. 22 THE NATURE OF PAiN that the sensations, of which pain constitutes a part, have their centers in the postcentral gyri. Calkins speaks more definitely. He holds that the centers for pleasure and pain are in the frontal lobes, and that it depends upon the state of nutrition of these cells whether the excitation which comes from the motor areas of the Rolandic fissure produces pleasure or pain. If the cells are in a building-up process, that is, in the stage of anabolism, the result is pleasure; if they are fatigued, the result is pain. If the state of nutrition exactly corresponds to the state of need, the result will be neither pleasant nor painful, but will be one of indiffer- ence. This is a purely speculative hypothesis. What produces the nutritive derangement in the frontal lobes? It is a fact that a patient who is fatigued will feel painful stimuli more acutely than one who is not in such a state of fatigue; but it is also true that fatigue is not necessary to the perception of pain, since even those who are in the best of health may suffer from it. More recently it has been held that the pain perceptive cen- ters lie in the cortex of the postcentral convolutions, but Thomas and Gushing (512) found, during an operation, that the post- central convolutions could be manipulated without pain, the pa- tient at this time being perfectly sensible and alert to all sensory phenomena. The operation consisted of incision of the cerebral cortex and removal of a tumor, all without pain. During the operation, the patient had not the "least sensation of any descrip- tion, though the operative technic required the cutting across and the breaking up of many fibers, as well as the irritation of the gray matter." It is interesting to observe that these areas cred- ited by many with pain production were, when irritated, entirely insensitive. This, however, may net entirely negate their pres- ence because painful stimuli are effective only in the receptor end of the neuron or in the course of the neuron, and it is likely that the center of perception, since it possesses no adequate ap- paratus to receive a pain stimulus, would be unable to perceive it. Centrally projected pains, as from thalamic lesions, are of an- other type. Here the associative memory centers lie and at the s^me time it is the region where the third neuron of the sensory METAPHYSICAL CONSIDERATION OF PAIN 23 nerves arises — and thence passes to the periphery. However, if centers for pain perceptions are admitted, there must be more than one; and at least two must be separated: (a) centers where the sensations are received, and from whence they are projected to the perceptive centers, as the thalamus, for instance {see tha- lamic lesions), and (b) centers which record the painful impres- sions in memory, and in the future, either upon some subjective or peripheral irritation, project them into the perceptive centers, where they give rise, in consciousness, to the sensation called pain. The following diagram exemplifies the meaning of this: ^ ^ SigHT HeftRirvg "Reception Center Tpvste lVlElV\OKy Center Center Fig. 3. — Schematic Illustration, Showing How the Various Sensa- tions ARE Transmitted from the Periphery to the Brain Cortex AND from thence TO THE TwO BrAIN CeNTERS. (I) The ideahon center wliere the different perceptions are correlated into thoughts and ideas (objective sensation), and (2) the mrinory center, where the separate perceptions are stored until again they are called into consciousness. A block at A would occlude all sensory perception of stimuli and the memory storage of the same. A block at b would occlude the transmission of present acting sensory stimuli, so that they would not l)c perceived in consciousness. However, the ctn- ter still receives impulses from the memory center, which it may evolve into con- sciousness where they are perceived as acting in the present (subjective sensation). If the path to the memory center is destroyed, all recollections of prior sensations are lost, and the ideation center, owing to lack of comparison with previous sensa- tions, would be unable to correctly interpret the ones it then receives and may interpret cold as heat, etc, (paresthesia). 24 THE NATURE OF PAIN Memory Centers for Pain. — It is further evident that all of the energy received in the areas for painful impressions is not transferred to the areas of perception of pain, but that some of it is transmitted to the memory areas, from v;hence, in the future, it may be transferred to the areas of mental perception of pain, thus giving rise to pain which is subjective in consciousness, and therefore called subjective pain. In regard to Marshall's second point, it will be shown later that special fibers for pain conduction do exist in the peripheral nerves, cord, and brain (cortex), and that these fibers carry im- pulses from pain receptors existing in special areas, and have the single function of carrying pain impulses and no others. Head has done more than any other observer to establish the fact that the different sensations have separate receptive organs, which re- ceive stimuli peculiar to them and to no others. Marshall's third objection is harder to meet, in the present state of knowledge, for it may be true that certain irritations, exerted to excess on some sense organs, may produce pain. While as yet no specific pain fibers have been discovered to be present in the retina of the eye,^ it is not improbable that such fibers exist; or, should they not exist, that the reaction which excess of stimulus produces in the receptive optic cells in the brain causes fatigue of those cells and that this is transmitted to the fibers of adjacent cells, in which a reaction interpreted as painful is pro- duced. That such a hypothesis is not entirely without basis, may be seen from the assertion that ^'thcre are special pain nerves run- Un this respect, Foster ("Physiology," 5th edn.. Part IV, pp. 281, 282) agrees with Goldseheider (473, " Ueber den Schmerz," p. 8), and in speaking of the pain from stimulation of the retina says: "We have no evi- dence that simple stimulation of the retina, however excessive, will give rise to pain, meaning, by pain, tlie kind of sensation we feel when the skin is cut or burnt. We have no evidence that an auditory, or an olfactory, or a gustatory sensation can, through mere intensity, become converted into a sen- sation of pain. We may assume that the pain which we feel when the finger is cut is a wholly different thing from the pain which is given to the most delicately musical ear by even the most horrible discord." These considera- tions suggest to Foster that cutaneous pain is not simply an exaggeration of tactile and temperature sensations, but a separate sensation developed in a different way. CAUSATIVE FACTORS IN THE PRODUCTION OF PAIN 25 ning parallel to and in the same trunk with the sensory nerves, having a special sense of perception in the brain, and operating only under the influence of intense irritation." Matzinger's (328, p. 138) statement, that "it is unlikely, and contrary to natural laws, that there should be an elaborate mechanism of highly or- ganized tissue which is destined never to come into use in some individuals, or at least only in a very limited way," will have to undergo modification, for it has been proven that there are such tissues in the form of special nerves (pain, etc.) for certain types of sensation (Edinger, Head, Strumpell, etc.). As to the fourth objection, that pain must be an attribute of sensation because each sensation may be both painful and pleas- ant, it is rather difficult to formulate a proper answer. Were it not for its clear separation, jn the skin, from all other sensations, one would be forced almost naturally to the con- clusion that pain really is only a qualifying factor in sensation. Yet it is possible that the pain sense which one finds in the periphery is a highly differentiated touch-sense; that pain is present in other organs from a too great stimulation of their sensory end organs; and in their centers from overactivity. The fifth and sixth arguments are not supported, in view of the general hypothesis that there are specific pain sensations. Causative Factors in the Production of Pain. — The produc- tion of pain depends upon the presence of a projDer stimulus and the integi'ity of the receptive, the conveying, and the interpreting apparatus. The stimuli may be divided into those due to me- chanical changes in pressure, to toxemia, to chemical changes, and to electric or thermic reactions. The stimuli due to mechanical changes are exerted either upon the terminal filaments of the nerve, or on some of the neurons extending from the brain to the periphery. This mechanical irritation may be due to pressure from an inflammatory exudate (see Inflammatory Pain), to pres- sure hy new groivtlis, or to prolonged, strong contraction of a hol- low organ (Mackenzie). Hemorrhage in the body tissues will almost invariably cause either deep pressure pain, or epicritic pain 26 THE NATURE OF PAIN (Head), unless the rupture is an areolar tissue, when, owing to the looseness of the tissues, pain is not j)resent until the local dis- tention becomes excessive, or until pressure is made on adjacent structures. In regions where the tissues are denser and more com- pact, pain is very severe, even from the beginning of the hemor- rhage, as in hemorrhagic pancreatitis. In cavities, also, hemor- rhage is often provocative of the most intense distress. This is particularly true of the peritoneal cavity. The cause of this ex- cessive pain is rather hard to determine, in view of the fact that in this location the resistance to the hemorrhage is almost nega- tive. It may be that blood possesses some substances which are particularly irritating to the peritoneum, and that this irritation is transmitted to the body wall as pain. Even as hemorrhage causes pain, so also in some cases of congestion, it eases the pain, as in swollen turbinates, premenstrual congestion of the uterus, etc. The extent of the surface stimulated is important in the pro- duction of certain kinds of pain. If the area of stimulated sur- face is too small, no pain is felt. It seems that, in certain areas, only an aggregate of stimuli can produce pain (Tigerstedt, 483, p. 467). The stimulus Avhich causes pain may not be of any greater magnitude than that which is daily experienced by the organism; yet, from frequent repetition, a condition is reached in which, before recovery from one stimulus, the cell receives another, and so on. Each stimulus leaves a little of its irritative quality, until the tension from the accumulation of these irritative remnants becomes too great, and release of nervous energy takes place in the cell, the pain threshold is reached and the sensation of pain results. After once having overcome the threshold, secondary discharges take place on a slighter provo- cation. Sudden alterations of blood pressure create pain, as is seen when a tourniquet, which has been on a limb for several hours> is removed. Toxemia is a cause of pain, particularly in severe anemia of CAUSATIVE FACTORS IN THE PRODUCTION OF PAIN 27 a part, such as is found in emboli of the arteries.^ James re- ported a case of complete obstruction in circulation of the aorta, in which, after the ligation, the patient had the most severe pain (D. W. Mitchell, 263, p. 52). The causes of this, ''Brown- Sequard thought to be an accumulation of CO2 in the tissues. Vulpian regarded it as being due to the lack of oxygen, while W. Mitchell thought that it might be due to sudden annihilation of nutrition, osmosis and conditions of pressure." Pain may also be due to the accumulation of toxic products I complete v , .imilaTior, \T omplele /^ strCclion ' Melabolisrt Abnormal ""^ Comolele / X, --Non-Complete Destruction ' \ Elimination . , \ increased Jensoru , Asiimilalion V .. A .. .. _. . / i„.,,i:.i.... ^^ Metaboi;5m_/ Compfete" XtoxIc Non compUlA Act on the ^Produce / l^'^'tabiilt^ Abnormal ~\ Non complete /Producti Elimination /N"^^^«liy^„ \ Increased Motor ^ \ Destrucfion ^ / iS^mejor Jn'^other Irritability, ^ / Non-complete V Metabolism / Assimilation \ Toxic P Abnormal ~A. Non complete / ^ Destruction -^ formed or on ottier ■ Non-complete V / nerve cells throuqli Assimilation \TollltProdut^^ A the means of the culalion This maij account for certain of tlie pains whicti we find in tiijsterical conditions Fig. 4. — Diagram showing How Changes in the Cell Metabolism May Produce Changes in the Irritability of the Cell and a Depar- ture IN ITS Reaction to External Stimuli, Either Making it More or Less Sensitive to Peripheral Irritation. in a part, as exemplified in the fatigue pains of muscle, wherein the products are the result of metabolic waste; or else the toxin may be derived from exogenous sources, as from the alimentary tract or from an outside toxic agent, alcohol, etc. It may also be the result of toxins from bacterial organisms. The toxin acts upon the receptor cells, or on the sensory nerve substance to which the irritant may be transferred. As to cliemical causative factors, there may be many, princi- pally in burns, severe ischemias, etc. From the nature of the condition, toxemias might also be classed among chemical agents, inasmuch as in toxemia the poison or irritant is of a chemical nature. M^ery severe pain is felt in infarct kidney (Halperin). Pain is also extremely severe in arteriosclerotic thrombosis (Buerger and Geis). Intense pain is also felt in arteriosclerotic thrombosis of the lower limb, a disease which is especially prevalent among the Eussian Jews. The pain is so agon- izing and constant that the poor sufferers will consent even to the extreme remedial measure of amputation rather than bear longer suffering. 28 THE NATURE OF PAIN Decreased allcalinity of the hlood, as suggested by Sir Lauder Brunton,^ may also produce pain. This may explain the cause of the generalized aching pain that is present in infectious diseases. Pliotocliemical changes in the rods and cones of the retina of the eye are produced by light. When the light is too severe, these changes are excessive, and the stimulation of the optic nerve is stopped or modified, so that vision is obscured and j)ain results (Matzinger, 328, p. 139). In some cases trophic changes in the skin may also produce pain. This may be peripheral, due to irritation of the sensory receptors (protopathic), or central, due to changes in the sensory cell distribution in the cord. Electrical reactions cause pain, as may be proven by the use of the painful, interrupted electrical current (Head, 519). This is one way of testing sensitiveness to pain (see Intensity of Pain), Heat and cold are frequent causes of pain production, the reason evidently being some chemical change in the region of the sensory receptors. This, however, will be more fully considered in the section devoted to the relation of pain to temperature. Freezing of a nerve will cause such an irritability of the nerve, below the point frozen, that the least pressure upon it causes pain in its distributive area (Weir Mitchell, 2G3, p. 18). Apparatus for Receiving and Conducting Pain. — The various forms of receptive apparatus are not, as yet, well defined. Special terminal filaments are present for certain forms of stimuli, but their distribution is little known. From the universal presence of pain, it Avould seem that the sense-receptive organs for pain are ^ Sir Lauder Brunton (516) states that he became infected with the staphylococcus pyogenes aureus, and that numerous boils developed which had a stinging, burning pain, generally worse about three or four hours after eating — a time when digestion would be most active, the absorption of the acid-formed contents of the stomach greatest, and the alkalinity of the blood, from their absorption, least. From this he concluded that the pain was due to a decreased alkalinity; and, proceeding on this assumption, he took fairly large doses of alkalies, with a resulting diminution of pain. He then tried the effect of the biearbonates, applied directly to the boils, with a consequent diminution of pain. In toothache, also, the application of bicarbonate of soda to the cavity of the tooth has a beneficial effect. APPARATUS FOR RECEIVING AND CONDUCTING PAIN 29 widely dijffused. These receptors are capable of receiving pain stimuli of various kinds, toucli, deep pressure, heat, cold. Their action may be abrogated by excessive cold, cocain, vibration, elec- tricity, etc. These terminal filaments in the skin have been called noci-ceptors (nocuous ceptors) by Sherrington (522). He classifies as receptors all organs in the skin and mucous mem- branes which have developed by a long series of evolutionary changes, and which have the ability to distinguish stimuli arising from different sources, such as temperature, pressure, or touch. Those portions of the body most subject to injury should, there- fore, have a more numerous supply of noci-ceptors than those portions which are not so exposed. If this is true, we should find the fingers, which are exposed to injury, better supplied with these ceptors than the brain, which, because of its inclosure in the skull, is prevented from injury. Such is the case; for in the brain, the cortex is found to be relatively insensitive to many stimuli which ordinarily cause pain sensations (Crile and Sher- rington). The pain-conducting a-pyaratus consists of the nerve fibers leading from the periphery to the sense-perceptive centers. Any irritation to the axis cylinders of the sensory nerves in this path- way will be transmitted to the periphery and be felt as pain. Irri- tation may be in the form of inflammation of the nerve (neuritis), of the ganglion (herpes), of the post roots (tabes) within the cord (transverse myelitis), or in the thalamus. Various agents may act upon the axis cylinder processes (nerves),, such as tetanus toxins, arsenic, alcohol, etc. The headaches of toxic origin, fa- miliar to all, are usually due to stimuli, acting upon the dural distribution of the trigeminus. Pressure on the conducting fibers causes, as a rule, a severe pain reaction. Yet, it is possible for pressure, when equal and constant, to be very severe without producing any pain reaction. It seems most potent for pain production when it varies in in- tensity; the more variable the pressure the greater the severity of the pain. Such a pressure we see exerted by new growths, as tumors or cysts, or by inflammatory changes, as in meningitis. 30 THE NATURE OF PAIN The sense-perceptive centers in the hrain may, from oft- repeated stimulation, become hypersensitive. It is often the case that, after the original cause has ceased, the hypersensibility re- mains, so that stimuli of ordinary intensity, when they reach these centers, may be interpreted as painful. Whether this is due to a hyperactivity of cortical cells, or to a lowering of the thresh- old values in the receptors, has not as yet been definitely estab- lished. The so-called occupation neurosis, in which pain is pres- ent when the patient attempts to perform some accustomed task of manual dexterity, may serve as an example of this. Here the pain, as well as the spasm which accompanies it, may be said to represent a rebellion on the part of the overused cortical centers. This rebellion does not seem to be so much upon the part of iso- lated centers as due to fatigue in the association of certain stimuli, which are carried to the affected area from other centers, and which have the power of producing certain coordinate actions. The same centers may be called into play to make other movements of the same muscles without producing pain. Thus, a person who is un- able to write without pain may be able to sew without any trouble (Walton, 517, p. 261). It should not be overlooked, however, that such acts are only apparently similar. In reality they are quite diverse. We have spoken of the lowering of the threshold to pain. In neurasthenia it would appear that, for reasons as yet unknown, such a reduction takes place so that the body is more capable of reacting to stimuli (including pain) than when it is in a normal state. Shock, anxiety, apprehension, have an effect in lowering the pain thresholds for various stimuli. Just what the molecular factors may be underlying this change no one knows. Clouston's phrase, "disturbance of molecular equilibrium," is as good as any other, whatever it may mean. Pain and Mental ^iaXe^.—E motioiis, like anger and fear, sometimes give rise to severe nervous attacks which are typified by headaches ; and in this relation it is an odd coincidence that only the unpleasant emotions give rise to disagreeable sensations. RELATION OF PAIN TO OTHER SENSATIONS 31 for surely no one has ever heard of a pain (headache) being pro- duced bj joy or happiness. Hypnosis may also have the power of bringing into the patient's consciousness an intense perception of pain. Some blindfolded persons will experience what they think to be pain, if, prior to running a cold instrument across the skin, they are told they were going to be cut. In the dream state, also, vivid sensations of pain may occur. One of my patients, a non- pregnant woman, has been aroused frequently by apparent labor pains, of which she had not the slightest perception upon awak- ing. The modus operandi of this perception was described when, in speaking of consciousness, the method of transference of im- pulses from the receptive center to the perceptive center was il- lustrated. There has been some controversy as to whether it is possible to imagine pain. The answer seems to be simple; for how else would it be possible for the hysteric to draw from mem- ory's store, and present to vivid view, sensations which are as realistic as though they were actually taking place ? And is not imagination, of which the hysteric unconsciously makes abundant use, but the power of transferring sensation from the warehouse of past experiences to the mart of present change ? Relation of Pain to Other Sensations. ^ — AVe now approach the most difficult part of our subject, namely the consideration of pain in its relationship to other sensations. Pain is so inextricably mixed up with other sensations that at first it would seem almost impossible to unravel the skein. Yet, the riddle is not so difficult to solve if we only recognize one factor, and always consider it in our study of this subject. This factor is evolution. If we reflect that our nervous system is the development of nameless thousands of ages ; that from a most simple form it has developed to a most complex system ; and that during this development its structures and functions have constantly been modified by and adjusted to the changes in environment, it is easy to imderstand how, by these constant changes and innumerable modifications, it has reached its present complex and intricate form. The nervous system at first (in our progenitors) was very crude, being little more than that which was essential for the carrying on of the two great functions 32 THE NATURE OF PAIN of the organism, nanielv, growth and reproduction. As the or- ganism developed, it became more and more susceptible to external influences, and more and more cognizant of its environment and the physical state of its being. At the same time, the means of defense vrere improving, so that the organism was better able to protect itself from injury and the external dangers of which it was just becoming aware. Probably it was at this time that the various external senses were called into activity. An analogue of this is seen in the human embr3'o, in which it is held (Mackenzie, 69) that the cerebrospinal system is a later development than the sympathetic, the sympathetic being concerned with the essential' processes of life, while the cerebrospinal is concerned only in communicating to consciousness the relationship to surrounding objects, the relationship of different portions of the body to each other, and the intensity and variety of stimuli which are received from different sources. In other words, cognition is dependent upon this exterior system. So, it is held that the development of the cerebrospinal system is for the purpose of defense against injury, and that the principal means of communicating the exist- ence of such an injury to consciousness is by a series of disagree- able stimulations which, by long association, have been grouped into various groups and are called pain. Yet, pain to touch is not the only sensation which, because of ancestral necessities, has been developed from the primal sensi- bilities of a simple organization. In the same class are tempera- ture, light touch, and deep sensibility. Light touch, as it was prob- ably the last to develop, is the most vulnerable ; so that, in lesions of the peripheral nerves it generally is found to be one of the first sensations to disappear. Touch and pain have been regarded by some as variations of the same sensation. From the following facts, however, these two sensations cannot be considered the same : (1) The distribution areas of touch and pain are not identi- cal. Were they but modifications of the same sensation, their localizations would be exactly similar, and both would be present at the same time. The exact opposite of this was present in a case reported by Head and Thompson (206, p. 553), where, in a RELATION OF PAIN TO OTHER SENSATIONS 33 lesion of the spinal cord, an area on the limb was insensitive to pain, while it was sensitive to light touch and pressure.^ (2) Another illustration in point is given bj Biernacki (Witmer, 527), who states that pain and temperature sense can be made to disappear bv pressure on the ulnar nerve, while the other sensations, as touch, localization, and muscular sense, remain. This would argue either for special nerves of pain, or else for the reduction in the conductivity of individual fibers ; so that if pain, in the case of touch, is due to increased molecular vibration, the fibers would not be able to carry the stimulus. Yet, such a suppo- sition is hardly tenable, from the fact that disease of the cord, and of a certain area of it, will produce a loss of pain conduction, but not of light touch ; and, vice versa, lesions in the cord may produce a disturbance of light touch perception and not of pain perception. In a case reported by Gowers a unilateral hemorrhage into the lateral columns and gray substance of the upper cervical cord pro- duced analgesia and thermoanesthesia. In this case there was a complete loss of pain on the opposite side of the body, without disturbance of light touch. From the above it would seem that the pain and temperature senses are more closely related than are pain and touch. In other conditions the senses of touch and pain appear intimately related, as is shown, when by gradually increasing the pres- sure on a part, the sensation produced changes from that of touch to actual pain, Witmer found that a maximal pressure of 1.0 gm. or 2.0 gm. will give the sensation of touch gTeater in- tensity. The same stimulus, ranging from 20,0 gm. to 15,0 kgm., produces a sensation of pressure, while at times a pressure of 5.0 kgm. to 15.0 kg-m, will give rise both to pressure and pain sensa- tions. A maximal stimulus above 15.0 kgm. gives rise to pain only. This Head has shown is due to specific receptors of deep ' This is frequently found in dissociation paralysis, which is conspicuously present in syringomyelia. It is also found, less marked, but much more fre- quently than is usually assumed, in neurotic processes, in tabes and in paralysis, as well as in alcoholic and hysterical persons. (Osier's "Modern Clinical Medicine," "Diseases of the Nervous System," p. 194). 34 THE NATURE OF PAIN sensibility whose threshold values are approximately stated hy Witmer. In tabetics, also, it is very common for some dissociation be- tween pain and touch to be present, as frequently the patient will feel the touch of a pin point much sooner (one or two seconds) than the pain caused by its penetration into the skin. The term delayed pain sensation is given to this state. A dissociation between pain and touch sensations may also be present under the action of cocain, chloroform, in tabes dorsalis, hysteria, hypnotism, etc. During operations, when anesthesia is not complete, it is rather common for the patient to complain that he feels the touch of the knife, but no pain. Should pain be present and touch be absent, the patient will be unable to localize the pain ; and, inversely, it is found that the more acute the tactile sense of a part is, the more accurate is the localization of pain in that part (Hall, p. 4-i2). Of the sensations, pain and temperature seem to be the one'' most closely connected — at least, this holds true in regard to the cord, for lesions here more frequently produce a dissociation between the other sensations than between pain and proto- pathic temperature. That they represent degrees of the same sensation cannot be held, because, in the first place, the tempera- ture sensation may remain when all the others are absent (Head and Rivers, Ref. 86). In such cases, the patient does not respond to painful tactile stimuli, but to painful heat or cold stimuli. This w^ould apparently show a difference cither in the origin of or in the conduction of these two sets of stimuli. Yet, heat pain can be produced by a temperature of 3G.3° C. to 52.6° C, and cold pain by a temperature of + 2.8° C. to — 11.4° C. (Dana, 529), when the tactile sensibility and the cutaneous pain sensa- tion are lost.-^ This differentiation of sensation can occur only ^According to Weber, "the pain produced by heat and cold is very dif- ferent from the sensation of heat or that of cold. If the pain is not extreme we feel at the same time the heat or cold which causes it, and can then dis- tinguish pain due to heat from pain due to cold. But if it is extreme, the sensation is the same, whether caused by heat or cold" (Strong, 473), The pain sensation is located deeper in the skin than the terminal filaments which transmit cold, because, "on contact of a cylinder, slightly heated, with the CONVEYING CHANNELS FOR SENSATIONS 35 wlien the superficial nerve is diseased, and deep sensibility I'cmains ; for the part of the nerve conveying deep sensibility runs with the muscular branch of the superficial nerves, and so may •.•3cape injury in case of destruction of the cutaneous sensory 1 :-anch. The sensibility to temperature changes is itot equally distributed, it being greater in some places than in others. That heat and cold sensations have separate receptors can be deduced from the fact that one may be present in the absence of the other. Ixivers and Head (86) report a case where the sensation to cold was independent of any other sensation. It has been known for some time that heat and cold sensations have special areas on the skin where they alone, of all the sensations, are present (Gold- scheider). Thus it will be seen that, in the course of development, certain nerve elements, becoming more highly specialized, have arrogated to themselves special functions, one of which is tlie l^ower of being stimulated by hot and cold objects. These recep- tors, devised for temperature, are insensitive to electrical and mechanical stimuli (Kivers and Head, 86, p. 385). It has also been found that stimulation of temperature points or spots by a needle will not produce pain (Tigerstedt, 483). Excessive stimu- lation by heat or cold may produce only the sensation of pain. While it is probable that the correlated sensations (heat or cold) are present, they are not felt because of the overwhelming of the consciousness by the intensity of the pain sensation. Hyperalgesia to temperature may be present without hyperalgesia to touch (Stern, "Archiv fiir Psychiatric," 1886); and it has also been noted that hyperalgesia for heat may not be as marked as it is for cold. Conveying Channels for Sensations. — It is apparent that while skin, on which a blister had been applied and the epidermis removed, a painful stimulus without a trace of heat sensation was felt" (Mettler, 505). A case in point is reported by Barker, in which, because of pressure of a cervical rib, certain conditions occurred in the area of distribution of the nervi cutanei brachii et antebrachii mediales of the left arm. He found that in some areas careful testing showed that pricks with a fine needle gave only pain, without calling forth previous touch or pressure symptoms. Ice at first gave no sensation, then pain. Heat gave rise only to heat pain, without pre- vious heat sen.sation. A stimulus of 47° C. (116.6° F.) and upward quickly caused pain, but no sensation of warmth. Barker claims that the pain was due to stimulation of pain organs. (Witmer, 527.) 36 THE NATURE OF PAIN the sensations of touch, temperature, pain, and deep pressure pain are closely related, they are separate entities, and that each is carried by its own specially differentiated and functionating nerves.^ We have already referred to these, but will discuss them again more at length. * There has always been considerable discussion among physiologists as to the presence of pain nerves and pain tracts. Advocating the existence of pain nerves are Strong (533), Krehl (534), Von Frey, Piersol (537), Nichols, Bianehi ("Psychiatry," p. 358), Funke, Head, Goldscheider, etc. Opposing the idea are Hall, Marshall, Mantegazza (536), Dana, Brown-Sequard, Mun- sterberg, James, Ziehen and Weir Mitchell (263, p. 40), who says: ' ' Do you suppose that there always exist in these organs pain nerves, and that only once, perhaps, in a lifetime, these filaments are to be roused into activ- ity?" He further says: -"As regards the skin, how shall we deal with the like dilEculty if we choose to believe that everywhere are peculiar nerve fibers de- voted only to transmitting painful sensations?" So he concludes that pain is not a "distinct sense, with afferent tracks peculiar to itself," but that it is "the central expression of a certain grade of irritation in any centripetal nerve." He goes on to say (p. 48) that if a nerve is cut, and "the nerve ends, having been allowed to cicatrize without union, should be constantly irritated by imprisonment in the hard tissue of stumps or scars, or by a neuritis, a great variety of peculiar sensations are felt, such as the feeling of being tickled, of motion in the lost or disconnected part, heat, cold, etc. These facts seem to prove that some peculiar peripheral arrangement for the production of touch, sense of movement, and the like, is without firm physiological foundation." The last example is hardly to the point; yet, at the time of writing, it was well taken. To-day it is recognized that, upon irritation of a nerve, the pain is referred to the peripheral distribution of that nerve because the brain cells have learned to interpret such a stimulus as coming from a particular area, and will so continue to interpret it when the direct communication with that area is interrupted ; so that irritation applied in the course of a nerve is always felt as though it were coming from the peripheral distribution. One of the strongest advocates of special nerves of pain is von Frey, who gives the following reasons for his belief: (1) "By observing certain precautions, mechanical stimulation of the skin with a bristle produces a pure sensation of pain, without any prelimi- nary or accompanying sensation of pressure. (2) "If a bristle be placed over a pressure point, the sensation appears immediately, but at once fades away again, and usually becomes unnoticeable after a short time. Over the pain point, the effect appears later, gradually increases in strength, and decreases again after reaching a maximum. (3) "When the head of a pin is pressed for a moment into the skin there follows very often, after the sensation of pressure, and separated from it by an appreciable interval, the sensation of pain." Von Frey claims that on the back of the hand, over the metacarpus of the ring finger, sixteen pain points can be demonstrated as against two pressure points. The nerve endings which convey pain are, he believes, prob- ably the free intraepithelia nerve endings (Tigerstedt 's "Physiology," p. 467). CONVEYING CHANNELS FOR SENSATIONS 37 The channels for conveying sensibility are divided into super- ficial and deep sets (Head and Thompson, 206). The superficial set is again divided into two others, the protopathic ^ and the epi- critic. These differ from each other principally in their power of conveying degrees of stimuli, the epicritic being finer, and capable of conveying slighter degrees of stimuli. It is probably a later evolutionary development than the other. Pitt (530) states that it is developed after birth. According to Head, Rivers, and Sherren (85), Head and Sherren (86), and Head and Thompson (206), the systems for conveying sensations, with the stimuli "which they carry, are as follows: I II III System of System of System of Deep Sensibility Peotopatiiic Epicritic Sensibility Sensibility Deep pressure, which, Painful cutaneous Light touch. when excessive, is stimulations. Character of touch. interpreted as pain. Extremes of heat and ]^umber of points of Localization of pres- cold (below 20° C. pressure. sure. and above 45° C). Distance points are Alterations in the Visceral sensation. apart. positions of the Painful sensation Chara.cter of surface joints, muscles and from a prick. touched. tendons. Electrical stimula- Slight differences in tion. temperature. Wiindt (Strong, 437) assumes that in the peripheral nerves the paths of pain impulses are the same as those of touch, heat and cold impulses. When tactile or temperature impulses reach the cord they find two paths open: a primary path, leading through the white matter, and a secondary path, or paths, leading through the gray matter. Impulses of moderate intensity take the primary path, and this path can accommodate only moderate impulses. When excessive impulses come, they overflow into the secondary paths and pass upward through the gray matter. Funke and Goldscheider ("uber den Schmerz, " p. 19) agree with the assumption that each nerve carries two sets of impulses, one giving rise to the ordinary correlated sensations, and the other producing pain. The very full discussions of Head and Holmes {Lancet, January, 1912) give the latest summary of these studies. * 1 Goldscheider (62b) holds that the protopathic system does not exist, and that the so-called protopathic sensibility is but an expression of the lessened functional power of the nerve apparatus. 38 THE NATURE OF PAIN According to Head and Rivers, the fibers conveying deep sensi- bility accomj^any the muscular branches of the nerves, and are distributed, in many cases, to the deeper tissues and the tendons of the muscles. This is in accordance with the anatomical find- ings of Sherrington (205, pp. 255-256), v^^ho says that ''^macro- scopic nerve trunks are not purely motor, but are sensorimotor or purely sensory. Such nerves as the phrenic, hypoglossal, re- current laryngeal, and posterior interosseous contain an abundance of fibers from sensory ganglia." In muscles, the special end organ for root ganglia fibers is called a muscle spindle (Kuhne). The nerve fibers conveying these different sensibilities do not all converge into the same nerve or roots, although the fibers con- veying the same sensation from the same part of the skin do so, as a rule. For instance, the protopathic fibers from the same area converge and are all found in the sam.e posterior roots. As a con- sequence, in root injury (diagnostic point for root injury) they do not overlap, while the epicritic fibers do, being conveyed, prob- ably, by several roots and first being merged in the cord. *% Deep, epicritic and pro- topathic sensation. Epicritic and protopathic sensi- bility. Fig. 5. — ^Areas of Epicritic and Protopathic Sensibility. In the accompanying drawing is seen the effect of injury of the sacral plexus below the point where it is joined by the second sacral nerve. The third sacral nerve had been destroyed, and the nerves were bound up in a dense mass of fibrous tissue (Head and Thompson, p. 552). This illustrates the effect of injury to the peripheral nervous system before the fibers have been joined into separate conduction paths in the cord. These conduction paths for pain, muscle sensibility, touch, and pressure are separate and distinct. This is illustrated in Tie;. G, taken from Head and CONVEYING CHANNELS FOR SENSATIONS 39 Thompson, which shows the effect of injury to the pain-conduc- tion paths in the oord. The painful impulses from the skin enter the cord by way of the protopathic system. They probably become combined at once, Fig. 6. — Effect of Injury to THE Pain-conduction Paths IN THE Cord. In the shaded area the parts were insensitive to all painful stimuli, while at the same time they were sensitive to light touch and pressure. (From Head and Thompson, 206.) Fig. 7. — Unilateral Complete Lesion on One Side of the Cord Produc- ing A Narrow Band of Anesthesia on the Same Side at the Level of THE Lesion and a Broader Zone op Anesthesia on the Opposite Side Slightly Below the Level of the Lesion. (FromEdinger, Nervosen Zen- tralorgane,6 Auflage, p. 377, Fig. 263.) and enter the intramedullary system at the level of their entrance. The fibers from the deep system do not enter by the same posterior roots as those conveying painful cutaneous stimuli. Thus, more than one segment of the cord is required before all the painful impulses from any one part of the body can be gathered together and recombined. After being recombined, they pass across the commissure to the opposite side, where they ascend in the tractus spinothalamicus et tectalis. The decussation takes place in the course of four or five spinal segments (Piltz, 40Y). According to Camp, it may take six 1o eight. This peculiarity of structure accounts for the irregular distribution of pain sensation in uni- 40 THE NATURE OF PAIN lateral lesions of the spinal cord. If the lesion is not extensive enough to involve all the fibers coming from a part, there may be a very indefinite loss of sensation ; but if the lesion is extensive, there is a definite loss of sensation in an area above and^n in- definite loss below the lesion, while on the opposite side of the body the sensations are entirely abolished below the level of the lesion. Fig. 7, from Edinger, shows nicely the sensory results following a unilateral lesion of the cord. In the accompanying drawing an effort is made to illustrate the course of the sensory fibers. The fibers for all the sensations enter the posterior root separately, and pass from thence to the cord. In the ganglion, these fibers come into relationship with the ganglion cells, with which they are connected, some of the Anterior or motor root. Posterior ganglion cell. Fig. 8. — Cross Section of the Spinal Cord. This represents on the left side the views of Dogiel and Snuf on the course of the sensory fibers in the posterior root; while on the right side is illus- trated the view of Donaldson in regard to the division of the sensory neuron. ganglion cells being connected with more than one afferent fiber (Head and Thompson, 306), It is in these ganglion cells that the afferent fibers from the viscera have their origin. According to Warrington and Griffith (414), not more than two per cent, of all the cells in the spinal ganglion are connected with the viscera. This accords with Langley's statement that the total number of CONVEYING CHANNELS FOR SENSATIONS 41 sensory fibers distributed to the viscera about equals the number of sensory fibers present in a posterior root. Dogiel and Onuf found the axis-cylinder processes of certain cells of sympathetic ganglia terminating around cells of a spinal type. Ludlum suggests that the visceral nerves may give off col- laterals in the spinal ganglia, and that these, coming in contact with a spinal neuron, may transmit the stimulus to it. This stimulus would then be perceived as coming from the peripheral distribution of the neuron, in the distribution area of which the pain would be perceived. On the other hand, Donaldson be- lieves that the peripheral branch of a spinal ganglion nerve splits, and that one of the branches is carried to the somatic distribution, while the other, through the ramus communicans, is distributed to the viscera. In this case, any irritation of the viscera would so alter the ganglion cell that, if the irritation were strong, enough, it might give rise to pain; or if it were not severe enough to cause pain, it might produce such an alteration in the cell that a state of hypersensibility would ensue, and the slight irritation in its peripheral distribution would then be per- ceived as pain. After the entrance of the sensory fibers into the cord, they are joined into well-defined bundles, all the fibers of a single bundle having the same function. The fibers entering the poste- rior cornua may be defined as follows (May, 397, p. 759) : (1) Fibers which enter the post-columns, and then divide into ascending and descending branches from each of these collaterals, pass at various levels of the cord and end in gray matter (Schultz Col., 430). (2) Fibers which pass forward and end around the cells of the anterior horn (Edinger, 421). (3) Fibers passing to Clark's column (Edinger, 421). (4) Fibers which go to the cells of the posterior horn, lat- eral column, then end in the gray matter of the poste- rior column of the same side, but do not cross (Rus- sell, 428, Mott, 429). These fibers terminate in the 42 THE NATURE OF PAIN medulla (post-column nuclei), but during "their course collaterals and some main fibers terminate in gray matter" (397). (5) Fibers which pass to the post-column. Collaterals are given off and pass to cells of the gray matter, and end generally around cells of posterior horns. The fibers themselves terminate around cells in the posterior col- umns, and some extend as far as the columns of GoU and Burdach in the medulla (397, p. 760). Fibers arising in cells of gray matter are: (1) Fibers running in antero-lateral columns, same side. (2) Fibers running in post-columns, same side. (3) Fibers branching, one part running in the antero-lateral column of same side, and the other branch passing over in anterior commissure to run in antero-lateral column of opposite side. The above are primary paths. Secondary paths are also pres- ent in the cord. They are represented by: (1) Fibers which arise in Clark's column of the same side, and run to the dorso-spino cerebellar tract (path of Flick and Foville) lying exterior to the crossed pyram- idal tract, and anterior to the post-root fibers. "In the medulla they are joined by a bundle of fibers from the crossed inferior olive, and pass directly into the restifonn body, and thence to the cerebellum" (397, p. 763). (2) The ventro-cerebellar tract forming part of Gower's tract, in which the fibers arise : (a) In the cells of the posterior horn and intermediate gray substance of the opposite side, (b) In the cells of the posterior col- umn of the same side. Both pass up in the cord and brain, and terminate in the cerebellum. S — Motor reflex from pain to a higher level on the opposite side. R — Fibers giving rise to reflected pain in muscles. Q — Transference pain to a higher level. P — Branch. O — Tracheus spl- nothalamus tac- talis. N — Ventral spino- cerebellar tract. M — Dorsal spino- cerebellar tract. L — Clark's column. K — Muscle and joint sensation J — Touch and pres- sure. A — Restlform body. B — Transference pain felt on both sides. C — Transference pain felt on op- posite side. D — Pain felt on same side. E — Motor reflex same side as pain. F — Touch and pressure. G — Transference pain. I — Temperat ure. Fig. 9. — Diagrasi Showing Intraspinal Course of Sensory Fibers. 43 OS tij.ag c " X o 15 •OaiS* o!3^gSg"g ». tea ns =3 a>H "a S„ Tjo — g o g o o <« 2 fe*^ = c « o "^ H « O O ;»: "S3 a a _. 1 a> cu a> lh S — Q) CO C^ 01 I Soas u I. •tjao s. ■a iia "3 1 •« 1 1 'r & H 09 « BB"OB"' •»MJ a ta "O o A 2 o a cm 09 +3 n^ s a** SO o S o g^ &■« 'V I g o e i^ ♦3 t o 1* i i ^ D a « « oJ o>. ♦^ a a s (U m A a O ■0 a ^ a «« 1 P OS 1 >^ia S lii U5 "If h d BSS >■ 03 5 a •^ is -4 43 o o a > o a a a MS o a £ i!a» a STS > 1 o C3 a u a2 t^ a O 0) ol a a 3 S a b a 2oi ol„ Is §1 a 3 A— Pal ing, b Ing an rent. o o 01 w A 1 «o !i ol 1 w Cj X3 s 1 I u s IS o o em o 0, >. A O o « a ■3 1 S 3 3 O, o a o •a a s a . o s s 3 . a HI 11 . a ill 5 -5 •- 3 o § 3 . c3 H 1 -B 511! « ^ . ? w s s £ 1 w 5 o ■3 1^ s = 1 a • os .Q 1 aj 3 o "5 3 a . oa 5S ■d a a ■a « is J3 3 1 3 3b is 3'"' V3 1 » 1 w 1 W O 1 W C 1 A 1 1 s f b 1 5 - . CVTAAfSOOS i . iNTCRhAL CUTANCOVS L P J>LE>(VS PATClLA .-•- - 4 eRANCftES rnon £xr pop sp. rtUJCULO CUTANEOUS i _ INTERCUTAliEOU^ BR ifi5)ap ,^P05T BiiANCnEP S-I-IALL SC/AT/C SP ..t^i^UL/^AfZ 0P VMii SOATtC i^ exf .^APn£f*0t/3:>P POST Tibial Cutaneous Distribution of Peripheral Nerves. (After Fowler.) The sensory nerves of a muscle probably belong to the same cord segment as the motor nerves of the same muscle. In the peripheral distribution of the sensory fibers, four dif- ferent areas must be defined, namely : ^ Tigerstedt gives the flexor surface of the thigh and foreleg and the an- terior side of the arm as the only exceptions to this rule. DISTRIBUTION OF THE SENSATION OF PAIN 51 (1) The areas of distribution of the peripheral nerves. (2) The areas of distribution of the different plexuses. (3) The areas of distribution of the posterior roots and their corresponding segments. (4) The areas of distribution of certain areas related to visceral disease, as defined by Head and his associates. Fig. 13. Figs. 13 and 14. — Cutaneous Nerve Supply, Showing the Distribution Areas of the Different Plexuses. (Toldt, Part VI, p. 811.) The area of distribution of the sensory fibers in the peripheral nerves, because of their overlapping, is rather difficult to outline. This accounts for the great variation in boundaries, as given by the leading workers in this field. Figures 13-17 are a composite of the description and the drawings (see figures) of the principal authors consulted. Any lesion causing irritation in the course of a peripheral sen- sory (pain) nerve would cause the pain to be refen-ed to the dis- tribution area of this nerve. Care must be taken, however, not to allow the overlapping of the distribution areas to render the de- ductions misleading. The distribution areas of the sensory fibers in the posterior roots and in the corresponding segments of tlie cord, as given by ^ ^ X S S s J O PLI Q n « TTn)ll L1-2-- CG-^ S3-] L3-1 ■W 0' ■-IJ-2 jCfi 52- --L4 / S.» SI— -M^ i S2 Fig. 18. — Cord Zones According to Kocher. These represent the cutaneous areas involved in lesions of different segments of the cord. The circles represent the areas of maximum tenderness according to Head. Head's zones and these do not entirely coincide because Head worked out his zones from a study of visceral lesions and somewhat arbitrarily defined them, while Kocher used the peripheral disturbances occurring in lesions of the cord as the means of defining his segments. These really represent the distribution areas of the posterior roots. 55 Supraclavicular, 3, 4, C. Circumflex, 5, 6, 7, 8, C. Intercoatohumeral. Nerve of Wrlsberg, 1, D. External cutaneous. Internal cutaneous, 8, C, 1, D. Musculocutaneous, 5, 6, 7, C Iliohypogastric, 1, I.. Ilioinguinal, 1, L. Genitocrural, 1, 2, L. Median. 6, 7, 8, O, 1, D. External cutaneous, 2, 3, L. Middle cutaneous, 2, 3, 4, L. Internal cutaneous, 2, 3, 4, L. Plexus patellae. Internal saphenous, 2, 3, 4, L. Branches from external pop- liteal, 4, S.L.I. 2, 3.4. S. Musculocutaneous, 4, 5. L, 1, 2. 3. 4, S. External saphenous, 4, 5. L, 1. 2, 3, 4. S. Anterior tibial, 4, 5, L, 1, 2, 3, 4, S. M...\ ^^^ ' ^B\ •• i^V\ 3^\/ \ M)" Fig. 19. — Cutaneous Areas Related to Spinal Cord Segments (Church and Peterson, p. 56, after Starr) and Cutaneous Distribution of Nerves (Church and Peterson, p. 52, after Fowler). 56 ,.-^-tf. to rfefiu tattralh ——to rectut anile, mlnop ..AnatlomotU ullh hypoglouat ■ Anaslomottt ulth pnrunogailrfc .___^. lo reelua anUc.maJor. .__//'. lo maatoid rej/ton. Orrat auricular n. • Tranavtrtc cervical n. Hai}.W. to Traptzlu*, Ang. Scop. andBhomboU. Supra ctavleutar n, Supra^cromiat n. PhreitU n. N. to levator ang. teap- M to rhomboid Suth-vapular lu .^Subclavicular n. .—./r. teputtralUmaia SfuKulooifaiicoiiJ n. Median n. Kadlatn. .l/fnorn. _/fi(emol c%tian€OUS n. I____^__ . AnaU Mtmal eiiCaiuOM a. , nto^ypooatlrle n. ..ntoJngutnaln. :..Xxter7ial eataneow ". ,_Oen((»cniral IL Antcrtar cmralti^ ,___06turafor r. K. toXevater an! ^ • IS • • « • 12 \ " J { '• ; CHART B Fig. 42. — Marking Code of Dr. Harris. numerals are used to indicate areas, centers, and radiations of pain, the numeral being placed at the point of the most intense pain and also on the line inclosing the pain area or indicating the pain radiation. Thus it may be seen that the primary characters can only be used in every fourth marking, but that the number of markings may be multiplied indefinitely. Figure 43 illustrates this. "Figure I, in Fig. 43, shows the first marking upon a patient, who we assume complained of a painful area, a center pain within the area, and a radiation of pain. It will be seen that the area of pain, its more painful center, and the radiation of pain from the area of pain are constructed from the first primary character. "Figure II, in Fig. 43, shows the second marking upon the patient who complained of a painful area with a more painful point within, which we designated as a center pain. The boun- METHOD or RECORDING PAIN 137 y^ ^\ ^ -~ *- ^ \ / ^ \ '^ J ( o ^ . > > > \ / V y / \ ^/ V ^ rig. I ^ _ ^ Tig. n .--• -. / \ _ • • * • / 1 \ • • \ fig. in ^•-— •—•—•— '-^ Fig. IV ^ s- ^ ^ ■ 6-^ \ \ / \ y / N 1 s y^""^ V y F.9. V ^ • -^Rg.Vf .'-—.-.._.— -^"'N • ••>^. •••• .■V. • ••^* •••• •>• Fig.Vn V.^«^ Fig. Vra ^ — 10 ^ __ /^ ^^ ^ N /^ "v ''/ > » 'i ii2 U^^ ^ ,// fig. IX \ V, // Fig. X \ >- - ^ '^^ ' "*- il ^' Fig. 43. — Figures Showing the Application of the Marking Code of Dr. Harris. dary of the painful area is formed from the second primary char- acter, as is also its center of pain shown by the Greek cross. "Figure III, in Fig. 43, shows the third marking upon the patient who complained of simply 1 painful point. The four dots 138 THE INTENSITY OF PAIN arranged in eqiii-latcro-qiiadrangular formation show the manner of marking a painful point or a center of pain from the third primary character. "Figure IV, in Fig. 43, shows the fourth marking upon the patient, ilhistrating a painful area and a center of pain. The markings are constructed by using the dot and dash, which consti- tute the fourth primary character. "Figiire V, in Fig. 43, demonstrates a painful area and a center pain. "Figure VI, in Fig. 43, shows the sixth marking. The dashes are employed, as in the case of the second marking, but here the insertion of the Arabic numeral 6 indicates the number of the marking. "In Figure VII, in Fig. 43, the Arabic numeral at the begin- ning of the dotted line shows the painful point, and the dotted line indicates the direction of radiation. "In Figure VIII, in Fig. 43, the boundary of the pain area is constructed from the fourth primary character, the insertion of the numeral 8 distinguishing it from the fourth marking. The location of the figure 8 at three different points indicates the location of the pain at three distinct points. "The Arabic numeral 9 in the ninth marking of the patienfc indicates a j)ainful point, while the continuous arrowed line, con- structed from the first primary character, illustrates a radiation of pain from the marked painful point. "Figure X, in Fig. 43, shows a recurrence of pain in the same region as shown by the second marking of the patient. In this tenth marking of the patient the boundary of the area of pain is constructed from the second primary character. The number 10 in the outer boundary line of the area distinguishes this boundary line from the boundary line of the second marking, which occurred in the same region having a longer and narrower area. The number 10 in this tenth marking shows the location of the center of pain, and distinguishes it from the center of pain indicated by the Greek cross of the second marking of this patient." METHOD OF RECORDING PAIN 139 A permanent record may be made on the patient's chart by transferring the outlines on the patient's body to a stamped figure, being careful that the relative positions of the outlines correspond both with the bony landmarks on the figure and on the patient's body. CHAPTER VIII PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD The nervous system, since it is the carrier of impulses from one portion of the body to another, and since its organization is much more delicate than that of any other structure of the body, suffers from disturbances, which, when affecting the sensory ele- ments, are, as a rule, announced by pain. For systematic consid- eration the following divisions may be made: (1) nerve terminals; (2) nerves or nerve trunks; (3) nerve plexuses; (4) nerve roots; (5) cord lesions; and (6) pontine, mid-brain and cortical lesions. AFFECTIONS OF THE NERVE TERMINALS AND NERVE TRUNKS Affections of the nerve receptors are due, as a rule, either to inflammation, to toxemia, or to pressure. These have been con- sidered in part in the section on parenchymatous pain (q. v.). Affections of the nerves or nerve trunks are due, as a rule, to the following causes: (a) congestion; (b) inflammation; (c) in- jury (traumatism, j)ressure) ; and (d) toxemia. The milder grades may, for purposes of convenience, be termed neuralgias; the more severe affections, neuritis. The distinctions between neuralgia and neuritis are quantita- tive rather than qualitative. It is largely a matter of degree. A severe neuralgia may be termed a neuritis ; a mild neuritis a neu- ralgia. We cannot, therefore, insist upon a separation of the two conditions. One finds one or all of the causes operative in pro- ducing either a neuralgia or a neuritis and the resulting lesion de- 140 AFFECTIONS OF THE NERVE TERMINALS 141 pends largely upon the severity of the action of the exciting factor. Thus exposure to cold may set up a neuralgia in the facial from involvement of its sensory roots (the geniculate ganglion), or it may cause a true neuritis, involving the motor components, as well. Similarly an inflammatory reaction in a mixed nerve may cause only slight pain, the sensory components being involved but slightly, or it will bring about both sensory and motor disturbances with distinct neuritis symptoms; slight traumata, as well as tx)x- emias, cause quite similar pictures. Certain meningeal diseases of the cord, as well as ganglion affections, give rise to exquisite neuralgic symptoms without any of the usual motor complexities of a neuritis. We shall here discuss the so-called neuralgia, although it should be remembered by the reader that one is continually stray- ing into the field of neuritis. Anstie, in his classical work on "iN^euralgia and the Diseases Which Resemble It" (1871), gave one of the first English presen- tations of the general subject. Bernhardt, in ISTothnagel's large system, has given the most extensive of recent discussions of the whole subject. However, he was incorrect in regarding neuralgia as a separate entity. It should not be so regarded, with the pos- sible exception of a few conditions, for instance, those which cause such a change in the conducting apparatus that a light stimulus is interpreted as painful, or pain is produced without any apparent stimulus. Such a condition may follow slight chill- ing of the surface, or the lodginent in the nerve or its sheath of toxic substances, either heterotoxic (phosphorus or mercury), or autoxic, the result of deranged metabolism. Such a condition is present in influenza, and also in old age, when, because of im- paired circulation, the tissues are not properly nourished. To these pains the term neuralgia may be applied. As early as 1873,^ Loomis also applied the term to conditions in which there is a disturbance of nutrition. Neuralgia seems to be without recog- nizable pathology; at least, no uniformity exists as to the kind of pathology which is present. By'some it is thought to be a form of 1 Loomis, Med. Becord, N. Y., 1873, p. 473. 142 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD neuritis (neuritis of the ncrvi nervorum, Thompson, 352), but it differs considerably from neuritis in its pain phenomena. Etiology. — By many authors neuralgia is the name given to a nerve-jiain "which is produced by any of the following causes : Exciting Causes. — Intraneural, in which the exciting cause is found in the nerve fiber or its central origin. This cause may, in many cases, be the presence of toxic materials producing irri- tation and pain somewhat akin to the action of rheumatic poisons in rheumatic myalgia, in which the poisons act upon the terminal filaments of the sensory nerves distributed to the muscles. Under this heading we would include all those pains of infectious origin which do not result definitely from an inflammatory change in the nerves, such as occur in acute infectious diseases (influenza, tonsillitis, common colds), malaria, gout, nephritis, anemia (chlorosis), diabetes, syphilis, typhoid fever, small pox, constipa- tion, and gonorrhea. Many consider copper, lead, arsenic, alco- hol, nicotin, and mercury causes of neuralgia ; others class them rather as irritant poisons with the production of neuritis. Other causes are molecular changes in the nerve itself, the character of which we do not know, although many regard them as a mild de- gree of inflammation. Also included under the heading of mole- cular disturbance pain are pain caused by exposure to cold (we are all aware of the headache produced by going against the wind on a cold day) and post-hoc-neuralgia, a term given to those con- ditions in which, following the removal of the cause of the neu- ralgia, there is a persistence of the pain, due, perhaps, to continued molecular change in the nerve substance or ganglion, which time alone can, but does not always remove. As an instance of this may be mentioned the pain persisting after removal of gall stones, after the removal of carious teeth, and after cure of a gastric ulcer. Sometimes these are called "habit pains" (q.v.). Extramural, under which we would include pressure by new growths, tumors, or bony processes, by foreign bodies, soft tissues, glands, bone (especially when the nerves pass through bony fora- men), cicatrices, misplaced visc^a, hernia, aneurysms, enlarged uterus, etc., upon the nerve. AFFECTIONS OF THE NERVE TERMINALS 143 Traumatism, such as injury of tlie nerve by a blow, by forcible contact with a foreign body, by the pinching of a nerve between two bones, as pinching of the intercostal nerves between two adja- cent ribs. Fractures by pressure from fragments, or from the callus, cause nerve pain. Dislocation of a bone may also cause pain. Infection has been mentioned as one of the causes, and perhaps it is the chief one. Cases of epidemic intercostal and of supra- orbital neuralgia have been described, as well as the neuralgia associated with typhoid fever and rheumatism. It is reasonable to suppose that the infective germs can lodge and grow in nerves as well as in blood and interstitial tissues, for it has been defi- nitely proven by many observers that typhoid fever germs are, in the later stages of the disease, freely circulating in the blood. Pneumococci, streptococci, and various other germs have also been isolated in pure culture from the blood; and these wandering hither and thither in the tissues locate themselves where there is the least resistance, be this in bone, tendon, nerve, or muscle. Should the nerve be the habitat, a mild neuritis is produced and this causes pain. Predisposing factoes leading to the production of neuralgia are inherited predisposition, the use of alcohol, tobacco and drugs, neurasthenia, and excessive sexual indulgence. Age seems also to act as a predisposing factor, those of advanced age being more susceptible than those who are younger. The other so-called pains are classified under referred, projected, sympathetic pain, et cetera, under which they will be described (q. v.). Symptoms.- — In the case of pain occupying any restricted area it is well to make an examination for local inflammatory changes in the skin and subjacent tissues. Should they be absent, with the skin very sensitive to light pressure and the deeper tissues not so sensitive, we may conclude that the cause of the pain is either a neuralgia or a neuritis. If neuralgia is present there are points of hyperesthesia and the course of the nerve is not painful to pressure, while in neuritis the course of the nerve is tender to pressure, and there are no 144 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD painful points. Should neuralgia be suspected, we must seek the cause, and consider acute infections, reflex irritations, as the cephalgias due to visceral disorders ; referred pain, as earache due to decayed teeth ; projected pain, as in the head after Gasserian ganglion resection, and sympathetic pain, when one sensory center is affected by changes in another center, and pain is felt as coming from the area of distribution of nerves arising in this center. The pain of neuralgia may be constant and dull, or there may be periods of freedom from pain and then times of sudden and severe pain. These paroxysms of pain occur at intervals varying from a few seconds to as many weeks. The duration of an indi- vidual paroxysm varies from a few seconds to as many minutes. Sometimes, after the pain reaches its acme it becomes almost con- tinuous and may last for weeks. The onset in many cases seems to be without any causal condition, and may be sudden or grad- ual. Abortive attacks may come quickly and quickly disappear. Sensations of cold, itching, and numbness in the areas of the skin, which subsequently are affected by the neuralgia, are premoni- tory signs of an attack. The pains are of a burning, darting, bor- ing, cutting, piercing, biting, or pulling character. In some cases there is an intermittency in the paroxysms, which may come every day or every second or third day. When this occurs examine for malaria. The pain generally follows the course of a peripheral nerve. It may remain confined to one nerve area throughout its course, or it may suddenly shift from one area to another. At times it is confined to a small area, but most often it radiates through large areas and may run toward the periphery (neural- gia descendens), or from the periphery inward toward the cen- ters (neuralgia ascendens). Anesthesia dolorosa (q. v.) sometimes is present in these con- ditions, especially when the nerve trunk is subject to pressure due to an irritative lesion. In neuralgia tactile sensation also is some- times lost. Local Points. — Pressure points, first described in 1841 by Valleix, are called Yalleix's points. Light pressure on these points sometimes aggravates the pain, while heavy pressure relieves it. AFFECTIONS OF THE NERVE TERMINALS 145 In other cases the reverse is noticed. Pain may he elicited by pres- sure with a single finger-tip. The galvanic current sometimes produces pain when finger pressure fails to produce it. (Technique: Place the positive pole on any part of the body, preferably over some part of a nerve; hold it stationary, and run the negative pole along the course of the nerve.) In neuralgia Valleix's points are found at the point of emergence of the nerve trunks, at sections where a nerve trunk traverses a muscle to reach the skin, at the point where a nerve fiber breaks up into branches, and at points where the nerve becomes very superficial. The painful points along the course of nerves in neuralgic affections may be due to irritation of fine terminal-sensory filaments, which are distributed to the sheath of the nerves (Jelliffe). Distant Poiiits. — "Points douloureux apophysaires" of Trous- seau, or distant painful points, are also found in neuralgia. These are located in the spinous processes of the vertebra, be- tween which the roots of the affected nerves leave the verte- bral canal. The spinous processes in the region of the middle cervical vertebra are very sensitive in neuralgia of the trigeminal nerve. While painful points vary greatly and sometimes are recog- nized only at the time of the paroxysm, they may exist all the time and become more painful only at the time of the paroxysm. Pressure on the painful points may in one case produce an attack, while in another case it may abort the attack. The effect is some- times lessened, sometimes intensified, depending upon whether the pressure is light or heavy. Light pressure sometimes produces a paroxysm, while heavy pressure sometimes causes its disappear- ance. After the neuralgia has existed a certain length of time, atrophy of the nerve may occur and the pain may subside, espe- cially when it is due to pressure along the course of the nerve. Vasomotor Changes. — In acute and recent attacks, because of the contraction of the vessels and stimulation of the vasomotor, there may be at first pallor of the affected area, followed by flush- ing. In chronic neuralgia there is chronic flushing, due to vaso- 146 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD motor paresis. In later attacks there is generally flushing of the skin on the affected area. In trigeminal neuralgia there may be a pulsation of the temporal artery on the affected side. In some cases a swelling of the affected side occurs, and this in time leads to chronic thickening. Trophic Changes. — The skin is sometimes thicker than nor- mal; or, as a rarer condition, it may be thinner, due to cutaneous atrophy. The hair on the affected side of the head in trigeminal neuralgia sometimes becomes coarse or rough, and falls out, or it may become gray. Areas of gray hair may alternate with the na- tural-colored hair. In some cases the hair grows profusely. Other changes, as herpes, desquamation, eczema, and pemphigus, are fairly common. The secretory and excretory apparatus are also affected. Saliva and tears are often increased on the affected side in trigeminal neuralgia. Sweating is common over the affected part, and urine is often excreted in abnormal amounts. The nasal secretion in a trifacial neuralgia is at times tinged with blood. Muscular Changes. — Atrophy of the muscles on the affected side is common. It is due to lack of motion, because of pain. The atrophy is very slow of onset, and after a certain time remains stationary. Trophic muscular changes generally indicate a more extensive involvement (protopathic system). Muscular contractions occur ; at times they are clonic, at other times tonic. Slowing of the heart's action has been observed dur- ing a neuralgic attack. Movement is often impossible, because of the irritation produced in the sensory nerves. Walking and flex- ing of the thigh will often produce pain in cases of sciatica. Eat- ing will frequently produce pain in cases of trigeminal neuralgia. Pupils are often dilated, the dilatation being unequal. Associated neuralgia may be present in some cases. Here the pain gradually appears on the opposite side of the face, and may then entirely disappear in the region where it commenced. Duration of Neuralgia. — Sometimes the disease ends after one or two attacks, or it may persist for long years, even for an entire lifetime. Diagnosis of Neuralgia. — Xeuralgia can only be diagnosed AFFECTIONS OF THE NERVE TERMINALS 147 by exclusion, and is only justifiable when all other causes having an anatomical basis for the pain production have been excluded, such as pressure from growths, inflammatory exudates, misplaced fragments of bone, etc. The term neuralgia is often only a cloak for ignorance. It indicates that the diagnostician has not been able to localize the cause of the painfuj condition. It is the same as calling a pain in the head headache, or a lesion of the heart heart disease. DiFrERE::^TiAi, diagnosis of neuralgia should be made from painful muscular lesions. . Here the muscle is tender to pressure, and there are swelling and thickening. Pain never extends be- yond the region of the muscle. Inflammation of the bones or periosteum is also to be distinguished. In these there are swell- ing and tenderness in the bones affected. Inflammation of the joints sometimes is mistaken for neuralgia; it is differentiated by the swelling and tenderness of the joints and the pain on mov- ing them. Xeuritis from a differential diagnostic standpoint offers the greatest difficulties. It is different from neuralgia, in that neuralgia is but the name of the sensory condition, while neuritis is the name of the pathological entity which is present. Syphilitic Neuralgia. — This form of neuralgia, because of the frequency with which it is entirely overlooked, merits separate consideration. Neuralgia may occur during any of the three stages of syphilis. During the first stage it is manifested princi- pally by fugitive transitory pain over the entire body. It is rather an aching than a well-defined pain. In the second stage, the pain also is fugitive, is worse at night, and shows remarkable improvement under syphilitic treatment ; while in the third stage the pains are more fixed and are due to pressure from syphilitic changes in the surrounding tissues (gumma, exostosis), or they are produced by changes in the nerve itself, due to syphilitic processes such as are found in locomotor ataxia. Types of Neuralgia According to Localization. — The principal types of neuralgia, according to localization, are: (1) trigeminal; (2) brachial; (3) intercostal; (4) circumflex; (5) sciatic; (6) peroneal; and (7) visceral. 148 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD Trigeminal, Neuralgia (Tic Douloureux). — Neuralgia may occur in any of the branches of the fifth nerve. In some cases lesions have not been demonstrable, but in the majority of in- stances some disease of the Gasserian ganglion has been found in intractable cases of tic douloureux. 1st Br. 5th nerve. Srd Br. 5th nerve. f — — — 2nd Br. 5th nerve. Points of tenderness in involvement of ' " 3rd division of 5th nerve. - — — — — — —--• Points of tenderness in involvement of the upper cervical nerves. Fig. 44. — Areas of Neuralgic Pain. The first branch involvement is seen most often by physicians; the second and third division involvement are seen most frequently by dentists. The dots indicate Vallei.x's points of tenderness in neuralgia of the fifth nerve. The crosses indicate the points of tenderness in cervico- occipital neuralgia. The most important of the peripheral trigeminal pains due to lesions of the nerve are in the teeth. In some cases the pain is referred to areas supplied by a different branch of the nerve than that which supplies the particular tooth. In other cases a central pain is referred to the teeth. One of the most frequent mistakes of dentists is to consider a tic douloureux as being due to teeth dis- orders. The result is the extraction of all the teeth for a lesion which really is in the Gasserian ganglion. The nose in many cases acts as a cause for neuralgia of the upper AFFECTIONS OF THE NERVE TERMINALS 149 branch. Thompson mentions a case of trigeminal neuralgia which was caused by a piece of necrosed bone in the nose. Lange calls attention to neuralgia being mistaken for incipient tabes. Diagnostic differentiation in tabes is the lack of sensitive- ness of the nerve trunks, and generally the simultaneous affection of the trigeminal and occipital nerves. On the other hand, a tabes may have its initial symptom in a trigeminal neuralgia. Neoplasms, gliomata, etc., at the base of the tongue have caused neuralgia which speedily disappeared after their removal (Coates). Blair gives the following as characteristics of trigeminal neu- ralgia: (a) The pain is generally sudden in one branch of the fifth nerve; (b) it is paroxysmal and always returns in the same spot; (c) it is spontaneous, or is produced by certain definite stim- uli peculiar to the individual; (d) no primary anesthesia is pres- ent over the involved nerve; (e) there is no tenderness of the trunks of the involved nerve. When trigeminal neuralgia^ is present in any or all branches of the fifth nerve, examine the branch involved from its area of distribution to its point of emergence on the face. True trigemi- nal neuralgia is due to a lesion of the Gasserian ganglion, and should not be confused with the nerve pain arising from inflam- mation of the nerves, tumors of the nerves, injury of the nerves, pressure upon the nerves from new growths (as aneurysm of the carotid artery), tuberculosis of the bony foramen through which the different branches pass, gummata, and malignant growths. In infectious diseases, as influenza, malaria, and typhoid fever, the severest pain is felt at the supraorbital foramen (Schmidt). The pain of trigeminal neuralgia is probably the most severe of any to which man is heir. As a rule it is unilateral. When at its worst the sufferer may cry out, roll, and toss in his agony. With a constant, steady pain, there occur paroxysms of greater severity, which are so intense that the patient would welcome any event, even death itself, if it would relieve him. If the inferior or middle branches are involved, eating becomes an utter impossi- bility, and drinking is only accomplished with great distress. The patient is in constant dread, for when the pain is somewhat les- 150 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD sened the slightest touch, even tlie vibration from a slammed door, Avill again cause a paroxysm. These attacks last from a few minutes or hours to several days. Valleix's points, which are present, are described by Jelliffe: (a) for the first division of the fifth nerve, as being located at the supraorbital notch, the external angle of the upper lid, the upper, outer aspect of the nose, and the globe of the eye ; and (b) for the second division at the infraorbital notch, the molar bone, opposite the upper last molar, at the outer angle of the mouth, and on the roof of the mouth. The points of tenderness (c) in the inferior maxillary involvement are just in front of the auditory canal, the side of the tongue, the border of the chin, and Trous- seau's points over the first and second cervical vertebral spines. Bkachial I^euralgia. — Brachial neuralgia, or neuritis, is due to a lesion of the brachial jdIcxus. The brachial plexus arises from the anterior roots of the lower four cervical nerves and the upper half of the first dorsal nerve. These then imite into trunks, the fifth and sixth uniting to form the upper trunk, the seventh nerve forming the middle trunk, and the eighth cervical and one- half of first dorsal nerves uniting to form the lower trunk (Fig. 45). These trunks then divide into an anterior and a posterior part, the anterior portion of the upper t"wo trunks again uniting to form the upper cord, and the posterior divisions of the upper and middle trunk uniting to form the middle or posterior cord. The inferior trunk continues as the inferior or lower cord. Each of these cords is made up of' both motor and sensory nerves. The sensory cutaneous nerves arising from the upper cord of the plexus are the musculocutaneous, from the fifth, sixth and seventh cervical roots. Those arising from the lower or inner cord are the lesser internal cutaneous, which arises from the first dorsal; the internal cutaneous, arising from the eighth cervical and the first dorsal ; the ulnar, receiving its fibers from the eighth cervical and first dorsal roots; and the meridian (inner head), arising from the sixth, seventh, and eighth cervical and the first dorsal nerves. From the middle cord arises the circumflex, re- ceiring fibers from the seventh and eighth cervical ; and the mus- AFFECTIONS OF THE NERVE TERMINALS 151 ciilospiral, radial branches receiving fibers from the seventh, eighth cervical and first dorsal roots. A lesion in any one of the cords of the brachial plexus may produce pam in the area of distribution NFRA'iPINkTUS SHOULDER JOINT SKIN OVER OELlOlO OEUOIO .SKIN OVER LOWER % POSTERIOR SURFACE DELTOID AND THE LONG HEAD Of TRICEPS -INTEGUMEMT Ot RADIAL BORDER OF FOREARM . DORSAL ft PALMAR INTEROSSEOUS ^ADDUCTORIS TRANSVtRSUi tt 0BLIQUI5 POLLIClS INNER HEAD FJ.EHOR BREVlS POLUCIS Fig. 45. — Brachial Plexus. of any of the nerves arising from it. A lesion on any of the nerves derived from the brachial plexus will cause pain in the area of distribution of the nerves involved. The areas of distribu- 152 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD Musculocutaneous. Supraclavicular. Palmar Palmar cutaneous branch branch of of ulnar, ulnar. Fig. 46. — Areas of Distribution of Nerves Derived from the Brachiai. Plexus. tion are shown in the accompanying figures (Figs, 46, 47). Should the lesion occur above the cords, and be in one of the trunks, it is very easy to define it by referring to the figures showing the Musculospiral. Radial. Circumflex. Internal cutaneous. Ulnar. Fig. 47. — Areas of Distribution of Nerves Derived from the Brachial Plexus. AFFECTIONS OF THE NERVE TERMINALS 153 distribution areas of the nerves forming the brachial plexus. It is only necessary to remember that the upper trunk is formed by the fifth and sixth cervical, the middle trunk by the seventh cer- vical, and the lower trunk by the eighth cervical and the first dor- sal nerves. These figures (Figs. 46, 47) clearly show the areas of pain in lesions of the different cervical nerves. The accompany- ing outlines (compiled from Piersol and Gray) show the nerve Posterior thoracic Suprascapular External anterior tho- racic Internal anterior tho- racic Subscapular Circumflex Musculocutaneous . . . . Median Lesser internal cuta- neous Internal cutaneous. Ulnar Circumflex Musculospiral . . . . 5 cervical 5 cervical 5 cervical 5 cervical 5 cervical 5 cervical 5 cervical 6 cervical 6 cervical 6 cervical 6 cervical 6 cervical 6 cervical 6 cervical 6 cervical 6 cervical 7 cervical 7 cervical 7 cervical 7 cervical 7 cervical 7 cervical 7 cervical 8 cervical 8 cervical 8 cervical 8 cervical 8 cervical 8 cervical 8 cervical 8 cervical 8 cervical 8 cervical 1st D. 1st D. 1st D. 1st D. 1st D. 1st D. 1st D. 1st D. roots from which the divisions of the brachial plexus are derived, and are very useful in localizing neuritis, which affects both the motor and the sensory fibers of the nerves involved.^ These primary distribution areas are represented in the out- lines in such a manner that they clearly define the area of distri- bution of the different nerves forming the brachial plexus. Dia- 1 The table may be used to define the cervical nerve, root or cord zone in- volved; for instance, suppose pain was felt on the ulnar side of the arm and over the shoulder, on referring to the figure one sees that the pain is in the area of distribution of the ulnar and circumflex nerves, and on referring to the table one sees that while the circumflex arises from the seventh and eighth cervical and the first dorsal, the ulnar arises only from the eighth cervical and first dorsal. The lesion may involve the seventh and eighth cervical, and the first dorsal, but if it involves the first dorsal, the lesser internal cutaneous would also be involved. Since it is not, the first dorsal must be excluded. Examina- tion of the internal anterior thoracic will show whether the eighth cervical or the seventh cervical are the ones aftected. If it is involved in the pain phe- nomena also the eighth cervical is the nerve affected. -^ s ys 3 O < 6" B . 2^ o« Pi &( a a t^ &k o & O o o o t> « , / 00 1 / ■^ S;, d ^ ■ cv aa ay ■og ai eg P4 154 AFFECTIONS OF THE NERVE TERMINALS 155 grammatic outlines of the distribution area of the cords compos- ing the brachial plexus are shown in Figiires 48-53. A lesion on one of these nerves would produce a disturbance in the entire distribution area of the nerve below the point involved. Fig. 49. — Areas of Distribution of the Different Cords of the Brachial Plexus. The areas marked U are suppUed by the upper cord. Those marked M by the middle or posterior cord, while those marked L derive their supply from the lower or inner cord. The area containing crossed hnes and marked U M is supplied by both the upper and lower cords. When the pain is bilateral, and atfects the areas of one or more segments (see figure showing cord zone distributed) of the cord, disease of the vertebra or tuberculosis should be looked for ; or, if it affects the cord itself, tabes should be sought. The asso- ciation of herpes indicates involvement of the posterior ganglia. Unilateral pain occurring (a) within the boundaries of a par- ticular cord-distribution area, (b) within the distribution area of a cord trunk, or (c) of one of the cervical nerves, or (d) even of the nerves given off from the brachial plexus, should always ^ J a 5 « (X. u O H ;? o r; M H H M t3 ^ m 9 H ^ « < H CO a fe^-^ o a w < H S fe K O < m rO I^ H • O to * .^3^ pR 1 tJ n •s* « D r> H t> ro « Q >^ w (£; H o m IS lx< H W H u< O Em O 5^ o 'A n H t3 (W pq ^ K H -»< 156 H ^ O ^ o ai M t-1 < ^ !z; « hH M -«1 ^ l-H CO ij M <* n r/} H CH OS O § Q t) Q X H >-) fH PL| » 1-1 n < rn O H W. U % w H 'A P4 O O P 02 P ;z; 1 o 157 158 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD cause a search to be made for the lesion in the special nerve seg- ment in which it has been localized. Lesions causing such a condi- tion are those producing pressure, as axillary tumors, sarcoma, aneurysm of the subclavian or axillary artery, abscess, and en- largement of the cervical and axillary lymph glands. Owing to the close relationship of the trunks and cords forming the brachial plexus, it is very unusual for one to be affected to the exclusion of the others. A method of making pressure on the brachial plexus and so causing pain to ap- pear in the distri- bution areas in- volved is shown in the figure. All of the in- stances given here are not, in the strict sense of the word, true cases of neuralgia. The term neuralgia should be used only to define those lesions of the nerves giving rise to pain and in which there is no ajiparent pathol- ogy. Such a condition is found in anemia and toxemia. In other cases pain produced by pressure is referred to the area of distribu- tion of the nerve, and is a referred pain, while pain resulting from an adjacent inflammation is due to a neuritis or to jDressure from the inflammatory exudate. Both cases resemble referred j)ain ; but since it is common to consider these pains under neuralgia, and neuralgia itself means pain, they have been placed under this heading. In cases in which inflammation is the cause of the Fig. 54. — Method of Eliciting Pain in Brach- ial Neuralgia. AFFECTIONS OF THE NERVE TERMINALS 159 neuralgia a considerable part of the local pain is as much the result of the inflammatory invasion of the connective and muscu- lar tissues of the affected part as it is of nerve involvement; indeed, it is probable that every one of the above so-called neu- ralgias will be found to be a neuritis. The pain in brachialgia is similar to all other neuralgic affec- tions. It generally occurs in sharp paroxysms, in the intervals between which there is no pain; yet, in some cases, the pain may be constant, and of a dull, aching type. In all cases sharp paroxysms of greater severity occur at regular intervals. In the early stages of the disorder, the pain is a dull, generalized ach- ing, and involves the entire arm ; then, as the attack persists, it be- comes localized to the distribution area of one or more of the cords of the brachial plexus (page 155). The pain may be so severe that the patient cannot sleep, and even though he should momentarily doze he is awakened by sharp paroxysms of pain. All sudden and forcible motions make the pain worse, but gentle manipulation is painless. In brachial neuralgia, stretch- ing of the arm causes pain in the region over the posterior margin of the scapula. The paroxysms frequently come on at night and it is nothing unusual for the patient to awake in the morning suffering from arm pains of the greatest intensity. The attacks may last for a short time, a few minutes, or a few hours ; then again, they may be present for weeks or months, during which time the pain may be interrupted by periods of rest or aggravated by paroxysms of great severity. An individual attack lasts, on an average, almost two or three weeks. The pa- tient seeks rest, and it is comnion to find him sitting in an arm- chair, nursing the diseased arm with the sound one. In some cases the patient lies down and places the arm across his chest or abdomen. Location of the Pain. — In brachial neuralgia the pain may in- volve the entire arm, but generally only the upper part of the arm and the shoulder are most severely affected. The reason for this is that the circumflex and the internal cutaneous nerves sup- 160 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD ply the shoulders and the upper part of the arm, and are the most subject to injury. Should the pain be entirely above the shoulder, it is due to involvement of the acromial and clavicular branches of the fourth cervical. If the pain is over the shoulder, or is at its anterior and outer aspect, it indicates involvement of the circumflex (Figure on page 154). Since the shoulder joint is also supplied by the cir- cumflex nerve, movement of the joint may cause pain in the dis- tribution area of this nerve. If the circumflex is involved the pain is confined to the cutaneous area of the distribution of this nerve ; but should the pain be the result of a lesion of that part of the cord from which the circumflex arises, the pain is felt also down the arm in the area of distribution of the musculospiral nerve which arises from the posterior cord in common with the circum- flex. Should the pain in the area of distribution of the circum- flex be associated with pain over the scapula, under the clavicle or in the neck, it indicates that it is the fifth root which is involved. In disease of this root pain may also extend down the arm in the distribution area of the musculocutaneous nerve. Pain on the ulnar side of the arm, extending almost half-way around and involving the hands and fingers, except the dorsal and external surface of the thumb, the index finger, and the adja- cent surfaces of the index and the ring fingers, indicates involve- ment of the middle cord of the brachial plexus. Pain in the radial side of the forearm generally indicates involvement of the upper cord of the brachial plexus. Depending on the location of the lesion, the muscles may or may not be involved. A square block has been placed on the upper trunk of the brachial plexus, just before it divides into the musculocutaneous, and the branch help- ing to form the median. A lesion at this point would not disturb the muscular and cutaneous supply of the nerves given off above this level, while the supply given below this portion would be disturbed in the manner described above. By placing a block on any part of the nerve, the resulting disturbance can easily be ascertained. In the early stages of brachialgia the pain is diffused over AFFECTIONS OF THE NERVE TERMINALS 161 the entire arm, forearm and hand, and runs down into the fingers, though it usually involves only the first, second and third fingers (Dana). According to Dana, neuralgic pain in the forearm is very rare. Tenderness. — Neuralgia, in the absence of neuritis, causes little or no tenderness along the course of the nerves, nor over the site of the brachial plexus, though there are well-defined tender areas in which points of maximal tenderness are located. Accord- ing to Dana, these areas of maximal tenderness do not always correspond with the tender points of Valleix. It is common for patients to rub those tender areas with some form of liniment in the endeavor to ease the pain. It is needless to say that this pro- cedure is productive only of irritation and inflammation at the site of the rubbing, without any alleviation of the pain. Others engage masseurs, who put the patient through a course of treat- ment, generally with a negative result, though in some cases they irritate the nerves, and increase, instead of decrease, the pain. The tender areas are located on the anterior and posterior surface of the arm and shoulder. Those on the anterior surface are found over the outer third of the clavicle and infraclavicular fossa, over the deltoid, at the outer surface of the arm, over the inner surface of the arm just above the elbow, over the middle of the forearm, and (one) over the wrist (Gowers). On the pos- terior surface the areas are found over the scapula in the supra- spinatous fossa, over the posterior margin of the scapula, over the upper surface of the arm where the arm and the shoulder join, over the middle of the arm, and over the middle part of the fore- arm. The areas along the posterior margin of the scapula are in close relation with the points of tenderness of occipital neuralgia. They lie over the second and third cervical spines. They are also closely related to the points of tenderness of cervicobrachial neu- ralgia, which lie over the first or second dorsal spines (Trousseau), and of brachial neuralgia, whose points of tenderness lie over the third and fourth dorsal spines. Associated symptoms may be present, but they are not com- mon unless a neuritis is present. When that is present there is i % aj 3 O 'i > ^0 •S.2 1 a O 3 1 v 3 0) o Tenderness marked in cer- tain well-defined areas which are hyperesthetic. Anesthetic areas may also be present. s 09 H p -S2 s *^ S rt ^ .a !» ,15 0) m 3 6 _ (V) to 1— ( 3 ■i 03 is lg K 1 CO P i i t2 a; o > III tO-T^ g S S w 3 to c3 > 2? tH '3 to 3 3 3-S Oi Sh 03 3 0) ""to 03-*^ 03 0) S § » |§^ < O >-] CO 1 i CO 03 C to p C 0; 1 CO .s S.2 o C .g +^ o eg £ M CO C O m c S oj-'^ U 03 P 03 f-i cs ^ a-' 1 _g u o "o o3 W 03 O 03 03 3 "5.2 tH- o; 5 !_ a! C D c CO <; s o c '■+3 > o C 0) 03 < 03 03 03 tn < 0) > o c oj 03 «« 03 I'd £ § «3 s % c t- 'co g CO o a 0; "a 8 ft t+- . CO o o p to 163 164 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD generally some muscular paralysis and atrophy. At first the elbow jerk is a little exaggerated, and then becomes decreased, and anes- thesia is absent. In brachialgia these changes, if present at all, are a later development. In the early stage no physical change can be noticed in the arm except a slight swelling and some flabbi- ness of the tissues. Circumflex ]^euralgia. — Circumflex neuralgia is more com- mon than one would naturally suppose, and of all neuralgias it is probably the most frequently wrongly diagnosed, and often mis- taken for rheuma- tism of the shoul- der joint. From this it is to be dis- tinguished by the absence of swell- ing in the joint, the more or less intermittent pain, presence of exacer- bations, etc. Per- verted sensations are also present, as tingling, burn- ing, and numb- ness. Tenderness over the deltoid and teres muscles is present, and is very severe over the line of the nerve. The causes of circumflex neuralgia, accord- ing to Disna (598), are toxic materials (as arsenic), infections (as tuberculosis), diabetes, rheumatism, gout, draughts, injury to the shoulder, blows across the deltoid muscle, fracture of the surgical neck of the humerus, and dislocation of the shoulder joint. Intercostal ISTeuralgia. — Intercostal neuralgia occurs, as a Fig. 55. — Method of Eliciting the Points of Tenderness in Intercostal Neuralgia. AFFECTIONS OF THE NERVE TERMINALS 165 rule, rather suddenly, and comes on after exposure to cold, etc. It appears in paroxysms, which are very severe while they last, the pain seeming to extend around the chest. Any exposure to cold excites a paroxysm. Pressure pain over the nerve is present, and it is specially marked (a) near the spinous process of the vertebra ; (b) near the mid-axillary line ; and (c) behind the left margin of the sternum. Herpes zoster is frequently confused with this condition. The pain may last from one to several days, then gradually becomes less and less severe, and finally disappears. Frequently after its disappearance a feeling of soreness remains. Pleurisy without effusion is often confounded with intercostal neuralgia. A point of difference is that in intercostal neuralgia the pain increases when the patient bends over toward the affected side, while in pleurisy the pain decreases (Schepelman, 24b, p. 1078). Differential Diagnosis Between Intercostal Neuralgia AND Pleurisy (Schepelman) INTERCOSTAL NEURALGIA DRY PLEURTSY Character Sticking, burning or lanci- Sticking and lancinating, but of Pain — nating — paroxysmal. occurs on breathing. Radiation Often to the inner side of the None. of Pain — arm. Location of Pain — In intercostal spaces. Over an infected area of the pleura. Pressure Points — (a) Near to the vertebra at Over the infected area of the the back of origin of the pleura, intercostal nerves. (b) Axillary line. (c) Sternal line Pressure — ■ Touch and pressure are very Painful over the area of the painful on the affected diseased pleura, nerves. Galvanization — Reduction of the pain. No change. Herpes — Often occurs. None. Rubbing Sounds — Absent. Present. {Friction Fremitus) SS;'- } • • • -Not so painful. Very painful. Neuritis of the Caudal Nerve Roots. — Kennedy and Cals- berg have reported cases in which pain, sharp, shooting and burn- ing was felt almost entirely in the backs of the thighs and in the calves. It generally begins as a unilateral pain, but after the lapse of some months is felt in both legs. The leg first involved remains 166 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD throughout the illness more affected than its fellow. There is also much tingling and numbness, sometimes in the feet, sometimes in the knees, and at other times in the entire lower extremities. An associated symptom is atrophy of the anterior tibial muscles. Sciatica. — By many sciatica is thought to be a neuritis, while others consider it a form of reference pain from some lesion, oc- curring along the course of the sciatic nerve. In some cases the sacroiliac joint becomes diseased; and since the lumbo-sacral nerve passes over it, any disturbance of the joint will affect the nerve. Sometimes, also, a spicule of bone from an osteoarthritis of the spine may press on the nerve. Pressure by a tuberculous abscess will also cause this condition (Adams, 603). Sciatica often fol- lows a fall or an injury, and is the result of infections, consti- pation, sudden changes of temperature, etc. Pressure on the nerve (relieved by an elastic stocking) has also been a cause (Edinger). Women are less frequently affected than men, in the proportion of one to four. It is most frequent after the age of forty, and up to sixty years of age (Duckworth, 604). The Pain. — The pain is constant, with severe paroxysms, which generally occur at night. x\t first, according to Climenko, there is an uneasy throbbing sensation in the dorsum of the thigh with some tenderness at the seat. In a day or two these sensations develop into sticking, boring, tearing, and even lightning-like pains along the distribution of the sciatic nerve and its divisions. At the time of the paroxysms the pain is sharp and lancinating. Between the paroxysms it is dull and aching. Frequently it comes on after exposure to cold, or following an injury. As a rule it does not last longer than a few months, though it may persist for a j'ear. Be- cause motion increases the pain, the patient tries to ease the weight on the affected side, and holds up the pelvis toward the sound side, thus flexing the trunk toward the diseased side and producing a static scoliosis. Location of the Pain. — The pain is felt principally in the back of the thigh, and runs. down the leg, following the course of the sciatic nerve. Sometimes it is over the sacral or lumbar area. Frequently, on motion, pain is felt at the sciatic notch. AFFECTIONS OF THE NERVE TERMINALS 167 The cause of this pain is the pressure of the nerve against the rim of the sciatic notch by the inflamed and contracting pyriformis muscle (Bashinger, 601). The tender points (Valleix's points, Fig. 56. — Cutaneous Distribution Areas of the Small and Greater Sciatic. SS= small sciatic; EP= external popliteal; PT=post tibial; S — sciatic; IS = internal saphenous; EP and PT are branches of the great sciatic. These drawings are composites from those given by Head and Thompson and represent the areas in which sensation was lost after division of their respective nerve supply, consequently they would also represent the areas in which pain would be felt in any painful lesion of the nerve. These areas correspond rather closely with those given by McKenzie (599). according to Edinger) are located: (1) over the anterior superior spine of the ilium; (2) in the center of the posterior surface of the thigh; (3) just inferior to the lower margin of the gluteus maximus; (4) in the middle of the calf of the leg; (5) under the IGS PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD head of the fibula; and (6) in the popliteal space. Dana also gives the back of the foot and the sciatic notch as points of ten- derness. In some cases the pain is referred, and it is found in the area of distribution of the sciatic nerve (see figure). Bruce (502, p. 511) advances an original idea when he states that sciatica is due to disease of the hip joint. He has found wasting of the gluteal muscles (59 per cent.) and obliteration of the gluteal folds (30 per cent.) in nearly all the cases which he has examined. Lameness was also most constantly present. Diag- nostic of sciatica is pain running up the back of the thigh when pressure is made on the posterior part of the knee with the leg extended a little more than a right angle (Dana, from Gowers). Kernig's sign is that hip motions are free as long as the knee is flexed, but become limited if the leg is straightened and flexion of the thigh is attempted. Sciatica should be diagnosed from hip-joint disease, disease of the cord (tumors of the cauda equina"). Fig. 57. — Method of Eliciting Pain in Sciatica. new growths (sarcoma), bone formations, etc. Gordon (608) reports two cases of tumor of the sacrum which had been mistaken for sciatica. Tabes has sometimes been mistaken for sciatica, but the presence of the knee jerk in sciatica will exclude tabes. In relation to sciatica, Faber (616) mentions several cases, in which, in addition to the sciatica, there was also present a well-marked degree of adiposa dolorosa. After the reduction of the adipose AFFECTIONS OF THE NERVE TERMINALS 169 tissue, the patients felt verj much better. In cases of this kind, patients mav have at the same time well-developed symptoms of both adiposa dolorosa and sciatica, and the one should not be treated to ■ the exclusion of the other. In all cases of sciatica examine the pelvis carefully (per vagina and rectum) and the hip-joint both bimanually and by the X-ray. In Figure 57 is sho^\Ti a method of eliciting pain in sciatica by making pressure on the nerve as it emerges from the sciatic notch. Pla^tak l^EUEALGiA. — Plantar neuralgia is due to a lesion of the plantar nerve, and anesthesia or paresthesia frequently ac- companies the pain. In the accom- panying figure the area of distribu- lat. piaatar i n s. tion of the nerve is outlined, and Ext. piantar iv. v, L, IS. it is in this area that the pain occurs. Morton's neuralgia, due to pres- sure on the digital branch of the external plantar nerve, is found in early stages of flat-foot disease. In some cases of typhoid fever the toes become very tender. This, ac- cording to McCrae (607), is due to a local neuritis. It closely resembles a plantar neuralgia. The first com- plaint of the joatient is of pain from pressure of the bed-clothes. Sacral or Lumbar-cord Neu- ralgia. — Sacral or lumbar-cord neu- ralgia is betrayed by pain in practically the same regions as Head has outlined as the distribution areas of the different cord zones. In Ivocher's figures the boundaries are, as a rule, held to be somewhat too high, the true areas in reality being one or two zones lower. It is useless to reiterate what has been said in regard to lumbar or sacral root neuralgia, because the symptoms are exactly simila'- FiG. 58. — Distribution of THE Plantar Nerves. The plantar nerves are branches of the tibial which is a branch of the sciatic (modi- fied from Cunningham's An- atomy; also from Gerrish's Anatoni}') . 170 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD to those found in brachial root neuralgia, to which the reader is referred. With this reference, and by the aid of the accompany- ing figures (Head zones; and Figs. 1889, 1890, Toldt), the reader should be able clearly to differentiate this condition. When a root or a root ganglion is involved, a continuous area of the skin is ahvays affected, even though the fibers derived from this root unite with others to form a plexu^. These regions of dis- tribution overlap so that when a root is diseased, sensation (epi- critic) is not completely destroyed over the entire area of the root distribution (Tigcrstedt). It is entirely absent only in a central area. It increases gradually toward the periphery until it be- comes normal in the areas of distribution of the unaffected roots. This border zone is not present, as a rule, for protopathic sensation. For this the cord zones seem to be more definitely marked. There is greater overlapping in the distribution of the nerve in the peripheral part of a limb than in the proximal part (Buzzard, ''Brain," Vol. 25, p. 308). This is due to a spreading out of the nerve fibers in the periphery of the limb. These border areas react to a much gi'eatcr degree than normal to painful stimuli, but the strength of the stimulus to produce a reaction must be much greater than that applied to normal skin. In regard to loss of sensation, Head and Sherren say that "it would seem that division (disease) of the posterior roots abolishes sensation to prick over an area larger and more sharply defined than that which becomes insensitive to light touch. Moreover, this insensibility to prick is accompanied by an inability to appreciate temperatures below 15° C and above 60° C, although 40° C. and 23° C. may appear definitely warm and cool." In lesions of the peripheral nerves the opposite is the case, the epicritic sen- sation being lost in a larger area than is the protopathic ; i.e., the sensation to fine touch was absent in a larger area than was the sensation to prick (Head and Sherren, 244, pp. 310-311). Buz- zard (613), in a case of injury to the cord roots, found the sensi- bility to pain and temperature abolished, but the tactile sensibility partially retained. When sensation returns, the first to recover is the sensibility to prick, and to the more extreme degrees of heat AFFECTIONS OF THE NERVE TERMINALS 171 and cold (Head and Sherren). In some cases lesions of the posterior roots are present, and sensations are lost without the patient heing aware of their absence. When the posterior ganglia are affected, herpes generally ac- companies the neuralgia. When it is present, a copious eruption of vesicles appears over the affected area. These, when they dry up and desquamate, leave a brownish sjiot. The pain does not disappear upon the disappearance of the eruption, but may con- tinue for some time longer. A diagnostic sign of value in differ- entiating cord lesions from root or nerve lesions is the dissociation of sensation. When the cord is diseased, pain, touch, tempera- ture, etc., may be individually or collectively abolished; but in nerve lesions they are always collectively abolished (Sherren, 612). The following is a differential diagnosis, compiled chiefly from Sherren : CoKD Lesion. Loss of pain perception. Temperature sense is changed, so that (a) sensibility to heat may be abolished without any change in respect to the sensi- bility for cold (the inverse may be the case) ; (b) all dis- tinctions between the minor and extreme degrees of tem- perature are lost ; and (c) "insensitiveness may be pres- ent to all forms of heat and cold, the lightest touch may be felt, and discrimination of the points of a pain may be present." Peripheral LESIO^". Pain produced by excessive pressure as long as there is any touch sensation. All sensations are affected, but not to the same extent, the epicritic being affected in a greater area than is the proto- pathic sensibility. 172 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD Cord Lesion. Both superficial and deep touch are usually unaffected, but when absent they usually dis- appear together. The patient may have touch sen- sation, but be unable to appre- ciate pain, heat and cold. Passive movement and position of the limb are not apparent to the patient. Spasticity of muscles on the same side below the level of the lesion. Paralysis and wasting of mus- cles at level of the lesion. Keflexes having origin below the level of the lesion are in- creased. Pupillary reflex may be affected if the lesion is in the cervical cord, on account of affection of the cervical sympathetic. Muscle atrophy may not occur. Peripheral Lesion. Absent in a peripheral lesion. "Light touches over the distri- bution area with cotton wool are usually not appreciated, though deep touch and pres- sure evoke a response." Passive movements and position of the limb apparent. No spasticity. Paralysis of the muscles sup- plied by the affected nerve. Reflexes originating in the af- fected area are decreased. Pupillary reflex is not affected. Muscular atrophy of the muscles supplied by the affected nerve is always present CENTRAL NERVOUS SYSTEM^ The discussion of diseases of the central nervous system re- quires a recapitulation of the normal anatomical relations, which will be given, as briefly as possible, in the following paragraphs. 1 Written by Dr. Alfred Neuman, Vienna, CENTRAL NERVOUS SYSTEM 173 It will be entered upon here only so far as appears necessary for the understanding of the subject. ANATOMY The surface of the brain is supplied with furrows and convo- lutions, which, though of many varieties, show a certain regularity through which it is possible to differentiate them in every case. A few of them have special importance, and will be more minutely discussed. The central convolutions on the convex side of the brain, the paracentral lobe, and the median wall of the hemisphere with the adjacent part of the frontal lobe, represent the motor region. Far- thest below is the center for the facial and hypoglossus ; in the middle is found the center or centers for the movements of the upper extremity; and in the uppermost third those for the move- ment of the lower extremity of the opposite side of the body. The centers innervating the musculature for the act of eating, for talking, for trunk movements, and for the closure of the eyes, are connected with the corresponding muscles of both sides, so that in case of a unilateral destruction of a center, the ability to perform these movements still per- sists. The speech center occupies the posterior part of the third frontal convolution, as well as the first temporal con- volution. In right-handed individuals it lies in the left hemi- sphere. In the third frontal convolution occurs the transforma- tion of ideas into words. The motor speech center in the tem- poral convolution is the seat for word sounds (sensory speech center). The centers for the sensation coming from the body lie, apparently, in the region of the motor centers, and, as it seems, are practically identical with them. However, the entire poste- rior central convolution, as well as the parietal lobe, evidently be- longs to the sensory sphere. The centers for vision lie in the oc- cipital lobes, viz., in the fissure calcarina and in the cuneus, per- haps, also, in the neighboring adjacent portions of the lingual globe. The recollections of sensations of sight (the field for optit paemory) are said to lie on the convexity of the occipital lobe, 174 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD The olfactory center is supposed to lie in the gyrus hippocampus and uncinatus. The auditory center occupies the upper convolu- tions of the temporal lobe. From these centers, on the one hand, pass the centrifugally conducting fibers to the periphery; on the other hand the centripetal conducting fibers enter them. Of course, it is neither possible nor necessary to discuss all the con- ducting tracts ; only the two most important ones will be discussed here. Passing inward and downward from the motor centers, the motor fibers are gathered in the posterior limb of the internal capsule, near the knee. They pass then into the brain peduncle, and from here the central portion passes through the pons into the medulla oblongata, Avhere a part undergoes decussation and enters the lateral column of the spinal cord, from whence it goes over into the anterior roots of the peripheral nerves. The smaller part, non-decussated, descends in the anterior column of the spinal cord, and undergoes partial decussation farther below, and finally enters the anterior roots. The fibers for the motor nerves, which spring from regions lying adjacent to each other, run to the capsule in front of the pyramidal tract, decussate in the pons and in the medulla, and reach the corresponding nuclei. The course of the sensory conducting fibers is more complicated, but it shows in many respects a resemblance to that of the pyram- idal fibers. These sensory fibers, entering through the posterior roots, run for a part of the time (uncrossed) in the funiculus gracilis and cuneatus to their nuclei, also to the nucleus of the funiculus gracilis and the nucleus of the funiculi cuneati in the posterior surface of the fourtli ventricle. From here they pass through the fibers of the arciformis internis, between the olives, to the opposite side (lemniscus decussation), which lies above the pyramidal decussation. One other part of the sensory fibers which ascends in the ground bundle of the anterior and lateral columns of the cord, and has previously crossed, joins with the first ones, after their crossing, and then again enters in common with them and passes through the crest of the peduncle to the brain cortex. CENTRAL NERVOUS SYSTEM 175 on the way undergoing, in the optic thalamus, another interrup- tion hj relaying cells. Besides this, on the part of the lemniscus tract (the median), there is another portion, namely, the lateral lemniscus, which is composed of the fibers of the acousticus and the sensory fibers of the cranial nerves, and which lies more later- ally. It also arises in the upper half of the pons, out of a collec- tion of ganglia which communicate with the corresponding sensory cranial nerves, and passes, partly decussated, into the corpora quadrigemina, and from thence to the cortex. The pains which are due to diseases of the nervous system or its sheath are localized, on the one hand, in the head, in affections of the brain, and on the other hand in the back and the extremi- ties in diseases of the spinal cord. Exceptions to this general rule occur. Thus, there are jDains radiating into the extremities in aifections of the sensory tracts in the brain (Edinger) and head- ache in spinal-cord diseases (tabes, multiple sclerosis). Although these exceptions are not very frequent, yet we cannot attribute every headache to an affection of the brain substance, nor every back pain to an affection of the spinal cord. Both symptoms also belong to other diseased organs, and w^e are obliged to include in our discussion those forms of headache, or of pain in the back, which are caused by injuries which are indirectly elicited or pro- duced by changes in the substance of the central nervous system or their sheaths (through the circulation or by reflex means) ; for instance, headache in anemia, constipation, abnormalities, or in refractive errors of the eye. ORIGIN OF HEADACHE !Row we should first ask ourselves where the sensations desig- nated as headaches arise, and in which tissue layer they are local- ized. It has been shown by clinical observations that both the brain substance and all its sheaths may be the seat of the pain. Concerning the membranes, it is seldom questioned that pains can originate therein; indeed, frequently they have been considered as the only bearers of headache, since they are supplied with cere- brospinal nerve fibers, which seem alone to be capable of pain con- 176 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD duction. The cortical origin of headaches, on the ground of the observations of Lennander, would be declared impossible, because of his observation, by operation, that the brain cortex may be sectioned without the patient feeling anything. Because of this, all intracranial headaches were attributed to irritation of the dura mater. Xothnagel objected that the mechanical irritation em- ployed on the brain was not sufficient to produce a reaction be- cause another sort of irritation (toxic, infectious) was needed to produce pain, as the headaches from poisoning, infectious diseases, and anemia prove. L. R. Miiller remarks, further, that symptoms of loss of function which accompany migraine, as the shrinking of the field of vision, prove that certain parts of the brain are func- tionless for a short time. The observations of Oppenheim also speak in a very instructive way, opposing the view that only the dura mater can be looked upon as a source of pain, be it the re- sult of direct or indirect irritation, through the intervention of brain pressure. The dura mater beneath the occipital bone is painful to irritation (Braun), but the dura beneath the frontal bone is not painful (Xystrom), and under the temporal bone has no sensation (Lennander). (Keen's System, p. 1048). Before it can be certain that pain which is felt as headache may arise in the brain substance itself, we must know the nerves which conduct these painful stimuli to the cortex. The only per- ipheral nerves known to be present in the brain are of the sympa- thetic system. If it could be shown that these fibers are able to carry stimuli in a centripetal direction, we would be justified in ascribing to the brain substance itself the power of originating painful stimuli. The circumstances are similar in regard to the sensibility of the abdominal organs. Here, also, are found nerves, which, only with the vagus or with the sympathetic, enter into the viscera. To both, only the motor functions were ascribed, there- fore it was concluded that the viscera possess no special sensibility. However, it has been demonstrated that the sympathetic nerves carry sensory fibers which convey irritations from the viscera to the central nervous system (Neuman) ; and this removes the most important objection to the acceptance of the idea that each organ CENTRAL NERVOUS SYSTEM 177 possesses its own sensibility. The fact that the cerebral cortex is insensitive to the touch of the fingers, or of instruments, only goes to prove that it is insensitive save to these types of stimuli, which never occur normally. Just as the eye receptors act for light only, so there are probably receptors in the brain tissues which react only to special forms of stimuli. Just what these are is not as yet definitely known. The further conduction of the irritation may then be described as being through the rami communicans into the posterior roots and then through one of the above-described sensory tracts over the cord back again to the cortical brain sub- stance. The conduction of the painful irritation from the cover- ings in diseases of the meninges, of the cranium, of the aponeu- roses, or of the skin is over the trigeminus to the terminal cells of the same in the mid-brain ; from there to the corpora quadrigemina, to the thalamus, and finally to the brain cortex ; in a similar way, by the upper cervical nerves through the median portion of the lemniscus (Edinger). Headache also appears as a symptom of disease of the brain substance and the meninges, and in diseases which certainly have nothing to do with these organs. As an example of the for- mer may be mentioned the headaches of brain tumor or of menin- gitis ; as an example of the latter, the so-called rheumatic or indu- rative headache may be mentioned. ISTot only have we to con- sider diseases of an organic nature, but also those in which purely chemical substances cause molecular alterations, and thus, perhaps, cause headaches. Uremia, the different metal poisonings, or the infectious diseases are examples. Here, also, belong the headaches of anemia, of congestive states, and possibly of migraine. -"^ In a similar manner, also, in the headaches of neurasthenia or of hysteria, we must think of a hitherto undemonstrated change in the central nervous system. The elicitation of pain through mighty efforts, irritation or fright, as well as some accompanying disturbances (for instance, dizziness), can hardly permit of an- other explanation. If we would, with the help of headaches, try to arrive at a 'This as yet has not been demonstrated. For another view, see pp. 189 and 190. 178 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD diagnosis of diseases of the brain and its membranes, we mnst determine first whether they do not also occur in other dis- eases, and, second, whether they possess certain special peculiari- ties which would be characteristic of different-diseases of the brain or of the brain membranes. Unfortunately, we have no such cri- teria. Neither are headaches limited to diseases of the central nervous system ; nor are they of as many forms as their causes are numerous. One can certainly say that there is no form of head- ache which would be pathognomonic for a certain disease, with the single exception, possibly, of a luetic headache. We must not per- mit ourselves, in making a diagnosis, to be guided by the character of the headache alone, but must utilize the other symptoms. Nev- ertheless, in the character of the headache there are several pe- culiarities, which, if they do not speak for a certain disease, may still give a hint as to the nature of the trouble. Since, here, only those forms of head })ain come into question which are connected, first of all, with diseases of the brain, or its membranes, all other kinds of j)ain belonging to the symptom complex of other diseases will be excluded. Should headache be present, w-e must, in our diagnostic in- vestigation, first search for disease of the outer coverings of the central organ ; that is, of the bony skull, of the aponeurotic layer, of the scalp muscle, and of the scalp itself. These are treated in Chapter XIV. Should these be excluded the brain and its cover- ing should next be examined. HEADACHE IN DISEASE OF THE BEAIN AND MENINGES Those diseases of the brain and the meninges in which head- ache forms an essential part of the symptom complex now will be described ; and in conclusion an analysis of these headaches will be given. First of all let us remember that not all pathological changes of the central nervous system are accompanied by pain, and gi-oss lesions of the brain are found (post mortem) without the patient having complained of headache. Therefore, an extensive dis- turbance of the brain may occur, as in cerebral hemorrhage, with- CENTRAL NERVOUS SYSTEM 179 out tlie patient making any complaint. Even laceration may occur so slowly that the patient either does not lose consciousness or does not at once become unconscious. The same is the case in brain-softening, in encephalitis, in infantile cerebral palsy, in general paresis, etc. ISTevertheless, headaches are also found in the course of these diseases, either as a prodromal sign, as in hemorrhage, or in the later stages ; but they are not characteristic of the disease. In other diseases, however, headache forms an important symp- tom. Here must be included pachymeningitis interna, leptomen- ingitis, brain-abscess, brain tumor, aneurysm of brain arteries, syphilitic diseases of the brain and the meninges, migraine, neuras- thenia, hysteria, and circulation disturbances in the brain. We shall not discuss the latter. Pachymeningitis Interna Hsemorrhagica (Hematoma of the Dura Mat'cr). — From a pathological, anatomical standpoint we have to deal with the formation of a fibrinous membrane on the inner surface of the dura mater, into which there occur from time to time smaller or larger hemorrhages. Headache may pre- cede or follow a developing coma, or, if there is no coma, the pain in the head may be the chief symptom of the disease. It may be associated with nausea and vomiting. Generally the pain is very intense. It may be felt as a circumscribed area, and then sensitiveness to percussion, circumscribed, unilateral, or dif- fuse, is present. When the hematoma is located on the convexity, the pain on the diseased side frequently predominates. When the hematoma is localized at the base of the skull trigeminal neu- ralgia occurs, with other symptoms due to pressure upon the cranial nerves. The remaining symptom-picture of pachymen- ingitis is not at all characteristic. The etiology (alcoholism, in- fectious diseases, trauma, general paresis, senility, lues, and blood diseases, pernicious anemia, leukemia and scorbutus) is, above all, important. In classic cases an irritative stage, wdth delirium, precedes, and this is followed by the attack with coma, during which signs of increased brain pressure can be demonstrated. There are slowing and irregularity of the pulse^ changed breatL 180 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD ing, vomiting, contracted, sluggish or nonreacting pupils, choked disc, general crami:)s, bilateral deviation, etc. (see page 271). Symptoms which depend upon the location of the hemorrhage are hemiplegias, monoplegias, and unilateral and disseminated twitchings. The gradual increase and frequent change of the phe- nomena, with remissions and recurrences, are considered a charac- teristic. Hyperidrosis and elevation of temperature to 41° C. (105,4° F.) frequently occur. Leptomeningitis Purulenta. — Here there is an infiltration of the pia mater, especially on the convexity. This is at first serous and later purulent. There is also a serous infiltration of the superficial layers of the cortex. In the tuberculous form a gela- tinous, rarely purulent exudate first spreads on the base between the brain and the peduncles and extends from there in all direc- tions, especially in the sulci, reaching a marked degree, however, only on the convexity. Headache is so characteristic in this dis- order that one should not make a positive diagnosis if headache is absent. It is extremely severe, mostly continuous, but pa- roxysmally increasing. The headache is, as a rule, located (by the patient) in the entire skull, sometimes more in the forehead or in the occiput. The patient manifests signs of pain, even in coma, in spite of the deepest stupor. He grasps his head, and at times cries out loudly, especially, however, if one tries to move the head. In tuberculous meningitis the pain in the beginning has a dif- ferent character. It occurs only temporarily, is not so great in intensity, and only later reaches the great severity just men- tioned. Gradually there appear disturbances of the consciousness, delirium, and eventually coma. Stiffness of the neck (the head being drawn backward), stiffness of the muscles of the back, and boat-like retraction of the belly occur. Hyperesthesia of the skin and the muscles, restlessness, and jactitations are characteristic. Not uncommonly we find unilateral convulsion&, and^ less fre- quently, general ones. The patients conspicuously and rapidly become emaciated. In extensive involvement of the base of th^^ brain, involvement of the cranial nerves occurs, the oculomotorius. CENTRAL NERVOUS SYSTEM 181 the optic and also the acoustic being especially implicated. The fundus of the eye often shows the signs of neuritis. The tendon reflexes, which may be increased at first, are later usually lost, as are also the skin reflexes. Paralysis of the bladder and the rectum occurs only just preceding death. Chronic Anemia of the Brain (Chlorosis, Pernicious Anemia, Leukemia, etc.). — The headache in these diseases is usually not very severe, often consisting only in hyperesthesia of the head. It can be recognized, sometimes, by the fact that it grows worse "when the patient is in an upright position, and decreases when he lies down. Other signs due to anemia of the brain are the occurrence of fatigue, both mental and physical, after a small amount of work. Drowsiness, humming in the ears, stars before the eyes, vertigo, and an apathetic state may be present. All these conditions improve when the patient lies down (see page 272). Hyperemia of the Brain. — Congestions which consist of a sud- den aiflux of blood to the head cause pressure and sometimes pain, which increases with the pulse beat. Other symptoms con- sist of a feeling of heat, of throbbing in the face, vertigo, and disturbance of consciousness. These attacks, however, usually last only for a few minutes, sometimes an hour, and, in rare cases, several hours. The headache in venous congestions of the brain, ear lesions, struma, etc., is made worse by coughing and sneezing, as well as by the patient assuming the horizontal posi- tion, especially with the head drooping. The rest of the symp- toms are not unlike those in chronic anemia, i.e., apathy, drowsi- ness, vertigo, and slight mental confusion. Brain abscess originates from a suppuration transmitted from the skull. It may be of traumatic or otitic origin, or may arise from remote organs. In regard to the latter, a lung abscess, lung gangrene, or a pyemia may form the primary starting point. Headache is one of the earliest and most constant symptoms of brain abscess. It increases, especially during the development and the growth of the pus focus, to such a high degree that the patient constantly groans and behaves like a maniac. In the latent 182 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD stage the pain may be slight. These paroxysms of pain often last only for a few hours ; sometimes, however, they persist for days. The pain is of a boring, throbbing character,, mostly dull, either spread over the whole head, or is more severe on one side, prin- cipally on that which is the seat of the abscess. However, the localization of the pain does not always correspond to that of the focus. An abscess of the cerebellum, for instance, may cause frontal headache. A circumscribed area of sensitiveness, on per- cussion, furnishes a much more important clew to the localization of the focus. Coughing, sneezing, stooping, as well as fever, make the headache worse. Other symptoms of brain abscess due to the suppuration, are elevation of temperature, which does not show any characteristic course, and the not very infrequent chill. Retardation or irregularity of the pulse, changed breathing, optic neuritis (which occurs here more frequently than choked disc, and, indeed, more frequently on the same side as the focus), gen- eral convulsions and mental disturbances, chiefly in the form of stupor, depression, delirium, and eventually coma are later symp- toms. Rapid emaciation is often very conspicuous. Brain Tumor.- — Headache is one of the most frequent signs of this disease. In accordance wath the gradual growth of the tumor, the pain is moderate in the beginning and variable in its intensity. Later it becomes very severe, but still sliows exacer- bations, w^hich occur generally in the morning. They may be partly spontaneous, and partly due to an increase of blood pres- sure from pressing, coughing, sneezing, stooping, etc. During such paroxysms the patient may either lie in bed, gi-oaning, often perfectly apathetic, or he may run about in the room, pushing and knocking his head against the wall, and behaving like a maniac. Stupor that occurs in the later stage dims the severity ; yet even then one observes that the expression of the face is dis- torted, and the seizing of the head by the hands proves the con- tinuance of pain. The pain is, as a rule, diffused over the entire head ; sometimes it is unilateral, more in the occipital, or more in the frontal region. Sometimes the localization depends ujjon the position of the tumor, as tumors of the posterior cranial fossa, CENTEAL NERVOUS SYSTEM 183 for the most part, cause occipital headache, which may radiate into the shoulders. One must, however, not depend upon this entirely. More stress should be laid ujion the circumscribed sensitiveness on percussion, which, however, does not regularly occur, but only when the tumor lies quite superficial. Trigeminal neuralgia, especially of the first branch, is ob- served in tumors of the chiasma, cerebello-pontine angle, and pons, and may later be followed by loss of function of the nerve. Signs of pressure on the optic nerve are rarely lacking. Papilledema (choked disc) is seldom missed. It may be absent in tumors of the central convolutions, and of the first and second frontal con- volutions, but it is almost never present when foci are in the pons. Otherwise, however, choked disc, or its forerunner, optic neuritis, is one of the cardinal symptoms. It is mostly double sided, fre- quently more intense on the affected side. l\ot less important are the changes of intelligence and of the psyche. The patients think, speak and act more heavily. Soon they become stupid and drowsy. They fall asleep while they are still speaking, or in the midst of a meal. At such times they pass feces and urine involuntarily. Delusional ideas, ideas of persecution, and finally delirium may be present. Very frequently vomiting (of a cerebral type) oc- curs, with retardation of tlie pulse, which may here assume a high degree, and, after some time, usually passes into pulse accelera- tion (vagus paralysis). Giddiness is frequently complained of. It has not, however, been accompanied by rotatory nystagmus, which occurs principally in tumors of the cerebellum. Convul- sions and loss of consciousness occur paroxysmally, together or separately. Parallel with these general symptoms are the so- called focal symptoms. By direct focal symptoms we mean those phenomena which are the result of pressure on that area of the brain in wliich the new gTowth develops. Focal Symptoms of the Motor Region, — Here are found the results of irritation, paresthesias and spasms, which are fol- lowed later by paralysis. These three phenomena generally begin in one particular place, and then spread over the neighboring areas, for the most part in regular order (Jacksonian fits). The 1S4 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD order in which the individual groups are affected is a regular one, and extends from center to center, beginning, for instance, in the right foot, and extending to the knee, hip, shoulder, elbow, hand, and distribution area of the facial nerve. Consciousness is intact, at first, and only later becomes cloudy in attacks of greater intensity and longer duration. Correct observation of the muscle groups initially involved is of importance for the localiza- tion of the tumor. As a sequence of such a spasmodic seizure, but also unaccom- panied by a seizure, paralyses arise, which, in the beginning, are transient, but which later become permanent, and attack (like cortical epilepsy), little by little, wider areas, imtil finally they present the complete picture of a hemiplegia, with all its char- acteristics, namely, increase of the tendon reflexes, spasms, ab- sence of skin reflexes, Babinski, clonus, etc. Tumors of the frontal lobe produce motor aphasia if they lie in the left inferior frontal convolution. In tumors of the left second frontal convolution one sometimes sees, as a result of the disturbances of the innervation of the muscles of the buttock, uncertainty in walking and standing, and in turning toward the crossed side. As a remote effect upon the motor region, Jack- sonian epilepsy may occur. When the tumor lies in the temporal lobe, disturbances of hearing, such as buzzing and whistling, may occur. There may, also, be disturbances of smell and taste. Finally, tumors of the left first temporal convolution produce word-deafness, memory aphasia and paraphasia. Here, as a dis- tant result, are observed Jacksonian epilepsy; and further, from the action on the occipital lobe, crossed hemianopsia, hemianes- thesia, and hemiplegia. Tumors of the parietal lobe give rise to little that is char- acteristic (disturbances of muscle sense, crossed hemiataxia). In fact, as a rule, they produce only distant effects, by pressure upon the motor region (Jacksonian spasms), or on the occipital (hemianopsia), etc. Still more uncertain is the diagnosis of tumors of the cor- pus CALLOSUM, which, according to Ziehen, have paraparesis as CENTRAL NERVOUS SYSTEM 185 the only sign of any value. Apraxia is often present in tumors of this region. Tumors of the CE^^TRAL gaxgliox characterize themselves by disturbance of the inner capsule. Therefore, they cause hemi- plegia, which gradually arises if more of the anterior part of the capsule is affected, and hemianesthesia if more of the posterior part is affected. Hemichoreas, hemianesthesia, and unilateral tremors may result. When the corpora quadeigemina are the seat of the tumor, sight disturbances, hearing disturbances, and double-sided paralysis of the eye muscles of a muscular character form the clinical picture. With the disease, also, come disturbances of equilibrium on walking and on standing. Tumors of the pedunculi cerebri produce paralysis of the oculomotor of the same side, and of the extremities of the oppo- site side (hemiplegia alterans superior), oculomotor paralysis, with tremor, similar to that in paralysis agitans. If the CEREBELLUM is the seat of the tumor, this can be recognized, in most cases, by a few important signs. The most characteristic is cerebellar ataxia. The patient sways from one side to the other. Frequently, also, he complains of a genuine dizziness, in which objects seem to be moving around him, espe- cially upon sitting up. With this dizziness nystagmus is fre- quently combined. Vomiting is very common. It is also an im- portant symptom that the headache is localized, especially in the occipital region, possible in the nape of the neck, and that the choked disc, which is mostly bilateral, is seldom absent. Along with this are opisthotonic and tetanic contraction of the muscula- ture of the neck. As indirect local symptoms, the affections of the different cranial nerves, of the pyramidal tract (paraparesis, crossed hemiparesis, intentional tremor) and also the occurrence of hydrocephalus interna must be considered. Tumors of the poxs show slight development of general symptoms, and the absence of a choked disc almost as the rule. The most classic symptom is the hemiplegia alterans inferior. There is paralysis of the extremities of one side, with paralysis 186 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD of the facial, trigeminus, or abdiicens, of the other side, in which case, of course, all three of the above-mentioned cranial nerves may be affected. Very frequently, before the paralysis, very severe attacks of trigeminal neuralgia occur. Further, associated eye-muscle paralysis of the right rectus internus on the side of the tumor must be mentioned ; also in right-sided paralysis there is a simultaneous disturbance of hearing, through pressure on the acoustic nerve at its place of origin. Tumors of the medulla may run a symptomless course, but when they produce symptoms they are similar to those of tumors of the pons, with the exception that they injure deeper-lying cranial nerves, namely, the eighth and twelfth, causing disturb- ances of hearing, speech and deglutition, as well as paralysis of the extremity on the other side, singultus, diabetes insipidus, breathing changes, etc. If the tumor is seated in the thied ventricle, drowsiness and change of intelligence are usually prominent. Tumors of the base of the brain give rise to few general symptoms. According to Oppenheim, choked disc and vomiting frequently fail. Pain, on pressure, occurs in the bones which are in relation to the base of the brain. Bleeding from the nose and pharyngeal cavities also occurs ; and, above all, is to be considered the involvement of brain nerves in a certain combination corre- sponding to their topographical arrangement. Tumors of the hypophysis also produce few general symp- toms. Here, also, choked disc is frequently absent, and headache may be very slight. On the other hand, the eye symptoms (bi- temporal hemianopsia, amaurosis, eye-muscle paralysis, exoph- thalmos) and certain disturbances in development (hypoplasia of the genitalia, feminine habitus), as well as adipositus universalis and myxedematous skin, form the most striking symptoms. Tumors of the posterior cranial fossa often begin with humming in the ears, difficult hearing and disturbances of equi- librium. Associated with these is irritation or paralysis of the trigeminus, with absence of the corneal reflex (Oppenheim). In relation to this, as a result of the pressure on the surrounding CENTRAL NERVOUS SYSTEM 187 region, cerebellar ataxia, nystagmus and sight paralysis (Oppen- heim) occur. The patient complains of occipital and frontal headache and vomiting. Objectively, one very frequently finds choked disc and localized sensibility on percussion. Aneurysm of the Brain Arteries.- — Here the headache is also one of the general symptoms. It is generally described as throb- bing, and may be half-sided, as in hemicrania, diffuse, or be felt more in the occiput (in aneurysm of the basilar artery). Vomit- ing, dizziness and stupor (corresponding to the reduction of brain space) are present, while, on the contrary, choked disc is infre- quent. A pulsating vessel murmur, heard over the skull, is con- sidered an especially characteristic symptom. However, this is found in other diseases, and also in normal children. The develop- ment of the process is often very rapid. The localization is to be inferred from the local symptoms. Parasites of the Brain (Cysticercus Cerebri). — Headache^ with dizziness, is a frequent symptom; but the characteristic signs are localized attacks of cramps, due to the location of the cysticercus in a circumscribed area of the motor region. At- tacks of an epileptiform character, with psychic disturbances (im- becility, confusion, irritability), are present. The local symp- toms differ according to the seat of the parasite. Frequently there is a conspicuous change in the intensity of the clinical symptoms. A cysticercus tumor may be diagnosed if the possi- bility of infection has existed (association with infected individ- uals, ingestion of raw pork, etc.), or if the cysticerci are found in another portion of the body. The echinococcus also produces tumor phenomena. However, it is very seldom that one can suc- cessfully diag-nose it, since, in order to do this, an echinococcus cyst must be found somewhere else in the body. Hydrocephalus Internus. — Headache, in this case, is usually constant. For the rest, the disease picture is similar to that of meningitis purulenta, with the exceptions that the fever is not so high, the headache is less severe, and frequently a perfect cure occurs, with sequelae of eye disturbances. The differentiation is easiest made through spinal puncture. Chronic hydrocephalus 188 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD progresses, in most instances, under the symptom-complex of a brain timior, or a tumor of the cerebellum. According to Oppen- heim, two points for the differential diagnosis are to be taken into consideration: (1) whether there exists a deficient congenital development (abnormal size and form of the skull) ; and (2) the occurrence of remissions or of intermissions of a month's or of a year's duration. Syphilis of the Brain. — Anatomically the process consists either in the formation of tumor-like gummata or in changes of the vessel walls, especially of the basilar artery. A tubercular basilar, gummatous meningitis, starting in the region of the chiasm, is even more frequent. Headache is one of the earliest symptoms. It may occur months or years before other signs. !Nightly exacerbations, recurring at a certain hour, and disappear- ing at a certain time, are characteristic. During the exacerbation the patient suffers considerably by reason of the severity of the pains. In the intervals, however, the pain is bearable. It is mostly felt as a diffuse pain, situated deep within the skull. Sometimes it has a circumscribed border, if the process reaches the convexity. In these cases, also, a circumscribed percussion sensibility may be present. Other constitutional symptoms be- long to the picture of cerebral lues ; for instance, vomiting, dizzi- ness, attacks of unconsciousness, psychic disturbances, dementia, stupor and states of irritability occur in a paroxysmal manner, alternating with periods of normal consciousness. In addition to these, there is paresis or paralysis of the cranial nerves, especially the optic, and oculomotor- j)tosis is especially frequent. Any of the other cranial nerves may be involved in differing combinations. The repeated change in the intensity and the final complete dis- appearance of all the symptoms are typical. The onset of hemi- plegia, which develops in the course of one or two days without disturbances of consciousness, is a frequent symptom. Hysteria. — The headache, frequently felt as a dull pressure in the entire area of the skull, may often be localized to a cir- cumscribed place on the vortex, in the occiput, or in the temple. It is, as a rule, associated with hyperesthesia of the scalp, so that CENTRAL NERVOUS SYSTEM 189 the slightest touch or the least disturbance of the hair causes a pain which increases on pressure. Bodily and mental exertion and emotion may also produce increased irritation. The condition is improved by diverting occupations and during quiet and dark- ness. It may last for hours, days or months, and does not leave the patient even during sleep. The remaining hysterical symp- toms are of so many forms that they cannot briefly be given here. Neurasthenia. — Here, also, the intensity of the headache is not very great. It appears mostly as pressure and constriction of the entire head, the feeling often being strongest in the region of the forehead, and not seldom in the occiput. The patient also complains of a contraction, as though the head were bound with an iron band. The headache of neurasthenia is also produced or increased through great bodily or psychic irritation, or by emo- tions. Hemicranic Headache (Migraine) . — The real attack of headache is often preceded by symptoms which bear a certain re- lationship to it. Some patients, previous to the attack, feel lan- guid, exhausted, and are without appetite, or, on the contrary, manifest great hunger. As aura, Moebius designates certain, paresthesias, which may or may not precede the attack, namely, eye symptoms, flying bodies, glittering, narrowing of the field of vision (especially hemianoptic), and glistening scotomata; these may occur, for instance, as a light point in one or both eyes, which is diffused or travels across the field of vision in a zigzag line. Other forms of the aura are unilateral paresthesia, aphasia, con- fusion, states of anxiety, etc. The attack itself consists in head- ache of the severest degree. Generally it occurs after waking, with slight intensity, and gradually increases to an unbearable degree. It lasts for a few hours to a few days. Frequently it stops during sleep. There are patients in whom migraine attacks are of slight severity, and in whom light and severe paroxysms interchange. In the intervals, which may last for weeks and months, the patient feels perfectly well. The pain is mostly one-sided, but is also double-sided, usually in the forehead and eye region. Less frequently the occipital region is attacked. As 190 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD a rule, the paiu is located by the patient as deep iu the skull, and is of a boring or tearing character. The patient may say he feels as though his head were in a vise, as though it were bursting asunder, or as though it were being belabored with a hammer. The countenance of the patient during the attack is, in most cases, pale, although in some instances the face and conjunctiva are reddened. During the attack, also, the patient is very sensi- tive to all forms of stimuli. Noises, smells and lights increase the pain. Nausea and vomiting sometimes are accompanying symptoms, and, in most cases, the attack concludes with them. DIAGNOSIS OF HEADACHE IN DISEASES OF THE BRAIN AND MENINGES The character of the headache alone rarely permits an accu- rate diagnosis to be made. Yet each and every one of the cranial lesions enumerated have some features which predominate more or less. Thus, in cerebral lues, our attention is drawn to the night attacks. This is rare in other forms of brain disorder. Intensity. — The intensity of the pain varies greatly in dif- ferent cases. The severest degrees of headache are most frequently observed in leptomeningitis, then in brain-tumors, in abscess, brain-syphilis and hemicrania. Tolerable, though still severe, headache is found in pach^aneningitis ha^morrhagica interna, in some forms of headache in hysteria, and in aneurysm of the basilar artery. Headache due to neurasthenia and disturbances in the circulation of the brain is naturally not very severe. In the first-named gi'oup of cases (pachymeningitis interna hsemorrhag- ica) paroxysmal exacerbations occur, giving rise to very con- spicuous manifestations of pain. The patient groans, whines, and either shows dull apathy or jumps out of bed, runs about and presses his head. Pain of this severity, however, is only temporary, and the very manner of its occurrence, as well as the character of the free intervals, is important for the diagnosis in some cases. It has been noted that the paroxysms of pain in cerebral sypli- ilis may be expected with great probability during the night. CENTRAL NERVOUS SYSTEM 191 The pain appears at a certain hour after the patient has gone to bed, usually at the same hour every night. In the periods be- tween the paroxysms the headache is either of little intensity or disaj^pears entirely. The typical form of hemicrania is also characterized by its paroxysmal occurrence. After an aura of short duration, or perhaps without an aura, there appears the most severe pain, compelling the patient to lie down and keep absolutely quiet. Usually sleep puts an end to the attack, but frequently the pain appears in the morning after awaking. In this point, therefore, the pain differs from that in lues cerebri. Another feature may be used for the diagnosis of hemicrania, namely, that the pauses between paroxysms, w^hich may last for days, weeks, even months, are perfectly free of pain. During these periods the patient feels absolutely well. Paroxysmal exacerbations occur in other affections; for in- stance, purulent leptomeningitis, abscess, tumor, etc. These exac- erbations, however, appear irregularly, and the periods between the paroxysms are by no means free from pain. It is important to know that in cases of brain abscess the paroxysmal exacerba- tions of the headache appear usually during the development and growth of the pus foci; and, obviously, for this reason they are frequently connected with fever-elevations. BetW'Cen the varieties of headache characterized by their great intensity and the headache wdiich is described by the patient as hyperesthesia of the head (pressure or heaviness) there are scarcely any intermediate forms. The latter sort of headache is seen in neurasthenia, hysteria, and disturbances of circulation in the brain. It is characterized in most cases by its continuous course; although variations in intensity may occur, they do not show any feature characteristic of the condition. In most cases direct spontaneous paroxysms of pain do not occur, neither are there any periods perfectly free from pain; yet the feeling of pressure in the head does not leave the patient, even in his sleep. Moderate degrees of headache occur in pachymeningitis in- terna, prior to, or after a comatose attack, and also without any 192 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD coma. Here, also, there are intermissions of pain of varying duration, which cease on the onset of another bleeding. The headache in aneurysm and the paroxysms of headache in hysteria, which, as a rule, occur in the parietal region, are somewhat simi- lar to those in pachymeningitis, so far as their intensity is con- cerned. Localization of Pain. — Localization gives but few clews for diagnosis. True, there are diffuse headaches, unilateral headaches, headaches involving only the frontal region, as w^ell as those of the occipital region. Finally a headache may have* a circumscribed area ; but there is scarcely one of those localizations which might be looked upon as characteristic of any definite affection. Xot infrequently one finds all of these localizations involved in one and the same disorder. This may be the case in a brain tumor, for instance. Nevertheless, some affections predilect a certain region of the cranium. We know, for instance, that in migraine headache occurs most frequently unilaterally. Moebius states that among patients of his from whom he could obtain reliable state- ments fifty-seven had almost constantly unilateral headache, whereas twenty-five declared that they had felt it on both sides. Moebius doubts the reliability of the second statement. On the other hand, there are diseases in which unilateral headache is, comparatively speaking, seldom present ; for instance, in leptomen- ingitis, neurasthenia and in disturbance of the cerebral circulation. Frontal headache is observed in neurasthenia comparatively fre- quently, and the unilateral headache in migraine is often most in- tensely felt in or behind the eye. Pressure in the parietal region is frequently met with in hysteria, is mostly circumscribed and is accompanied by sensitiveness on pressure. In a comparatively large number of diseases the painful area is sharply circumscribed, a fact often noted in pachymeningitis, in brain abscess and in cerebral syphilis. This circumscribed pain is generally, also, associated with a circumscribed sensitiveness on pressure (the so- called sensitiveness on percussion). The tension of the pain helps less frequently than its localiza- tion in making a diagnosis. Certainly even here the greatest CENTRAL NERVOUS SYSTEM 193 caution is necessary ; for cases in which a tumor in the occipital region causes frontal headache are by no means rare; and it also happens that a tumor of the left side may give rise to pain felt in the right half of the cranium. If, however, a pain is con- stantly felt in one place, or, when generally diffused, it originates from one place, no mistake will be made if one locates the cause of the disease, be it a tumor or an abscess, in that region. Pain in the occiput or neck, radiating into the back, justifies one in assuming that the focus lies below the tentorium. We may as- sume, with great probability, that a lesion exists in the same area in which pain is present, if we have to deal with a pain con- stantly confined to one side, or to the frontal region. Of course one should strictly avoid depending upon pain, alone, in forming conclusions. To form a diagnosis, which often implies a great responsibility, all the other observations and examinations (which will be discussed later) must be resorted to. Character of the Pain. — The character of the headache tells us very little concerning its cause. Patients describe various kinds of headache in quite different ways, most frequently as dull, pressing, drawing, cutting, lancinating, constricting, driving asunder, roaring, pulsating, and throbbing. Since every form may occur, in very different intensities, there result an exceed- ingly large number which are of only very little value for the diagnosis. If there is a kind of headache to which we may ascribe a characteristic feature, it is the pulsating and throbbing variety. It is found most clearly pronounced in an aneurysm of the cerebral vessels, but also in hyperemia, and sometimes in cases of abscess. A knowledge of those external influences wdiich may cause an exacerbation of an already existing headache, or which are capable of producing headache, is more important for the diag- nosis than are the location and the character of the pain. It has been emphasized that, in those affections in which the sensitive area is circumscribed, an increase of the headache can be brought about on pressure, with the finger, or by striking with the percus- sion hammer. These affections are pachymeningitis, brain abscess, 194 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD cerebral syphilis and hysteria. There are other cases in which the headache gi'ows considerably worse by the increase of internal brain pressure, such as occurs in coughing, sneezing, pressing, stooping. This is the case in brain abscess, brain tumor, and passive congestion. Sometimes movement of the head increases the headache, especially in meningitis and migraine. In the latter, according to Moebius, movements of the eye have a much more unfavorable effect than those of the whole head. The upright position of the body has an unfavorable influence upon anemic headache, whereas horizontal position increases an hyperemic headache. Headache due to abscess, tumor and hemi- crania may be increased by alcoholism. In conclusion, it may be added that mental exertions and emotions are able to elicit and to increase headache in neurasthenia, hysteria and hemicrania, and the same factors may aggi-avate the headache in case of tumor. Influence of Therapy. — Diverting occupation, eating, and rest influence headache in a favorable way, especially nervous and hysterical headache. According to Moebius, however, they may alleviate, also, less severe attacks of migraine. This latter often may be cured or alleviated, without any other treatment, by removal of irritants (light, noise, etc.). By the observation of these circumstances, it will often be possible to draw, from the character of the headache, a conclusion as to its cause. A severe pain, for instance, which apjjears paroxysmally on one side, and which is favorably influenced by rest and ends with vomiting, may be looked upon with great prob- ability as hemicrania ; nightly exacerbations point to cerebral lues, whereas headache that occupies the cortex makes us think first of hysteria. It is not the task of the diagnostician, however, to make the diagnosis from one single symptom, but eventually he will utilize, in making the diagnosis, all the signs of the disease. In the following lines, therefore, we will discuss all those factors by which the individual affections of the brain and spinal cord may be differentiated; and for the sake of completeness those CENTRAL NERVOUS SYSTEM 195 affections Avill be discussed here which are not accompanied hy jDain. DIFFEEEXTIAL DIAGNOSIS Brain Abscess. — If tlie analysis of the pain has shown that we have to deal with a brain abscess, the following conditions will come into consideration for the differential diagnosis: Beaix Tu:mok. — Against this would speak the etiology (with the exception of traumatism, which also may cause a tumor), the fever, the chills, and the comparatively more rapid course (weeks to months). A well-marked, choked disc (optic neuritis occurs also in an abscess), as well as the better-marked phenomena of pressure, in general, would indicate tumor. Leptomexixgitis Purulexta. — This takes a course even more rapid than abscess — days and weeks. It shows high fever and acceleration of the pulse (in case of abscess only low grades are observed), hyperesthesia of the organs of sense, of the skin and muscles, involvement of the cranial nerves, scaphoid retrac- tion of the abdomen, and rigidity of the muscles ; whereas optic neuritis, retardation of the pulse, less stupor and a negative result of lumbar puncture, i.e., a clear puncture-fluid, rather speak in favor of a diagnosis of brain abscess. Leptomexixgitis Serosa. — This occurs either as a primary affection, or as an accompanying symptom of an otitis media. It may heal spontaneously. In addition to this, the greater fre- quency of a choked disc and of disturbances of sight would speak against brain abscess. Otitis Media. — This may cause diagnostic difficulties by the occurrence of cerebral symptoms, but can be recognized by the disappearance of the latter on removal of the pus. ExTE.yDURAL Abscess (In Sequence to a Suppuration of the Ear). — This is indicated by the presence of focal symp- toms and the absence of local signs, i.e., the absence of the inflammatory swelling and painfulness in the region of the mastoid process. Sinus Thrombosis. — Here are found, in contradistinction to brain abscess, pyemic fever and acceleration of the pulse, com- 196 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD plete absence of any disturbance of consciousness, more frequent occurrence of choked disc, and externally a thrombosis of the jugular vein in the neck. On the other hand, focal symptoms speak for the presence of an abscess. Hemorrhages into the Meninges. — When caused by trau- matism, they proceed without any fever, and follow directly after the injury. Migraine. — Against it speak both etiology and absence of fever. Traumatic ISTeuroses, Hysteria and Neurasthenia. — They may occur as concomitant symptoms of a brain syndrome, or may be independent affections, and only simulate these. Brain Syphilis. — This is mostly accompanied by the loss of pupillary reaction to light, and can be surely diagnosed by the positive result of Wassermann's reaction and of antiluetic treat- ment. Leptomeningitis. — In the differential diagnosis of leptomenin- gitis quite a number of diseases come into consideration in which focal symptoms always decide in favor of meningitis. Pneumonia^ Typhoid Fever and Pyemia. — Rusty sputum and dullness over the lungs speak for pneumonia; gradual devel- opment and the positive result of Gruber-Widal's reaction speak for typhoid fever ; retardation of the pulse, stiff neck and paraly- sis of the cranial nerves, as well as the intense headache, continu- ing also during the coma, speak for meningitis; frequent chills, skin and rectal bleeding, and joint swelling speak for pyemic condition. Brain hemorrhages^ embolus and thrombosis^ as well as encephalitis ilemorrhagica never cause fever-elevations of such a duration as seen in meningitis. Otitis media is confused with meningitis principally because the ear trouble is followed by a serous leptomeningitis. As such a serous meningitis often can be differentiated from a purulent one only with difficulty, a differential diagnosis can be made in most cases only by the disappearance of the meningeal symptoms after the evacuation of the otitic focus. CENTRAL NERVOUS SYSTEM 197 In uremia, albumin and formed elements, as a rule, are found in the urine. The SEROUS form of meningitis is, as above mentioned, diffi- cult to differentiate from the purulent form. In most cases the fever is less. Delirium Tremens, — Stiff neck and the extremely severe headache speak against it. Tuberculous meningitis occurs in early childhood (2 to 14 years). It does not set in in such an abrupt manner, and shows frequent remissions (of temperature, stupor, etc.). In children the stomach and intestinal disturbances may cause symptoms similar to those of leptomeningitis, and may give rise to confusion in diagnosis. However, the influence of the diet and the action of a purgative will soon clear the diagnosis. Brain Tumor. — Hysteria may be differentiated by its head- ache, spasmodic attacks and hemiplegic paralysis. Choked disc and focal symptoms will guide us here, but it must not be for- gotten that both affections may occur together. The possibility of influencing the condition psychically speaks for hysteria. In case of a tumor we find also, during the acme of the pain, retarda- tion of the pulse and vomiting. These are found in hysterical headache, only when it occurs on one side. Concerning migraine^ which might give rise to confusion by the severity of the headache and vomiting, we must be guided by the history (heredity in migraine) and by the presence of choked disc and focal symj)toms in tumor of the brain. Paresis often comes into review in the diagnosis of brain tumor. The clinical symptoms may be very similar. A positive Wassermann, a positive cell count, and a positive globulin reac- tion almost certainly speak for paresis and against a brain tumor. In paresis choked discs are not frequent. The attacks of cortical epilepsy occurring in both, and which in the external manifesta- tions are similar, usually leave little permanent palsy in paresis. Multiple sclerosis comes into consideration in affections of the cerebellum, of the pons, and of the corpora quadrigemina, which likewise produce intention tremors, nystagmus, spastic 198 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD ataxia, as well as paretic s^inptoms in the extremities. To these must be added the occurrence of atrophy of the optic nerve, if they are accompanied by brain symptoms. However, the general symptoms of the tumor, such as severe, continuous headache, the retardation of the pulse, vomiting and stupor, do not belong to the clinical picture of multiple sclerosis. In epilepsy, which has a certain similarity to tumor in its paroxysmal character, the gen- eral symptoms will facilitate the differential diagnosis. Pachymeningitis Haemorrhagica Interna. — Differential diag- nostic points speaking against pachymeningitis are either the en- tire absence of stiff neck or the presence of a slightly stiff neck, as well as the rare involvement of the basal cranial nerves; how- ever, both signs occur also in pachymeningitis, if it is located at the base of the brain. Cerebral hemorrhage frequently is with difficulty differen- tiated from pachymeningitis. The absence of the above-described symptoms would lead to a consideration of a hemorrhage into the brain substance; and the change of symptoms, the choked disc and the intercurrent appearance of convulsions to that of pachy- meningitis. In EMBOLISM and thrombosis elevation of temperature is rare in the later stages, and phenomena of brain pressure are absent. Migraine may also come into question in the basal form of pachymeningitis. Inherited predisposition, as w^ell as a rapid course without fever, speaks for migraine. THALAMIC PAINS AND THE THALAMIC FUNCTIONS' While central pains, probably due to lesions in and about the basal ganglia, were first suspected by N^othnagel, it is chiefly to the studies of Dejerine and Roussy that we are indebted for the clearing up of the question of pains due to lesions of this region. Dejerine and his students have shown that lesions of the thalamus, especially of certain of its nuclei, proauce a character- ' Written by Dr. Smith Ely Jelliffe, New York, U. S. A. CENTRAL NERVOUS SYSTEM 199 istic picture, the thalamic s^Tidrome (Jelliffe). in which severe and persistent pains form a prominent part. These pains usually involve the side of the body on which the lesion takes place, and are noted for their severity, their per- sistency, and their resistance to analgesics. The entire picture of the thalamic syndrome is so character- istic that its somewhat — at first sight — anomalous symptoms should be given in detail. This is all the more important since many patients with the thalamic syndrome are thought to be ma- lingerers or hysterical. The usual thalamic syndrome begins, as a rule, with a mild apoplectiform attack. It may be severe, or it may be so mild as to escape ordinary observation. After a certain length of time, the motor weakness of the early slight or severe hemiplegia disap- pears entirely, or to a greater or less extent. The patient has some difficulty in managing his hand and leg, and it appears to be dif- ferent from the hand of the well side. Then pains are felt on the affected side. They may at first have been only uncomfortable sensations in the skin of the side; they usually take the form of acute shooting pains, and may be in the entire half of the body, or may be limited to the face, to the upper extremity, or to the lower limbs. They rarely cross the middle line, although in double thalamic lesions both sides of the body show painful distributions. The nerve trunks are absolutely painless; they are not swol- len, and careful search for Valleix's or Trousseau's points is unavailing. There is nothing to point to a neuralgic or a neuritic process. These pains stab and jump and throb, and are complained of as excruciating. The ordinary analgesics do not touch them ; even morphin is unavailing, at times, in checking their severity. ^Notwithstanding these severe pains, it may be that careful sensory examination shows that the patient is unable to distin- guish pain at all. This anomalous condition is further compli- cated by the fact that a pin prick which cannot be recognized a? a pin prick, the patient being unable to tell the difference between the head and the point of a pin, is nevertheless felt as a disagree- 200 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD able sensation. Here, then, is the apparent absurdity of a patient who cannot tell pain, yet has a disagreeable sensation when pinched, still suffering excruciating pain. Not only may the patient be unable to tell a pin point from a pin head, but he cannot recognize the difference between heat and cold, and burn- ing sensations, recognized on the sound side, are translated as dis- comfort only on the thalamic side. He also loses superficial sensi- bility. The touch of cotton wool is lost. Furthermore, these pa- tients have lost their deep sensibility. The position sense is gone, and they fail to recognize objects placed in the hand. The rough- ness of a lump of sugar may be interpreted as a disagreeable sen- sation, but is not recognized as roughness. Moreover, these patients sliow slight motor incoordination in the hand or leg; they are ataxic, and more or less choreiform or athetoid-like movements are present in the afflicted side. In some patients there are residual signs of a hemiplegia; slight spasticity, perhaps; slight clumsiness, increased radius- periosteal reflexes, triceps reflexes ; perhaps lost abdominal reflexes on that same side; increased patellar reflex, a clonus and exag- gerated Achilles jerks. A Babinski extension of the great toe is often absent, but may be present. Chaddoch, Gordon and Oppen- heim's signs vary considerably. The motor synergistic phe- nomena, described by Babinski, Grasset, and Hoover, are all apt to be present. One feature of special moment found in thalamic lesions and which has been emphasized by Head and Holmes is an excessive response to affective stimuli and the change in behavior in states of emotion of the abnormal half of the body. Thus, in many eases of pure thalamic lesion, if a pin be lightly dragged across the face or trunk, from the sound to the affected side, the patient exhibits intense discomfort when it passes the middle line. He not only complains that it hurts him more, but the face may be- come contorted. JSTotwithstanding this, he is unable to tell the difference between the point and the head of the pin. The same type of over-response is found to other forms of stimuli. Thus deep pressure, which cannot be measured at all, also ev^oket CENTRAL NERVOUS SYSTEM 201 an over-response ; the same is true for extremes of heat and cold, in spite of the fact that the patient is imable to distinguish be- tween them. Visceral sensibility, scraping, roughness, vibration and tickling all show this over-response in the affected side. Not only are painful stimuli over-reacted to, but pleasurable stimuli occasion a like over-response. Furthermore, in states of emotion, there may be different manifestations on the two sides of the body, just as painful and pleasurable stimuli may produce a stronger reaction on the affected side. Thus some patients can- not hear music without its causing sensations in the affected side, or even causing motor unrest, movements of the leg with shaking. The choreiform movements, which are notable motor features, under the influence of emotional stimuli may be markedly in- creased. From this it can readily be seen that the thalamic syndrome is a most important clinical picture, and that its more careful study is bound to throw considerable light upon the whole ques- tion, not only uj^on the subject of pain-perception, but also upon emotional attitudes to all forms of stimuli. In fact, it opens the way to the most important of all of the questions taken up in this book. Through the study of the thalamus the entire sensory side of the human organism will be revealed, and it may readily be seen that sensory neurology will be the neurology and possibly the psychiatry of the next decade. Thus far the study of the thalamus has shown that it contains the terminations of all of the secondary sensory paths. In it sensory impulses of every kind are regrouped and again redis- tributed. This redistribution takes place not only within the thalamus itself, giving us thalamo-thalamic paths, but it also goes to the cortex in a fairly large series of thalamo-cortical paths. The thalamo-thalamic j)aths seem to pass to important centers, constituting what Head and Holmes have termed the "essential organ" of the thalamus which forms the main center for certain fundamental elements of sensation. It is a center which is com- plementary in function to the sensory cortex, and has distinct though related functions. The lateral part of the thalamus con- 202 PAIN IN DISEASES OF THE NERVES, BRAIN, AND CORD tains the cortico-thalamic paths through which the cortex influ- ences the essential center, controlling and checking its activity. Analogous, in a way, is the activity of the motor cortex upon the anterior horn nuclei of the medulla and spinal cord. The ex- cessive response to affective stimuli, pain as well as others, is due to a removal of this cortical control, just as an excessive motor reflex reaction recurs when the pyramidal tract does not bring down cortical stimuli from the motor area. The activity of the thalamic center is of special import in our study of pain, for it has been pointed out that in lateral thalamic lesions there is an actual overloading of sensation with feeling tone. The pains and paresthesias, found in many thalamic cases, have been thought to arise from "irritative" lesions, but this is probably not so. It would seem that the thalamic center is a true center for perception of sensations, including pain, and that the cortex has a definite relationship to these, so that it may modify the affective response and naturally, thereby, the motor responses. The essential thalamic organ is a center for conscious perception for certain elements of sensation. It responds to those stimuli which are capable of evoking pleasure and discomfort or con- sciousness of a change in state. The feeling tone of the body, which has often been termed the somatic or visceral tone sensa- tion, is a thalamic function. What the interrelations between the thalamus and the cortex are, so far as sensation is concerned, need not detain us at this point. We have chosen to isolate, for the purposes of our treatise, that sensation known as pain, therefore a discussion of the whole question would be somewhat out of place. Yet, a word should be added as to the cortical function in sensation. The sensory cortex permits a concentration of attention on any part of the body which is stimulated. Such stimuli are passing through sensory paths to the thalamus. Many of low threshold value pass to the cortex or are automatically taken care of by the thalamus. Those of high threshold value pass into the essential organ of the thalamus and into consciousness, where CENTRAL NERVOUS SYSTEM 203 they bring about a tendency to excessive reactivity, just as the anterior horn cells of the cord react excessively if uncontrollo 1. The sensory cortex gives a quick reacting mechanism to dampen down the affective response to thalamic over-activity. This leads us to an interesting deduction made by Head and Holmes, in the study herein freely made use of, that the aim of human evolution is the domination of feeling and instinct by discriminative mental activities. This struggle on the highest plane of mental life is begun at the lowest afferent level, and the issues become more sharply outlined the nearer sensory impulses approach the field of consciousness. In the accompanying table an attempt is made to simplify the diagnosis between a cerebral (sensory) cortex lesion and one of the thalamus. The defining factors are obtained principally from the work of Head. !z; c a ►J < g o O Sensation present, but the response of the patient to the same stimulus shows a want of uniformity and irregularity of response, so that at one time he may respond to a pressure of 100 gm. and at another 21 gm. may produce on the same spot a response. Tendency to persistence of sensation so that an interrupted stimulus may seem to be con- tinuous. Hallucinations of touch, owing to the persistency of stimulus sensation, may occur. Fatigue quickly results in the part supjjlied by the affected area. That is, the part may re- spond to pressure of 30 gm., but will not to 100 gm. Sensibility to touch by cotton wool is never lost over hair-dad parts. No change in the threshold to measurable pain- ful or uncomfortable stimuh. No increase or decrease of response to painful stimulus. iz; c a o M May be lost on affected half of body. In all cases the objective pain, when present, is defi- nite and the threshold of response is con- stant. Objective pain lost in half of body. Subjective pains are present in the same side of the body as the lesion. They are persistent, paroxysmal, often are intolerable and yield to no therapeutic measures. There is a tendency to react excessively to unpleasant stimuh, such as the prick of a pin, painful pressure, excessive heat or cold ; on the affected side these produce more pain than on the normal side. Though in some cases the threshold of response may be lowered, it requires a less stimulus pressure on the affected than on the normal side to pro- duce pain. This does not of necessity apply to the stimulus produced by a prick, which may have no reduced threshold. o CM a; 1 3 s 204 Cd > d '_2 " ^V ^ ^ 2 <=> "» g 6 s -f^'S £ So o 0) '^ o 02 P c3 S2 .5 "^ O ;3 OJ 't^ d (^ i^ -^ ^ i c ms CM <3J fe _r O c3 §^ fe "C^S.ci « ri-° b _ g c3 O o ^ b o o ?" 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"3 « -4-3 G OJ 1 p-l 03 G a; 03 u -4^ g a; :5 iz; o n H o .2 3 o3 ^^ -'•^ 03 -o^ ^ § C.2 Si fi > "-S '^^^ >>'■§'" «2 -i^ ^--s ™-*^ 03 03 03 3 !h a;.*^ «-g 1) c aJ ■^ °=3 £ a '^^ ^45 3't3 ^ M ^ G £ O-^ =2 « CO ft p +J 03 Vhh +J -u > .bcg o § G -a o 1 .2 1 ■g § o bC .s G 3 G ,o b3 ■a e3 1 CO G bC O a 2: fl (d 0- IB O 111 n i- "3. a o .£"3 a, '-^ a a 5 0-5 3 St^ cd t lU cj S i a < > a fl ;s Q O K S a a o p 0* fl .a «1 ■< s o Q < a p. 1 a " S «g5f^g " "u >- 0) "o 6 a ;z; fl % oi a a 0- •a g '3 0, IS = S fl ,•„ .S" 'S "3 Si fl '3 bO m fl % -< a a) >>i C3.Q t (t! si ;z; H •< rS Co — 3 3 is OJ -^ ... Q d S g 6 fl fl _>. "3 \ +3 fl 3 a 2: C3 c fl-g g1 o .2 H-4 ■2 "2 is"o — Ml a a " "0 £ fl ■2 a fc s «2i .S .a _>>o'3 "3 '- « 1 fl fl u 0) 1 0- a^ «■' £ ? ,r 0^ S Jog CO o H a. "5 a. C X. ■c c a . 1 "0 fl .0 3 "a .9" '3 3 i c3 Q ,g "3, S •S •0 fl « 3 " > X 260 THE THYMUS AND THYROID 261 dance of abdominal fat." On examination of the abdominal wall one is sometimes impressed with the excessive tenderness which is present. The Mesenteric Glands. — The mesenteric glands, even though enlarged, do not of themselves cause much pain, unless the enlarge- ment is excessive, when, by encroachment upon neighboring struc- tures and interference with their function, they may indirectly be the cause of pain production. In tuberculosis, when the mesen- teric glands reach an enormous size, the patient often complains of aching and distress, or, as frequently expressed by negro sub- jects, "a misery in the abdomen." This misery becomes an acute pain, should the gland, becoming degenerated and caseous, sud- denly rupture and cast its contents into the peritoneal cavity. The pain now assumes the characteristics of that due to general peri- toneal irritation. The Thymus and Thyroid. — The thymus and thyroid are en- tirely without pain production, unless they become acutely in- flamed, when pain phenomena appear. Frequently in thyroid tumors and in disease of the gland pain is felt in the occiput, in the shoulder and back of the ear, due to irritation (pressure) of the posterior auricular. In one case pain was complained of over the second dorsal spine. In Hodgkin's disease pain in the arms is very common, be- cause of the pressure exerted upon the nerves in the axilla. In the same way pain may be felt in the lower limbs from pressure upon the anterior crural nerve by enlarged inguinal glands. CHAPTER XIV EEGIONAL PAINS As an aid to a quick orientation of the canse of pain which is felt in a special area, the body may be divided into different re- gions, as the head, neck, arms, chest, abdomen, and the extremities. Each of these will be fully discussed under special headings, but at first a brief, general review of the different pains in these regions and their significance will be undertaken. THE HEAD The head is a most important localizing center for pain, for it seems that here all the aches and ills of the human body converge to bring torment and suffering to the unfortunate individual. Head pain is partially considered under headache, which includes the pains felt in the cranial part of the head, but headaches do not include face pains. These are very important, as they in- clude one of the most sinister of all human ills, namely, trigeminal neuralgia (tic douloureux). Its pains occur in the forehead, the cheek and over the lower jaws. There are well-defined spots of maximum tenderness, which are shown in the drawings. Of other important causes of face pains, sinus disease probably ranks next. These sinus diseases include the frontal, ethmoid and an- trum of Highmore. When any of these structures is affected, pain is complained of by the patient, and at the same time tender- ness is marked over the diseased area. Should tenderness not be present in the area in which the patient complains of pain, it indicates that the pain is a referred pain from some distant region. 262 S ^"5 § gB 1 l§ M JgljJ! 00 S 05 oid ach d tipati asthe al car med se of erof t c3 Typh Stom Cons Neur Dent Otitis Disea Cane 3 >> .2 3 t"*- S? '■S 5f g 2 o 2-E "^^^ S >> ►2 S ^mo2;2;HQM^h:^Ma«oQ£ 03 a 1 03 o a a o 'P t/J o fa o . 03 2 .2 S ■a tZ3 o > O "o a o o CO o a 1^ .a "2 •is < O Si 3 o .a a 03 '^ r; 03 o 03 a; 0) ^ ^ 03 O 1— 1 2 o a a > O > 03 s a H s sh a^ "o. s d " o § ^.a> 3 03 Antrum dise Neuralgia, 2 Entire scalp Rheumati tofront o 0) ft «2 ,20 263 264 REGIONAL PAINS A good example of this is pain in the temples, referred from carious teeth. Reference to Figures 61 and 62 will do more to localize these different pain areas and their significance than an entire volume of description. Head pains referred (reflected) Lithemia Anemia Neurasthenia Ovarian Mental tire Infectious diseases Typhoid Influenza Malaria Small-pox Meningitis Brain tumor Coryza Toothache Supramaxillary inflammation Neuralgia Inf. dental branch Fig. 62. — Pain Areas in the Head. 4 Epilepsy Uterine disease Pregnancy Anemia Meningitis Ovarian disease Hysteria 5 Migraine man- ner of radia- tion 6 Arteriosclerotic headache ■7 Ethmoid. Ar- rows indicate the direction of radiation 8 Orbital headache Typhoid fever Eye strain Anemia Inflammation of eye 9 Point of ten- derness in in- f r a-o r b i t a 1 neuralgia 10 Antrum disease 11 Point of tender- ness in mental neuralgiH Periostitis inf. from abdominal and thoracic organs are described in the chapters under their respective headings. The most important of the local head pains is headache, or, as it should be called, head pain. When a patient complains of headache, he should always be asked, "Is it a pain, or is it only a sense of pressure ?" If it is a sense of pressure, the consideration will be entirely different from that of true head pain. Sense of Pressure in Head. — Edinger has graphically dis- cussed this condition, especially in its relation to neurasthenia. He notes that "the pressure is felt in the top of the head, and is espe- cially severe in the morning. It generally continues all day, though it may lessen toward night. This head pressure, which is THE HEAD 265 not a pain, is particularly a characteristic of tired persons ; those who have overworked, either physically or mentally, and those whose hours of labor are too long or too continuous ; those who are hereditarily weak ; and those who have suffered from severe dis- ease (influenza) and have exerted themselves too soon thereafter. If the sensation is described by the patient as a pain, head- aches should then be considered. Head Pain. — In the diag-nosis of headache it is well to ascer- tain first whether the pain is unilateral or bilateral. If it is bi- lateral, it generally is an indication that the underlying cause is of systemic origin, while if it is unilateral, as a rule it is an in- dication that the cause or causes acting to produce it are also uni- lateral in their origin. Where headache is unilateral, it is always wise, before making a more extended search, to examine the head for local causes, such as inflammations, or to examine the organs located in or associated with the skull, such as the eye, the ear, the nose, the teeth, and also the throat, which in many cases is at fault. The following outline of the principal causes of head pain may be of value in the diagnosis. The classification used is based upon an anatomico-physiologic basis. Accord- ing to this, head pains may be divided into two great classes: (1) those of extracranial origin, and (2) those of intracranial origin. Head Pains of Extracranial Origin. — Extracranial head pains are caused by lesions of the skin, muscles, tendons, bones, and nerves. The shin includes the epidermis and subcutaneous tis- sues, and is the seat of pain in neuralgia and superficial inflam- matory lesions. Excessive weight of hair may be the cause of severe and chronic headache. The muscles are the seat of pains, the result of such metabolic disorders as occur in rheumatism, gout and diabetes. Inflamma- tion likewise may be a cause of local pain. In this connection it is well to mention a condition described by many Avriters, in which headache is due to indurative processes, occurring in the muscles of the bead and neck. Edinger claims that, though 266 REGIONAL PAINS almost unknown, the indurative variety of head pain is probably the most common of all headaches. In those suffering from it, it is found that at the insertions, or within the bodies of the muscles of the head and neck, there appears a thickening w^hich at first is transient and then later becomes constant. This thickening, prob- ably of chronic inflammatory origin, irritates tlie sensory nerve fibers supplying the part, and thus produces pain. The pain occurs in parox- ysms, which may be brought on by emotional disturbances, physical or mental fatigue, sudden exposure to cold, in- sufficient drying after wash- ing the hair, a stay in bad- ly ventilated places, and the approach of damp or chilly weather or storms. The par- oxysms are least common in summer and most frequent Fig. 63. — Figure Illustrating the in the fall and the spring. Places Where Induration Takes i^ ^he development of the Place. These areas are tender to pressure. induration three stages can be defined. In the first stage a swelling of a soft, yielding consistency, often present in the bodies of the muscles, makes its aj^pearance. A puffiness to the touch is now felt at this point; then, in a short time, a slightly elastic resistance develops, as though some organization had taken place ; and finally an induration, in which there is an absence of elasticity, occurs. Organization has now advanced to the stage at which a substance of cartilaginous consistency presents itself to the examiner. The older these thickenings are, the harder they become and the more resistant they are to treatment. The symptoms are characteristic. Attacks of pain occur, which at first are slight and infrequent, and then gradually be- THE HEAD 267 come more frequent, greater in severity and longer in duration; Sometimes they are of a dull, aching type, and are almost con- stant; again, they are sharp and fleeting. They occur in various parts of the head, the location depending upon the site of the local enlargements, over which they are usually found. They may, however, radiate to other joarts. Local pressure often gives relief. Before an attack the enlargements become swollen and sensitive. The symptoms associated with this disorder are the marked susceptibility of the patient to colds, depression of spirits, and to mental torpor. Gastrointestinal disturbances, toxic in character, occur, and spasms in the leg-muscles and myalgia in different parts of the body take place. Ilypersensitiveness of the teeth and a pyorrhea alveolaris are also seen, and on forcible twisting or turning of the neck there is intense pain at the insertions or along the bodies of the neck-muscles. Local tenderness over the sites of the enlargements almost always is present. • It is most common at the insertions of the trapezii, scaleni, splenii and sternomastoid muscles. Hypersensitive points are often found round the base of the skull, from one mastoid process to the other, and on the spinous process of the cervical vertebrje, j^articularly the upper cervical vertebrae. The supraorbital region also is often involved. These indurative headaches are to be diagnosed from: (1) Meningitis, in which fever is present and induration and hyper- sensitiveness are absent. (2) Migraine, in which sensitive aura are present, indura- tion and local hypersensitiveness are absent, nausea and vomiting are present, and no relief comes from massage. While hereditary migraine begins in early youth, indurative headache appears in later life. (3) Bone diseases, such as inflammation, caries, gummata and tuberculosis should also be carefully diagnosed, as they often give rise to local head pain and indurative areas. A careful study of the general symptom-complex will often clarify the situation. As a rule, though, the indurative headaches are very common. They are very easy to differentiate, because of their local character. 268 REGIONAL PAINS That long-continued contraction of a gTonp of head-muscles may cause pain is possible. Thompson (630) describes such headaches which arise from the long-continued contraction of the occipito-frontalis muscle, as the result of a strong sensory impres- sion, coming from the eyes, ears, or other channels of sensation. They may, however, be produced only as a result of the irritation of cold and strong winds. Nerves. — The head pains due to nerve involvement are to be classed under neuralgias and neuritides. There is also a local irritation which has not progressed to the stage of inflammation. Neuralgia, which means nerve pain (for a complete descrip- tion see under Neuralgia), is a rather frequent cause of pain in the head. In it pressure points can be found, corresponding to the emergence of sensory nerves from the skull. The nerves most frequently involved are the trigeminal and the cervico-occipital branches of the cervical plexus. Neuralgia is frequently the result of wasting diseases, malnutrition, exposure, poor hygienic condi- tions, rheumatism, gout, diabetes, anemia, chronic malaria and acute infectious disease. Neuritis, a somewhat allied condition, differs from neuralgia in being a much more active inflammation of the nerves or nerve sheaths. In it the nerve is painful to pressure, muscular twitcli- ings occur, and, if the condition continues long enough, a final atrophy and paralysis of the related muscles may result. Head pain may also be induced by the products of metabolism/ which act locally upon the muscles of the scalji and produce pain by irritation of the sensory nerves in the same manner as it is produced in gout and rheumatism. Especially is this liable to happen should the resistance of the muscles have been previously reduced by exposure to cold or drafts. In neuralgias and inflam- mations there is always a certain amount of associated hyperes- thesia, the affected part being, in many cases, exquisitely tender. In addition to headaches due to local causes are those which are the result of conditions present at a distance from the area in which pain is felt. These are classified as projected, reflex, or re- ferred headaches. Projected headache is the result of pressure THE HEAD 269 upon the cranial nerves, either in their extracranial or intra- cranial course. Such pressure may be due to tumors, caries of bone (especially caries or periostitis of the bone at the foramina of exit) and to foreign bodies. Reflex headache is due to a stimulus carried through the nervous system from some distant organ. In these headaches the action is upon the nerve centers, or nerves, either indirectly through adjacent nerve centers, or directly by the action of irri- tating bodies (toxins of disease and organic or inorganic poisons). The fifth nerve seems to be especially subject to irri- tation from extraneous causes, and the part that seems to be most commonly affected is the Gasserian ganglion. Referred headache is the result of a reference of stimuli along associated or related nerve pathways, as is exemplified in the frontal headache following immediately after the drinking of ice- water, etc. Head Paixs of Intracranial Origin. — The intracranial causes of headache are : Meningeal changes, functional and or- ganic; cerebral toxemia; cerebral anemia; cerebral congestion; increase of cerebrospinal fluid. Meninges as a Cause of Headache. — Stretching and pressure exerted on the meninges is the most important cause of headache,^ and produces the most severe and persistent pain, as in cere- bral tumor ; here, owing to the general increase of pressure from the growth, the headache is apt to be diffuse. However, when the cortex membranes are involved, the pain becomes localized ; and this localization is of the utmost value in defining the site of the tumor. The general cause of meningeal stretching and traction is pressure from underlying structures. The piaarachnoid is prob- ably not supplied with sensory nerves, and it is very likely that its only nerve supply consists of those supplying the blood vessels. Therefore, in cases of leptomeningitis, it is the congestion inci- 1 The meninges seem to be almost insensitive to the ordinary stimuli, as when the skull is opened under local anesthesiae they may be touched, pinched or cut, without the patient complaining much of pain, 270 REGIONAL PAINS dental to the inflammation that causes pressure upon the dura and its nerve filaments, and so produces pain. Stretching and pressure on the meninges may also be caused by an increase in the cubical contents of the cranial cavity, such as occurs by an increase in the brain substance from new growths, abscesses, and increase in the fluids of the brain (blood and cere- brospinal fluid). Increase in brain substance is foimd in new growths, such as tumors of the brain. These cause pain by increasing the intra- cranial pressure. This they do in two ways: (a) by an increase in the intracranial contents, which, owing to the pressure of their mass, cause an increase in the intraventricular pressure, and (b) by raising the intraventricular pressure, either by shutting off the means of exit of the intraventricular fluid by blocking the foramina of communication between the ventricles and the suba- rachnoid spaces, or else, by pressure on the veins of Galen. A loose fibroma in the lateral ventricle may also act as a plug and thus prevent the escape of cerebrospinal fluid, and cause intoler- able headache, optic neuritis, coma and death. Pain, in some cases, in which the tumor is cortical or sub- cortical, is produced by the growth pressing directly upon the meninges, and in this way squeezing the terminal nerve filaments incorporated in its substance. Tumors of the posterior fossa of the cranium probably cause the most pain. Diagnostic symptoms of tumors of the brain are pain, which, in cerebral tumor, owing to the general increase of blood pressure from the growth, is as a rule diffused. When the cortex mem- branes are involved, the pain becomes localized, and this locali- zation is of the utmost value in defining the site of the lesion. When the pain becomes circumscribed, it is most often confined to the forehead or to the occipital region. Accompanying the pain there are disturbance of sensation and motion, choked disc, rigidity of the pupils, vomiting of a projectile character (with an entire absence of gastric symptoms) and dizziness. Sometimes symp- toms of headache may be almost entirely absent in brain tumor, a? in a case reported by Edinger, in which, on autopsy, a tumor THE HEAD 271 was found in the Island of Eeil of a patient, who had had head- ache only a short time before death. Brain tumors may be syphilitic, tnberculons, hydatid, carci- nomatous, sarcomatous, or osseous formations within the cranial vault. Brain abscess causes headache in the same manner as do tumors. Organic Meningeal Changes. — Organic meningeal changes due to adhesions, inflammations and hemorrhages cause head- aches. Adhesions between the dura and the cranium are often the cause of severe pain, localized over the affected area. Local- ized head pain may also be caused by syphilis and trauma, or it may be the result of inflammation. The inflammations causing these headaches are of two types : (1) Pachymeningitis interna, which is very common in old people, and quite frequently accompanied with small and minute hemorrhages. The headache frequently is introduced by vomit- ing, which sometimes occurs in paroxysms, wntli brief intervals. Occasionally it is combined with a disturbance of consciousness or of paralysis of some cranial nerve (see page 180). (2) Acute meningitis gives rise to an increased blood pressure, which, in turn, causes an outpouring of serous fluid into the meninges. This produces pressure on this membrane and on the terminal sensory nerve filaments. It may also cause headache by involving the nerve filaments and meningeal endings in the inflammatory process. Toxemic Headaches. — These are due to: (1) Exogenous poisons, as alcohol, lead, iron ether, nitroglycerin, amyl nitrite, or arsenic, and (2) endogenous poisons, as the toxins of pneumonia, typhoid fever, influenza, small-pox, chronic gastritis, chronic Bright's disease, diabetes, cirrhosis of the liver, cerebral syphilis, gout, hyperthyroidism, starvation, and possibly diseases due to alimentary disturbances. Toxins act by altering the intracerebral pressure through their action on the vasomotors and possibly also directly upon the sensory filaments in the meninges. In addition to the reflex head pain, some slight sluggishness of intellect is gen- 272 REGIONAL PAINS erally associated Avith these conditions, and this may progress to delirium. Of the toxemias the starvation products due to nutritional defects, caused bv anemia, are the most frequent cause of head pain. The head pain which they produce is mostly of local origin and has been ascribed to a lack of nutrition of the trigeminal nerves, or, according to Xeuman, to a disturbance of the brain cortex. This disturbance leads to pain. This manner of pain pro- duction explains why the headache is relieved when the patient reclines, for, in doing so, he increases the blood supply to the brain and incidentally the nutrition. Anemia. — The diag-nostic criteria associated with anemic headaches, which, in a way, are starvation headaches, are pain, generally vertical, and made easier on the patient reclining; pal- lor, especially marked on the lips ; disturbed sleep ; drowsiness ; edema of the ankles ; drooping of the eyelids ; and feeble carotid pulsation, a symptom which is of great diagnostic importance. Lenhartz (Munich Med. Woch., 1876, Nos. 8-9) showed that the headache and dizziness of chlorosis are associated with an in- crease in the subarachnoid pressure ; therefore, it is this increase in pressure and (in many cases) not the anemia which is the cause of the headache. Congestion. — Cerebral congestion seems to be a true cause of headache. Edinger claims that the headache of migraine is of this type, i. e., that it is due to a vasomotor congestion. For the expla- nation of the causes of these headaches, see under Vasomotor, Paralytic Headache, which is described under Headache of Chronic Origin. Cerebral congestion leads to on. increase in the amount of fluid in the hrain. This increased amount may be the result of an increase in the amount of blood in the b^'ain substance (edema), or in the quantity of the cerebrospinal fluid. The increase in the amount of blood in the brain is the result of an increase in the intracranial blood pressure, or of venous congestion. Increased arterial pressure in the cranium may or may not be associated with increased (systolic mean) arterial pressure, THE HEAD 273 In some cases an increased arterial supply to the brain is due both to an increased heart action and to an interruption to the return flow through the venous channels. Some causes of increased intra- cranial blood pressure, which may, in certain conditions, incite head pain, are the following : stooping, lifting weights, sitting up suddenly, lying do^vn quickly, the horizontal position, hard strain- ing at stool, physical exertion, running and extreme heat. Predisposing F actors.- — There are certain factors wdiichreflexly act upon the blood vessels or the vasomotor centers and cause such a lessening in control that slight causes, wdiich otherwise would have no action, act upon the cerebral centers, and lead to a cerebral congestion. These factors are mental excitement, anger, or men- tal labor (severe), acting as a reflex cause of neurasthenia, which in turn acts principally as a predisposing factor in headache pro- duction. Other reflex and clinical factors are found in alcoholics, coffee and tea drinkers, and in those suffering from fevers. Sun- stroke and rapid chilling of the surface, as in colds, also have the same effect. In come cases there is a further lessened resistance to the above acting causes, because of a vasomotor ataxia due to nicotinism (Schmidt). In headache due to increased intracranial arterial pressure the pain generally is of a throbbing nature, the throbbing being due, perhaps, to a backward and forward flow of the cerebrospinal fluid. The pain is accompanied by a fulness of the head especially marked on coughing or on any sudden exertion. A flushed face, injected eye grounds, general irrita- bility, sensory disturbances and increased heart action also accom- pany this condition. There is also a form of arterial congestion due to a vasomotor paralysis in which pain is present in all parts of the head, but is especially severe on the top and in the temples, where it seems as though the head would burst. There is also a painful sense of pressure behind the eyes, which seem to bulge forward. Periods of freedom from pain intervene; then there are recurrences, often just before the menses, or when the atmos- phere is heavy. In headache due to general hyper hlood-tension, Matthew (Quarterly Journal of Medicine, 1909, II, 261) found that a 274 REGIONAL PAINS reduction of about 30 mm. Hg in the blood pressure was almost invariably followed by an alleviation of the head symptoms. Another cause of hypertension headache is the local increase in blood pressure, the result of inflammation, as in meningitis. Here the pain is generally associated with a slow, strong pulse, though no rise in the mean arterial pressure may be noted. In this it differs from aortic regurgitation, which also causes headache, but in which, although there is a sudden strong pulse (high systolic pressure), the mean arterial pressure is reduced. A third cause, the result of cerebral arteriosclerosis, is the elevation in the cerebral systolic pressure, which may be high, though the mean arterial pressure may be normal. Moleen writes : "Of the general symptoms of cerebral arterio- sclerosis, headache stands first. It is usually dull, not throbbing, and quite often is described as a feeling as though a tight band were compressing the head. It occurs most frequently in the morning after walking about, and diminishes as the day advances, except in syphilitic arteriosclerosis, in which it is usually most severe at night. Dizziness, or vertigo, as a symptom, is next in importance to pain. I^umbness, tingling, twitching, weakness in a limb, or in one-half of the body, and disturbances in articulation are also common." Headache may be caused by increased venous pressure^ as well as by increased arterial pressure ; or both may interact to produce increased intracranial pressure. Headaches of the first type are present when there is any obstruction to the return circulation, as in tricuspid regurgitation (which produces back pressure), thyroid enlargement (producing static back pressure), sinus thrombosis, and paroxysms of coughing. Tight neck bands and epilepsy (Knowlton) may also cause headache. General Consideration of Hypertension Headaches. — Hypertension headaches are very severe and usually are badly borne. It is most likely that in all hypertension headaches there is a supersensibility of the nerves supplying the dura, and thus more cognizance than normal is taken of changes in intracranial pressure. In these headaches the pain is eased by the patient draw- THE HEAD 275 ing his head far backward and burying it in the bed clothes. If the neck-muscles are in a state of tonic contraction, we may pre- sume the lesion causing the condition to be of an inflammatory nature, probably one affecting the meninges. If this is the case, bending the head forward seems to increase the pain, and rotation is also ]3ainful, the pain being in the nape of the neck, and fre- quently on the side opposite to that toward which the rotation has taken place (Schmidt). Swallowing, as well as lying down, at times causes pain. The patient often attempts to fix the head with the hands, so that movement cannot take place. Hyperten- sion headaches are quickly relieved by the taking of a purgative. This would hardly happen if the headache were due to a toxemia, in which case the headache would last for some little time, un- til the toxic material could be removed. Xow, it behooves us to ask, how a purgative so quickly relieves the headache. It is rea- soned by Schmidt that intestinal stasis causes meteorism, and that this in turn causes "stasis in the superior vena cava and in the cerebral veins through the restriction of the respiratory venous aspiration" ; and purgation causes a revulsion in this condition, and a normal respiratory circulatory activity. He also remarks "that the important part played by normal intestinal "peristalsis in facilitating the venous circulation in the jDortal district must not be forgotten. The headache may be temporarily increased if the act of defecation is accomj^anied by considerable straining" (Schmidt, p. 43). A point of value in diagnosing increased ven- tricular pressure is that the pain of increased ventricular pressure is always referred — while that due to meningitis or tumor (menin- geal), etc., is always localized to the area involved. Associated with hypertension headaches are changes in the fundus of the eye, such as dilatation of the veins, hemorrhage into the retina, and choked disc, all of which are due to mechanical agents. There are also present mild inflammatory lesions, partly due to obstruction of the lymphatic return flow. Pressure points (see Neuralgia, Fig. 44) can often be dem- onstrated in the area of distribution of occipital-trigeminal nerves. Hiccoughs, vomiting, abnormalities in pulse and respiration, pos- 276 REGIONAL PAINS sibly due to vagus involvement, are also found. The spots seen dancing before the eyes are due to optic nerve involvement, while the buzzing in the ears is the result of involvement of the audi- tory nerve. Increased intracranial pressure is often evidenced by a visible distention of the veins of the brow or of the scalp. The degree of stasis may be fairly well judged by the magnitude of the dila- tation of the venules of the upper eyelid (Gushing). Where in- creased intracranial pressure is present, repeated examination of the urine should be made in order to detect, if possible, the presence of a nephritis. Among other associated symptoms of tension headaches are great debility, disinclination for any kind of work, anorexia, and distressing dreams with fright on awakening. Actual hallucina- tions are occasionally present ; edema of the cortex of the skull sometimes occurs ; red blotches at times cover the entire surface of the body, and the strise of the skin, which are produced by stroking with the finger, often persist much longer than the normal time. Thunderstorms aggravate or initiate the pain. Headaches of this variety should be diagnosed from those due to brain tumor by an eye examination. Choked disc is present in tension (tumor) headache, and is absent in vasomotor paralytic headache. Head pain may also be due to an actual, as well as a relative, increase of the cerebrospinal fluid. This increase may be local- ized to either the meninges or the ventricles. Increase in the men- ingeal fluid without an accompanying inflammation may be due to anemia (such as chlorosis or constipation with acetonemia). Increase in the ventricular fluid may be caused by an increased production of the fluid, or, if the production of the fluid is normal, by a blocking of the foramina of exit (Foramen Magnus or the Ac- queduct of Sylvius), which causes an accumulation of fluid in the ventricles. Accumulation of fluid may occur in any of the cavities of the brain, from a blocking of their foramina of exit by new growths, inflammatory exudates, or foreign bodies. That a foreign body may cause such an obstruction is proven by the many reported cases in which the removal of an extraneous THE HEAD 277 substance, such as a bullet from a position in the brain where it was producing obstruction, relieved the pressure and cured the headache. Angioneurotic hydrocephalus is also a cause of head pain which is due to an accumulation of the cerebrospinal fluid in the ventricles. Cerebral compression may also be the cause of an internal hydrocephalus, and thus cause head pain. Gushing, in speaking of cerebral compression the result of tumor growth, says that he succeeded in demonstrating, in the dog, that the longitudinal sinus may completely colla2:)se at an early stage of compression with a venous stasis of high degree. If there is increased tension, from any source, a similar collapse may be pro- duced in the sinus rectus, with stasis in the vena galena, and this produces an internal hydrocephalus withoi:t direct implication of these vessels by pressure from a neighboring growth. This in- ternal hydrocephalus produces pressure and traction on the dura mater which results in head pain. Reflex causes of headache are the last to be considered, but they are not by any means the least important. Reflex headaches are due principally to organic disturbances of the uterus, ovary, eyes (iritis, glaucoma, chronic eye strain), sinus disease (nasal and frontal), hemorrhoids, decayed teeth, digestive disturbances, and toxic disturbances. The reflex headaches are due to irrita- tion of the nerve centers, and owe their presence to circulatory changes in the brain. Under reflex headaches it is also proper to consider headaches which follow intense irritation of the organs of special sense, for in many cases headaches follow a loud noise, exposure to an in- tense light, or a strong and disagreeable odor. These headaches are probably reflexes from the centers affected to the centers of the cutaneous area in which the pain is felt. Hunger headaches are due to a lack of nutrition in the brain cells of the cerebral cortex (in reality toxic headaches). This condition is common in children. Headaches which follow excessive venery are probably due to cerebral fatigue. To the same class belongs the headache which follows loss of sleep, such as occurs in those who have been 278 REGIONAL PAINS up all night, or in those who have missed an accustomed mid- day nap. Disturbance of the brain substance from worry, etc., may cause some change in the molecular structure of the cortex, and this, in turn, produces reflex circulatory disturbances, which may be the cause of pain. Associated symptoms of such a state, according to Drein, are malaise, irritability, digestive and visceral disturbances, nausea, confusion of ideas, and vertigo. Hysteria Carious teeth Cerebral arteriosclerosis Ear disease (Furunculosis) Parotiditis Pharyngeal diaeaae Tonsil disease ronsillar gland is at this point Maximum pain in angina pectoris Fig. 64. — Locations of the Principal Headaches. Neuralgia of the cortex is also given as a cause of headache. As neuralgia means but an increased irritability of the sensory centers, or of the nerves conducting sensation and is used more to define a functional lesion, it may not be entirely proper to apply the term to the condition in which pain is produced by a cortical organic irritative lesion leading to lessened resistance and increased susceptibility. We find an increased suscepti- bility of this kind in neurasthenia and allied depressive states, in which a bright light, a thunderstorm, etc., will produce THE HEAD 279 headache. It is also held that there is a headache caused by an irritation of the cerebral cortex by toxic materials, such as was claimed by the older writers (Boerhaave, Van Sweten) to occur Referred pain from vertebra Caries Tumors Arthritis deformans Meninges — meningitis Malignant disease (sarcoma) of vertebra I Aneurysm of vertebral artery Elevation of the intracranial pressure, as in: (1) Hydrocephalus (2) Nephritis Fig. 65. — Figure Illustrating the Locations of the Principal Head- aches. The back of the head and the nape of the neck are supplied by: 1. Occipitahs major, which lies toward the mid-line and which is a branch of the 2d cervical nerve which passes through between the axis and atlas, and may be easily injured, owing to the great mobility of these parts; it is also affected in tuberculosis of this region; therefore pain would be felt in the occipitalis major area of distribution in disease of either the atlas or axis. 2. Occipitahs minor, which lies more laterally. 3. Auricularis magnus, which supplies the posterior Surface of the ear. Occipital head- ache pain begins at the junction of the skull and the cranium and runs up the back of the head to the vortex or laterally to the back of the ears. in rheumatic headaches. These headaches are of a mobile char- acter, and occur at various parts of the cranium, being especially common in the occipital and frontal regions. The pain seems to be well within the skull, and pressure on the surface does not modify its character as is the case in rheumatism of the scalp. 280 REGIONAL PAINS The muscles of the neck are more or less rigid, and the movement of the head is painful. Conditions of cold and dampness influence Fig. 66. — Occipital Headache. the head symptoms the same as they influence rheumatic affec- tions of the joints. Fig. 67. — Frontotemi'ural Headache. In many painful lesions of the brain the skin over a cer- tain area of the head is very sensitive to pressure. This is THE HEAD 281 thoiiglit to be due to the relations existing between the nerve filaments of the meninges and those of the scalp overlying the affected area. Diseases producing reflex headaches are : brain abscess, chronic appendicitis, gall stones, chronic gastritis, intestinal de- rangements, etc. The menstrual period also is often ushered in with a severe headache. In the accompanying drawings the locations of the principal headaches are given ; and since these locations can be illustrated much better than described, the latter has been thought unnec- essary. (Figs. 61, 62, 63, 64, 65.) Fig. 68. — Temporal Headache. In almost every case of headache the patient tries to ease the pain by making pressure on the head. This is illustrated in figures 66, 67, 68. Diagnosis of Headache. — The following may be of use in the diagnosis of headaches : Origin. — First, ascertain if the headache is of recent or of remote origin. If it is of recent origin, examine for : (1) Acute infectious diseases in which the pain may be the result of a direct action on the pain-conducting trigeminal tract, 282 REGIONAL PAINS or due to an elevation of the intracranial pressure. The most common infectious diseases causing head pain are influenza, ty- phoid fever, tonsillitis, and the acute exanthemata (measles and scarlet fever). . (2) Injury (traumatism). (3) Toxemia: (a) endogenous (hepatic torpor); (b) exogen- ous (constipation, drugs). (4) Intracranial lesions (meningitis), either tuberculous or septic. In either case, the characteristics are a constant pain, in- terrupted by paroxysms of greater severity, and increased by movement or on the taking of food or drink. Vomiting and nausea occur in the absence of the ingestion of food. In some cases, when the intracranial pressure becomes high, optic neuritis follows. Tuberculous meningeal headaches, as a rule, are frontal or occipital (Taylor, 632). Probably the headaches of all the acute diseases are due to toxic causes. While headache is a common accompaniment of all acute infectious diseases, yet some, as pneumonia, may be entirely free of headache throughout their whole course. Remote Origin. — If the headache has been of a chronic type, a knowledge of the relative frequency of the different forms of chronic headache may aid greatly in forming a diagnosis. Accord- ing to Edinger, two-fifths of the chronic headaches are of the in- durative type, two-fifths are of the migraine type, and one-fifth consist of other types. The majority of all headaches are in the frontal region. In our examination of structural changes, as a cause for chronic headache, we begin an examination of the dif- ferent organs in the following order: (1) The eyes produce the so-called ocular headaches. In these headaches the pain is, as a rule, more severe on using the eyes. Brooks thinks that the principal eye conditions giv-. ing rise to headaches are errors of refraction, by which an excessive amount of work is thrown upon the ciliary muscles; want of balance between the external muscles of the globe; and retinal hyperesthesia, in which the retina is very sensitive to light. Ocular headaches are usually located over the middle of the eye- THE HEAD 283 brow and the pain radiates into the back of the eye ( Jessop, 634). (2) The nose ^ causes a pain that lies to the inner side of, and extends higher on the forehead than the pain due to eye strain. The nasal conditions causing headache are stenosis (chronic ob- struction due to foreign bodies, rhinoliths, tumors, hypertrophy of the turbinate, bending of the septum), vasomotor alterations, epi- staxis, sinns involvement. lodid coryza should also be thought of, especially in those who are undergoing treatment for syphilis. The cause of the headaches in cases of nasal obstruction seems partly at least to be due to the lack of oxygen, because it has fre- quently been found that patients suffering from recurring head- aches, or from neurasthenia, are immediately relieved of the trouble by the removal of some obstruction in the nose or sinuses. Turbinate headache is usually periodic, depending on the inter- mittent swelling of the mucous membrane covering the surface of the anterior end of the turbinate. Sinus involvement may cause severe pain; for in one of Hartman's cases trigeminal neu- ralgia, due to this condition, had persisted for weeks, the pain being so intense that sleep had been impossible. The most diverse treatment had given no relief. All pain vanished im- mediately after the maxillary sinus was evacuated of the cheesy matter with which it had been filled. In other cases supraorbital neuralgia, which recurred every day at a certain hour, was the result of inflammation in the frontal sinus, and was cured by appropriate treatment. The pain may be due to the inflamma- tion itself, to compression from secretions, or merely to rare- faction of the air in the sinus. The trouble may not be due to an inflammatory process, but merely to the occlusion of the sinus, by which communication with the air is shut off. This is a com- paratively frequent occurrence, and is liable to cause distressing pain. Opening a communication into the nose banishes the pain at once (Hartman). A particular variety, met most frequently by Thompson (488), and associated with old fractures of the nasal bones, seemed to begin at the roof of the nose and to pass * See page 342, Nasal Stenosis. 284 REGIONAL PAINS horizontally backward to the occiput. It was always aggravated by prolonged bending forward of the head, as in writing, and had a special tendency to cause incapacity for mental work. (3) Diseases in the accessory nasal sinuses are also causes for headaches. The sinuses affected are the frontal, antral, eth- moidal and sphenoidal. Headache due to disease of these sinuses is generally relieved by the discharge of pus or mucus from the nose. In these conditions, the seat of pain is generally frontal, although most authors believe that it bears no special relation to the site of the disease. Lack (623), however, holds that the head- ache due to sphenoidal sinus involvement is "referred to the back of the head and then radiates down the back of the neck." That due to the ethmoid is found in the frontal region, in the eyes, and deep in the head behind the eyes; while that due to the antrum is found over the molar bone and may extend upward to the temporal region. He also states that the frontal sinus headache is most severe at the "top of the head over the posterior part of the frontal bone." The original location of the pain is generally continued throughout the disease. (4) The ears, in many cases, cause head pain. The prin- cipal causes acting upon the ears to produce head pain are anemia and mastoid disease. (5) The alimentary tract gives rise to headache. Various forms of mouth disease, gastrointestinal disorders, intestinal para- sites, constipation, dyspepsia, and cholelithiasis may be the cause of severe pain in the head. Dull, generalized headache and coated tongue are due to indigestion. (6) In kidney lesions the pain is felt particularly at the back of the head, and radiates down the neck. Torticollis and disease of the vertebrae should be eliminated. (7) Brain tumors and abscesses are common causes of headache. The location of the pain often corresponds with the site of the tumor. Sometimes the pain is increased by pressure. It may not be constant, but generally it is periodic. Cerebellar tumors commonly are on the side opposite to that in which the headache is found. Tumor headaches are caused by the pressure THE HEAD 285 of the growth obstructing the vena magna galeni or the aqueduct of Sylvius (Schmidt), both conditions lead to increased intra- ventricular pressure. The location of a brain tumor cannot be diagnosed from the situation of the headache. For a fuller con- sideration of these headaches, see page 182. (8) Psychical strain will produce severe headache. This is likely to be frontal, and generally is the result of long-continued worry or severe mental effort. A headache of this character is Influenced most by psychic states. Mental effort gi-eatly in- creases it. In this it differs from a headache due to increased intracranial pressure, which is most influenced by mechanical factors, such as change in position of the head and body, bleeding from the nose, or blood-letting. (9) Between lead poisoning and gout, and the uric acid diathesis, probably there is a close relationship. All these pro- duce headache. (10) The headache of anemia is due to a hydremic hydro- cephalus, with a consequent rise in the intracranial blood pressure. Elevating the head often causes great relief. (11) Cerebral arteritis: Of the general symptoms of cere- bral arteriosclerosis, headache stands first. It is usually dull, not throbbing, and quite often is described as a feeling as though a tight band were compressing the head. It occurs most frequently in the morning, after walking about, and diminishes as the day advances, except in syphilis, in which it is usually most severe at night. A peculiarity worth noting in this class of patients is that, even though arteriosclerosis is present, there is also a lowered blood pressure, which is probably the result of secondary cardiac weakness. It averages from 110 to 130 mm. Hg. The causa- tion of the headache can be explained from the fact that, since the cerebral arteries are terminal arteries, a sclerosis of the coats would cause a narrowing of the lumen, which would produce an anemia of the cortex of the brain. The anemia, of course, would then produce headache and giddiness. Why there should be a systemic lowered blood pressure, is difficult to explain. The patient should also be questioned in regard to the con 286 REGIONAL PAINS stancy of the lieadache ; that is, whether it is intermittent or per- sistent, and then, if it is intermittent, whether the intermittence is regular (periodic) or irregular. Intermittent Headaches (Periodic Type). — According to Edinger, two-fifths of all headaches from wliieh patients suffer are of the periodic type. The most important, as well as the best known, of the periodic headaches is migraine. Two types of migraine are recognized : (1) The reflex migraine, which begins later in life than does the true variety, and is dependent principally upon a non- inherited, peripheral cause. In this class of cases there is no evi- dence of a neurosis in the family, and the headache becomes worse instead of better in middle life. A preliminary visual spectrum is absent. The headaches are warded off by purgatives and laxatives, while, in contrast, the true migraine headaches are not influenced by such means, but are lessened by phenacetin. The principal causes of reflex migraine are eye strain, constipa- tion, and intestinal toxemia. These headaches may also be pro- duced by peri2:)heral factors, as injury to the nerve following a blow on the head, or a fall, in which the third nerve has been damaged. In some cases, after recovery from a head injury, a patch of meningeal thickening may remain and cause head pain. In this form there is sometimes a recurrent third nerve paralysis, and the patient is attacked by severe headache lasting a day or two. The third nerve recovers its functions in the course of some weeks, A visual spectrum rarely develops. (2) In the hereditary form of migraine there is a distinct history of the heredity. Generally some member of the family has been a sufferer from this condition. If none has been affected with headaches often there is one member who is subject to attacks of epilepsy, neuralgia, etc. Migraine appears in adult life and may be caused by prolonged debilitating diseases. An individual attack is frequently induced by the menses, which it may precede or follow, a prolonged railway journey, a close, badly ventilated room, great heat, emotion (as anger), excitement, the use of a small quantity of alcohol or tobacco, unusually early awakening, THE HEAD ' 287 omission of a meal, or strain of the eyes, especially if the strain is on the ciliary muscles. Migraine gives rise to a throbbing j^dif^- It begins with dis- comfort and gradually increases until it is agonizing in its severity. It generally begins over one eye and then spreads to the forehead and the side of the head. It is increased by bending over, by noises, or by any sudden exertion. Eating may also in- crease it. Drinking alcoholic beverages and smoking make it worse. Strong light augments the distress. Because of all these, the patient generally seeks a quiet and dark room and lies very still. A symptom almost pathognomonic of migraine is scintillating scotoma, which appears before the pain commences. The scotomata appear as floating dark spots in the visual field, the borders of which are often serrated and illuminated. Some see only the illuminated edges of the spots, and may complain of dulness of vision. The individual paroxysm of pain may last for a few minutes, or an hour, while the period of attack may last for a few hours or all day. The premonitory symptoms of migraue are lassitude, irritability and incapacity for arduous work. They often appear in the evening before the attack, while on the morning of the attack the patient complains of numbness in the head and an ex- tremely tired feeling. The pain begins gradually, and is felt deep in the head, with a sensation as though the head were split- ting. There are also a burning and a sense of pressure in and behind the eyes. The pain, as a rule, is unilateral. It is asso- ciated with a feeling of distress. Loss of appetite and cold feet are often present. The physical signs associated with migraine are: a generally pale face (though it may be red), injected con- junctivae, narrowed palpebral fissure and contracted pupils. The contraction of the pupils is an important differential sign, as in all other conditions where severe pain is present the pupils are dilated. Vomiting, as a rule, finally occurs, and when it does the headache ceases. True migraine is the most important and commonest of the 288 REGIONAL PAINS forms of periodic lieadache. The severe pain in the head seems to be due to an increase of the intracranial pressure. The hemian- opsia, the dimness of A'ision, the numbness in the tongue, cheek or arm, and the temporary aphasia are all suggestive of sudden ar- terial constriction in the cortex.-^ Vomiting is also a most char- acteristic sign of elevation of intracranial pressure. Brunton is also in accord with the arterial constrictive hypoth- esis, for he claims that the pain of migraine is due to a con- traction of the peripheral part of the temporal artery, and a dila- tation of the proximal part. He noticed that in every case of migraine the carotid was widely dilated, while in many cases the peripheral part of the temporal artery seemed to be contracted, and in other cases dilated; but, in every case, the little branch which turns upward on the forehead was found to be firmly con- tracted. Pressure upon the carotid would oftentimes relieve the pain, which ceased as long as the pressure was maintained, but returned as soon as the pressure was removed. Pressure upon the carotid artery of necessity produces pressure upon the pneumo- gastric nerve, causing great disturbance to the respiration, with a "feeling as though the entire chest were contracted, or as though someone were pressing down with a giant's weight upon it." Therefore, pressure on the artery, because of these symptoms, cannot be long continued. These views of Brunton are in accord with the opinions of Edinger and Harris, who also think that migraine is accompanied and conditioned by a contraction of the peripheral arteries. While as yet no vasoconstrictor nerves can be found in the brain, the pale eyegrounds, the general vascular spasm which causes dizzi- ness, and also the occasional disturbances of speech all seem to confirm the anemic hypothesis. Another idea of the cause is ex- pressed by Jelliffe, who follows Spitzner in believing that migraine is due to an absolute or relative stenosis of the foramen of Monroe. According to the same authority, an occasional hyperemia of the 1 Although cerebral arterial constriction has been given by many authors as a cause of increased intracranial pressure, it seems to me that the arterial constriction does not cause a congestion but an anemia, and that phe primary condition is not an arterial constriction but a dilatation. THE HEAD 289 brain leads to a hyperemia of the choroid plexus. This, in turn, causes a greater narrowing of the foramen, and an increase of tension in one or both ventricles. This causes a still further con- gestion of both choroid plexuses, and increases the narrowing. The vicious circle continues until the pressure is relieved or the tension is reduced by a shock reaction, such as occurs in vomiting, or in the use of the vasodilators. According to Levi and Rothschild, there is also a migraine due to a diminished secretion of thjroidin. These doctors have succeeded in ameliorating seven cases of migraine with thyroidin ; and in their description of thyroid migraine they say that "the existence of this affection is evident by the migraine being re- lieved with thyroidin ; by the hypothyroid signs we meet in people suffering from migraine ; by the autotherapy of preg-nancy ; by the influence of female sexual life (puberty) on the appearance of the affection; by the paroxysmal crises (during menstruation) of the affection; and by their cessation at the menopause. Thyroid migraine symptoms do not differ from those of common migraine. It is either precocious or tardy, hereditary or acquired ; unilateral or bilateral; syndromic or symptomatic. It may last only some hours or days, but is always paroxysmic." " Other causes of periodic headaches are, malaria, syphilis, habit, hysteria, lymphatism. If the periodic headache is due to malaria, there is some malarial history. Chills, fevers and sweats occur, an enlarged spleen can be palpated, and plasmodia can be found in the blood. In headache due to syphilis, the pain, as a rule, occurs at night, and is usual after excitement. Hahit Headache.— If a periodic headache occurs at the same time of the day or week, examine for some disease or habit, in the history of the patient, which would be likely to bring on headache, or to act as a predisjDosing factor in its production. Inquire into the manner of work, sleeping, eating, etc., of the patient. Hysterical headache may be present, in which case there are other signs of the hysterical involvement. 290 REGIONAL PAINS Ross speaks of a form of headache which he calls the lymphatic headache. He describes it as having the following characteristics : (1) It is present, and most severe, on walking, and tends to lessen in intensity, or altogether disappear, in from one to six hours. (2) It usually manifests itself as a dull, heavy ache, or as a frontal or temporal throbbing. Less frequently it is occipital, vertical, or unilateral. Infrequently, also, it is neuralgic. (3) In its typical form it is exceedingly chronic, often of several years' duration, and most intractable. It is the common, occasional headache to which most people are subject. (4) It is associated with a deficient coagulability of the blood. The posliDxs assumed by patients suffering from the different varieties of headaches are illustrated in Figs. GG, G7 and 68. In all of these headaches, the principal factor sought by the patient seems to be the application of pressure over the painful area. This, in nearly all cases, relieves the pain; so it is possible that in these headaches the pain is a superficial pressure phenomenon (skin, muscles, etc., of scalp), and that pressure applied over the area of local pain removes the congestion and thus relieves the pain. Hyijeralgesic zones of the head, according to Ilannsa (G2b), frequently occur in lesions at the base of the skull. The most common of these are the result of bullet wounds of the skull, basilar fractures, and concussion. The zones may lie in the area of distribution of the second to fifth cervical segments — or in the distribution area of the trigeminus. Ilannsa, as well as Wilms, Milner, Vorschiitz, Clairmont, etc., claim that the cause of these zones is a lesion of the sympathetic. In this connection, also. Head has observed that most of the viscera cause pain which is referred both to an area in the body and, in many cases, also, to one in the head, where it is expressed as tenderness. Head found that these areas were associated with certain visceral areas of tenderness. These associations are given by Head in the table on page 295 (Head, Brain, 1894, p. 4G4). — ^i >« ^ >« « , h O t- 3 2 a 5 a 8 b§ 2 lU 3 . « o 9) u a 1 1 2 ■^ .at* a feg 00 cS 3-2 03 o 0. 12 )r laryngeal isease of wise ower jaw isease of pos of dorsum of «j m B 2 o >> "3 ill " « G 2 — 2 SB IS i Q. o o -3 CU O 03 C V "S a o c ^1 a OUO >i B 0) 3 o O ■£a Q ^S :2K c3 j' u :2K ^ §=) .a O.oi ^ ^ Q s H s < ^ w a; o w o O 1 J3 J3 e3« M -*j • HS: oj 3 "^ 1 emporal ference pain from acic viscera tis So Pi s. 0) a. B u 03 0) a-B.S 00 B OJ a o o 3 2 asal astance of the c terior chamber if ^ o >->l-l 3 ry aucoma "lease of certain pper jaw •^ _o *c v B eJ "o o §1 io bIi o S-2 5 laryngeal se of larynx, es vocal cords an 3w them — feel ugh something i oat 6 uchal se of the org rax or abdomen onto a. K b. Ii o a . . P 5j^ 'x . . 03 OJ -^ 03 B (-1 Q .2 g5^5:g §15 fa M fa S S B a? 291 TeiDporal a. Glaucoma b. Caries of upper teeth c. Gastric disturbances asso- ciated with nausea and vomiting Midorbital Hypermetropia Rostronasal Nasolabial a. Disease of respiratory part of nose b. Caries of teeth Mandibular Disease of last two molars of upper jaw Superior laryngeal a. Disease of wisdom teeth of lower jaw b. Disease of posterior part of dorsum of tongue Parietal Diseases of the ear Sternomastoid area Diseases of the chest, as tur berculosis of the lung, etc. Fig. 70. — Lateral View of Head's Zones. Solid black areas show points of maximum tenderness. 292 THE HEAD 293 It seems that ''all the thoracic and abdominal viscera, which refer pain into the dorsal areas of the scalp, are supplied by what might be termed the vago-glosso-pharyngeal ner\'e — this con- sisting of the vagus and the glosso-pharyngeal nerves. These two y , • 1 j Disease of posterior portion of the eye '( Elevation of tension in the middle ear Occipital a. Lesion of posterior part of dorsum of tongue b. Referred pain from the abdo- men Hyoid a. Disease of tonsils b. Disease of teeth c. Disease of tongue Sternonuchal Diseases of organs of thorax, ab- domen, etc. Frontotemporal a. Reference pain from t h o rac i c viscera b. Iritis c. Glaucoma Fronto-nasal a. Substance of cornea b. Anterior chamber of eye c. L'pper o£ nose d. Incisor teeth of up- per jaw Mental a. Disease of anterior part of tongue b. Disease of incisor and canine teeth of lower jaw Superior laryngeal a. Disease of wisdom teeth of lower jaw b. Disease of posterior part of dor- sum of the tongue Fig. 71. — Lateral View of Head's Zones. (From Head.) nerves represent the visceral branches of a set of nerves whose somatic sensory roots are to be found in the sensory portion of the fifth nerve. Therefore, it is possible to understand how the impulses passing up the vagus may be referred to the distribution area of the fifth nerve. » □ a Q <1 a a H !3 O m » Z O tS3 Q <; w w o > o H 02 O pin O 294 Area on Body Associated Area on Scalp Organs in Particular Relation with Those Areas Cervical 3. Frontonasal. < [Apices of lung. 1 Liver. 1 Stomach. [ Aortic orifices. Cervical 4. Frontonasal. Lung. Dorsal 2. Midorbital. fLung. < Heart (ventricles). [ Ascending arch of aorta. Dorsal 3. Midorbital. f Lung. i Heart (ventricles). [ Arch of aorta. Dorsal 4. Doubtful. Lung. Dorsal 5. Frontotemporal. / Lung. \ Heart (occasionally). Dorsal 6. Frontotemporal. f Lower lobes of lungs. \ Heart (auricles). Dorsal 7. Temporal. f Bases of lungs. \ Heart (auricles). [ Stomach (cardiac). Dorsal 8. Vertical. f Stomach. \ Liver. [ Upper part of small intestine. Dorsal 9. Parietal. f Stomach (pyloric end) . \ Upper part of small intestine. Dorsal 10. Occipital. f Liver 1 Intestine. 1 Ovaries. [ Testes. Dorsal 11. Occipital. r Intestine. 1 Fallopian tubes. 1 Uterus. [ Bladder (contraction). Dorsal 12. Occipital. f Intestine (colon). \ Uterus. 295 296 REGIONAL PAINS PAIN IN THE BACK This includes all pains from the base of the skull to the coccyx. They may be the result of a lesion of the structural units of the back (skin, muscles, nerves, or bone), or may be referred from other regions. The skin of the back is hypersensitive in many of the diseases of the internal organs — in these the zones of Head are, as a rule, pronounced — and in all cases should be sought. In many of the infectious diseases the skin is also very sensitive, both to touch and to pricking. In examining the back for the presence of pain phenomena first try light touch and pin-point pressure. If these are not painful, make deep pressure, or gTasp the muscles between the fingers ; shouid the patient now complain of pain, we may conclude that it is the muscles which are affected. The muscles most frequently affected are in the neck, and the most common afi^ection is rheuma- tism, which in the neck produces torticollis, and in the small of the back lumbago. These rheumatic affections are characterized by a sudden onset, the great pressure sensibility over definite muscular areas, the increase of the pain on movement, and the favorable influence through massage, faradization and heat. In many cases, also, the pain and tenderness seem to be inilncneed by the weather, becoming much worse on rainy days. Only by their course do the chronic rheumatisms of the back muscles differentiate them- selves from acute forms. Johnson (Brit. Med. Jour., 1881, p. 221) mentions back pains, which lasted a long time, and which appeared on bending forward. They were double-sided, and only unilateral if the vertebrae were held crooked. These pains were worse after their onset, and diminished after a little movement. I have observed a similar case in a colleague. In this instance, however, not the muscular but the tendinous structure was dis- eased. The colleague complained of back pain, which would ap- pear at certain parts of the vertebral column, upon motion or fixation ; for instance, it would appear if he stepped from the pavement incautiously, and upon strong pressure. Examination showed, in this otherwise healthy individual, a high degree of PAIN IN THE BACK 297 sensibility of the vertebral spines of the two lower thoracic verte- brae. Especially sensitive were the connecting fascial ligaments. The overlying skin was also sensitive. Deformity was not pres- ent, and sudden pressure over the vertebrae was not especially painful. There was, therefore, no reason to think of a destruc- tive process in the bodies of the vertebrae. I learned that the col- league had worked with a microscope, in a somewhat uncomfort- able position, several hours daily for many weeks, the microscope being placed so low that he had to work with his back very much bent. After working with the instrument in a better position, the pain disappeared in a short time without further therapy. Since lumbago is so frequently confused with that of neuras- thenia the following table of diagnostic difference is appended. Lumbago Neurasthenia Pain located. In the region of the lower lumbar vertebra and spreads out sideward. In the sacral region and spreads upward. Method of onset. Sudden. Very gradual. Influence of motion. Increases pain. No action on the pain. Points of tenderness. Pressure on increases the pain or also produces it. No pressure points. Psychical influence. Mental states have no in- fluence. Is influenced greatly by men- tal states, irritation (psy- chical) increases the pain, diversion reduces the pain. Vertebral column. Often some change or de- formity present, such as scoliosis: this can be dif- ferentiated from other forms of scoliosis by hav- ing the patient lie on the affected side, in a sharp angle, when the scoliosis disappears. No change or deformity. Myalgia, due to toxemia, is nicely illustrated in those infec- tious diseases in which backache is one of the most prominent symptoms. In small-pox the pain in the back is so severe that the patient, in many cases, is in the greatest distress. The nature of this pain, however, does not long remain in doubt, for the presence 298 REGIONAL PAINS of the eruption soon clarifies tlie situation. In the so-called break- bone fever, of the Southern States, it is also most severe. Among the other infectious diseases in which backache is a prominent symptom are relapsing fever, influenza, tonsillitis, typhoid fever and diphtheria. ■Rheu.m&ti5m ■ Strain* _ Carious Sp\T\e- FractuTe Spvne-t^^ Tendalou.s Abd^&*- Disease 0/ -i*-*. Pelvic orjaiT^ Sa-cro-Iii ac-7-i^ DiSe^&e ^"^ / EiG. 73. — Figure Showing the Modifications of Pain in the Lumbar Region by Change of Position. The arrows indicate the direction of movement and + indicates increase of pain, while — indicates decrease of pain in the diseases mentioned when the motion is made as indicated. In myalgia from sprain some history of injury is usually obtainable, and in some cases evidences of traumatism are present. In myalgia due to fatigue the pain is more of an aching character. Sitting upright or standing increases the pain. Ease may be obtained, as a rule, by reclining. This condition is frequently associated with neurasthenia, anemia and depressed mental or physical states. Such a fatigued state is frequently experienced by dentists, mechanics, barbers, surgeons, or comes on after cer- tain forms of exercise, such as rowing. Pain may also be due to PAIN IN THE BACK 299 inflammation in the subcutaneous tissues, as in perinepliritic ab- scess and inflammation of the retroperitoneal glands. In the neck, the stemomastoid muscle; either as a result of changes in its substance (result of toxic irritations), or as a re- flex from other adjacent structures (neck glands, Ludwig's angina, vertebral, or local lesions), or from neurotic influences (either congenital or acquired, acute, or chronic), becomes so sensitive that it remains in a state either of tonic or clonic contractions. When the contractions are chronic they abate gradually but quickly reappear on the least irritation or attempt at movement. This condition is termed torticollis. For a fuller description of this the reader is referred to special works on the subject. After a consideration of the muscles as causative factors of the back pain the vertebra and joints should next be considered. Vertehral diseases, as tuberculous caries (when inflammation is acute), cause pain, elicited either by sharp spinal shocks made by forcibly pushing the head downward, or by having the patient stand with feet together and then, after elevating himself on his toes, bring the heels down to the ground with considerable force. When vertebral disease is present, pain will usually be felt in the diseased area. Involvement of the third to the fifth vertebra generally gives rise to more pain on bending forward or back- ward than does involvement of other vertebrae, because it is at this level that flexion and extension of the spine most frequently occur (Cooper, 807). Leukemia with vertebral myeloma may also give rise to back pain, likewise, also, the vertebral metastatic growths, especially prostatic, mammary, or adrenal tumors. The sacrovertebral joints are also a frequent cause of back pain, whicli may be either the result of inflammation, or of dislo- cation. If of inflammation the same signs and symptoms of in- flammations are found as in other inflamed joints (see page 239). Dislocations also display here the same signs as when they occur elsewhere. Here, however, should be mentioned the sacro- iliac dislocation, the pain of which causes it frequently to be mis- taken for lumbago and sciatica. However, in this condition the 300 REGIONAL PAINS pain is in the sacroiliac region, and extends down to and over the anus. There is also rigidity of the retrospinal muscles. For the elucidation of this lesion Goldthwaite (800) has for- mulated two tests (an anterior and posterior one), which are known by his name. He describes them as follows {Annals Surg., Vol. LI, N^o. 3, p. 420) : "For the anterior test, place the patient on a bed with, say, the right limb fixed on the bed ; then the left leg is lifted from the bed without flexing the knee. If it does not go as high, if the extension or flexion of the limb, when the limb is extended, is not equal to that on the other side, and if the pain is acute, we suspect an anterior displacement of the sacrum. The posterior test can be made by extending the limb upward, with the patient lying on the face." The diagnosis between muscular and ligamentous pain of the spine (Cooper, 802) is that passive posturing will cause pain if the ligaments are involved, while if the muscles are involved, active posturing will cause pain. Reynolds and Lovett (805) also speak of cases in which, owing to an abnormal stooping-forward position, the center of gravity is moved forward, and, as a consequence, considerable strain is thrown upon the ligaments and back muscles, with the consequent production of pain. Osteomalacia is also productive of very severe back pain, but the associated pregnancy and the typical pelvic and sacral de- formity render its diagnosis easy. Pain over the coccyx (the so-called coccydynia) may be due to injury of the coccyx from a fall, or from over-distention of the inferior pelvic outlet during childbirth. It is also found in hemorrhoids, anal fissure, and proctitis. Lesions of the conus medullaris also may cause pain referred to this region. Referred pain may be felt in the back and be present, either as a result of disease of the viscera, or of some more distant organ or region. The viscera lesions, most of which commonly give rise to pain in the back, are : the lungs, stomach, intestine, liver, and gall-bladder, kidney, pancreas, spleen, and pelvic organs. Lungs. — Affections of the lungs, if they extend to the pleura, PAIN IN THE BACK 301 frequently lead to pains which are felt in the back, especially as the patients localize the pains in the upper part, in the intra- scapular space and in the shoulder, if the area of disease is local- ized in the apex or in the upper lobe. The more frequent cause for such a condition may be a beginning tuberculosis. Pressure sensibility of the skin and musculature, in the above-mentioned region, is not often present. Increase of the pain in breathing, and especially in coughing, gives an indication, and an exact examination of the lungs makes the cause clear. Heart and Aorta. • — Just as frequent causes for back pains are affections of the heart or of the aorta. Here the pain occurs not only in the back, but also may be found as radiating pain in the arm, especially in the left arm and in the left shoulder. A fre- quent complaint of such patients is a sensation of constriction of the thorax, as though it were being pressed in a vise ; but in this case the hand of the corresponding part of the back, or the shoul- der and the left arm, are oversensitive. It will not be hard to differentiate these varieties of pain from those which are caused by disease of the spinal cord or of the dura. The circumstances that heart pains almost always occur in paroxysms, and that these attacks, in the first place, are called forth through bodily exer- tion, psychical irritation, etc., indicate their origin in the heart. An exact examination discovers changes in the aorta and the car- diac muscle. Absence of signs of a spinal cord disease completes the finding. Stomach. — With the referred pains of gastrointestinal visceral disease are associated the hypersensibility of the skin and muscu- lature of the painful region, and of the corresponding part of the vertebral column, on the left side, in particular. But these pains, as they are especially observed in ulcer of the stomach and in pyloric stenosis, are not very difiicult to connect with the stomach, since their appearance and variations in intensity depend chiefly upon the taking of nourishment, and especially upon the quality of the food. It is unnecessary to say that the further examina- tion of the stomach, in such a case, must yield signs of disease of that organ. In many cases of total stenosis and cramp of the 302 REGIONAL PAINS esophagus, a severe pain is frequently felt in the shoulder region, and a girdle sensation is experienced in the thorax. Intestines. — Pelvic pains are frequently due to diseased proc- esses in the intestine. Gas collections in the large intestine pro- duce pain in the pelvis and in the flanks, the cause of which reveals itself upon the ajiplication of a purgative. Intestinal ulcers do not so frequently cause pelvic pain. On the contrary, pelvic pains in carcinoma are an important diagnostic phenomenon. Very frequently they are associated with a radiation in the limb and in the perineum, especially if the carcinoma is situated in a deeper part of the colon. Yet, here the pains almost never appear without accompanying symptoms. Very frequently they are asso- ciated with intestinal symptoms, so that their recognition causes no difficulty. Only an inflated colon can, as a single pathological entity, jDroduce dull pain in the hack, usually on a level with the kidneys. But here an exact anamnesis, with the fact that the onset of the pain dejjends upon the passage of feces or of gas, makes the diagnosis clear. Liver and GaJl-bladder. ■ — One observes, very frequently, in liver and gall-bladder troubles, jiains in the shoulder, in the arm, and in the back — almost always on the right side. There is often, also, an excessive sensibility of the skin and of the correspond- ing musculature. This can be demonstrated upon picking up folds of the skin and pressing upon certain places (the region near the tenth to the twelfth vertebral spine). When the remaining signs of gall-bladder and liver disease are found, the diagnosis is complete. Kidney. — The spontaneous and pressure sensibility in diseases of the kidney (inflammation, embolism, congestion, tuberculosis, neoplasm) is situated in the flanks and pelvic region. Frequently, also, hyperesthesia of the skin is found. Here chemical and microscopical examination of the urine make an important dif- ferentiation. In connection with pus inflammation (perinephritic abscess) pain occurs in the lumbar region, which is increased by touch and pressure, as well as by coughing, sneezing and motion. In a similar manner, the pain of nephritis manifests itself. Radi- PAIN IN THE BACK 303 ation occurs in the thigh or is present in the form of an intercostal neuralgia. Patients with kidney stones complain of trouble and pressure in the lumbar region. If the pain is intense, and takes the form of colic, it radiates downward, as a rule (thigh, testicle, ovary). Frequently, however, it is found in the lumbar region and in the loins. The direction of this radiation, and the circum- stance that the lumbar pain is increased, if one makes a journey over a rough road, would lead one to think of a kidney stone, further signs of which are disclosed upon examination. Pancreas, Spleen, etc. — Of the pains of many pancreatic af- fections, it is likewise known that they radiate in the back, or (in girdle form) towards the front. Frequently diseases of the female geniialia lead to severe pelvic pain, and finally the spleen, also, under some conditions, produces pain which radiates into the pelvis, the left shoulder, the left shoulder blade, and the inter- scapular region. Spleen tumors, especially, produce pain, and their presence will be thought of as an associated condition by the presence of the above described pain. The pelvic organs (uterus and ovary) are probably the most frequent causes of backache in women. The principal lesions are a malsituated uterus (retroversion, retroflexion, or the binding of it down to the pelvic floor by adhesions, in which the pain is worse just before the menstrual period) ; and inflammation of the uterosacral ligaments (Garrigues, 803). Tender spots on either • side of the second sacral vertebra are due (Garrigues) to cellulitis of the uterosacral ligaments. Pressure over the inflamed utero- sacral ligaments produces pain at these places. The pain is worse on exertion, especially in sweeping. Sexual intercourse is pain- ful, as a rule. Examination will disclose the abnormal and pain- ful ligaments. Pregnancy and menstruation are also potent causes for backache; but in these conditions there is generally present some previous disturbance of the lumbar structures which pre- dispose them so that the addition of congestion or traction, result- ing from pregnancy or menstruation, produces pain. In some cases, during pregnancy, an actual relaxation of the sacroiliac ligament is present (Andrews and Hoke, 806). 304 REGIONAL PAINS Inflammations of the uterus may also cause backache. (For a fuller consideration, see "Pain in the Female Genitalia," Chap- ter XXXIL) The genitouriimry organs in the male (prostate, seminal vesicles) cause lumbar pain. The urinary bladder, also, when diseased, frequently gives rise to pain in this region. Back pain may also be caused by static foot errors, hysteria, anemia and chlorosis. In static foot errors the pain is relieved on the patient lying down, or on the correction of the errors of position. "In hysteria the backache is usually referred to the lumbar and sacral regions. It often extends upward over the dorsal area and downward over the gluteal muscles" (Clara F. Dercum, 150). Anemia and Chlorosis. - — The anemic and chlorotic individual very frequently complains of back pain. It occurs as rheumatic pain, which is most severe in the morning, after arising, and im- proves during the forenoon, if the patient moves about. The lesions of the spinal cord causing back pain have been previously considered, and will not be dwelt upon here. PAIN IN THE LIMBS After the consideration of back pains, it is next in order to discuss the pains which usually are present in the limbs. The upper limbs are probably not so frequently subjected to pain sen- sation as are the lower limbs; and when they are, the causative factor is more likely to be of a circulatory nature. The principal pain areas are in the joints, which are frequently affected by rheumatism. The shoulder joint, in particular, is subject to gonococcus infection. Over the shoulder are also found the re- flected pains from the liver on the right side, and from the spleen, pancreas and stomach on the left side. On both sides pains re- flected from the diaphragm, extrauterine pregnancy and pleura are found. In the shoulder also is present the pain resulting from inflammation of the deltoid bursa, which lies between the humerus and the acromion process of the scapula. A characteri§- PAIN IN THE LIMBS 305 tic of this pain is, that it is caused by elevating the shoulder, and is very severe until the arm becomes horizontal, when the pain dis- appears. The pain is localized immediately below the acromion process, between this process and the head of the humerus. Ten- derness is also most marked at this point. Generalized pains are usually neuralgic in origin (for which the reader is referred to the section under Brachial Neuralgia). The LowEK EXTREMITIES are greatly affected by circulatory changes. A slight indication of the type the symptoms may as- sume is given by the so-called sleeping pains which follow upon the partial stopping of the circulation in a limb. Generalized pain of a paroxysmal character, more pronounced On the external and posterior surfaces than on the internal surface of the limb, is likely to be due to a sciatica (a complete description of which is given in a separate section). When the pain is on the anterior surface of the thigh, and runs down and to the inner side, it is probably due to involvement of the anterior crural nerve. Should neuralgia be present the pain is paroxysmal and is of great in- tensity. If it is a referred pain from pressure on the nerve from tumors or bowel accumulations (William Bruce, .502), it is more of a steady, constant, dull ache. In the lower limbs, the joints, especially the hip joints, are very prone to tuberculous infection. The hip, when so affected, at first causes a pain on the inner side of and somewhat posterior to the knee; so that, in many cases, disease of the knee joint is falsely diagnosed. Rheumatism is also common in these joints, and frequently pain and swelling in the knee follow upon the locking of the joint by a so-called rice body. The pain is due to a stretching of the ligaments. It may be only a pinching pain, or it may be excruciating, if the cartilages are caught (Barker) . Flat-foot, also, is a potent cause of pain in the region of the knee. The pain is on the inner side of the patella and may radi- ate up and down the front of the leg. The pain is much in- creased on active exercise of the foot, especially by running or walking. Pain in the legs which is not influenced by position, pressure, heat or cold is often the forerunner of brain hemor- 306 REGIONAL PAINS phage. When it occurs in persons of advanced years, with hard arteries, it should be looked upon with suspicion (Musser). At times the heel is very painful (pododynia) — so much so that the patient is unable to walk. This pain may be due to local conditions (exostoses on the surface of the os calcis). Those on. the posterior and inferior surfaces are the most frequent (Thorndike, "Orthopedic Surgery," p. 164) ; there may also exist spurs run- ning out from the under side of the os calcis ; bursitis of the bursa under the os calcis; or an associated flat-floot may be present (Keen's "System of Surgery," Vol. II, p. 56). Painful swelling may also be present on the posterior surface of the heel at the insertion of the tendon-achilles into the os calcis. The patient walks with the feet everted, while the use of the calf-muscles is painful. Pain in the heel may also be caused by lesions which are at a distance, as from uretliral stricture (Luxmoor, Brodie, Thompson, Van Buren, Keyes, and Gouley), vesicle calculus, cys- ticoprostatitis, inflammation of the neck of the bladder, cystalgia, or neuralgia of the neck of the bladder, which, in some cases, may be mistaken for bladder stone (Von Pitha, 272), renal calculus, gonorrhea (Fournier, 274), and locomotor ataxia (Begun and Buz- zard). It is also jDresent in pregnancy. Pain on the sole of the foot may be caused by exostoses on the internal cuneiform or the base of the first metatarsal, or at the junction of the scaphoid and cuneiform (Thorndike). A peculiar and painful affection of the foot, occurring only in adults, and most frequently in women, is termed metatarsalgia (Morton's disease). "Typical cases of this affection have sudden cramp-like pains starting in the third or fourth metatarsophalangeal articulation and radiating to the tips of the toes and up the leg. The sudden onset may be brought on by a misstep, or by the fatigue of stand- ing a long time, and occurs almost invariably when the shoes are worn. In some attacks are infrequent ; in others they practically disable the jDatient and are provoked by inappreciable causes. The pain is so great that the patient removes the shoe, rubs and com- presses the front of the foot, flexes and extends the toes, and, after PAINS IN THE ABDOMEN 307 a time, the pain ceases, leaving no sign, or only a very slight sore- ness over the articulation on deep pressure. The cramp-like pain may be referred to a single or to several adjoining joints or to all the bones of the metatarsal articulation. It is due to a pinching of the j)lantar nerve between the bones, or to an abnormal strain on the ligaments connecting the heads of the metatarsal bones" (Thorudike). Tenderness is found on pressure over the heads of one or more metatarsal bones, or on lateral pressure in the region of the meta- tarsophalangeal joint (Forbes, Montreal Med. Journ., April, 1909). PAINS m THE ABDOMEN If a pain is of a i^eculiar, dragging nature, increased on breath- ing, and esj)ecially when deep inspiration or complete expiration is performed, and if it runs round the chest from the ensiform cartilage in a slightly do\\aiward direction to the tenth rib pos- terior, it is generally the result of diaphragmatic traction. It oc- curs in great cardiac and respiratory activity, dilatation of the stomach, severe tympany, coughing, sneezing, or hiccoughing. A pain slightly lower, and restricted to the area of the liver, may be caused by hepatitis (see Liver). On the left side, over the area of the- spleen, a perisplenitis similarly will cause a pain. Pain localized immediately in the middle of the abdomen, be- tween the ensiform and the umbilicus, may be due to pancreatitis, ulcer of the stomach, gall-stones, cardiac lesions (tricuspid regur- gitation), liver and adnexal diseases, epigastric hernia, and duo- denal ulcer. If the pain is located around the umbilicus, the causative lesion may be a hernia of the linea alba, volvulus, em- bolus of the superior mesenteric artery, meteorism, tympany, in- testinal obstruction, swollen mesenteric glands, early stage of appendicitis, ileocolitis and intestinal strangulation. Pain downward and slightly to the right is very severe in appendicitis, oophoritis and salpingitis. Pain on the left side is severe in salpingitis and oophoritis. On either side pain running from the back around to the anterior surface of the abdomen and 1 Diaphragmatic trac- tion, as in great cardiac and respir- atory activity Dilatation of stom- ach Coughing, sneezing, hiccoughing Perihepatitis Ovaries and tubes Appendix and Fal- lopian tubes Broad ligament 6 Femoral hernia Inguinal and femor- al adenitis Pain radiating down to foot Phlebitis Crural neuralgia Disease of femur Femoral hernia Abdominal tumors pressing on crural nerve: Aneurysm Uterine or ova- rian tumors Tuberculous abscess (psoas) 8 Joint Rheumatism Tuberculosis Inflammation Stretching of liga- ments Erythromelalgia Neuritis Premonitory of apo- plexy Disarticulation Artie, cartilages 10 Lithemia Spurs on os calcis Bursitis under os calcis Associated flat-foot Gout Bunion 11 Fig. 74. — Pain Areas in Trunk and Lower Extremities. 12 Cancer of breast Mastitis Uterine disease 13 Splenic disease Perisplenitis 14 Pancreatitis Ulcer of stomach or duodenum Gall-stones Cardiac lesions (tri- cuspid regurg.) Liver involvement 15 Hernia of linea alba Volvulus Embolus, sup. mes. artery Meteorism Tympany Intestinal colic Intestinal obstruc- tion Intestinal strangula- tion (hernia) Swollen mesenteric glands Peritonitis (general- ized) 16 Bladder lesions (cys- titis, etc.) Uterine lesions Renal and ureteral colic Lesions of large intestines, colic, etc. Embolus of inf. mes. artery Tubo-ovarian dis- ease Pelvic peritonitis Rupture of abdom- inal hollow viscus Extra-uterine preg- nancy Pelvic cellulitis (broad ligaments) 17 Referred pain in hip joint disease Obturator hernia 18 Tender point in flat-foot 19 Pain in flat-foot 20 Postcalcaneal bur- sitis 21 Disease of ovary Neurasthenia 22 Morton's disease (metatarsalgia) Pain above the um- bilicus Lesions of small intestine Strangulation Volvulus Intussusception Embolus sup. mes. artery ArterioscI e r o s i s sup. ma. Pancreas disease Inflammation Cancer Liver, gall-bladder or duct disease Stomach disease Pain below umbili- cus Colonic disease Cancer Intussusception Colonic impac- tion Rectal disease Cancer Embolus inf. mes. artery Fig. 75 — Pain Areas in Breast and Abdomen. Breast diseases Uterine disease Pregnancy Menstruation Circum umbilical pain ■ Appendicitis Typhlitis Perityphlitis Ileum disease Pain over entire ab- domen Peritonitis Rhe-'matism or neuralgia of the abdominal wall Intestinal perfor- ation Tympanites Pneumonia (chil- dren) Aneurysm (abd. aorta) 309 310 REGIONAL PAINS then down to the testicle or labia generally indicates a renal or ureteral disorder. Pain below the umbilicus in the mid-line is found in colonic disease, rectal disease, embolus of the inferior mesenteric artery, uterine disease, or disease of the urinary bladder. Pain over the entire abdomen results from disease of the abdominal wall (myalgia, neuralgia, rheumatism, peritonitis), in- testinal perforation, tympanites, enteroptosis, referred pain in pneumonia (in children), and aneurysm. For a more complete discussion of abdominal pain, see Chapter XIX. . Pains due to tabes are very frequent in the abdomen. CHEST PAIN Pain over the chest in the sternal region may be caused by diseased bone, mediastinal inflammation, changes in the medias- tinal glands, aortic aneurysm, bronchitis and stomach disorders. Over various areas in the chest are the pains from pneumonia and pleurisy. Radiating around the chest wall and paroxysmal in type are the pains of intercostal neuralgia and vertebral and cord diseases. Pain localized to the pectorals and made worse on raising and lowering the arm results from rheumatism of the pectoral muscle. It can also be the result of invasion of the pectorals in cancer of the breast. Pain on the left side, over the cardiac region, indicates a possible lesion of the heart, and this is confirmed, if it is found that the pain runs down the ulnar side of the arm; even as far as the little finger. Pain in the breast is frequently present during menstruation, in pregnancy, and in uterine and ovarian diseases. It may, also, be. the result of a local inflammation, in which case the entire breast is markedly tender and signs of inflammation are present. CLAVICULAR PAINS Pain in the clavicular region is frequently associated with new growths (pleura, clavicle), aneurysm of the subclavian, and pulmonary tuberculosis. In the supraclavicular region it may be 3 Sternomaatoid disease (wry- neck) 4 Liver disease Extrauterine preg- nancy (in fe- male) Suprarenals Diaphragmatic pleurisy Colon 5 Disease of bone (sternum) Necrosis Tuberculosis Periostitis Mediastinal inflam- mation Mediastinal glands Inflammation Enlargement Aneurysm of aorta Bronchitis Stomach Hyperchlorhydria I 2 3 4 5 6 7 8 9 10 11 6 12 Circumflex neural- gia 7 Pectoral neuralgia 13 8 Axillary gland in- volvement 9 Intercostal neural- gia Necrosis rib 10 Girdle pain-tabes Diap hragmat ic traction in coughing, sneez- ing and hic- coughing 11 Hepatic congestion Hepatitis Referred pain Pneumonia Pleurisy Vertebral diseases Tabes Subphrenic abscess Nephroptosis 12 Gall bladder disease Pancreatic disease Gall duct disease 13 Renal colic Ureteral colic Mental neuralgia Toothache Disease of inf. max. Laryngeal disease Thyroid disease Tracheitis Fig. 76. — Pain Areas in Neck, Chest, Clavicular Region and Abdomen. 14 Parotiditis Ear disease Toothache 15 Tonsillitis Pharyngitis Ludwig's angina Inflammation o f base of tongue or submaxillary gland 14 16 15 16 17 Spleen Stomach Colon 18 19 17 20 21 22 23 New growths, glan- dular, etc. Aneurysm, subclav- ian Pulmonary tuber- culosis 24 18 25 Deltoid bursitis 19 Lung disease Pectoral neuralgia 27 20 Cardiac disease (an- gina pectoris) 21 Pancreatic disease Cholelithiasis 22 Mastitis Pericarditis Stomach disease Uterine and ovar- ian pregnancy (in female) 23 Stomach lesions Pneumonia 24 Spleen Perisplenitis Displacement 25 Gastric disease Pancreatic disease 26 and 27 Epididymis Swollen and in- flamed inguinal glands Inguinal hernia 311 312 REGIONAL PAINS due (on the right side) to liver disease, or (on the left side) to disease of the colon or stomach (in new growth of which also search for metastatic glands in this region). In extrauterine preg- nancy with rupture, pain, when present, is on the same side as the rupture; in colonic disease and diaphragmatic pleurisy, pain, as a rule, is on the diseiased side. Pain over the shoulder is present i:i deltoid bursitis and also, in a wider area, in neuralgia of the circumflex. NECK PAINS When a patient complains of pain in the neck, the first idea suggested to the physician is that he is sufi"ering from some in- flammatory disease of the upper respiratory passages. This idea is increased almost to a certainty if, with the pain, there is also present an inspiratory stridor. It may be a sign of laryngitis, thyroiditis, or tracheitis. Should pain be felt only on turning the neck to one side or the other, and should one of the sterno- mastoids be in a state of tonic contraction, sternocleidoid disease or wry-neck is indicated (see Fig. G9). This tendency to lateral flexion and rotation is also seen at times in brachial neuralgia. Pain above the sternomastoid and below the inferior maxillary is found in tonsillitis, inflammation of the inferior maxillary gland, or in inflammation of the floor of the mouth, the so-called Ludwig's angina. Pain over the os hyoides or larynx is a sign of inflamma- tion of the bone. In some cases an inferior maxillary neuralgia may be present. Pain just anterior to the ear, on the side of the face, indicates ear disease, jiarotitis, or diseased teeth (inferior maxillary). SUMMARY Pain in the back, over the entire vertebral column, indicates neurasthenia, traumatic spine or mediastinal disease; in the area between the scapula it indicates pericarditis, lung disease, dia- SUMMARY 313 phragmatic i^leurisy and aortic lesions ; over the scapula, lung in- volvement or pleurisy is indicated. On the left side, between the vertebrae and the scapula, pain Spleen Pericarditis Diaphragmat ic pleurisy Lung disease Pleurisy Splenic involve- ment Aortic aneur- ysm (gnawing pain) Stomach Overdisten- tion Inflammation Ulceration Liver Vertebral dis- ease T. b. c. tu- mors, frac- tures Cord (crush, fractures, etc.) Liver 6 Kidneys Sacroiliac dis- ease Pain Areas in the Back. 8 Liver, gall blad- der 9 Headache, back of head, pain radi- ating down the back from brain pressure 10 Pericarditis, lung disease Diaphragmatic pleurisy 8 Aortic lesions 9 11 Vertebral and 10 rnediastinal disease 12 11 Liver disease 13 12 Lungs: pneu- 13 monia, pleu- ral disease Rib disease 14 Intercostal neu- ralgia 15 Pleurodynia 14 Tabes, local- ized menin- 16 gitis 15 Liver (perihep- atitis) 17 E iaphragmatic disease IG Lidneys (peri- nephritic abscess) C'dlon impacted Retroperitoneal glandular enlargement 17 Disease of coc- cyx Cervicitis Anal fissure Hemorrhoids is present in aortic lesions and stomach disorders ; at the apex of the scapula, on the left side, splenic disease is indicated ; and, at about the same level on *the right side (in many cases a little lower), liver disease is indicated. Pain generalized over the back of the chest may be due to myalgia, lung or pleural disease. Pain radiating around the side of the chest is due to intercostal neu- ralgia. By reference to Fig. 78, the local points of tenderness in brachial neuralgia and in the so-called diaphragmatic neuralgia 314 REGIONAL PAINS are shown, as well as the points of tenderness in intercostal neu- ralgia and in angina pectoris. Pain in pulmonary \ tuberculosis Dots indicate points of tenderness in intercostal neu- ralgia General tenderness over all the verte- brse in neuras- thenia Subacromial bursi- tis Trousseau's points of tenderness in diaphragmatic neuralgia Plane of emergenf of the dors; Uterus Ovaries Colon Rectum Subjective pain Hypertension head- ache Spine of the 7th cervical vertebra 1 Painful points in angina pectoris Trousseau's point of local tender- ness for brachial , neuralgia Tender points over the 2nd and 3rd dorsal spine in brachial neuralgia Spinous processes all tender in neu- rasthenic spine r Pressure causes pain in 1. Spinal caries 2. Aneurysm 3. Spinal menin- gitis 4. Tuberculosis Uterine disease Kidney disease Lumbago Acute infectious dis- eases Fig. 78. — Pain Areas in Spinal Column. Lower down in the back, in the neighborhood of the lower ribs, are fonnd the areas which are painful in perihepatitis and dia- phragmatic disease, while a little lower is found the area in which pain is located in kidney disease. Lower still, and in the neigh- borhood of the sacrum, are the areas where pain is present in colon involvement, retroperitoneal gland, and uterine disease. In the entire small of the back are found the occupation-pain, uterine- SUMMARY 315 disease pain, perinephritic-abscess pain, lumbago, and lumbar- abscess (tubercular) pain. In the same area, but extending over tbe sacroiliac articulation, is the pain of sacroiliac disease. Over the coccyx and adjacent regions is located the pain due to disease Area of re- ferred pain in liver disease Aortic aneur- ysm 3 and 4 Tender points often present in gastric ad- hesions Renal disease Perirenal ab- scess Lumbar abscess Lumbago Neurasthenia, pain running along verte- bral column Tuberculous ca- ries Intercostal neuralgia Herpes Fig. 79. — Pain Areas in Back. Spleen 10 Area of tender- ness in gastric ulcer 11 Uterine disease Postoperative Occupation tire Surgeons Dentists Clerks, etc. Appendicitis 12 Uterus Sacroiliac dis- ease 13 Sacroiliac dis- ease 14 Coccyx injuries and disease Rectal disease Cervical disease 15 Broad ligaments Ovaries (Butler) of the coccyx, rectal disease, and cervix disease. Pain over the buttocks, and running down the outer surface of the limb, is especially frequent in ovarian and broad ligament disorders. Pain in the inguinal region may be due to inguinal or femoral adenitis, and if it radiates down toward the foot it may be due to phlebitis, crural neuralgia, disease of the femur, femoral hernia, abdominal tumors pressing on the crural nerve (aneurysm, uterine or ovarian tumors, tuberculous abscess of the psoas). Pain in a joint may result from rheumatism, tuberculosis, acute synovitis, stretching of ligaments, or floating bodies. CHAPTEK XV THE SIGNIFICANCE OF PAIN IN DISEASE OF THE EYE ^ When sensitive and sensory impressions falling upon the retina exceed a certain maximum in intensity they become dis- agTeeable. If their intensity reaches a still higher degree the sensation provoked is painful. Just what are the threshold values for various forms of stimuli of the retina are not all determined. Thus, the action of very strong light on the eye causes a painful sensation, with blinding. Such sensations scarcely ever arise spontaneously. They are nearly always the result of the action of adequate stimuli which have been increased above the normal limits. These disagreeable sensations are to be distinguished from others due to irritation of the nerves of common sensation. In the descriptions to follow the latter will be simply called pain. Under normal conditions an individual is not ordinarily con- scious of the normal retinal stimuli, and if the existence of this organ intrudes itself upon consciousness this is usually a sign of a pathological condition. Xhis consciousness is usually brought about through the medium of pain. As we do not possess any objective method for measuring pain, we must rely upon the information given by the suffering individual, which must be checked up by our own experience. Self-training, self-control, physical and psychical distraction are circumstances which con- siderably influence the intensity of this pain perception, increas- ing, diminishing, or even abolishing it completely. The same uncertainty which exists in the estimation of the intensity of the pain dominates the characterization of the quali- 1 By Decent Hans Lauber, M, D., and Olaf Kuttin, M. D., assistants of the Eye Clinic, Vienna. 316 ETIOLOGY 317 ties of pains. In the same disease the same pain will not be described in the same way by several patients, and will be differ- ently described by the same patient at different times. The pain may be described as blunt, dull, boring, burning, pulling, throb- bing or tearing, but, unfortunately, there is no possibility of ascer- taining whether the similar terms used by different patients describe similar sensations. As far as the duration of pain is concerned, we are in a far better situation. We can more easily believe the correctness of statements which describe pain as continuous, periodical, inter- mittent, or periodically exacerbating. Under certain circum-. stances these characterizations can be of great diagnostic value. ETIOLOGY In examining the different factors that can cause or increase pain in the eye, or its surroundings, we find that they may be touch, pressure, atmospherical influences, temperature, light, and tiring of the eyes by work. The topography of the eye and its adnexa points to the rami- fication of the first and second branches of the fifth nerve as the source of the tactile and consequently also of painful sensations. The third branch is of but secondary importance. All the other nerves can be excluded from further consideration. As a conse- quence of the very extensive ramification of the fifth nerve, it is found that irritation of different branches of the nerve may pro- duce a sensation of pain, or even other symptoms, in the ocular region. It is important to emphasize, at the very beginning, that irritation of any branch of the trigeminus may provoke a sensa- tion of pain in its whole distribution, and, further still, reflex pain can be elicited in all those nerves that are in close anatomical or physiological relation to the irritated nerve — for instance, the in- timate association of lachrymation to irritation of the trigeminus. Mechanical influences, acting upon the cornea, elicit lachrymation, iust as easily as can the irritation of a tiny nerve stem in the pulp cavity of a tooth, or the irritation of the nasal mucous membrane, 318 SIGNIFICANCE OF PAIN IN DISEASE OF EYE which are likewise innervated by the fifth nerve. Irritation of the bulbar terminal branches of the fifth nerve is generally accom- panied by hyperemia, which extends from tlie immediate sur- roundings of the irritated place to the neighboring parts, and can lead to visible hyperemia of the conjunctiva. The numerous anas- tomoses of the fifth nerve with the seventh and the sympathetic explain the frequent reflex phenomena, such as sneezing, swallow- ing, pupillary dilatation, vasomotor and secretory disturbances. All these reflexes can occur in association with pain in the realm of the fifth nerve. From a practical standpoint, pain is very important in a double sense, first, as a symptom of partial disturbance, which is often vague and allows many different explanations ; second, as the patient's prominent subjective complaint, by the removal of which the physician can gain much credit. LOCALIZATION OF PAINS The exact localization of pains in the eye region may be of symptomatic significance, yet here we encounter many uncertain- ties. In a case of iritis, for instance, we firmly believe that the pain originates in the ramification of the fifth nerve in the iris itself, and yet many patients do not complain of pain in the eye, but in the bone surrounding the orbit. The pain in glaucoma has its source in the globe ; nevertheless, many patients complain only of headache or hemicrania until the tenderness of the globe on pressure convinces them that the eyeball is the aifected organ. ^Notwithstanding the fact that the localization of the pain may lead to false judgments, the following pages will attempt a diag- nostic analysis of pain, based upon its localization. The Eyelids. — The skin of the eyelids and their surroundings may be a source of intense pain in cases of inflammation. This pain may be spontaneous, and is generally very intense when the inflamed skin is touched. This kind of pain which is localized in the skin occurs in eczema, febrile herpes, herpes zoster, cases of phlegmon and abscesses of this region. In many cases the pain is LOCALIZATION OF PAINS 319 associated with swelling of the tissues, so that the real focus of the disease can be found on palpation. In marked inflammatory edema of the lids one finds on touch an increased resistance of the tissue, which is considerably increased in some places. If the region of the internal can thus ligaments be the seat of tenderness to palpation the possibility of a beginning dacryocystitis or peri- ostitis should be thought of. Pain and resistance at the margin of an eyelid suggest a hordeolum ; superficial pain of the skin, accompanying movable resistance, points to the diagnosis of a furuncle or an abscess, whereas an immobile resistance is an argu- ment in favor of periostitis. It should be remembered that inflam- mation or cicatrices in the region of the external canthus lead to marked edema of the eyelids, so that the localization of the painful spot and the accompanying resistance alone permits a diagnosis. Tumors of these regions, which are exceedingly painful, are occa- sional. jSTeuroma or neurofibroma are to be expected. Under cer- tain circumstances ulcerated carcinomata occur. They are in- tensely painful to touch. The pain in herpes zoster has a special character. It, at times, begins a few days before the appearance of an eruption; that is, during a period when the patient complains of general malaise. It is frequently impossible to explain such attacks of pain cor- rectly until the appearance of the eruption shows the nature of the disease. The pain in herpes zoster may persist with the same intensity for weeks and months after the skin lesions are healed and the accompanying keratitis and iritis have subsided. Nightly exacerbations of the pain are not rare. The pain frequently irra- diates into other branches of the trigeminus not apparently af- fected by the herpes. Simultaneously with the appearance of the intense pain there arises a hypo- or even anesthesia of the skin and superficial parts of the eye, so that the characteristic symptom complex of anesthesia dolorosa may appear. The sensibility re- turns slowly. Hyperesthesia is rare. These cases of herpes zoster represent the projection of a central lesion onto the peripheral endings of the nerves. Investigations of Barensprung, Head and Campbell, and Lauber have proved that the primary process is 320 SIGNIFICANCE OF PAIN IN DISEASE OF EYE localized in the Gasserian ganglion. The skin, conjunctival and corneal chajiges are probably to be regarded as trophic lesions. In some cases (Eisenlohr) a peripheral neuritis has been found, so that not only lesions of the ganglion, but also those of the nerve are to be considered in herpes of this region. From these statements it can be seen that the pain in herpes zoster is a true neuralgic pain, as it is caused by a lesion of the ganglion or of the peripheral portion of the nerve. It is of the character of acute inflammatory neuritis, caused by some toxic agent. It is a pathological process, occurring in the sensory gan- glia, analogous to that in the motor ganglion cells in acute anterior poliomyelitis or polioencephalomyelitis. In addition to the virus, the nature of which is as yet unkno^vn, other causes of herpes zoster exist. Such are traumatism, tumors, disease within the cavernous sinus, aneurysms of the ophthalmic artery, pulsating exophthalmos, poisoning by carbon dioxid and arsenic. All of these affect the fifth nerve, and are of etiological importance. A disease which resembles herpes zoster in some ways is neu- ralgic herpes of the cornea (herpes cornse neuralgicus of Schmidt- Kimpler). This is a periodically appearing affection, often re- curring at the same hour of the day. The attack begins by pain in the supraorbital branch of the fifth nerve, and is characterized by an eruption of small vesicles in the distribution area of this branch. The whole attack passes off in a short time. The pain which accompanies a febrile herpes of the cornea is due solely to the epithelial lesions, and does not show the typical neuralgic character of the two affections previously considered. Several other forms of neuralgia of the same region are to be distinguished from typical trigeminal neuralgia, which is a persistent and very torturing disease. They show the same symp- toms, but are secondary affections of the trigeminus. Acute neu- ralgias are caused by inflammatory conditions, such as orbital periostitis, empyema of the accessory sinuses of the nose, etc., and occasionally show relapses. Chronic neuralgias are due to tumor, keloids, or to chronic forms of periostitis and empyema. ISTeuralgia of the fifth nerve can also be caused reflexly by lesions LOCALIZATION 01 PAINS 321 in distant regions, as by caries of the teeth or in nasal affections. These can mislead the patient, as well as the physician. It is con- sequently necessary, in cases of neuralgic pain of the fifth nerve, to examine the entire distribution area of this nerve for causation lesions before making a diagnosis of idiopathic or primary (essen- tial) neuralgia. A diagnosis of neuralgia is generally based upon the tenderness of the nerve-stem to pressure. In the investigation of a case of neuralgia, pressure should be applied to the nerve exits ; i.e., over the supraorbital foramen, the infraorbital, and mental foramina. This excessive tenderness, accompanied by spontaneous periodi- cally exacerbating pain, is very characteristic. Tenderness to pres- sure is absent only exceptionally in neuralgia. This symptom alone, however, is not sufficient to make a diagnosis of neuralgia, as in hysteria, also, the brandies of the fifth nerve are frequently tender to pressure. Furthermore, tenderness to pressure may be a symptom of a general polyneuritis and not of an isolated affec- tion of the trigeminus. Especial attention should be called to the fact that neuralgic-like pains of the trigeminus may be sympto- matic of glaucoma, or they may be precursors of this disease, appearing a long time before the glaucoma can be recognized. Another type of periodically returning pain in the trigeminus, though generally affecting only its meningeal branches, is hemi- crania, or migraine. Here the so-called scintillating scotomata, with their characteristic features, are diagnostic. The attack be- gins ivith eye symptoms, and, during this period, the patient no- tices the scotomata with their luminous and generally moving margins. These attacks are then followed, as a rule, by intense unilateral headache, with frequent radiation of pain throughout the entire fifth nerve area. The cause of the phenomena is prob- ably a vasomotor disturbance, which, acting upon the meninges, is felt in the peripheral branches of the nerve. A very rare affection, likewise characterized by intense liemi- crania, is a recurring third nerve palsy — ophthalmoplegic mi- graine. Intense hemicrania introduces the attack, to which ptosis and almost total immobility of the eye, nausea, or vomiting are 322 SIGNIFICANCE OF PAIN IN DISEASE OF EYE added. Such attacks persist for from a half a day to two days or more, and may recur at irregular intervals of a few weeks or months. Durino; the intervals of the attack the third nerve paralysis recedes, but nuiy not completely disappear. Surroundings of the Eye.— Tender pressure points, so charac- teristic of neuralgia, may exist in other affections of the surround- ings of the eye. The cause of indefinite pain in the head, espe- cially of dull pain in the forehead, can occasionally be found by careful palpation, which reveals the nerve tenderness at a certain place. Tenderness of the bone to percussion and tenderness in the region of the trochlea are found in many cases of acute or chronic affections of the frontal sinuses and the anterior ethmoid cells. Thus, one may be guided to a correct diagnosis. Such cases can be differentiated by the existence of delimited sensitive areas from those other cases where the bone is sensitive through- out to pressure or percussion, and at the same time is diffusely thickened. These latter symptoms lead to the diagnosis of perios- titis and osteoperiostitis. Indolent thickenings of the bone are but rarely due to inflammation (lues, tuberculosis), and, as a rule, represent tumor or protrusion of the bones by meningo- or meningoencephalocele. Conjunctiva and Cornea. — Pain in the conjunctiva and its cor- neal continuation is of the greatest interest to the oculist. The abundant end ramifications of the nerve plexus of the super- ficial layers of the cornea penetrate as far as the basal cells of the epithelium and explain the great sensitiveness of this organ, as well as the great intensity of the pain in superficial lesions (erosions) of it. The conjunctiva is much richer in nerves than other mucous membranes of the body. Inflammatory or traumatic irritation of the nerve endings in the conjunctiva gives rise to very severe jDain, alike torturing to the patient and difficult for the physician to abate. Great sensitiveness to thermic, atmos- pheric, and light influences is present, and exposure to these in- creases the pain to the highest intensity. While there is not the least doubt, so far as thermic and atmospheric stimuli are con- cerned, that the nerve terminations in the conjunctiva and cornea LOCALIZATION OF PAINS 323 can transmit pain stimuli and cause suck reflex disturbances as lachrymation and blepharospasm, yet light can also give rise to painful stimuli, and it is not so easy to determine bow it acts and causes pain in corneal and conjunctival lesions. It is a fact, however, that in corneal erosions or in other super- ficial lesions of the cornea, likewise in iritis, there exists a great sensibility to light (photophobia), even when the patients keep their eyes closed, thus excluding atmospheric and thermic in- fluences. In iritis, whether primary or secondary to keratitis, one is inclined to attribute the pain caused by light to reflex contractions of the sphincter, and to the irritation (on pupillary dilatation or contraction) of the sensory nerves in the stroma of the iris. But if the iris is normal, and its contractility is suppressed by means of a mydriatic, it can no more be considered as a source of pain, and other causes of the corneal irritation to light (photophobia) must be sought. Wilbrand explains photophobia as follows: "Exposure to light leads to the formation of products of metabolism in the piginent of the retina; if the forma- tion of such products becomes increased, they may cause pain in the ciliary nerves of the choroid, which contain filaments of the fifth nerve. If those nerves are in a condition of pathological irri- tation, even small quantities of these products of katabolism can cause considerable pain. This theory, however, does not explain why the instillation of cocain into the conjunctival sac, in quanti- ties which can act only upon the superficial endings of the nerves, can in many cases quite suppress the photophobia. This would be in favor of an explanation which attributes light sensibility to the endings of the trigeminus in the cornea and conjunctiva, analogous to the direct action of light upon the iris. This theory is, how- ever, not satisfactory. Hyperemia of the conjunctiva, infiltration of both conjunctiva and cornea, detachment of the corneal epithelium in the form of vesicles and blebs surely lead to mechanical and possibly also to toxic irritation of the nerve endings. This explains why the pain is so very severe in conjunctivitis and superficial keratitis. 324 SIGNIFICANCE OF PAIN IN DISEASE OF EYE Superficial traumata, which expose the superficial and subepithe- lial nen'ous plexi, are exceedingly painful. Deeper wounds, which penetrate the substance of the cornea and sever the nerve- stem, are less painful. In an irritative condition of the cornea and conjunctiva, tear-secretions retained in the conjunctival sac can cause consider- able complaint. The accumulation of tears in the conjunctival sac, when an eye is kept under a bandage after an operation, may cause great discomfort, and even pain, which can be instantane- ously relieved by removing the bandage and opening the eye. Small quantities of mucus or muco-pus, on the surface of the eye, are perhaps the cause of the sensation of a foreign body in con- junctivitis. In cases of gonorrheal or dijihtheritic conjunctivitis the edema of both conjunctiva and lids may lead to such stretching of the lid that it can be the source of pain. However, this is easily re- moved by simj)le canthotomy. After foreign bodies of the cornea or conjunctiva have been removed the sensation of their presence frequently persists for a few hours and disappears, together with the subsidence of hyper- emia and the reparation of the tissue lesions. Observations of this kind prove tliat both hyperemia and the pressure of an almost imperceptible exudate are able to irritate the nerve termination to a high degree and cause pain. In erosions of the cornea the j^ain often has a recurring char- acter. According to von Reuss, two types of this affection can be distinguished. In the first slight pain appears on first opening the lids after sleep, or after they have been kept closed for a long time. This soon ceases. In the second type, after a period of apparent health, attacks of pain occur, having the same char- acter and intensity as those following the original trauma. They are caused by a plainly visible loss of epithelium in the same place where the primary injury had originally led to the loss of sub- stance. Both types of the affection are the consequences of an abnormal condition of the epithelium established by the trauma. Close examination of the cornea with a lens, or by the ophthalmo- LOCALIZATION OF PAINS 325 scope, show minute ojDacities in the epithelium. In the first group of cases the corneal epithelium, which during the night is in close contact with the tarsal conjunctival epithelium, sticks fast to the latter and is torn off when the eye is opened. In the second group of cases (the recurring erosion in a strict sense) the epithelium degenerates, is cast off, and exposes the nerve plexus lying in the superficial layers of the cornea. The pain associated with corneal herpes and punctate superfi- cial dendritic and stellate keratitis is due to similar causes. Cor- neal ulcers of various types all expose the nerve plexus of the cornea, and can, therefore, cause more or less pain. Tlie pain becomes more intense when the exposed nerves are irritated by the moving lids. For that reason a bandage is applied to prevent the movement of the lids, and thus to diminish the pain. It cannot relieve it completely, as the infiltration of the .tissues exer- cises pressure upon the nerves and stretches them. Toxins pro- duced by bacteria also cause painful irritation of the corneal nerves. Sudden pain arising in a case of ulcerating keratitis frequently indicates perforation of the ulcer. The chief cause of pain in perforation of the cornea ia the mechanical irritation of the iris. If the iris prolapses and cicatrizes, sudden and in- tense pain may again arise. This is a symptom of secondary glaucoma. The severe pain which frequently accompanies deep keratitis is largely due to a concomitant iritis. Referred pain is also present if the ulcer extends into the deeper layers of the cornea. The area of reference is in the fronto- nasal area, and also to some extent in the midorbital (Head). This referred pain is probably due to a deepening of the anterior cham- ber. Should a true cyclitis be present, the pain is referred fur- ther to the side in the forehead than in corneal ulceration, the midtemporal area being, as a rule, concomitantly involved with the midorbital. (See page 291.) The Iris and Ciliary Body. — The existence of a dense nervous plexus in the iris and the ciliary body fully explains the severe pain found in diseases of these parts. The specific etiology of iritis and iridocyclitis is also a factor in the origin of iritic and 326 SIGNIFICANCE OF PAIN IN DISEASE OF EYE cyclitic pain. Its importance, however, should not be exagger- ated. The pain is frequently continuous, and may be localized in the eyeball itself, or in the surrounding bones, even in the entire half of ^the head corresponding to the affected eye. As in many other diseases, so in iritis and iridocyclitis exacerbation of the pain is observed toward the end of the night or in the early morning. This is not only characteristic of syphilitic affections, but occurs in the same way in rheumatic and traumatic cases of iritis. In rheumatic iritis, more often than in those due to other causes, severe pain during the night is a sign of a relapse or of an exacer- bation of the inflammatory trouble. Examination of the eye the next morning shows fresh fibrinous exudate in the anterior chamber, or the presence of a fresh hyperemia. Such acute at- tacks of pain are usually of short duration. Metastatic gonorrheal iritis is a type of iritis which causes the most intense and obstinate pain. The referred pain, as a rule, is in the frontotemporal, maxillary and temporal areas. Should the tension in the vitreous chamber rise, the pain has a tendency to be referred further back, and also, in some cases, the teeth of the upper and even of the lower jaw may become painful and very sensitive to pressure. Rest in bed, atropin, warm applications, dionin, and diapho- resis are serviceable for all forms of iritis. If the pain is very intense aspirin, pyramidon, or morphin must be given, and even these analgesics may prove insufficient to relieve the pain. In chronic iritis and iridocyclitis the pain is generally very moder- ate. Circumscribed areas in the region of the ciliary body, which are tender to pressure, can be sometimes detected. They probably correspond to small inflammatory foci which do not cause any other clinical symptoms. It is important to ascertain their pres- ence, as they direct attention to the possible recurrence of the disease. A sudden exacerbation of pain in an acute or a chronic iritis should always arouse the suspicion that a secondary glaucoma is developing. The pain caused by such an attack of secondary glau- coma can reach the highest possible degree. The increase of intra- ocular tension is diagnostic for acute glaucoma, although the dif- LOCALIZATION OF PAINS 327 ferential diagnosis between a primary and a secondary glaucoma may be very difficult, especially when the cornea is dull and opaque. A painful condition, which closely resembles iritis, and which is in direct contrast to glaucoma, is an acute hypotonia of the globe, complicating detachment of the retina. Hypotonia of this kind can exist without any pain. In very pronounced and acute cases, however, pain appears. To this subjective symptom there corresponds an objective change, consisting of a slight ciliary in- jection of the globe, a deepening of the anterior chamber and a tremulous condition of both iris and lens. The vitreous is gener- ally very turbid, and permits only indistinct recognition of the increase of a preexisting or the first appearance of a retinal de- tachment which previously had not existed. The pain, as a rule, is mild and, together with other symptoms, slowly disappears. In the course of retinal detachment there also occurs another painful process, i.e., an iritis, which, similarly to the detachment, is a consequence of the high myopia. If pain appears in the eye affected with posterior staphyloma iritis might be present. Such myopic iritis seldom appears in posterior staphyloma without in- volvement of the retina, and may be a precursory symptom of this grave affection. Sclerotic Coat. — Areas, tender to pressure, similar to those previously described as occurring in chronic iritis, but correspond- ing to hyperemic and swollen areas of the sclerotic, are characteris- tic for scleritis. This affection may cause violent, spontaneous pain, but may also be absolutely indolent. It is not exactly known why some cases of scleritis are very painful and others are not. This certainly does not depend upon the etiology, as both forms may be caused by the same etiological factors. Anatomical inves- tigation (Oatman) may explain it. In some cases the ciliary nerves, as they pass through the foci of the scleritis, remain nor- mal; while in others they are infiltrated by leukocytes. The in- filtrated nerves show the anatomical picture of a neuritis, and this is probably the cause of the pain. Inflammatory foci of the scleritis may be invisible, on account 328 SIGNIFICANCE OF PAIN IN DISEASE OF EYE of chemosis. If such is the case, palj)ation of the globe will easily disclose the situation of the sclerotic foci. A sclerotic iufiltration, situated under one of the muscles, or at a muscular insertion, will be irritated by contraction of the muscles and cause pain in move- ments of the eye. Similar pain following- eye movements may be the sign of rheumatism of an eye-muscle. The diagnosis of this condition is based on the subjective symptom of pain without any visible changes. Diplopia as a sign of impaired movement is, however, not present in these cases of rheumatism. Choroid, Retina and Optic Nerve. — Inflammation of the inter- nal membranes of the eye, choroid and retina, as well as inflam- mation of the optic nerve, generally does not give rise to pain. Acute retrobulbar neuritis is an exception. Dull pain in the orbit, increasing on extreme or violent movement of the eye, or on pressure upon the globe, and associated with rapidly increasing amblyopia and negative ophthahiioscopic findings, is the chief symptom upon wliich the diagnosis is founded. A similar deep pain on pressure occurs in posterior scleritis, which sometimes shows an intermittent exophthalmos, and also in periostitis or em- pyema of the posterior ethmoidal cells. Bulb.- — Pain originating in phthisic eyes deserves especial attention and may arise from different causes. In most cases it is due to increase of pressure of the process which originally caused the phthisis, and is of the greatest importance, because a reappearance of a previous inflammation may produce a sympa- thetic affection of the other eye. Therefore, it cannot be exj^ressed too strongly that all phthisical globes which cause spontaneous pain ought to be removed. Up to the present time no symptom is kno\vn jjermitting a differential diagnosis between an eye aj)t to induce sympathetic ophthalmia from those which are harmless. Great attention must be given to the other eye. Dull pain in the healthy eye may be the first symptom of a sympathetic trouble. The suspicion of a beginning process of this nature will be aroused, especially by the appearance of photophobia, ciliary hyperemia, and diminution of LOCALIZATION OF PAINS 329 the range of accommodation. These symptoms, which have heen described as sympathetic irritations, may precede the outbreak of an iridocyclitis for a varying period of time. Sympathetic ophthalmia may also begin without irritative symptoms. Sunken globes may become painful also from other reasons. Such are ossification of the choroid, which causes pressure upon the branches of the ciliary nerves, and folding of the sclerotic, which acts in the same manner. Attention may be directed to the fact that, even after the enucleation of a globe, the trunk of the optic nerve or its surroundings may be very painful to pres- sure, and is an indication for the resection of these parts in order to enable the patient to wear a shell. The cause of this pain is a neuroma of the ciliary nerves. Glaucoma. — The most violent pain which can exist in eye dis- eases is that found in acute glaucoma. The increase of intraocular tension and the consecutive pressure upon the nerves in all the tissues of the globe are given as the explanation of this pain. Radiation of pain into different distributing areas of the trigemi- nus is quite frequent, and has caused the condition to be mistaken for a neuralgia, a hemicrania, a toothache, or, when vomiting is present, even for a meningitis. It is unnecessary to analyze the nature of an acute attack of glaucoma. It should be remembered that inexplicable pain in the first branch of the fifth nerve is frequently a symptom of glaucoma ; either prodromal or the devel- oped disease. No doubt neuralgia may precede the outbreak of an acute glaucoma by months or years. This pressure may be reduced (with consequent relief of pain) by miotics. The diminution of intraocular pressure due to miotics may be considerably enhanced by the use of one per cent, solution of morphin, used as a collyrium simultaneously with the miotics. Eserin is excellent in subduing pain caused by glaucoma. If, however, it is instilled into a nor- mal eye it is liable to cause considerable pain. This is due to the compression of the nerve fibers by the tonic contraction of the sphincter of the pupil. This pain may be quickly removed by the use of a mydriatic. Iridectomy and other operations devised to replace iridectomy 330 SIGNIFICANCE OF PAIN IN DISEASE OF EYE alleviate the pain rapidly when they reduce the ocular tension. If after an operation for glaucoma intense pain arises, or an increase of pressure is noted, it is a symptom indicating the malignancy of the glaucoma, and forebodes the loss of the eye. If the eye is blind and painful from glaucoma one may attempt to relieve the pain by anti-glaucomatous operations, if they are possible; otherwise, there remains only opticociliary neurotomy or enuclea- tion of the globe. The operation first referred to is a dangerous undertaking, as its results are doubtful, and in many cases it must be followed by enucleation. Panophthalmitis. — Pain in panophthalmitis is caused in a similar manner to that of glaucoma. The presence of a focus of purulent inflammation in the globe, with the consequent pres- sure, explains the painfulness of the disease. That the simple opening of the globe by incision or spontaneous perforation at once considerably relieves the pain proves that increase of pressure due to the purulent exudation plays a great part in the etiology of pain in panophthalmitis. Asthenopic Disorders. — An entirely different group of painful conditions is met with in the asthenopic disorders and the closely related cases of eye-strain. In both accommodative and muscular asthenopias, whether the latter be caused by exophoria or insuffi- ciency of convergence, the phenomena are blurring of objects and a dull pain in the forehead. This is accompanied by a feeling of heaviness and pressure in the eyelids, lacrymation and a sensation of heat in the eyes. If, in spite of these symptoms, the eyes are used for work, headache may appear and continue even during the next day. Asthenopic disorders manifest themselves, as a rule, in the late afternoon or in the evening, when the muscular apparatus is tired by the day's work. Proper glasses or prisms can totally suppress the trouble, or at least alleviate it con- siderably. In muscular asthenopia stereoscopic exercises can also be of benefit. How far a low degree of astigmatism may cause trouble is not quite determined. Most of the European oculists are sceptical in regard to this question, whereas English and American oculists, LOCALIZATION OF PAINS 331 especially the latter, attribute a gTeat number of subjective dis- orders to uncorrected or insufficiently corrected astigmatism. They also have created and developed the term "eye-strain," to which disturbances in all parts of the organism are ascribed. Disturb- ances due to hyperphoria are les$ frequent than simple asthenopic phenomena, and differ from muscular asthenopia in exophoria, in that they trouble the patient not only in close work, but cause incessant aching. The prescription of corresponding prisms with the apices upward and downward suppresses such disorders promptly. To Bielschowsky we owe the knowledge of a rare group of painful disturbances related closely to asthenopia. This author has discovered cases of disturbed innervation of binocular vision leading to considerable subjective disturbances and simulating squints. Their treatment either by operation or drugs is rarely successful. In hyperopics the over-strained accommodation leads to asthen- opia. Disturbances caused by straining of the accommodation do not occur in myopics, who, nevertheless, experience disagree- able sensations. Myopics of the middle and higher gTades fre- quently complain of pain in their eyes when they use them for close work. This pain, which is intermittent but not severe, may yet be very troublesome to sensitive and neurasthenic individuals. 'No generally accepted explanation of this kind of pain exists, but it would seem quite plausible to connect it with the process of stretching of the sclerotic, which may also affect the nerves lying in the sclera. This pain cannot be influenced by the wearing of correcting glasses, or by the extractions of the lens for removal of the myopia. CHAPTER XVI PAIN IN DISEASES OF THE EAE i It passes as current fact among the laity that ear pains can scarcely be surpassed in severity by any pain elsewhere in the body. Relief may be secured from pain occurring in any part of the external or middle ear, but not from pain of labyrinthine origin. External Ear. — Trauma of the external ear is scarcely more painful than trauma in other parts of the body, but it may be followed by two troublesome conditions, namely, othematoma and perichondritis. Othematoma is an exudate of serous, bloody fluid between the cartilage and perichondrium of the ear. It results from a blow, especially one from a fist. Consequently, we find it frequently among prizefighters, and perhaps most frequently among the Japanese wrestlers, because they use the head and neck against the head of an opponent, and in this way the ear often becomes subject to very great pressure, giving rise to the above- mentioned exudate. It also is frequently seen among patients suf- fering from acute mental disturbances. The pain in hematoma is usually trifling. It is mostly of a dull, aching character, worse at night. If, however, the othema- toma becomes infected through unskilful surgery, a very painful perichondritis may follow. Such a perichondritis arises sometimes, also, after a radical operation, as a result of infection of the cartilage. This cannot always be avoided in plastic work upon the external ear. If the bacillus pyocyaneus is present in the middle ear secretion, this germ, which has a fondness for attacking cartilage, may bring 1 By Dr. Euttin, assistant in the Ear Clinic of the University of Vienna. 332 EXTERNAL AUDITORY CANAL 333 about a perichondritis. In fact, one can always grow the bacillus pyocyaneus in pure culture from the perichonclritic secretion. Such a perichondritis advances very slowly, and lasts about four weeks, when the disease has reached its highest point. The suppuration then ceases, and the cartilage begins to shrink. Un- fortunately, early and energetic incision does not shorten its course. During the period of development, to the beginning of the shrinking of the cartilage, extraordinarily severe pains exist. It often requires much persuasion to convince the patient that this distressing condition is not dangerous. Of the tumors of the external ear, carcinoma and sarcoma sometimes give rise to severe pains, but they often run a painless course. The same is true of the inflammatory granulomata of lupus and lues, in which the slight pain may be completely over- shadowed by the itching. Pain of the external ear due to frostbite is especially note- worthy. It is peculiar in that it is likely to recur with every return of cold weather. The previously frozen parts often begin to be painful again, even with a moderate fall of temperature. A very painful disturbance in the pinna, which is, to be sure, only a symptom of another disease, is herpes. The pain begins even before the appearance of the herpetic vesicles, and continues usually until they vanish. Gouty nodules, which have a prefer- ence for the helix margin of the pinna, may be the cause of pains which are of a very unstable and changing character, a peculiarity of gouty nodules in general. External Auditory Canal.— The external canal, with its nu- merous hairs and glands, is directly predisposed to furunculosis. The frequency of middle-ear suppuration, and the circiunstances that such a condition, after only a short existence, in most cases shows a secondary infection with pyogenic staphylococcus, carries with it the probability that during the necessary cleaning manipula- tions of patient or physician the liair follicles become inoculated, a procedure which, according to the researches of Schimmelbusch, Garre and others, brings about furunculosis with tolerable cer- tainty. 334 PAIN IN DISEASES OF THE EAR Furuncle of the external canal manifests itself through a special painfulness, because the pus, on account of the closely woven, subcutaneous, connective tissues, is held under a high degree of pressure. These pains are of a boring, sticking, throb- bing nature, and radiate, by preference, toward the teeth. There- fore, the patient can take only a very limited amount of nourish- ment, since every movement of the mouth increases the pain. This is due to the fact that the head of the inferior maxilla lies against the anterior wall of the external auditory canal, and movements of the jaw joint are accompanied by movements of the adjacent aural tissues. The pain usually subsides with the rupture of the furuncle, or with its opening. The pain of diffuse inflammation in the external canal, the so-called otitis externa diffusa, is of longer duration, and much less certainly influenced by operation. ForeigTi bodies in the external auditory canal cause pain usually only by penetration, by wounds brought about by unskil- ful attempts to dislodge them, or by the swelling or growing of the foreign body in the ear. Peas, beans and fruit kernels remaining for some time in the canal swell, and cause a very noticeable pressure upon the canal wall, thereby producing more or less pain. The larvse of the large meat-fly ("blue-bottle fly"), developing from eggs laid in the canal, often attain great- ness, both in number and in size. They may cause such pressure upon the external canal that it becomes widened to the breadth of a finger. Since these maggots are provided with sharp hooks at the ends of their bodies, and seek to attach themselves by sticking these hooks into the skin, the pain which they produce is extraor- dinarily severe. This becomes still greater, because the worm masses are always in motion, and consequently the pain is of a continuous, changing, undulating character. I have observed such a case, in which twenty-six maggots had brought about a consider- able widening of the canal, with very intense pain. In lesions of the middle ear the patient assumes a position in which the ear of the affected side rests in the palm of a supporting hand, the elbow resting on a table, as is illustrated in Fig. 80, MIDDLE-EAR DISEASE 335 Tympanum. — Pains may originate in the drum membrane. One often speaks here of a myringitis bullosa. This is, however, not a bacterial invasion, but is only a herpes of the drum. Bac- teriological examination in large numbers of such cases showed the vesicles to be sterile. The sudden beginning of the pain is very characteristic for myringitis. Often the patient is awakened at night by a sudden, severe, sticking pain in an ear previously entirely sound. The pain lasts as long as the vesicle remains, but ceases just as suddenly as it began. ^ In lesions of the exter- nal meatus from the tym- panum outward the pain is localized to the diseased area, but from the drum in- ward the pain is, as a rule, referred to a distant area, the most common reference area being the hyoid, which has two points of maximum tenderness, the first in the meatus and the second just behind the angle of the jaw. These areas are also asso- ciated with the tonsil, the posterior teeth of the lower jaw, and the lateral aspects of the tongue (Head). When the tension in the middle ear is raised pain may also be referred to the vertical and parietal area of the scalp. (See pages 293 and 294.) Middle-ear Disease. — Acute Otitis Media. — Most marked are the pains of acute middle-ear inflammation. Here they are not limited to the membrana tympani, and are most severe until ' Hunt, of New York, has shown that this type of herpes is usually associai^ed with disease of the geniculate ganglion. Fig. 80. — Postuee Assumed in Earache 336 PAIN IN DISEASES OF THE EAR perforation of the drum takes place. We must, however, differ- entiate two kinds of acute otitis, namely, that caused by capsulated bacilli, and that caused by noncapsulated bacilli. While in the first type the pain is usually trifling in nature, and only "stick- ing" in the first day of the disease, as in middle-ear catarrh, the second type, caused by noncapsulated cocci, calls forth the most capricious and troublesome symptoms. The pains begin with moderate intensity and increase, within two or three days, to quite unusual severity. They are, as a rule, of a boring, sticking or tearing nature, and reach the greatest degree when the drum mem- brane becomes deep red, shoAvs no details, and is nearly ready to rupture at some markedly bulging spot. After rupture the pain for the most part ceases. Obviousl}' one can shorten the patient's sufferings by carrying out artificial rupture of the drum through incision (paracentesis). It must be regarded as an unfavorable sign, if, after perforation of the drum, the pains do not immedi- ately subside. In such cases the mastoid process is likely to be included, and if this comes to pass spontaneous pains of greater or less severity manifest themselves. However, this symptom may be completely lacking, or may only be elicited by pressure, either upon the mastoid tip or over the antrum, in which latter case the mastoid cells are undoubtedly involved. To be sure the prop- agation of the inflammation to this degree must depend upon the anatomical structure of the mastoid process. A pneumatic mas- toid is always affected in the beginning of an acute otitis, and this is the reason why tenderness at the tip in such cases is so frequently seen. But this inflammation may at any stage retro- gress without going on to suppuration and, therefore, in the begin- ning of an acute otitis this symptom has no pathognomonic sig- nificance. If, however, the tenderness or the spontaneous pains last a relatively long time, or if, after having once vanished, they reappear, then it is probable that we have to do with an abscess in the mastoid process, and in this regard the symptom becomes of great importance with respect to operative inter- ference. Cheonic middle-eae, discharge causes, as a rule, no pain; MIDDLE-EAR DISEASE 337 but pain may arise, of course, as a result of an acute exacerba- tion, or if the perforation in the drum is so small that opportunity is given for retention of pus. Sometimes chronic middle-ear sup- puration, which otherwise would give no pain, is, when accom- panied by cholesteatoma, subject to manifestation of severe pain. Complications of Middle-eae Disease. — If acute or chronic middle-ear suppuration becomes complicated by extension of the inflammation to neighboring regions, then the pain thus pro- duced is usually quite sigiiificant, especially if suppuration takes place in the mastoid, whereby the mastoid cells are broken down and the excavated interior of this bone becomes filled by pus, which, through gi-adual accumulation, exerts great pressure. If this pus breaks externally through the bone cortex, it can dissect the periosteum free from the bone to a very gi'eat extent. We then find a large swelling behind the ear, which is covered by a much- reddened, very tense epidermis, giving rise to gi-eat pain. This swelling may become so great that the entire half of the head is in- volved, especially in badly neglected cases. This subperiosteal ab- scess formation is very frequent in children, because the pus passes through the open fissura mastoidea in a very short time, and then lies directly under the periosteum ; but here, on the other hand, instead of producing pain, the pain may be actually lessened after penetration to the periosteum for a time, at least, through relief of pressure within the mastoid shell. If, however, the pus burrows inward, the dura becomes ex- posed through destruction of bone, either in the posterior or mid- dle fossa, according to the direction which the destructive process takes. The tough dura and, in the posterior fossa, the sinus lat- eralis are fairly resistant structures, and may often be sur- rounded by pus for a long time without becoming especially af- fected. They become covered with granulations, which serve further to protect them, and thus are brought about the conditions known as pachymeningitis externa, or periphlebitis of the lateral sinus, as the case may be. With this disease-picture at hand, the pain is likely to be of a trifling, ill-defined, dull nature, but if the pus extends outward between the dura and the bone, or between the 338 PAIN IN DISEASES OF THE EAR sinus and the bone, we have the picture either of an extradural or of a perisinus abscess. We speak of a "closed" extradural abscess if the opening through which the pus has penetrated to the dura is so small as to be nearly undemonstrable ; but if, on the other hand, the communication with the purulent mastoid cavity is greater, we speak of such a condition as an "open" extradural abscess. I^aturally the pain in a closed extradural abscess is much more severe than in the open type. If the pus spreads out toward the tip of the petrous portion of the temporal, then periorbital pains often arise, which N^eumann holds to be characteristic for this type of extradural abscess. On the con- trary, if the abscess spreads more laterally in the middle fossa of the skull, pain and swelling in the temporal region near the zygomatic process simultaneously arise, as Ruttin has described. Perisinus abscess may also cause very severe pain, especially if the pus collects in the bony sinus groove between the mem- branous and bony sinus walls, where it often remains under such high pressure that, upon opening the mastoid process, it gushes forth in a pulsating stream. Still greater may the pain become, if, besides the pus, gas forms (gas abscess), and raises the pres- sure to a very high degree. Perisinus abscess, like extradural abscess in the posterior fossa, causes a more or less severe head- ache in the occipital region. If the suppuration destroys the dura mater, then intradural suppuration, meningitis, temporal lobe abscess, cerebellar abscess, or sinus thrombosis may arise. Intradural suppuration is such a rarity, and so seldom clinic- ally pure in type, that with respect to pain as a symptom it offers very little that is characteristic. On the contrary, otogenic men- ingitis may produce a tolerably pronounced picture, since in it the pain is extraordinarily intense, of a sticking or tearing character, and accentuated in its last phase. I am accustomed to describe this to my students in the following manner : The location of this pain varies according to the extension of the meningitis. The basal type usually causes occipital or frontal headache, but the head type, that is, the form of suppuration which spreads out over the convexity of the brain, produces pain at the vertex of the skull. Character- LABYRINTH 339 istic, also, of meningitis are the remissions of pain, great suffering being often followed bj a period of comparative ease and comfort. Brain abscesses may also exist in the middle and posterior fossae. Headache is seldom lacking in these cases, and may be referred, in both cerebellar and temporal-lobe abscesses, to the frontal or occipital regions. In temporal-lobe abscess it is not seldom localized at the vertex of the skull, but in both temporal- lobe and cerebellar abscesses the pain is usually limited to the half side of the head — hemicrania. Middle-ear Catarrh. — Middle-ear catarrh is a frequent cause of pain, especially in children. This pain, to be sure, is not especially intense, but may, through its sticking character, be quite disagreeable. It seems that such pains are induced through the strong retraction of the membrana tympani ; at least, this is true of those cases in which the drum is markedly re- tracted, for they vanish after inflation of the tympanic cavity, or after aspiration through the external auditory canal. High- grade inveterate catarrh, with maximal retraction of the drum, which is of a milky color, also causes pain, which is not, how- ever, to be influenced through Politzerization, catheterization or massage, because the drum is fixed in the retracted position and cannot be corrected through these manipulations. In these cases the pain, nevertheless, ceases immediately if one introduces a hook ■\yith a straight shank just in front of the hammer and draws the entire membrane outward, after the method which Ruttin has described. Otosclerosis. — In this disease, which consists of pathological changes in the bony labyrinth capsule and which has an exquisite hereditary anamnesis, but whose etiology is still unknown, pains are seldom to be found. However, there exist, sometimes, in addi- tion to diminished hearing, noises and manifold paresthesias localized or diffused through the entire ear tract, as well as pain- ful sensations in the external canal, and in the surrounding struc- tures. Labyrinth. — Whether pains of distinctly labyrinthine origin are to be recognized or not has hitherto not certainly been proven. 340 PAIN IN DISEASES OF THE EAR However, pains in labyrinth disease scarcely come into considera- tion in relation to the other extraordinarily troublesome and dis- tressing symptoms, such as difficulty of hearing, noises, dizziness, vomiting, etc. Referred Pains.-^First of all, there are pains due to diseased teeth, which may so closely simulate aural pains that a typical disease-picture is described as otalgia excarie dentium, since a bad tooth is so often the cause of a pain described by the patient as localized in the ear. Secondly, swollen glands in the neck region may produce pains which the patient falsely refers to the ear on the side affected. Especially, however, do inflammations in or around the tonsils (peritonsillar abscess) produce pains which the patient describes with great certainty as being situated in the ear. These pains are increased by every act of swallow- ing, because muscles of the Eustachian tube are thus brought inte action. CHAPTEK XVII PAIN IN DISEASES OF THE NOSE i The Sensory Nerves of the Nose, — The nose receives its sensi- bility from the first two branches of the trigeminus. The lateral wall receiving its sensory snpply from the anterior and posterior ethmoidal nerves, which take their origin from the first branch of the trigeminus, while the infraorbital and sphenopalatine nerves, which come from the second branch, participate in the innervation of the other parts. The nervi septinarium, which are the sensory nerves of the septum, also have their origin in the second branch of the fifth nerve. Of the sinuses the frontal sinus and the anterior ethmoidal cells receive their nerve supply from the ophthalmic ramus (trigeminus I), while the posterior ethmoidal cells and the sphenoidal sinus are supplied by the nervi nasalis lateralis superiores and the nervi ethmoidales posteriores. The exact relations, according to the description of Zucker- kandl, are the following: The nervus nasalis anterior passes through the foramen ethmoidale anticum toward the anterior cavity of the skull, where it extends to the edge of the cribriform plate toward the anterior portion, and is there covered by the hard sheath of the dura mater; then, after passing through the ethmoidal canal, it goes to the nasal cavity, where it divides into the ramus septinarium, the ramus lateralis, and the ramus an- terior. The posterior nerves of the nose are derived from the sphenopalatine ganglion, and after passing through the fora- men enter the nasal cavity, where they are distributed to the lateral and median Avail. The nervus nasopalatinum scarpi, the 1 By Privat ^ocent Dr. Emil Glas, assistant in the University Clinic ia Vienna (Director Hofrat Chiari). 341 342 PAIN IN DISEASES OF THE NOSE true septum nerve, which originates from tlie same source, sup- plies the anterior mucous membrane of the pahite after having passed through the canalis incisorus. Diseases Which Produce Pain and Their Manner of Produc- tion. — Introitus narium, folliculitis, eczema introitus, and the spe- cific inflammations in the region of the anterior portions of the septum produce pains such as one finds in all inflammations, and need no special explanation. One should never forget, in acute pains arising suddenly in the region of the introitus, closely to inspect the anterior angle of the entrance of the nose, for in this place one often finds a hidden folliculitis, or a small retention of pus, which may easily produce severe pain. This is of special importance in case of erysipelas, which not infrequently begins at the introitus narium. It is well to mention the sej)tum abscesses, which are always accompanied by severe pains, and are most frequently of traumatic origin. Pains in the region of the cartilaginous portion of the nasal septum, combined with a sten- osis of traumatic origin, at the nasal entrance, point to the forma- tion of a septum abscess. The pains may be caused either through inflammatory irritation of the terminal ramification of the septal nerves, through compression or degeneration, or through pressure from the supiDurating hematoma. Long, persistent pains, after a discontinuation of suppuration, point to a fracture or to a spreading of the fissures of the skull. Nasal Stenosis. — The various headaches that are caused by nasal stenosis deserve special consideration, for they are often accompanied by other phenomena, such as psychical depression, inattentiveness, loss of appetite, neurasthenic symptoms, and lack of concentration. These phenomena, wdiich were mentioned by Piorry as symptoms of rhinostenoma, are caused by nasal polypi, large hypertrophies, higher grade septum deviations, and tumors of the nose, and can be cured by endonasal therapy. Hartmann, in his work on "Xasal Headaches and Xasal Xeu- rasthenia," has given the following explanation for headaches caused by nasal stenosis: If too little oxygen passes into the lungs through a partly stenosed nose, and consequently a diminu- EMPYEMA 343 tion of exhaled air, as is physiologically necessary, occurs, the oxygen content of the blood is diminished and an accumula- tion of carbon dioxid takes place in the blood. It is not only the accumulation of carbon dioxid that is to be considered, but there are other by-products formed that are classed as toxins. Hart- mann states that, through partaking of poor nutritive matter, a bad influence is produced upon the nervous organism, and that only in this way is the appearance of headaches and neuras- thenic symptoms to be explained. Just as neurasthenic condi- tions appear in persons v^^ho are crowded into closed or poorly ventilated ajDartments, so, also, difiiculties are called forth through lack of nasal breathing-space. In children with adenoid vegetations Lichtwitz and La- brayes have proven that the oxygen of the blood and the number of red blood-corpuscles are considerably reduced, while the white ones are increased ; and that, upon removal of the adenoids, the number of red corpuscles and the oxygen constituents of the blood are heightened. This change, especially, should be consid- ered by those who do not estimate highly enough the importance of adenoids, and who deny the disappearance of a number of reflex symptoms after the nasal pharynx has been freed of its encumbrances. The headaches produced by nasal stenosis can, in most cases, be cured through operative procedures. However, one must not forget that quite a number of internal diseases may also produce these cephalalgias, which fact should receive consider- ation in applying therapeutic measures (see Headache, Chapter XIV, page 262). Empyema. — The headaches arising in empyemas of the sinuses are found in acute as well as in chronic empyemas, and each has a different genesis. Should it be possible that, at the same time with the inflammatory changes of the sinus mucous membrane, the terminal ramifications of the sensory nerve apparatus also suffer inflammatory changes ; or should it be possible that distant in- fluences might also be acting as causative factors (the latter be- ing classified in the group of referred pains), only after exclusion of these factors is it proper to think of the neuralgic pains, which, 344 PAIN IN DISEASES OF THE NOSE arising in cases of empyema, can be traced back to a stasis of secretion and secondary pressure phenomena. The other neu- ralgic pains caused by nasal affections will be considered in regular order. In his work on ''The Significance of Rhinology for Internal Diagnosis and Therapy" Glas has especially called attention to and emphasized the fact that often the cause of these headaches is not discovered for a long time, and that all possible measures to relieve the sufferings may be utilized without result. Other pains found in inflammatory states of the sinus are the local paijis that occur in the cavities themselves, as aching, boring and piercing pains, and occasionally, as in cases of stasis, severe and throbbing pains. These pains, which are similar to sinus abscess pains, may also be produced by percussion of the external wall of the suspected sinus, or, if previously existing, may be increased. In this way in those sinuses whose walls are percussible (as the maxillary sinus, frontal sinus and anterior ethmoidal cells) one is able to decide, in some cases, even the extent of the diseased area, and the size of the diseased sinus. Occasionally, through the detection of percussion pains, one can determine whether there are abscess formations and septum deviations in the frontal sinus. These observations may be sub- stantiated by X-ray examinations. Finally, pains arising in otlicr parts of the hody may bs genetically related to diseases of the nose, especially to empyema, as described by Flies in several cases. These phenomena belong to the large group of reflex neuroses of the nose. A careful study of these pain reflexes has also been made by Head, who finds that diseases of the olfactory (upper part of the nose) cause re- ferred pain and superficial tenderness over the nasal and mid- orbital areas (q. v.) : disease of the nasopharyngeal part of the respiratory tract may cause pain and tenderness in the nasolabial area. But, as a rule, the nasal affections do not cause pain. Since the i^ressure pains are of value for the localization of the diseased areas, the statement of the patient in regard to the location of the headache would be of special diag- DISEASE OF THE SPHENOPALATINE GANGLION 345 nostic importance, were it not for the fact that there are many cases in which the subjective sensations do not coincide with the objective findings. Similarly, one often finds that patients with a disease of the sphenoid sinus or posterior ethmoidal cells often refer the pains to the region of the anterior sinuses, wdiich, upon examination, are found perfectly healthy, and vice versa ; so that one cannot use pain localization as an absolute indicator in the topical diagnosis of diseased sinuses. That neuralgias may be produced by suppuration of the sinuses has been proven by Peyre, who had a case of facial neuralgia, which had been complicated by the removal of the Gasserian gan- glion, and which disappeared after a septum and maxillary sinus operation ; or by Hartmann, who had a case of trigeminus neu- ralgia, accompanied by insomnia of several weeks' duration, which was completely cured after removing a caseous mass from the antrum. The writer is at present observing a case of intensive infraorbital neuralgia of several weeks' duration, which was treated galvanically without result, and which completely disap- peared after Cowper's alveolar operation of the maxillary sinus. Also, cases of frontal sinus empyema, accompanied by supraorbital neuralgias, are not infrequently cured by operation. Headache from Disease of the Sphenopalatine Ganglion. — The experiments of Greenfield Seiider, who believes that the spheno- palatine ganglion is an important factor in the production of head- aches of nasal origin, are of much interest. He believes that, sec- ondarily, the ganglion is sympathetically affected in intranasal in- flammation, and applies his therapeutic measures accordingly. He has tried to anesthetize the ganglion by making cocain applica- tion behind the posterior end of the middle turbinate, and suc- ceeded in several of his cases. At the same time he describes cases in which headaches have disappeared after cauterization of these areas, a fact which seems to point to an affection of the ganglion. Obstructed Sinuses. — Here we may consider the observations which convince the writer, as well as Hartmann, that also in cases of nondiseased, but obstructed, sinuses, or in cases of poor com- 346 PAIN IN DISEASES OF THE NOSE munication between the sinuses and the nose, severe pains may exist, which, upon removal of the obstructions, are immediately decreased. I know of a colleague whose left maxillary sinus I must puncture four or five times a year, without being able to detect at any time any inflammatory affection of the antrum. However, I noticed at the first puncture that I made, on account of the severe, one-sided headache, that by the inflation of the antrum with air the characteristic antrum murmur was missing, and that it took more pressure than normal to inflate ; therefore, I was forced to conclude that the ostium relations were unsatisfac- tory, and were either injured or had been insufficiently developed. Although there was no secretion to be found in the return solution after douching the antrum, nevertheless the colleague felt well after the rinsing. The headaches disappeared for some time, until the conditions demanded another puncture, which had to be re- peated four or five times a year. The patient has not accepted my proposition to enlarge the communication and thus relieve him of his sufferings, although this operation might free him of his pains forever. Such cases indicate that the destruction of the communication, or a hindrance between the sinuses and the nose, can produce headaches even where there is no sinusitis present. Hartmann has also made similar observations, and gives the following explanation to prove the truth of his assertion: (1) In those cases in which existing frontal headaches cause one to believe that there is a frontal sinus disease, the frontal sinus may be opened without finding any diseased condition. In such cases the pains may disappear after opening the frontal sinus, to reappear, however, when the external opening heals, unless in the meantime a communication has been made with the nose. If a communication has been made, the pains are absent as long as the communication exists. (2) There are cases in which, after an operation on the frontal sinus, exacerbatory symptoms arise in the form of head- aches without a real recrudescence of the disease, but only a clo- sure of the opening into the nose, and it is this closure which pro- duced the frontal headaches. In such case it suffices to open the TUMORS 347 thin scar on the forehead with a sound. This allows the entrance of air, and thus relieves the headaches. (3) The third deduction of Hartmann's is not absolutely unchallengeable, for in those cases in which an empyema had ex- isted (about eight), and which were cured, the reason that the headaches disappeared after the formation of a communication between the nose and the frontal sinus can be traced, possibly, to a retention of secretion, and not to the exclusion of air in the sinus. Tumors. — Headaches are, furthermore, a very important symptom, and are often the most prominent phenomena observed in the malignant tumors of the nose. Harmen and Glas have shown that the headache was the most important symptom in nine out of thirty-two cases observed.^ These headaches, in spite of the better drainage of the pus, the result of an existing empyema, continued in the same degree after the removal of the growth. This showed that a deeper affection must have been the cause. The two following cases may prove the truth of this assertion: (1) Pa- tient Z came, for dispensary treatment, with severe pains of the right cheek, accompanied by periodic, right-sided headaches. Rhinoscopical examination showed pus in the right nostril, espe- cially in the middle meatus. Considerable pain was present upon pressure on the right maxillary sinus wall. The probable diag- nosis made at the time was empyema of the antrum. Puncture of the right maxillary sinus was positive. Since the suppuration was not lessened by repeated douching through the ostium, the maxillary sinus was opened, through the alveolar process. Re- peated douching was given. ISTevertheless, the pain did not cease. The continuation of the pains, in spite of the opening and the douching of the antrum, indicated that another process must be present besides that of empyema. The histological examination of the resected lower turbinate showed cylindrical-celled carci- noma. (2) A woman, fifty years of age, had a polypus removed from the right nostril a year previous to her admittance. Eight months later, on account of profuse suppuration, the maxillary 1 Deutaclle Festschrift fiir Chirurgie. 348 PAIN m DISEASES OF THE NOSE sinus was opened through the alveolus. In this case there were two factors which indicated the probability of a malignant for- mation of new tissue, namely, the intense pain and the fetid con- dition of the returning fluid of the douching solution. The his- tological examination of an excised mass then gave the diagnosis of stratified epithelioma. The cause of the headaches in maligiiant tumors of the nose may be various. The origin may be one of the following: (1) reflex irritability, (2) blood and lymph stasis, (3) nerve pressure, (4) meningeal irritation, (5) the result of an empyema occurring at the same time. Zuckerkandl shows, in his anatomy of the nose, the superficial position of the ethmoidal nerve in the anterior portion of the skull, and adds that this exposed position allows approximating swellings to cause pressure symptoms. That headaches some- times arise as localized symptoms is sho^^^l in the second case, cited by Harmen and Glas in their article on "Malignant Tu- mors," in which right-sided, frontal headaches existed. Autopsy showed penetration of the roof of the orbit and a growth of the tumor into the right frontal sinus. We deduce, therefore, that, after cleansing of the sinuses, constant pains should call forth the suspicion of malignant neoplasms. In one of my last cases, on autopsy, I found a meningeal hyperemia, which may have been the cause of the violent and increasing cephalalgia during the last days of the patient's life. Finally, we cannot deny that those swollen areas in the interior of the mucous membrane, found on section, may, by compressing certain structures, ^ very frequently be the cause of severe, continu- ous headaches. DIAGNOSIS In cases of acute empyema the pains are sometimes very vio- lent, and one cannot be reminded too often of the fact that, when pains arise during a coryza, or an influenza, a thorough rhino- logical examination should be made. The result of therapeutic measures in empyema is often marvelous. A puncture through DIAGNOSIS • 349 the inferior meatus, or a douching through the natural opening in sinusitis maxillaris, or the application of cocain on the anterior end of the middle turbinate, in frontal-sinus affections, can relieve the most acute pain. Unfortunately, even at the pres- ent time, one finds many cases which are treated for weeks, either galvanically, or faradically, are massaged, or receive other result- less treatment, without the attending physicians even surmising that the sinus is diseased. A test of importance, which I have introduced into rhinology, may frequently be applied. The principle of this test is the fol- lowing: The tuning fork, which is held anteriorly in the median line above the bridge of the nose, is lateralized to the side where the diseased sinus exists. In case the ear is not affected the patient hears the tuning fork only on the side, or more intensely on the side in which the sinus is affected. This method, which was tested in several hundred cases, affords important service to one who is not thoroughly conversant with exact rhinological technic, as he is able to state, in cases of neuralgic headaches, whether they can be traced back to affections of the sinuses. I have seen cases in which patients complaining of severe neuralgias were sent to a rhinological specialist for examination, in whom Glas's tuning-fork test proved to be nega- tive (i. e., the tuning-fork was heard only at the point of appli- cation, or, as the patients said, heard alike at all parts of the head), and in whom, as a result of complete rhinological examina- tion, empyema could be excluded as the cause of the neuralgic pains. On the other hand, this test affords the rhinologist im- portant service in a diagnostic and prognostic manner, in regard to which Glas gave more explanatory details at the International Rhino-Laryngological Convention in Berlin, 1911. * At the same time one must not forget those cases in which there is no stenosis, but in which hypertrophy of the middle tur- binate is the determining factor of the headaches, which disappear after resection of this part. These headaches are classed by some as symptoms of stenosis, but by others they are placed in the groufi of Flies' reflex symptoms. At any rate the pressure of 350 PAIN IN DISEASES OF THE NOSE the turbinates on the septi may cause reflex pains. The explana- tion of Casali, however, is more reasonable. He assumes the cause to be compression of the vessels of the nasal mucous mem- brane, which are in communication with the veins of the dura mater and the superior longitudinal sinus, the blood and lymph stasis of the mucous membrane of the nose causing a stasis in the dura covering the brain. There is no doubt that, in such cases, the result of resection of the hypertrophy of the turbinate is strik- ing. On negative internal findings, the diagnostic sig-nificance of this therapy should not be forgotten. Here may be included those cases in which severe neuralgias are relieved by endonasal opera- tions. In regard to this point, I have expressed myself in my work on "The Significance of Rhinology for Internal Diagnosis and Therapy," in the following manner : Any one who has had occasion to cure a severe neuralgia by an endonasal operation will know how to emphasize the importance, indeed the utmost neces- sity, of a rhinological examination in every case of neuralgia of the fifth nerve. The following cases may illustrate the foregoing statement : (1) In the case of a patient who had suffered for years with a neuralgia of the infraorbital nerve, I found, by rhinological examination, a rhinolith lying under the middle turbinate and pressing upon the processus uncinatus. On its removal the neu- ralgia disappeared. (2) A patient who had tried various therapeutic treatments for a trigeminal neuralgia, in his despair consulted a rhinologist. By chiseling a broad crista of the septum, which extended in an especially sharp angle to the middle turbinate, relief of the neu- ralgia was at once obtained. A single example of this kind is of more value than a multitude of reflections, and proves the utmost necessity of a rhinological examination of such cases. In conclusion, it may be added that sometimes, after a radi- cal operation on the frontal sinus, neuralgias of the supraorbital nerve arise. Therefore, it seems rational that, while doing the Killian operation, one should remember this fact, and resect the supraorbital nerve CHAPTER XVIII PAIN IN DISEASES OF THE THEOAT PAIN IN DISEASES OF THE PHARYNX ^ The sensory nerve of the pharynx is the lingual. From it are derived the sensory receptors of the anterior palatine arch, the tonsils, the floor of the mouth, and the tongue. This and the glosso-pharyngeal divide the supply of these parts, while the re- gion of the gingiva is supplied by the alveolaris inferior. Pain in Acute Diseases. — All the inflammatory processes in the region of the pharynx contribute toward pain production, for in- stance, the different forms of angina, the inflammation of the pharyngeal tonsil, retropharyngeal abscess, and herpes, febrile and zoster form. In this group of diseases phlegmonous angina, retro- pharyngeal abscess, and diphtheritic inflammation are especially prominent. Phlegmonous angina often produces very severe pain, which is increased by every movement of the mouth, and which has radia- tions in the ear which are often unbearable. These are sometimes produced through a pus area developing in the deeper tissues, sometimes through an inflammatory edema of the surroundings. The pains are sometimes boring, sticking, excessive, or trivial. The localization of the pain is frequently inexact. When it is located in the nasopharynx, in the ear, or in the region of the ostium tubse, the increased pain upon pressure outside on the anterior mandibular muscles is characteristic. Upon opening a "peritonsillar abscess, the making of the inci- sion in the right place, that is, at the point where the pus conies ' By Privat Doeent Dr. Emil Glas, of Vienna University. 351 352 PAIN IN DISEASES OF THE THROAT nearest to tlie surface, is of the utmost importance, since the inci- sion and dilatation of the point of incision in an edematous but not pus infiltrated area occasion very severe pains, which fre- quently cause fainting. On the contrary, the incision in the in- filtrated area is relatively painless, and causes an instantaneous improvement. Retropharyngeal abscess often produces pain similar to that of phlegmonous angina, save that in the former the location cor- responds to the deeper seat of the affection, which lies further back and lower down. Deglutition also occasionally is difiicult and is associated with severe pain, which is increased by the swell- ing of the corresponding glands of the neck. The acute process, as a rule, does not affect the vertebra, but chronic retropharyngeal abscess may cause necrotic processes in the vertebral column. Con- cussion of the vertebral column, produced from above, causes no increase of the pain in the acute form. In diphtheria swallowing pains are usually severe. Fre- quently, from the swelling of the velum, the taking of food be- comes difficult and painful, although in many cases no trouble of any sort is present. Generally there occurs a painful swelling of the submaxillary glands; likewise, of the lymph glands lying under the sternomastoid muscle; these frequently grow into a large, very painful lump, especially sensitive to the touch. Here, one must not forget, in pharyngeal diphtheria, the pains arising (through the general infection) in the head, neck, back and the region of the buttocks, which often cause the patient very much trouble. The acute infectious diseases, especially influenza, wliich causes very severe neck pain, with but little objective findings, are of interest. Escat has described such cases and has diagnosed them as pharyngodynia from influenza. Here one finds, at the most, a slight degi'ee of erythema. This painful angina is closely related to the herpetic angina and disappears in- the course of a few days. The febrile herpes of the pharynx, which is often associated with laryngeal herpes, appears very frequently in groups, occur- PAIN IN DISEASES OF THE PHARYNX 353 ring, also, in the form of small, diffuse, epidermic vesicles, and is especially characterized by pain on swallowing. In a work given out from the Chiari Clinic of the Vienna University, Glas mentioned that frequently, after a short prodromal stage, severe difficulties of swallowing and sticking pains occurred in the throat, accompanied frequently by hoarseness and difficulties of breath- ing. The dysphagia often reaches such a pronounced cfegree that the patient is unable to take nourishment. Examination of the mesopharynx very frequently gives an entirely normal pic- ture. Laryngoscopic examination first shows on the base of the tongue, in the region of the follicular papillae, on the vault of the pharynx or on the pharyngeal wall, symmetrical vesicles. These are very prominent, varying in size from a poppy seed to a lentil, and are filled with white contents, lying on a red base. These vesicles may be scattered, without any arrangement, or they may be gathered into groups. At this point it is time to emphasize (as we shall do later, in our description of chronic affections) the fact that one should always, in cases of pain on swallowing, ex- amine the region of the hypopharynx, w'here these efflorescences are likely to occur. As an example of these interesting infections, in wliich severe pain is always present, the following case is of note : ''The patient, fifty years of age, felt, for a few days, weak and tired ; three days previous, chills and high-grade dysphagia. The patient gave the impression of being very ill, the head being held as it is in peritonitis gravis. The temperature Avas 38.9° C. (102.2° F.) and the pulse frequency was 110. The pharynx was perfectly free, and the tonsils were not in the least inflamed. The opening of the larynx (aditus) was greatly changed; the epiglottis, the aryepiglottic folds, the valliculai in the recessus pyriformis, were covered with vesicles of a somewhat similar size, not very prominent, and filled with gold-colored contents." Herpes zoster may, as I have frequently seen, give rise to very special pain in the region of the pharynx, which assumes a neuralgic character and reaches such an intensity that the other- wise fairly resistant patient whines and complains. Kaposi has 354 PAIN IN DISEASES OF THE THROAT described cases which correspond with the distribution of the maxillary nerve, the pains at the same time occurring in the cheeks, the palate and the pharyngeal mucous membrane of the affected area. The herpes arises sometimes as a diffuse, painful redness, sometimes as a gToup of efflorescences of a short duration, or even as gangrene of the rami palatini and pharyngei. Frequently with the significant difficulties of swallowing severe toothache is present, with the resulting continuous neuralgi- form pains. I have seen two cases of herpes zoster associated with high-grade dysphagia. In these cases only the mucous membrane of the mouth and pharynx was affected, and the efflor- escence was interrupted sharply in the median line. Cases have also been described in which it is almost impossible either to speak or to chew, each movement calling forth a tic dou- loureux. Herpes zoster is occasionally mistaken for acute pharyngeal ajfections. Here, also, phlegmonous inflammation of the base of the tongue is to be considered, for it very often occasions unbear- able j)ain, and, like peritonsillitis, makes deglutition impossible. The pains, which are severe, sometimes radiate to the ear. These diseases, because of the action of the inflammatory exudate on the glosso-pharyngeus, give rise to stimuli which are conducted back through the vagi, and are often associated with profuse salivation, high-gi-ade prostration, and difficulty of breathing. Pain in Chronic Diseases. — Among chronic diseases of the pharynx, which cause interesting pains, tuberculosis, lues, and malignant neoplasms of this region are prominent. Tuberculous ulcers of the pharynx produce severe pain, which is increased in swallowing. The pain frequently radiates to the ear, and the deeper the process extends the more severe it be- comes. The maximum is reached in tuberculous affections of the aditus laryngis, a very frequent disease. The ulcers located in the epipharynx, especially those having their location near the tuba of the ostium of the pharynx, are very painful, and, because of their location, are noteworthy, since for their diagnosis an exact posterior rhinoscopy is necessary (the unskilled rhinos- PAIN m DISEASES OF THE PHARYNX 355 copist, in order not to overlook these diseased parts, should use a pharyngoscope). Swallowing, in cases of pharyngeal tuberculosis, is often very painful, and causes vomiting, which, in turn, aggravates the pain. Very frequently otherwise active anodynes, such as cocain, mor- phin, orthoform, etc., are entirely without effect, and the physi- cian finds it necessary to resort to morphin injections. For the severest laryngeal pain the alcohol anesthesia of the nerves is especially to be recommended. Luetic ulcers, at first, are not associated with very great pain, the superficial mucous membrane plaques causing only slight trouble ; and attention should be called to the disparity between the extensive process and the slight trouble as characteristic of the first stage of syphilis. The first pain occurs on the deep exten- sion of the process, and may (for example, in deep, ulcerating gummata) reach a very high degree. Gummata of the base of the tongue and of the epipharynx, lying principally on the roof of the pharynx, may exist, in which the most prominent symptom is the excessive pain. Diffuse pain, radiating chiefly into the ear, accompanies this stage of the syphilitic process. It is also to be emphasized here that, with this group of symptoms, an exact retronasal examination should be made, and the region of the cir- cumvallate papillae carefully examined, because it is exactly here that the concealed seat of the affection is often to be found. In carcinoma of the base of the tongue there may be no pain in the early stages. The patient experiences only a scratching or a tickling in the neck. Often, upon pronounced movement of the tongue, he has the sensation as of a foreign body in the pharynx, and his complaint of this may lead to a false diagnosis. The deep extension of the carcinoma first produces severe, often signifi- cant pains radiating into the ear, the jaw, or the larynx. Pro- fessor von Bergman held the hemorrhage and pain which are pro- duced through the movement of the tongue, and through the con- tact of the hard food, as characteristic features of carcinoma of the tongue. He says : "They frequently are as pronounced as in the flat, tuberculous ulcers on the margin of the tongue. Fre- 356 PAIN IN DISEASES OF THE THROAT quently tbcj are neuralgic in character, and radiate toward the ear, and the unhappy patients often complain fearfully" ("Hand- book of Surgery"), Of the group of chronic infections with w4iich severe pain is associated i)empliic)i of the mucosa are conspicuous. Often they suddenly burst open, or the vanishing vesicle, through hemorrhage of the submucosa, may occasion an increase of the pain, especially in the efflorescence of the mucous membrane lying adjacent to the pemphigus follicle, which causes a diffuse epithelial desquama- tion, produces a high degi'ee of dysphagia, and, as a result of inanition, quickly incapacitates the patient. The NEURALGIAS OF THE PHARYNX, which, without demonstrable organic changes, are found in hysterical individuals, are also to be considered. The patient often, for hours, will complain of lightning pains arising in the different parts of the mouth and radiating into the pharynx. Here, one should always seek for the pressure points, w^hich are located in the region of the laryngeus superior glosso-pharjoigeus or the lingualis. Those affections arising through tonic contraction of the swallowing muscles may be designated as hysterical dysphagia. In these strong pressure, accompanied by the closing of the teeth, produces a sticking or tearing pain. PAIN IN THE LARYNX ■ The sensory component of the vagus is the superior laryngeal nerve, which, arising from the vagus, runs median to the internal carotid as far as the thyrohyoid ligament. At the upper half of the greater cornu of the hyoid bone the nerve divides into an outer and an inner branch, of which the outer has motor and the inner sensory fibers. The latter passes through the thyrohyoid ligament and reaches the recessus pyriformis, where it supplies the mucous membrane covering the plica of the laryngeal nerve, and ends in the mucous membrane of the larynx. At the same time it forms an anastomosis with the laryngeus inferior, and concerns itself with the delivery of sensory nerve fibers to the recurrens. At this point, the observation made by Massei, of anesthesia of PAIN IN THE LARYNX 357 the laryngeal entrance in recurrens paralysis, may be cited. This he gives as a reason for his opinion that the recurrens really conducts sensory fibers. My examinations, following those of Massei, do not confirm his observation, so that I, as the result of an enormous amount of clinical experience, and because of other reasons, have reached the conclusion that the recurrens has nothing whatever to do with the sensibility of the larynx. Referred Pain. — Diseases of the larynx generally produce no referred pain nor tenderness, but when pain does exist, it is gener- ally felt in either the superior or inferior laryngeal area, the upper area being particularly associated with disease of the epi- glottis and aryteno-epiglottidean folds, the lower area being par- ticularly associated with disease of the cords (Head). Pain in Acute Affections. — Laryngeal pain may be found in all acute inflammations, chiefly in those associated with pus for- mation. Here the intensity of the pain depends especially upon the location of the process. The aditus laryngis, that is, the epiglottis, aryepiglottidean folds in the arytone, is the region in which inflammation produces the most severe pain. It depends, on the one hand, upon the richness of the sensory nerves in this region, and, on the other hand, upon its relation to the process of swallowing. The bolus, gliding over the aditus, irritates the inflamed area and produces, at the same time, an increased reac- tion as well as pressure pain. A clear proof of the increased pain sensibility in involvement of the aditus is found in acute affec- tions; for example, in herpes laryngis, involvements of the ary- epiglottidean folds and the recurrens pyriformis are so painful that swallowing becomes impossible. Here the pain frequently radiates into the region of the base of the tongue and the middle auricular nerve of the vagus in the ear zone. On the side of the larynx a clearly defined ulcer may frequently be present for a long time without causing severe pain, because swallowing is not dis- turbed. Here, upon manifestations of pain in these parts, I again, suggest a minute examination of the entrance of the larynx, espe- cially of the recessus pyriformis, in order to avoid the overlooking of a diseased process. 358 PAIN IN DISEASES OF THE THROAT Chronic Processes.- — Under the chronic processes are, again, the tuberculous ulcers, as well as the crumbling carcinoma (extra- larjngeal), which may give rise to an intense, often unbearable, pain. The dysphagia of a patient suffering from a diffuse laryn- geal tuberculosis often reaches such a high degTce that he will refuse to take food. The blowing in of orthoform, the instillation of menthol, the insufflation of morphin, dysphagia tablets, paint- ing with cocain, etc., very frequently fail, in the ulcerative form of laryngeal tuberculosis, to relieve the pain, so that in a short time after the onset of this affection one can do nothing for the conditions. The anesthesia of the entrance to the larynx, by Hoffman, through injection of alcohol in the superior laryngeal nerve, at its place of entrance through the thyrohyoid ligament, has given a very satisfactory result in many cases, in that the dysphagia diminishes and the otherwise rapid inanition is hindered. I can, upon the basis of a large number of injections made in very sick tuberculous patients, warmly recommend this treatment, and I would like to emphasize the fact that, in a number of cases, I was able to induce an anesthesia persisting through many weeks. The pain in carcinoma of the larynx depends upon the locali- zation of the tumor. Extralaryngeal tumors, lying in the region of the aditus, give rise very early to pain on swallowing, while in intralaryngeal tumors pain may not appear for a long time. There are, then, because of the overgrowth of the tumor, severe disturbances of swallowing. One may say, in regard to the early diagnosis of carcinoma of the larynx, that the first symptom of the extralaryngeal carcinoma is, as a rule, dysphagia and that the first symptom of intralaryngeal carcinoma is hoarseness. Yet there are cases, to which Leopold von Schroetter, especially, has drawn attention, where, in spite of severe destruction in the region of the aditus, pains are entirely absent. However, these are very rare. The explanation lies in the fact that in these cases there are sen- sory disturbances in the area of distribution of the superior laryn- geal nerve. Generally the pains are spontaneous, on deglutition as Avell as upon external pressure. The pain in carcinoma of the PAIN IN THE LARYNX 359 larynx is explained through the simultaneous occurrence of in- flammatory conditions, necrosis formation, and hardening, while the pressure symptoms, or the propagation of the irritability, occur from the involvement of the superior laryngeal nerve. Often the pains assume the form of neuralgia, and radiate as lightning pains into the region of the nervus auricularis vagi. Laryngeal neuralgia is infrequent, and is observed in hys- terical and neurasthenic subjects. The neuralgia often radiates to the ear and frequently reaches an unbearable severity. Lemon has reported a case in which a patient, in the climacteric period, threatened suicide if freedom from her raging pain was not obtained for her. In other patients, when the pain occurs on speaking, it shows itself as a typical phonophobia. Finally, it is mentioned that, in these glottis spasms which we so frequently find in tabes dorsalis, the so-called laryngeal crises, hyperesthesia and hyperalgesia, in the form of sensory aura?, are often found, and introduce the cramp crises. The explanation of these forms of pain is probably analogous to that of the adduction spasm, they being due to an irritation of the sensory sphere. The typical attack in such cases occurs as a peculiar sensation in the larynx, in the form of a sticking, burning, lightning pain, accompanied by states of anxiety or feelings of sultocation, after which the spasm of the glottis follows. CHAPTER XIX ABDOMINAL PAIN Classification. — There are two classes of abdominal pain : sub- jective and objective. The subjective pains belong to the class of symptoms usually termed hysterical. For their production no organic basis can be found. They seem to be due to the awakening into consciousness of sensation-phenomena stored away in the subconscious mind. Objective pains, on the other hand, have for their produc- tion either some definite pathologic change, functional or or- ganic, or a changed relationship of the organs as a whole to other adjacent organs, such as occurs, for example, in a ptosis of the stomach or of the liver. Subjective pain, in relation to the abdominal viscera, will not be considered here. It has already been discussed in the opening chapters. Objective abdominal pain is important because of its rela- tionship to changed iDathology in the abdomen. It may be due to a lesion of the skin, the subcutaneous tissues, the muscle, the peri- toneum, or the viscera. The SKIN is frequently painful, especially when it is the seat of some inflammatory skin-disease, such as erysipelas. It is also very painful in certain nerve lesions, as neuritis, or herpes. The MUSCULAR LAYER OF THE ABDOMINAL WALL is Credited by Mackenzie with pain production. He says : ^'It is the muscular layer in the abdominal wall which is so exquisitely ten- der in all affections of the viscera, giving rise to severe reflex musculovisceral pain, as in appendicitis. Also, the abdominal 360 OBJECTIVE ABDOMINAL PAIN 361 muscles above the lesion are in a state of contraction and are extremely tender to pressure." That Mackenzie erred and exag- gerated the importance of the muscular coat in pain production is proved by the researches of Lennander and others. Later, Mac- kenzie (862) himself, modifying his previous statements, says that the subperitoneal layer is the most sensitive, and, in confirma- tion of his views, quotes Ranstrom, who has found many nerves and nerve endings in this layer. The nerves are derived from those supplying the muscular layer. All direct painful muscular lesions in the abdominal wall are the result of inflammation, neuritis, neuralgia, myalgia, or new growths. Inflammation in the abdominal ivall is accompanied by all the signs and symptoms usually associated with inflammation in general, such as swelling, redness, heat and loss of function. The pain is of a throbbing character. Tenderness on pressure is also present. In some cases the inflammation precedes abscess forma- tion. Such cases are described by Hitzrot (337). The pain was localized, and was increased on assuming the erect posture and on deep pressure. He quotes Fouquet (370), Sonnenberg (371), Spellisy (372), Heller (373) and Allison (374), who have all described similar conditions. Neuralgia of the nerves of the abdominal wall occurs and is frequently observed with or after infectious diseases. When it is present the skin is exquisitely tender, and is very painful to the , pressure made by pinching it between the fingers. In this it dif- fers from peritonitis, in which the skin is not so tender, and the pain is produced only on deep pressure. In neuritic lesions of the abdominal walls the pain is usually unilateral. When the lumbar nerves are affected, the pain is commonly felt in the hypogastric region, a little to one side of the median line. In this area, too, there is localized tenderness on pressure. Tender spots are also found, one a little to the outside of the first or second lumbar vertebra, and another immediately above the crest of the ilium. In women, who are by far the greatest sufferers from this disease, there is also sometimes, about the middle of the Fallopian tube, a spot, pressure upon which causes, pain to 362 ABDOMINAL PAIN be referred to the anterior abdominal wall. There is another sjjot above the uterus. In men, points here and there on the scro- tum are found which are painful to the touch. These points of tenderness serve as characteristic signs of neuralgia. Neuralgia is to be diagnosed, not only from colic, but from lumbago and rheumatism of the abdominal walls. Diagnostic sigiis of neu- ralgia are the absence of fever and the relief which is sometimes produced by pressure and ordinary antineuralgic remedies. Neuritis of the intercostal nerves is fairly frequent. This frequency occurs because these nerves are particularly subject to the deleterious influences of cold and traumatism, on account of their exposed position. (For a more complete description see under Neuritis.) Myalgia is closely related, as far as etiology is concerned, to the neuralgias. It seems to be due in very many cases to a dis- ordered metabolism. This is the condition to which the term "rheumatism of the abdominal wall" is given wrongly. New growths, such as cysts and various kinds of tumors, may occur in the abdominal wall. If of slow development, they cause no great inconvenience, for by their slow increase in size they gradually push the surrounding structures to one side, and the tissues learn to accommodate themselves to the presence of the foreign occupant. Should nerves be incorporated in the growth, and pressure be exerted upon them, pain, generally of an aching character, results. This pain may be localized to the region of the growth, or may be referred to some distance in an area to which the affected nerve is distributed. The size of the growth bears no relationship to the amount of pain which it may pro- duce, the smaller growths producing as much, if not more, pain than many of the larger ones. The amount of the pain depends upon the rapidity of the growth, the number of nerves incorpo- rated in it, and the pressure exerted upon them by the inclosing tissues. Peritoneum. — According to Mackenzie, the peritoneum is devoid of pain nerves. However, he claims that the subperi- toneal layer is plentifully supplied with pain nerves, and that OBJECTIVE ABDOMINAL PAIN 363 it is liere tliat the painful impulses arise. In its lack of pain perception, the peritoneum, he says, is not unique among serous membranes, for this is characteristic, he holds, of all serous mem- branes, since they have no nerves which will transmit pain stimuli of the kind foimd in the skin, the tunica vaginalis testis being the .only serous membrane which is sensitive to the usual tests for pain sensibility. This is due to the fact that the tunica vaginalis testis is innervated by a cerebrospinal nerve, the genital branch of the genitocrural nerve. Mackenzie's proofs that serous membranes are not the seat of pain production were: (1) that the abdominal wall is very tender in certain visceral colics in which there is no inflammation of the peritoneum; (2) the skin of the abdominal wall generally is not so sensitive in visceral lesions, for it can be pinched between the fingers without producing pain; but if the muscles are grasped between the thumb and fingers, acute pain is felt; (3) direct stimulation of exposed pleura, pericardium, and peritoneum does not produce pain. That this is not absolutely true will be shown in the discussion of j)eritonitis. The peritoneum is the lining membrane of the abdominal cavity. It consists of two layers: (1) the visceral layer, -which covers the inclosed organs, and (2) the parietal, which lines the external wall of the cavity. It has been held by many that the visceral peritoneum is without pain sensibility, but, as will be pointed out, much depends upon the type of stimulus. The adequate stimulus in the viscera is deep pressure ; that largely produced by tension. It is the type of deep sensibility described by Head. It was the belief of Lennander that "all painful sensations within the abdominal cavity are transmitted only by means of the parietal peritoneum and its subserous layer, both of which are richly supplied with cerebrospinal nerves around the whole of the abdominal cavity, with the exception of a small area in front of the vertebral column lying below the crura of the dia- phragm, and between the two chains of sympathetic nerves." Here he found no cerebrospinal nerves, but only nerves running more or less transversely between the two sympathetic chains. 364 ABDOMINAL PAIN He found that within this area the patient does not respond to hard pressure with a finger, or with an instrument, and that stretching of the mesenteric attachments at this point is not pain- ful. So far complete uniformity does not exist as to presence or absence of pain sensibility in the peritoneum, though many ob- servers are in accord with the dedu-ctions of Lennander. Diseases of the peritoneum producing pain are inflammations, hemorrhage, and new growths. Inflammations of the Peritoneum. — Inflammation of the peri- toneum (peritonitis) causes pain only when acute. The chronic inflammatory forms, as a rule, produce but little pain, except as the result of adhesion formation. The seat of the pain in peri- tonitis, according to INIackenzie,^ is not in the peritoneum itself, but in the subperitoneal tissue. This layer is exquisitely tender, and Ramstrom found it richly supplied with nerve fibers, which, in turn, are derived from the nen'^es of the anterior abdominal wall. These nerves also supply the abdominal muscles, and thus one can account directly for the reflex rigidity of these muscles (supplied by the same nerves) when the peritoneum is affected. In some cases, however, acute peritonitis may be present with- out producing any pain phenomena. This is especially so in the violent cases in which the abdomen contains a quantity of pus (Bradford, 207). This lack of pain may be due to the rapid destruction of the nerve endings, or to the impairment of their efficiency. Such a state is frequently met with in puerperal sepsis. However, in all cases of sudden, sharp, exacerbating pain, with rigidity of the abdominal muscles, generalized tenderness, normal or subnormal temperature, and a rapid, rising pulse, peri- tonitis should be thoughtfully considered (Richardson, 23). Should the pain be dull and aching, the sub-peritoneal connective tissue is probably involved. 1 It is also claimed by Mackenzie that the parietal peritoneum or rtseft is insensitive to pain; that it is the tiny nerve filaments, distributed in the cellular tissue subjacent to the peritoneum, which are extremely sensitive, and that the slightest traction or pressure on them produces the most ex- cruciating pain, INFLAMMATIONS OF THE PERITONEUM 365 Tuberculous Peritonitis.^Iii cases of tuberculous origin pain may be an almost negligible symptom. Tbe exceptions are those conditions in which adhesions have developed, or in which the tuberculous material has become encysted and has ulcerated or suppurated. This gives rise only to a little pain on walking, while obliterative, encysted, or sciatic forms may cause no pain (Rolleston, 619). In case of tuberculous peritonitis Bainbridge has found that the injection of oxygen into the peritoneal cavity will relieve the pain. This may be due to the separation of the two adjacent surfaces from each other, possibly to an anesthetic action of the oxygen. A common source of mistakes in the diagnosis of peritonitis is the confusion of referred pain with that due to peritonitis. Diagnostic criteria between the two conditions are: (1) The ten- derness of referred pain is produced by slight stimulation of the skin and the subcutaneous tissues, and seems to be relieved by deep pressure; (2) the exact opposite is found to be the case in peritonitis, deep pressure being painful, while light pressure is not so distasteful; according to Lennander (618), the boundaries of the hyperesthetic zones in peritonitis can be mapped out almost to a centimeter; (3) in peritonitis proper there is gener- ally no referred pain; this is given by Moullin (226) as a good indication that no other viscera are involved, for as soon as the viscera become involved hyperalgesia is present; (4) in perito- nitis the abdominal reflexes are not exaggerated, while in referred pain they are exaggerated. Should a peritonitis be sudden in onset, as is the case in the perforation of an ulcer of the stomach, or of the duodenum, the pain is generally paroxysmal and is most severe. When the car- diac end of the stomach is involved, the pain, as a rule, is under the left scapula. When the pyloric end is the part affected, the pain is under the right scapula (Mayo Robson, 619). If the abdominal pain is associated with tenderness it is neces- sary to distinguish between inflammation of the constituents of the wall (skin, muscle, peritoneum), neuralgia and neuritis. In peritonitis pain is produced only on the making of pressure on the 366 ABDOMINAL PAIN abdominal wall, while in neuralgia or myalgia it may be necessary to pinch the skin or muscle between the fingers before pain is elicited. If peritonitis is present there is also pain on the patient taking a deep breath, upon the making of a pelvic examination, and also, in some cases, upon flexion of the bod}'. Should the pel- vic peritoneum be inflamed, pain is produced when the inflamed jDcritoneum is pressed ujion by the examining finger. Tilting up of the uterus by pressure on the cervix will always cause pain, and pain is also present on making deep, and, if the peritonitis is severe, light pressure low do"\vn on the abdominal wall. Biman- ual externovaginal examination will cause pain if the peritoneum at the brim of the pelvis is inflamed. Defecation, micturition and sexual connection (if a female) are also painful. The visceral peritoneum is different from the parietal peritoneum in that pain is not produced by pressure wpon it ; but it is very sensitive to traction made upon it through the mesentery. The pain produced by this traction is interpreted as coming from some zone of the body and not from the affected viscera. This Mackenzie ex- plained by the fact that the abdominal viscera are supplied en- tirely by the sympathetic system, which has no sensory nerves. When it is irritated its nerves carry impulses to the cord cells and stimulate, in turn, adjacent sensory cells to activity, thus caus- ing a painful impulse to be conveyed to the brain. This impulse is projected as if coming from the peripheral distribution areas of the sensory nerves, whose cells are stimulated. Chronic peritonitis is somewhat different from the acute, and is much slower in onset and duration. The pain is due to the following causes : (1) Traction and pull from adhesions, the result of the chronic inflammatory process. (2) Distention of the bowel from gas or fecal matter, owing to obstruction of the lumen by adhesions which may be old or recent. (3) Localized collections of fluid encysted by the peritoneal adhesions. These localized collections may be either serum, pus, or blood. After the fluid contents have reached a certain stage. NATURE OF PAIN FROM ADHESIONS 367 thej begin to exert pressure or traction on the adjacent structures, and thus cause the pain. In some cases of slow, insidious peri- tonitis, especially those of tuberculous origin, there may be no pain of any moment until adhesions form, when pressure causes tension pains. The location of the pain may give an indication of the viscera which are involved by the adhesions (for the points of reference on the abdominal wall of visceral pain, see Viscera, Chapter XX, pp. 383-389). Hemorrhage. — -In sudden, severe hemorrhage into the abdomi- nal cavity, such as occurs in the rupture of an extrauterine preg- nancy, pain is present ; but in hemorrhages following operation, pain, as a rule, is absent. This latter condition can probably be accounted for by the previous insult to the peritoneum by the operative procedures, wdth the consequent reduction in its sensi- bility. In some cases of excessive dilatation of the abdomen from tympanites, or from obstruction, the abdominal tenderness is ex- cessive, but at the same time the pulse and temperature sfre not of a peritoneal character. Tumors of the Peritoneum. — Tumors of the peritoneum gener- ally cause pain. "When they are in the back, and lie posterior to the peritoneum, they frequently cause pain by the pressure which they exert upon the spinal nerves. This pain is referred to the back or along the course of the nerves of the lumbosacral plexus. It must be diagnosed from the pains due to aneurysm, vertebral caries, or spinal tumor. Nature of Pain from Adhesions. — As an end result of nearly all processes, both inflammatory and otherwise, in the abdominal cavity, is adhesion formation. These adhesions, as a rule, cause pain, wdiich is generally localized to one spot, at which point pain is also produced by pressure. The pain may come in paroxysms ; when it does so, the attacks resemble each other, and have the same train of symptoms. The pain also is influenced by certain muscular movements or positions of the body, and may be lessened or increased by mov- 368 ABDOMINAL PAIN ing about or by turning over from one side to the other. It is increased by peristalsis, especially if the adhesions are between the stomach or intestine and the anterior abdominal wall. When the adhesions are between the stomach and the anterior abdominal wall, the pain is often increased after eating. Adhesion pain is also increased by tension of the anterior abdominal wall, when, by a backward motion of the upper part of the body, or hyper- extension of the thigh, the distance between the ribs and the pelvic bones becomes increased. In such cases the recti muscles become rigid and traction is made on the adhesions. The magnitude of the pain varies indirectly as the area of the adhesion. This is due to the fact that, in extensive adhesions, the traction upon the parietal peritoneum is not limited to any one spot, as it is in very limited adhesions, but is spread out over a large area, and consequently, not being perceived acutely in any single nerve distribution, is felt rather as a dull, dragging pain, instead of a sharp, pulling one. Increased tension of the anterior abdominal wall also causes pain is cases of hernia in which stretching of the omentum is probably present. Adhesions pulling upon the peritoneum, as a rule, cause greater pain if there is a sudden variation in the traction, such as can occur when a hollow viscus of changing size and position, such as the stomach, is attached to the anterior abdominal wall. In this case the pain depends upon the variations in the force of the traction, depending upon the amount of the stomach contents and the state of its functional activity. Adhesions between the omentum and the anterior abdominal wall are a frequent cause of pain, because the bowel places the omentum on the stretch, by forcing itself into the pocket between it and the anterior abdominal wall. Adhesions between the viscera if not connected with the anterior abdominal wall cause no pain unless traction or pressure is made upon the mesentery or other pain sensitive organs, by the changing relationships or the hindered movements of the adherent viscera. In this connection it might be well to consider the causes of NATURE OF PAIN FROM ADHESIONS 369 abdominal adhesions. Tliej are the following: (1) tumors, which form adhesions because of the pressure on, and consequent trau- matism of, adjacent organs; (2) intestinal ulceration, which is not an active cause of adhesion formation unless perforation has occurred; (3) after laparotomies adhesion between the omentum and parietal peritoneum ; and (4) inflammation, particularly that due to or associated with tuberculosis. Inflammatory lesions of the gall-bladder are also potent causes of abdominal adhesion for- mation. Abdominal adhesions, according to Cumston, are divided into : (1) A gastric group, including cholelithiasis; ulcer of the stom- ach and duodenum ; traumatism to the stomach, liver, pancreas, and duodenum ; carcinoma of any of the above-mentioned organs ; (2) the intestinal group, which is particularly associated with the appendix and the siginoid; (3) the pelvic group, which in- cludes lesions of the tubes, ovaries, and the uterus ; and (4) the peritoneal group, including all lesions in which primarily the peritoneum is involved, as in tuberculous peritonitis. Gastric Adhesions. — The diagnosis of adhesions may be made easier if it is borne in mind that when adhesion of a viscus to the anterior abdominal wall or to another organ occurs, pressure or traction on the abdominal wall, so made that it will tend to separate the two adhering surfaces, will produce considerable pain. Thus, in gastric adhesions, if pressure is made on the anterior abdominal wall in an upward direction, from the region of the lower border of the stomach, the pain which is present on ordinary manipulations is greatly increased. If the adhesions are on the right or on the anterior border of the stomach, pressure made over the epigastrium will cause the pain to shoot out from the right over the area of the adhesions. If they are on the posterior gastric wall, pressure over the first and second lumbar vertebrae will often cause pain. Adhesions between the anterior abdominal wall and stomach are not so frequent, and are very apt to be confused with gastric ulcer. Pain due to intestinal adhesions, as a rule, is sud- den and acute, and is the result of stenosis of the gut by the ad- hesions; generally it is of short duration, disappears as quickly 370 ABDOMINAL PAIN as it came, and is frequently followed by a discbarge of fluid feces or flatus. Intestinal Adhesions. — An interesting case of intestinal adhe- sions is that of a young lady, whose history is as follows : Nearly two years before admission to the hospital she began having acute pains in the abdomen, of a spasmodic character. During the past year these have become more frequent and are ac- companied by vomiting and eructations of gas. The attacks seem to be brought about by eating indigestible foods and exposure to colds and dampness. She has had two attacks at night without apparent cause. The menses are painless. The pains are always relieved by a bowel movement. At flrst they are diffused over the abdomen, but soon show a distinct right-sidedness. During the last attack the pain was mostly toward the median line, slightly to the right. Operation showed the cecum and adjacent intestinal coils all matted together by dense adhesions, which, in some places, were so thick that they had to be cut between ligatures. A tumor, cor- responding in location to this mass, was felt on the right side before operation. Pelvic Adhesions. — Pain due to pelvic adhesions is present (a) at stool, (b) during micturition, (c) during the menses, (d) on moving, (e) on subjecting the body to light shock, and (f) dur- ing coitus. A case in point is that of Mrs. X , whose ovary and tube on the right side, and appendix were removed, drainage being in- serted because of the pronounced gangrenous state of the appendix. Some weeks after operation she complained of aching which was worse after moving, after lying down at night, and on sweeping. This aching begins in the lower right middle region anteriorly and extends through to the back in the lumbar region. Another case is that of Mrs. Y , in whom pain began in the right side and was constant. She had a feeling as though a knot were being tied inside her. On the same side a small mass was present. A year previous she had had an operation per- formed, in w^hich the ovaries were removed. In this case there NATURE OF PAIN IN HERNIA 371 was present a band of adhesion, extending from the uterus, its appendages, and the intestines, to the lateral pelvic wall. General Peritoneal Adhesions. — If the pain is due to general- ized peritoneal adhesions, for instance those following a gastric perforation, it is often present after eating, and comes on when the stomach is full or when the patient assumes certain positions. Pritchard (620) reported a case of abdominal pain, in which the diagTiosis was obscure, but on operation adhesions were found between the stomach and the anterior abdominal wall. iSTo previ- ous symptoms indicating inflammation could be elicited ; no ulcer- ated areas, nor indications of ulcer, could be found. After re- viewing the case and excluding the gall-bladder, stomach, or duo- denal ulcers as the cause of the adhesive formation, Pritchard, because of the presence of an edema of the lower extremities, without sufficient cause in the same patient a year or two previ- ously, offered the novel explanation that the edema was due to neurotic influences, and that the abdominal adhesions were the result of the same influences acting in the abdominal cavity so as to produce edema of the stomach and duodenum, and consequent adhesive formation. Nature of Pain in Hernia. — Because of the mechanical rela- tionship of hernia to the abdominal structures, it has been thought wise to consider it in this section. Pain is not a prominent symptom of simple uncomplicated hernia^ except in those cases wherein the hernia is of sudden development. Here the pain is due to: (1) Traction on the mesentery. This occurs in the early stages of the condition. Later the pain is due to: (2) In- flammation of the bowel, which is the result of deficient circula- tion, edema, and the presence of toxins. This inflammatory process causes the contents of the hernial sac to swell, and, if the neck is small, the hernia becomes strangulated, and the traction and pull upon the involved mesentery are increased. The inflam- matory process may also extend to the parietal peritoneum, and to the pain of the traction there is also then added the pain of the peritoneal irritation. (3) Peritoneal irritation. The inflam- mation may progl'ess to such an extent that adhesions finally form 372 ABDOMINAL PAIN between the peritoneum and the bowel, and then every movement may be capable of producing pain of a dull, dragging character. Thus pain of hernia may be due to involvement of the mesentery, the bowel, or the peritoneum. The mesentery as a factor in the pain production is generally of little moment unless the onset of the hernia is sudden, when there is present, in the majority of cases, a severe, dragging pain, most frequently about or above the umbilicus, if the hernia is of the small intestine ; while if it is of the lower bowel, the pain or distress is generally below this level. The mesentery probably also receives a few iibers from the cerebrospinal system; and, when irritation to them occurs, the resulting pain is generally referred to their somatic distribution. When this is the case, the area of tenderness and of subjective pain is generally outlined by the area of distribution of one or more of the spinal nerves. The ilioinguinal nerve passes out of the abdomen at the exter- nal abdominal ring, and is distributed to the ilioinguinal region of the upper and inner part of the thigh to the scrotum in the male, and to the labium in the female ; hernia, producing pressure on this nerve, causes pain to be felt as coming from these parts. Bowel pain proper differs from that of hernia, in that the pain sensation is due to the carrying of stimuli to the cord, where some of the cells of the spinal nerves, being stimulated, give rise to pain sensation, which the brain interprets as coming from the peripheral distribution of these fibers. The area of tenderness and subjective pain felt in the distribution areas of these fibers does not follow the plan of distribution of any spinal nerve or nerves, but is located in the area of distribution of fibers arising from certain cord segments, as marked out by Head. The points of tenderness, which, in many cases, bear no definite relation to the lesion causing the trouble, are but the maximal points of tender- ness of these cord segments. If the hernia is in the small intes- tine, the most common site of the referred pain is in the region of the umbilicus, while in involvement of the large bowel the pain is located as being below this point; if peritoneal irritation is present, a local tenderness is felt at the place of the lesion. A NATURE OF PAIN IN HERNIA 373 part at least of this bowel pain is due to distention of the involved portion of the bowel by gas. When this factor is present, the pains are generally paroxysmal, occurring at the time of the bowel distention, and are eased as soon as the gas and the fecal contents have passed on ; but should the swelling at the neck of the sac increase, the hernia then becomes strangulated, and to the other factors producing pain is then added a third, namely, peritoneal irritation. In peritoneal irritation the pain at first is slight, and similar to that described above ; but after it once develops, it is so much more severe than the other two that they are of minor importance. The tissues are now exquisitely tender, and are sensitive to the slightest pressure. It is at this stage that, in case of femoral or inguinal hernias, the patient instinctively draws up and rotates inward the leg of the affected side. The omental hernias are generally not very painful, because the omentum, of itself, has little pain sensibility ; but, in some instances, as in a case of ventral hernia, where the patient had suffered from cramps and severe abdominal distress, with vomit- ing, an operation showed a small omental ventral hernia about two and one-half inches above the navel and a little to the left of the median line. There was no localized tenderness. Pain, as a symptom of simple uncomplicated hernise, is gener- ally of minor importance. Few of the cases of hernia are acute in their onset, most of them being the gradual development of years ; and even when the hernia is acute, the pain symptoms are not of special diagnostic importance, only in so far as they indi- cate the special region of the bowel attacked, and the magnitude of the involvement. In chronic cases there may be a smarting or burning, which De Garmo thinks most likely indicates an omental protrusion. The most common pain is of a dragging nature, and is worse in the evening and better in the morning, because during the night the intraabdominal pressure is relieved.^ * Sir William Bennett {Lancet, Feb. 2, 1907, p. 270) mentions a case in which the hernial sac had a very small opening; and he suggests that it was due to the accumulation of fluid in the sac, as the day went on, which caused the pain to be so much more pronounced toward evening. 374 ABDOMINAL PAIN Anything causing a rise of the intraabdominal pressure, snch as coughing, sneezing, straining, or lifting, is likely to produce this pain. Strangulated hernia generally gives rise to the greatest dis- tress, very often present around the umbilicus, and when this is associated with vomiting the diagnosis of gall-stone colic or gas- tritis is very apt to be made, and the hernial condition neglected, while the patient goes rapidly on to his death. In some cases of strangulated hernia the pain begins about the umbilicus, and thence, as the severity of the lesion increases, radiates to the region of the strangulation. Umbilical, hernia is generally associated with considerable local and referred pain, most of which is probably due to traction on the stomach from the involved omentum, adhesions existing be- tween either the stomach or the adjacent omentum and the an- terior abdominal wall. In inguinal hernia forcible extension of the thigh is painful. In some cases of inguinal hernia, also, the pain may be felt in the epigastrium, and radiates to the back, as in a case reported by Witherspoon (125, p. 219), in which the patient complained of pain in the epigastrium radiating to the back, and of tender areas on either side of the vertebral column opposite the eighth and ninth thoracic vertebrae. Abrupt pressure over the epigastrium, centrally, and to either side, over the recti muscles, excited severe paroxysms of pain. Gradual pressure iva-s well home. Operation relieved the condition. The following is a case of pain due to inguinal hernia. The patient complained of pain, or rather of a dragging sen- sation, running from the region of the pubic spine doAvnward and inward to the scrotum. This pain was made worse by walking, by lifting, or even by sitting, and was eased on lying down. He would be all right in the morning, but as the day wore on he would become so ill that he would have to give up his work, which was that of a driver on a grocer's wagon. On releasing the hernia, the pain entirely disappeared. The sac did not seem to be adherent to the surrounding fascia. Stockton, in speaking of inguinal hernia, describes a condition NATURE OF PAIN IN HERNIA 376 in which the complaint is pain generally referred to the lower quadrant of the abdomen : it is of a colicky character, and is some- times burning. There may also be present continuous suffering. These symptoms are relieved when the patient lies down, and are increased on active movements, also in lifting. They appear and disajjpear at irregular intervals. Examination discloses a patu- lous internal inguinal canal, not large enough to permit a well- marked hernial protrusion, but sufficient to cause a bulging outward of the peritoneum, which is made worse by coughing or straining. Epigastric Hernia. — Epigastric hernias sometimes simulate gall-bladder or duct disease, or even a gastric disorder. They are to be differentiated from the small subcutaneous tumors found in the epigastrium, and are due to the protrusion of small, fatty masses through openings in the anterior abdominal wall. Hernias of the anterior abdominal wall sometimes produce symptoms of pain which disappear on lying doA\Ti. Examination may elicit no apparent abnormality, and the physician is at a loss to account for the persistent cryptogenic pain which recurs so regu- larly on motion, or on the performance of tasks involving an in- crease of the intraabdominal pressure. In many cases, while a superficial examination shows nothing, a more thorough one may reveal some slight thickening, or some little localized swelling of the abdominal wall. When this is found, hernia should be thought of. When small, there are no absolute diagnostic criteria of a hernia of this character; but if it is large and reducible, the gurgling accompanied by the disappearance of the tumor on reduction indicates the condition. McEwen (919), in speaking of small umbilical hernias, with a very narrow and distensible sac, states that the pain (violent abdominal pain) frequently comes on at an early stage, before any prominent external tumor has appeared, and he attributes the pain in such cases, in part, to the cupping of a portion of the bowel in the narrow mouth, and in part to the distention of the narrow mouth, causing pressure on, and irritation of, the peripheral nerves. The j^ain of fe:moral herxia in the male may sometimes be referred to the penis. o H .J O Enlarged gall bladder can of- ten be felt. It also is very ten- der. 1 "o c _o a; The pain has a tendency to ra- diate, either to the back (under the right scap- ula) or to the right shoulder. If the duct is entirely blocked it may remain constant and be very severe. 1- c (K 0. 1 g Is 1 a "0 . 0) ^1 til •"id I" >, .S 41 O •^.S.S ft C OS ai^ OPL,fc O -^1 11 s ^ c c :;, £ c Ji a C'.Hf^t S t. :^ ft&„ Ei^Sig ra ^ c o ,. c;:;^ a a IS 2 ft a d) "0 05 tig O .2-0 ".2 M aJ *^ I- w ft„ t„ 03 O g i^-B g:=.s sI-B ^^^^2 S2-S-5 e-'3 c c c ttJj3 o -Ofc-5o3--^^CJ**i -a o =! t, t. u n-- >* o 3 g :C o g g ij o >. S . a Si"£S— 0:::: 3.Zm/i!'B^c3cSoSp-iMc;n ■s % ft _>. "3 0) a 0) X! t: lu ft fed s 3 ft" S 2 ; O •s.e Isi a % ft DC 03 a < 3 .J -< « < -S-gft 5 a g « 0) o ■J 3 03 1 1 > m 1 d) ft 376 CHAPTER XX PAIN IN ABDOMINAL VISCEEAL DISEASE History. — The question of the sensibility of the abdominal viscera is one which has been much discussed, and, at the present time, it cannot be stated with certainty that the problem has been definitely solved. As long ago as 1753 Haller had noted that he failed to obtain evidence that the internal viscera were sensitive to painful stimuli, but it has become increasingly evident that the nervous mechanisms of the visceral activities are exceedingly mani- fold, and that no adequate explanation of their functions is possi- ble without a searching investigation of their rich nervous supply. The work of Lennander and Mackenzie seemed to point to the fact of there being no pain fibers in these nerves, but that of Ross, of Kast, and Meltzer has shown that the observations of previous experiments were faulty and that the ordinary tests which they used for the elicitation of pain phenomena in the viscera, which were the same as those used to elicit pain response in the skin, were not suitable, since the viscera, because of their structure and position, are non-responsive to these stimuli, but may respond to other forms of stimuli than do the skin and mucous membrane. The ordinary facts of digestion prove the response to chemi- cal stimuli, and also to those of heat and cold, and it is becoming apparent that some modification of the earlier views must take place. The sensibility of the abdominal organs has been, for many years, a question of debate between two opposing schools, the one maintaining that the abdominal viscera of themselves were not capable of producing pain phenomena, the other holding that they were. Evidently both were right to some extent, for it has been 377 378 PAIN IN ABDOMINAL VISCERAL DISEASE found that organs wliich under normal conditions do not produce pain will, when inflamed, give rise to pain phenomena (Rosthorn). However, in many cases it must be admitted that the sensibility to pain shown by the abdominal organs is very unusual, for in many cases operative interference may be undertaken without excessive pain production, ovariotomies having been performed by Riedel (865) and Johnnen without any especial pain. The uterus is painful only when inflamed (Bernard, 8G7). All varie^ ties of abdominal operations were performed by Lennander with- out pain production, except when traction was made on the mesen- tery. For a better understanding of pain production in visceral disease, it may be well to review the innervation of the abdominal viscera. The innervation of the viscera is from both the cerebro- spinal and the sympathetic system. The cerebrospinal or medul- lated fibers are carried in the vagus and in the splanchnics, and are distributed to the various abdominal plexuses. Where they finally terminate is an undetermined question, but it seems likely that they end in the mesentery. The sympathetic has its own special nerve system — its fibers pass on farther than those of the cerebrospinal system, and are ultimately distributed to the ab- dominal organs, whose functional activities they coordinate and regulate. They consist of vasoconstrictor, vasodilator, motor, and inhibitory fibers, etc. (Tigerstedt). They originate in the lateral horn on the same side of the cord in which they are found, pass through the posterior ganglion into a nerve trunk, and finally end in a ganglion, from which fibers are carried to the ultimate distri- bution area. These ultimate ganglion cells have no connection with each other. All the sympathetic fibers do not arise in the cord, many of them arising in the posterior ganglia, or from the abdominal ganglia themselves. Mackenzie, Peterson (72), and others hold that the sympathetic system is oldest in origin, and that the cerebrospinal system is merely an outgrowth of the sym- pathetic, and has been built up for its protection. This may be, as remarked by Mackenzie, the reason for its proneness to convey pain, one of the functionally protective sensations. In this way COntlUNlCOTlNG BR 10 VAC.Ui.OJHt»AL\,V ONLY ON THE RIGHT SIDE N. SPLANCHNIC MAJOR N.SPLANCHNIC MIHOR COELIAC GAN&LION COnnUNlCATm&BR.TO UPPER lUMBAROAHOLI* UPPER tUMBAR GANGLIA -^-_T0 PHRENIC GANGLION ^_^._T0 SUPRARENAL GANGLION -^TORENALIS GANGLION 1 ^_^-tO bPERMATIC OR OVARIAN PLt!<.Ui CALL BLADDER PYLORUS PANCREAS DUODENUM GREATEF OF STOI TO PLEX05 PANCREAS DUODENUM 5MALL INTES. CAECUM ASCENDING COLON LARGER PART OF ASCENDING COLON TO PLEXUS GASTRICUS Sl/PERIOR PLEXUS GASTRIC OV THE VA6US(BIGMT) LEb^ER CURVATURE TO PLEXUS UIENALIS SPLEtN PANCREAS UNDUSOFTME STOMACH PLEXUS AORTICA ABOOM. TO PLEXUS MESENTERICUS INFERIOR RANSVERSE COLON, DtSCENOING COLON ilGMOlD SUPERIOR HEMORRNOlOALNERve UPPER PART OF RECTUM -HYPOGASTRIC PLEXUS Fig. 81. — Scheme of Innervation of Abdominal Viscera. The above diagrammatic drawing shows the reason for the tendency of diseases of the gall bladder, pancreas, duodenum, the pylorus and the greater curvature of stomach, to cause pain on the right side of the body; while lesions of the lesser curvature, fundus, spleen and pan- creas have a tendency to produce pain on the left side of the body. Drawing modified from Spalteholz. 379 380 PAIN IN ABDOMINAL VISCERAL DISEASE it guards, against injury, the internal organs supplied by the sym- pathetic, "which ordinarily has no direct pain-conducting sensi- bility, as such is generally understood. The sympathetic contains both afferent and efferent fibers, but it is only the afferent which may, under unusual circumstances, be concerned in the conduction of pain stimuli. Ordinarily, these nerves are incapable of con- veying impulses which are interpreted as painful ; but under cer- tain modifications, such as are produced by injury, a change of irritability may take place,' so that stimuli which ordinarily do not produce pain now give rise to the most excruciating agony. Such modifications have been observed, especially by Buch and Macken- zie. Buch, on correlating the researches of Wutzer, Florens, Brochet, Valentin and Longet with his own clinical findings, con- cluded that a normal sympathetic nerve is incapable of carrying pain-producing stimuli ; but that, when inflammation ensues, some change in its excitability occurs, so that, instead of the dull perception, which it previously had, it acquires an exquisite sensi- tiveness, so that pinching, pressing or dragging on it is very pain- ful. This increase of sensitiveness can also be produced by con- tinued electrical stimulation, or by stretching of or pressing upon the nerve (Lemmering). Hitter, after experimenting on dogs, concludes that the fibers conveying the impulses interpreted as painful run in the nerves distributed to the blood vessels, for he found that ligation of the vessels was much more painful than irritation of the parietal peritoneum or traction on the mesentery. This is in accord with the statement made in a previous chapter, to the effect that in the internal organs it is probable that the sensory fibers accompany the vasomotor nerves. Should such be the case, it is likely that the pain-conveying fibers are collected into the same ganglia, or in the ganglia associated with those of the vasomotor nerves. It has been found that the vasomotor cen- ter for the stomach and upper intestine is in the plexus coeliacus (Buch, 171; Pincus, 465; Budge, 466; Techlenburg, 467; Lowen, 468, and Boer) while Laignel Levastine located the vaso- motor center for the liver in the right semilunar ganglion, and the vasomotor center for the spleen in the left semilunar ganglion, HISTORY 381 and the vasomotor center for the small intestine and the upper part of the large intestine in the superior mesenteric ganglion. From the association of the vasomotor and sensory fibers, it would seem that these ganglia also are the sensory centers for the dependent organs. Lennander, however, states that it is traction of the mesenterj' which, in turn, produces pull and traction on the sensory (cerebrospinal) filaments in its substance that produces the visceral pain. The apparent discrepancies between the statements of Eitter and Lennander may be due to the fact that Hitter's ob- servations were made during experiments on animals, while Len- nander's were made during abdominal operations. On one fact all observers are practically in accord, and that is that the parietal pe.ritoneum is very sensitive ; and there is also concord in the belief that the viscera themselves are but slightly sensi- tive to pain. These latter views are in accord with observations of physicians from time immemorial. Perhaps the oldest exam- ple is in Xenophon's "Anabasis," wherein mention is made of Nakarchos, the Arcadian, being wounded in the abdomen in battle, and coming in flight, holding his entrails in his hands. Then, as we pass down the ages, here and there examples are given of the insensitiveness of the internal viscera. Haller, about one hundred and fifty years ago (1753), noticed that the liver, spleen, kidneys, heart and lungs possessed little sensibility ; that the parietal peri- toneum was slightly sensitive, while the visceral peritoneum was entirely without sensation. He also states that the subcutaneous coat is very sensitive, while the mesentery has no sensation. In this connection, I shall quote in pxtenso from Meyers, who has so well described the progress of our knowledge in this direction. He says that ''Bichat noticed, at the end of the eighteenth century, that electrical, chemical and mechanical stimulation of the organs supplied by the sympathetic system do not produce pain." This agrees with the clinical findings of Prony (343), who states (1821) that Bichat had seen dogs devouring their own intestines and tearing their own peritoneum, which had prolapsed through abdominal wounds. Many observations have been made on man, seeming: to show absolute insensitiveness of the abdominal viscera 382 PAIN IN ABDOMINAL VISCERAL DISEASE (Mitchell, 263, in the year 1872 ; Bier, 331 ; Mackenzie, 332 ; Lennander, 380; Ilofmeister, 869; Gushing; Block, 870; Mitch- ell, 840; Partsch, 871).^ The absolute reliability of these deductions has been ques- tioned by Kast and Meltzer, and more recently by Neuman. Kast and Meltzer claim that the insensitiveness to pain present in the abdominal viscera under local cocain anesthesia is due to the gen- eral toxic action of the cocain, which so reduces the sensitiveness of the internal viscera that they no longer respond to stimuli, to which, without the cocain, they would respond and which, being carried to the cerebrum, would be interpreted as pain. These deductions are apparently controverted by Mitchell (155, pp. 200-201), who, under hypodermic subcutaneous injection of normal salt solution, was able, after the peritoneum had been opened and the intestine delivered, to seize it with a clamp, rub it with gauze, and prick it with a needle, all without the produc- tion of pain. The pain sensations from the abdominal organs are probably * It is claimed by Lennander that none of the abdominal viscera is sen- sitive to pain, and that when pain occurs it is due to the following causes (given by Kast and Meltzer, 134, pp. 1017-1019). (1) pressure, sliding or pulling of the parietal peritoneum; (2) pulling of the mesentery, and thus irritating the posterior wall of the abdominal cavity, which is provided with pain fibers derived from the spinal nerves; (3) lymphangitis and lymphaden- itis occurring and reaching the nerves of the posterior wall; (4) irritating toxic products or chemicals, like HCl in gastric ulcer, reaching the lymphatics of the posterior wall. Maunsell Moullin says that the effect of traction on the mesentery is the same, whether there is a " free mesentery or whether the peritoneum is reflected from the sides of the viscera, leaving a portion of the circumfer- ence of the bowel attached to the parietes by cellular tissue" (Moullin). In this case, besides the stimulation of the nerves in the peritoneum, there would be traction upon the nerves in the connecting tissue. These nerves are de- rived directly from the cerebrospinal system, and any traction upon them would be referred as pain to the distribution area of their somatic branches. It is a well-known fact that the surfaces of the internal viscera are not painful to pressure, pinching or squeezing, nor to heat and cold. Their only function is reference of impulses having to do with the well-being of the organism; and in cases of inflammation, as suggested by Lennander (23), it is possible that toxins may be carried by the lymphatics to the nerve fila- ments, thus rendering them more sensitive, so that they respond to stimuli with a reaction which is called pain. Inflamed organs are slightly more sensi- tive than organs not inflamed. HISTORY 383 carried chiefly by tlie va^;s and the greater splanclmics ; both con- tain medullated fibers, found, according to Edgworth, in the vagus at the level of the diaphragm. This view is opposed to that held by Lennander and Meyers (122), that the sensory fibers of the vagus do not extend below its recurrent laryngeal branch. Edg- worth also makes the observation that on the warming of the vagus its conductivity seems to increase. As to the manner of production and conduction of the visceral pain impulse little is known, though it is held that the pain is: (1) "due to induction of a current in adjacent fibers in a manner comparable to the electrical induction in two adjacent but uncon- nected nerves" (probably not correct) ; or (2) that the "nerve cen- ter, spinal or cerebral, which receives the afferent impulses is so unduly excited that in its disturbed condition it attributes the afferent impulses to the wrong afferent nerve" ; or it may be possi- ble (3) that "transference may take place in the sensorium." Although the method of the production and conduction of the impulse is in doubt, yet no doubt exists as to the actuality of its presence. A peculiarity of its perception is that it is not felt in the organ in which it is produced, but is referred or reflected to the body wall, where it becomes either the so-called somatic pain, or is perceived as a form of hyperalgesia.^ Location of Pain. — That the pain of visceral disease is not necessarily located directly in the involved viscera may be seen from the following: (1) On movement of the involved organ there is no change in the character or location of the pain : (a) Movement of the heart produces no change in the char- acter of the anginal pain. If the pain were in the heart itself, each contraction of the heart would produce a change in the char- acter of the pain. (&) Peristaltic contraction of the stomach produces no change in the type of the pain of gastric ulcer ; also, changes in the posi- ^ This view has recently been very strenuously opposed by Hertz, who claims that pain sensation can reside in the internal viscera themselves (Hertz, 106b, p. 48). 384 PAIN IN ABDOMINAL VISCERAL DISEASE tion of the stomach due to respiration produce no change in the location of the pain. If the pain were located in the stomach, movement or change in the position of the organ would of neces- sity produce a change in the character or location of the pain. (2) The pain is not located directly over the diseased area in the involved organ ; indeed, it may not even be over the organ at all : (a) Cardiac anginal pain may be felt down the arm or even up in the neck. (&) Pain of gastric ulcer is not directly over the site of the ulcer, as has been proved, time after time, by operations. (3) The area of hyperesthesia may be distributed over a much wider area than that under which the organ is located. Transference of Pain. — Because of the apparent non-location of pain in the diseased viscera producing it, many attempts were made to explain the relationship between the area of pain and disease in the viscera. The most successful of these was by Head, who, in a thesis read before the University of Cambridge, in June, 1892, and before the Neurological Society of London, November 10, 1892, first opened the way for the study of peripheral sensory manifestations of visceral lesions. He claimed that the manner of transference of pain sensation is this: that the stimulus affects the peripheral distribution of a nerve distributed to a viseus, and that this stimulus is carried to the cord and enters the sympathetic system through the sensory root posterior to the ganglion. In the cord the nerve cells of these fibers (from the sympathetic) come into intimate contact with the cells of the fibers from the periph- eral sensory system, and incite them to reaction, so that stimuli occur, and are transmitted to the brain, so that the brain centers perceive them as coming from the peripheral distribution of these same somatic or body nerves. By a reference to Figs. 31, 32, 33, it may readily be seen how the stimulus can be reflected from one set of neurons to another set ; and it is thus that the excessive irritative stimulus arising in the splanchnic area is interpreted in some distant area as pain. Head has laid down a law particularly applicable to this state, TRANSFERENCE OF PAIN 385 namely, "that where a painful stimulus is applied to a part of low sensibility, in close central connection with a part of much greater sensibility, the pain produced is felt in the part of higher sensi- bility, rather than in that of lower sensi- bility to which the stimulus is actually applied." Wilamow ski's (109 b) experiments, while confirm- ing Head's deduc- tions, show, in some cases, areas of re- duced sensibility cor- responding in outline to the areas of in- creased sensibility in other cases. He be- lieves that this hypo- algesia obeys the same laws and is subject to the same influences as the cor- responding hyperal- gesia, and that both are of the same origin. In this relation it was noticed by Mackenzie that in but very few cases does the hyperesthesia associated with visceral disease occupy the entire area of distribution of a particular nerve, as the area of cutaneous hyperesthesia associated with cardiac dis- ease does not extend throughout the entire area of distribution of the fourth dorsal nerve, but is generally confined to the skin on the anterior surface of the chest. It does not pass around to the posterior surface ; also, it is sharply delimited at the clavicle, and does not spread upward into the area of distribution of the fourth cervical, which lies above the clavicle. It may extend down the Fig. 82. — Figure Showing the Anterior Dsi- TRIBUTION OF THE NiNTH, TeNTH, ELEVENTH AND Twelfth Dorsal Nerves. The shaded parts indicate the areas in which pain is most frequently observed in abdominal visceral disease. 386 PAIN IN ABDOMINAL VISCERAL DISEASE inner side of the arm and forearm into the areas of distribution of the second and third dorsal. Mackenzie (110b) claims that these fields of hyperesthesia are not accurately defined, that they may overlap each other, and that they are not particularly limited to any definitely defined, special area. These areas of hyper- algesia of Mackenzie are most likely nothing but the zone areas of hyperalgesia, as described by Head, whose work at that time was unfamiliar to Mackenzie. In some cases the visceral lesion may produce an irritable focus in the cord, so that stimuli coming to this place would be perceived as pain, while normally they would not be so per- ceived, or, in some cases, would not be felt at all. For instance, the liver and the stomach receive their nerve supply from the same seginent of the cord. Liver disease may produce such an irritation of this segment, that, on the entrance of food into the stomach, the nen^e impulses from the stomach to the cord, which ordinarily are not painful, would then be perceived as painful. Such examples we all have seen, and, in many cases, they lead to a wrong diagnosis (Mackenzie), Persistence of irritability of associated segmental areas of the cord may explain the presence of hyperalgesia, due to excitation of these associated areas. Thus, in a case of gall-stone colic (Mac- kenzie), in which there was jaundice, there was also extreme hy- peralgesia of the skin of the upper part of the abdomen, especially marked in the epigastrium. This persisted for some days after the stone had been passed and had been found in the stool. Dur- ing the time the hyperalgesia persisted food taken into the stom- ach produced severe pain in the epigastrium. With the disap- pearance of the hyperalgesia of the skin the pain on taking food ceased.^ Mackenzie, in continuing, says that "here there seems little doubt that the stimulation, set up by the ingestion of food, which passes to the spinal cord normally unperceived, reached that por- tion of the cord which had been abnormally excited by the gall- 1 This association of pain with the ingestion of food may also be due in many cases to the associated peristalsis set up in related organs by the entrance of the food into the stomach. TRANSFERENCE OF PAIN 387 stone colic, and had hjpersensitized the centers of the cutaneous nerves for j)ain which supply the epigastric region." Shock, also, sometimes affects certain cord areas, as in per- sons who experience pain in a certain area (hyperalgesia) when startled. Mackenzie's explanation is that when startled a stimulus passes down certain tracts in the spinal cord, affecting normally the centers of the muscular nerve supply, as evidenced by the sudden contraction of nearly all the muscles in the body. The stimulus is not of sufficient strength to affect the sensory nerve centers in a healthy cord, unless there are abnormally irritable foci in the cord. However, if such should be present, the stimulus in passing through them affects the excitable sensory nerve centers, and pain arises and is referred to the peripheral distribution of the nerves stimulated. It may also happen that pain is produced by a stronger and more powerful contraction of the excitable and hyperalgesia muscles. Some mention should be made of the views of Hertz, who has carefully discussed this whole question in his 1911 Goulstonian lectures (''Sensibility of the Alimentary Canal"). He points out that Lennander and Mackenzie did not take into consideration the fact that a nerve ending may be sensitive to one form of stim- ulation and may be insensitive to another. The one is an ade- quate, the other an inadequate stimulus. The eye does not react to sound stimuli, nor the taste buds to those of light. Thus, the abdominal viscera, not being exposed to touch, are probably not stimulated by touch stimuli, but that they react to adequate stim- uli there is no question. All that the older observers showed was that pinching, pricking, cutting were not natural, adequate stimuli. The fact of the matter is that the abdominal viscera are exquisitely sensitive to deep-pressure stimuli, such as those pro- duced by tension. Thus, slight distention of the intestinal mus- cular coat leads to discomfort, and marked stretching to severe pain. The normal stimuli reactions in tlie intestine are those of contraction and relaxation; these two are going on continuously. There is, as Meltzer has pointed out, a law of contrary innerva- 388 PAIN IN ABDOMINAL VISCERAL DISEASE tion, which permits of this wave of contraction and relaxation, and any interference with this law, such as occurs in colic, in obstructions, etc., gives rise to paroxysmal and severe pain. The pains of gastric ulcer and duodenal ulcer are to be thus interpreted. In colic an abnormally strong peristaltic wave occurs in one part of the alimentary canal, the part immediately below which should normally relax, following the law of con- trary innervation, is unable to do so, owing to organic disease, or to spasm; the intermediary segment is thus subjected to steadily increasing pressure, which soon produces pain, the distention be- ing the adequate stimulus. Hertz believes that the only cause of true visceral pain is ten- sion. Thus, a study of the visceral pains resolves itself into an analysis of the two forms, the tension pains and the reflex pains, which, as has been pointed out, are exceedingly rich and varied, and of great diagnostic value topographically. Even with the adequate stimulus, however, the intestines are much less sensitive than is the skin to its adequate pain stimuli. The inaccuracy of localization of the tension pains is no argu- ment against them, since the brain is the perceiving organ and it registers the general topography of an organ, not its variations in location, as, for instance, in the movements of the stomach. Thus, there is no valid reason why the pain of a gastric ulcer should vary with every movement of that viscus. With the vis- cera, however, which move the least, the localization of pain re- mains the most stable, other things being equal. Should the resistance of the patient be lowered from any cause, such as occurs in the anemic and weakened state which follows upon a severe fever or illness of any kind, it has been found that reflected and referred pains are much more likely to occur. After the elicitation of referred or reflected pain, it is neces- sary to localize the viscus producing it. The technic is the fol- lowing: (1) delimit the area of hyperalgesia as nearly as pos- sible, and orient it with a cord segment; (2) find out what or- gans are supplied by this segment; (3) examine the organ or or- TRANSFERENCE OF PAIN 389 gans for disease; (4) see if, by manipulation of the organ, the pain can be reproduced. The transmission of stimuli to the cord also affects the mus- cular centers which lie adjacent to the sensory centers involved. These stimuli augment that which is normally present in the muscle, and, instead of the normal tonicity, cause a state of tonic contraction. This contraction may be limited to a portion of a muscle, may involve the entire muscle, or may affect several muscles whose centers lie adjacent to each other. This muscular center hypersensibility also accounts for the exaggerated reflexes (principally abdominal) which are so often present in visceral diseases. As irritation of the viscera causes pain to be referred to certain areas, it has been found that stimulation of these areas also is referred back and causes reflex changes in. the viscera. CHAPTER XXI DIAGNOSIS OF ABDOMINAL PAINS NATURE OF VARIOUS ABDOMINAL PAINS The lesions of the abdominal viscera producing pain are prin- cipally those which cause contraction, active spasm, or excessive passive dilatation of the involuntary muscle fiber in the walls of these viscera. Inflammation of the viscera also causes pain ; but in many cases ulceration of a hollow viscus may exist for years without producing the slightest distress. This is well exempli- fied in ulcers of the stomach, gall bladder and appendix (Moullin and others). In nearly all cases in which a severe and long contraction of a hollow organ is present, there is, above the area of contraction, an area of dilatation, so that, at the junction of the contracting segment wdth the dilating segment, a jDlace is present where trac- tion on the mesentery is severe and prolonged. It is likely that this traction and pulling cause the excruciating pain of intestinal and other hollow viscera colics.-^ That excessive passive dilatation of an abdominal organ may cause pain, is verified in many cases, such as when tympany of the stomach or colon, with severe pain, comes after operation. After relief of the dilatation by the pas- sage of the stomach or rectal tube, the pain disappears. Many have experienced the sense of discomfort and distention after the ingestion of a hearty meal, and it is easy to understand how this disagreeable sensation, if the distention of the stomach were pro- longed beyond tho limits of its normal capacity, might be in- 1 Hertz claims that colic is due to an irritation directly on the sensory terminal fibers in the muscle layer of the visceral walls. NATURE OF VARIOUS ABDOMINAL PAINS 391 creased to one of actual pain. There are many cases, also, in which, during dilatation of the stomach for the purpose of record- ing its capacity, the patient complains of a sharp pain in the epigastrium. These are but isolated examples of conditions which are very common. In the spasmodic contractions and the dilatations of hollow viscera the pain is generally referred to the body wall, and hence is called somatic. The point of reference, in many cases, is some distance away from the location of the lesion. Thus, the pain felt in stomach distention is in the epigastrium, immediately be- neath the ziphoid cartilage, at a point that is somewhat remote from the region of the stomach as projected on the abdominal wall. The logical way to explain the apparent non-association of the area in which the pain is felt with the organ in which it is produced is that these remote regions are in relation with one another by means of nerve connections. An explanation of this seeming inconsistency may be formed from a study of cord zones, as elucidated by Head. It is known that the stomach is supplied by the seventh, eighth and ninth dorsal visceral zones, and that it is especially related to the seventh zone. It is also known that the maximum point of tenderness and sensibility of the seventh zone is in the epigastrium, immediately beneath the ziphoid. Therefore, in any lesion of the stomach which may be painful, the pain, as a rule, is reflected to this point, or to an analogous area on the back opposite the ninth or tenth dorsal spine. These pains are spoken of as reflected pains, and should more properly, perhaps, be considered under the class of pains which are felt at a distance from the lesions causing them, such as referred, reflected, transferred and associated or sympathetic pains. Referred pain is frequent in lesions of the nerves or of the centers of these nerves, which supply the integument of the an- terior abdominal wall. Under referred pains are to be placed those due to tabes dorsalis, tuberculosis of the vertebi-ie, fracture of the verte- bra, osteoarthritis of the spine, insufficiency 'of the vertebrae, spinal meningeal inflammation or tumor, neuritis of the lumbar 392 DIAGNOSIS OF ABDOMINAL PAINS or dorsal nerves, pressure by growths, inflammatory products, or broken ribs upon the nerves, pinching of the nerves (especially of the last two intercostals) between the adjacent ribs, diaphrag- matic pleurisy and rheumatism of the diaphragm, and aneurysm of the abdominal aorta. Acute mediastino-pericarditis, from direct extension, sometimes causes pain to be felt in the higher epigastric and lower breasjt region. For a proper consideration of all these pains, the reader is referred to the section under which referred pain is considered. Reflected abdominal pains are the most common variety, and probably number fifty per cent, of all varieties of visceral pain. They are the result of a stimulus applied either to a sympathetic or to a cerebrospinal nerve. This stimulus is carried to the posterior horns of the cord, and actively stimulates other asso- ciated sensory fibers. The stimulus is then perceived as pain, and the sensation is referred to the peripheral distribution of the stimulated sensory neurons, and thus it occurs that the peripheral' distribution of the pain may be in an altogether different region from that in which the stimulus originated. Transferred abdominal pain is that form of pain in which the impulse is transferred, either directly across the cord to the other side, or to a higher or a lower level in the cord, thus changing the location of its peripheral distribution to a higher or lower level on the body wall. This is one of the most annoying pains to interpret. It may be found in the opposite side of the abdomen in appendicitis, pus tubes, diseased ovaries, renal calculus and pelvic peritonitis. Pain transferred to a higher or a lower level than that of the disease is illustrated by the abdominal pain in pneumonia (q. v.), the clavicular pain in extrauterine pregnancy, and the pains over the fourth costal cartilage (left side) in disease of the common duct. The shoulder pain, which may be present in diseases of ab- dominal organs, has been considered by Peter to be due to phrenic nerve irritation, which carries the stimulus to tlie roots of the cer- vical nerves, from whence the sensation is referred as pain to their area of distribution (Mackenzie and Peter). NATURE OF VARIOUS ABDOMINAL PAINS 393 Syinpathetic pains are sometimes produced when the irrita- tion of a center in the spinal cord is so great that other adja- cent centers are stimulated and send impulses to the brain, so that pain is also interpreted as coming from their distri- bution areas. This may happen in acute appendicitis when the cord segments above and below the segment connected with the appendix are irritated and refer pain to their area of dis- tribution. By reference to the diagram of pain paths, it may readily be seen how the various paths are propagated and conveyed. It SHOULD ALWAYS BE BOKNE IN MIND THAT IT IS IMMATERIAL WHAT PART OF A NERVE-CIRCUIT IS AFFECTED ; THE PAIN WILL ALWAYS BE INTERPRETED AS COMING FROM THE PERIPHERAL DISTRIBUTION OF THE NERVE FIBERS WHICH ARE INVOLVED. Regional Pains. — For the zone segments involved in disease of the different viscera see Figures 24, 25, 26. Each zone segment has one or more maximal points of tenderness which are sensitive in any painful disease of the viscera supplied by this special segment. It should be noticed that the term "painful" diseases of the viscera is used ; for, as is known, every disease of the abdominal viscera is not painful; and while the majority of the visceral diseases at some period of their development become painful, there is a well-defined percentage which never do. The peculiarity of these nonpainful diseases may be accounted for from the fact that, in the evolution of the disease, the parietal peritoneum or the peritoneal attachments, as the mesentery, meso- appendix or mesocolon, have never been involved. We have already seen that Lennander explained all abdominal pain as a result of pulling, pressure or traction upon the peritoneum. In this relation, I would like, by means of an interpolation, to call attention to the experiences of physicians of a previous genera- tion, who frequently groped in the dark in a vain attemp)t to cor- relate the symptoms and the disease seen in their patients. A case in point is one in which pain extended from the midline posterior above the hip to the midline in front, in which shingles were present. The patient, a woman", died on the third day of 394 DIAGNOSIS OF ABDOMINAL PAINS the disease, and on autopsy an inflammation of the peritoneum and appendix was found. "During life it was quite impossible to form a reliable opinion as to the nature of the lesion which gave rise to the pain. In view of our later knowledge, we would be able to diagnose the difiiculty with ease*' (McCall Anderson, 8G0). A full discussion of these views will be given in a subse- quent chapter. One of the first results of abdominal pain is the crippling of the respiration. This is noticed especially in men, who are accus- tomed to use the diaphragm in respiration much more than women. Where painful intraabdominal disease occurs, the dia- phragm partakes of the reflex of all other muscles, and becomes rigid and motionless, so as to protect the diseased area. As a consequence, abdominal respiration is hindered or abolished. EXAMINATION FOR PAIN After this necessarily brief consideration of the pathology of various abdominal pains, it is in order to consider more closely, and in a more detailed manner, the routine examination for ab- dominal pain and tenderness. After that, it may be permissible to review the various divisions of the abdomen, and the pains which lie within their borders. ,In the examination of the abdomen for pain, the routine is as follows : Localization of Pain. — The patient should be recumbent, the shoulders raised, knees flexed, mouth open, and the breath- ing regular and easy. The examiner's hand should then be laid flat over the abdomen, at first with very slight pressure, to elicit general tenderness ; then the fingers should be pressed in with more force, in order to elicit localized tenderness at special points. The tips of the different fingers should now be successively de- pressed, in order to define more accurately the localization of the area of tenderness. After the location of an area of tenderness, it is well to determine its extent by concentric palpation. Con- centric palpation is made by starting from the periphery and gradually making pressure towards the point of greatest tender- EXAMINATION FOR PAIN 395 ness. In this way the area of hypersensitiveness and the point of greatest pain are determined. Localization of the Organ Producing- Pain. — After deter- Liver Gall bladder Pancreas Enlarged liver Intestines Large Small Enteritis Lead colic Omentum Cysts Carcinoma Floating kidney Appendix Ovary Fallopian tube Typhoid fever Referred pain Pleurisy Pneumonia Uterus Aneurysm of descending aorta Stomach Spleen Pancreas Fig. 83. — Anterior View of Abdominal Zones with Corresponding Organs. Midline pain maj'- be due to hernia of the hnea alba. Pain over entire abdominal wall with tenderness on pressure indicates rheumatism of the abdominal muscles. Pain over any part of the abdomen may be found to be due to disease of the vertebra (caries, sarcoma, etc.). Intercostal neu- ralgia Referred pain in pleurisy, pneumonia, pericarditis, appendicitis, visceroptosis Splenomegaly 10 Kidney, ureter Descending co- lon (pericoli- tis) 11 Referred pain Girdle pain of locomotor ataxia, myeli- tis, spinal meningitis Arteriosclerosis of abdominal vessels 12 Ruptured extra- uterine preg- nancy Hernia 13 Uterus(midline) Ovary and Fal- lopian tubes (laterally) Bladder Distention Tuberculosis Calculus Ruptured ex- trauterine pregnancy Hernia mining the presence of pain, it is in order to locate the organ pro- ducing it. For the purpose of localization, the abdomen is divided into three regions: (1) the upper, (2) the middle, and (3) the lower. The upper, Avhich lies in the angle formed by the costal margins and a line connecting the lowest points on the costal arches, practically coincides with the epigastric area, The middle 396 DIAGNOSIS OF ABDOMINAL PAINS area lies between this zone and another line connecting the two iliac crests. Below this, and bounded at the base by the iliac and pubic bones, is the lower zone. Each of these areas is divided by a line extending from the ensiform cartilage to the pubes into a right and a left region, and the middle zone is divided by an Aneurysm of the_ _ descending aorta " " Liver Lungs Pleura Kidney Spine Lumbago - Sacroiliac disease Fig. 84. — Posterior View of Abdominal Zones. imaginary line passing down the extreme lateral aspect of the body into an anterior and a posterior zone. In the annexed figure an attempt is made to outline the organs producing painful affections of each zone. • In the upper zone, which is included between the diaphragm and the zonal line divid- ing the middle zone from the upper, two lateral zones are present at either side beneath the ribs. They are called the hypochon- driac zones. Reference to the figures will show the organs giving rise to pain in each zone. Lesions Causing- Epigastric Pain. — In considering the re- gional localization of abdominal pain it is well to pay at least partial attention to the great variety of lesions to which pain in the epigastrium may be due ; for, owing to the presence in the epi- EXAMINATION FOR PAIN 397 gastrium of the solar-plexus, with its somatic peripheral distribu- tion, pain in this region may be symptomatic of a lesion of almost any of the abdominal organs. The organs most frequently causing epigastric pain are: (1) The Stomach. — The pain is very often associated with vomiting, and generally bears some relationship to the ingestion of food. It is found in acute gastritis, gastralgia, hemorrhage, ulcer, perforation, injury, carcinoma, and obstruction from any cause. (2) The Intestines. — The pain is due to hemorrhage, rupture from ulcer or injury, obstruction accompanied by increase of peri- stalsis, and the formation of a tumor. (3) The Appendix. — In all forms of acute appendicitis pain is present at first in the epigastrium, but quickly radiates to the right iliac fossa. (4) The Liver, Gall Bladder and Ducts. — In acute peri- hepatitis breathing is painful, and localized tenderness is present ; biliary colic is often followed by jaundice; in cholecystitis the en- larged gall bladder can be felt, and chills and fever are generally present; in rupture of the gall bladder or of the ducts symptoms of peritonitis rapidly supervene ; in carcinoma there are general signs of the disease, such as emaciation, and a positive hemolytic test. According to Riedel, ninety-seven per cent, of epigastric pains are due to gall-stones. (5) The Pancreas. — In acute pancreatitis there generally is a history of previous ^all-stone disease, with no cholecystitis, and no signs of a gastric lesion. (6) The Kidney. — In renal colic, pyonephrosis and hydro- nephrosis there are urinary findings, such as blood or pus in the urine, to indicate the disease. (7) The Spleen. — Splenitis, or traumatic rupture, may cause epigastric pain. (8) Ectopic Pregnancy. — Rupture of an ectopic preg-nancy sometimes causes ej^igastric pain. (9) Locomotor Ataxia. — Locomotor ataxia causes a pain which may be referred to the epigastrium. There are also present 398 DIAGNOSIS OF ABDOMINAL PAINS other signs of the disease, such as Romberg incoordination and Argyll-Robertson pupil. (10) Pneumonia. — In pneumonia there are signs of lung consolidation. (11) Pelvic Lesions. — Embolism of either the superior or the inferior mesenteric artery may be present, and produce epi- gastric pain with all the symptoms of bowel obstruction, but of much greater severity; in these cases some other grave disease, from which the clot obstructing the vessel is derived, is also present. (12) Adhesions between any of the organs underlying the seat of pain may also be the cause of pain. Character of the Epigastric Pain. — If the pain in the epigas- trium is sudden and severe, and does not follow a straining effort, examination should be made for: (1) Appendicitis, which, if present, finally causes the pain to become localized in the appendix area. Typhoid fever, which in some cases, when it is of sudden onset, commences as a severe abdominal pain, and has often been mistaken for appendicitis. (2) Cholecystitis, in which the pain finally becomes -local- ized to the right hypochondrium. (3) Acute hemorrhagic pancreatitis, in which the pain re- mains in the epigastrium. (4) Perforating ulcer, in which the pain remains where it first appeared for but a very short time, and soon, because of the development of peritonitis, becomes generalized ; or, in some cases, owing to extension of the exudate may at first be most severely felt in the pelvis. (5) In obstructed intestines the pain, as a rule, has a ten- dency to ascend toward the ensiform, until tympany becomes ex- cessive, when it is felt over the entire abdomen. (6) In perforated gall-bladder the pain remains in the region of the gall-bladder, or passes down to the appendiceal region, until generalized peritonitis develops, when the pain be- comes diffused over the entire abdomen. Sudden abdominal pain, following a straining effort and not EXAMINATION FOR PAIN 399 confined to the epigastrium, may be due to: (a) hernial strangu- lation; (&) ruptured extrauterine pregnancy; (c) ruptured ap- pendix; (d) tearing of peritoneal adhesions; (e) rupture of a cystic tumor; (/) twisting of an ovarian tumor or cyst on its pedicle. As they will not be extensively considered elsewhere, a little time will be devoted here to cysts in which the pain is of sudden onset, very severe, and paroxysmal, sometimes continuous. The cause of the pain is torsion of the pedicle (ovarian cyst or tumor). This causes an extravasation of blood into the tumor substance and a consequent rise of internal cystic or tumor pressure with tension and traction on the capsule. Such an increase is espe- cially apt to occur when the return circulation through the veins is obstructed. Should the capsule be lax, and the capacity of the tumor great, the pain from extravasation may not be great, even though symptoms of hemorrhage may supervene. Should the tor- sion occur in the pedicle of a wandering spleen or of a prolapsed kidney, the pain may be due to a beginning necrosis of the tissue, although it Avould seem more logical to define the increased in- tracapsular tension as being the active and potent cause. Pain, while of the greatest use in the diagnosis of twisted pedicle, is not of paramount importan-ce. Richardson says that ''a history of tumor, a sudden enlargement and tenderness in that tumor, pre- ceded or accompanied by pain, are sufficient to make the diagnosis of twisted pedicle." If the abdominal pain is due to irritation of the sympathetic fibers, it is present at first, as a rule, in the central part of the abdomen and later becomes localized more definitely to the area associated with the diseased organ or organs. On the contrary, if the cerebrospinal nerves are involved, from the development of a peritonitis, the pain is localized directly over the affected vis- cera. Bed clothing cannot be tolerated, and the abdominal mus- cles are rigid. The rigidity of the abdominal muscles over the diseased area is the result of somatic muscular reflex contraction. Hyperesthesia of the skin over the affected viscera is also present. This sensitiveness is generally not so sharply delimited as is the 400 DIAGNOSIS OF ABDOMINAL PAINS reflex tenderness from visceral disease. It is most severe at the site of the most severe inflammatory reaction, and diminishes concentrically from this point. Sudden abdominal pain is diffuse, or is localized in the umbili- cal region (where the solar-plexus, the so-called abdominal brain, the sensorium of the abdominal viscera, is located). This pain may be associated with shock and collapse, which, when present, are fairly certain indicators of a severe abdominal lesion. In the condition of shock the associated symptoms of importance are a rapid pulse, obliteration of the liver dullness (look for rupture of a viscus), and rigidity of the abdominal musculature.^ Should the pain result from rapid and extensive extravasations of septic material, it is sharp, sudden and overwhelming. It is often ushered in by a feeling as though something had given way. At first it is continuous, violent, and almost unbearable; later it becomes paroxysmal and intermittent, or is dull and con- tinuous. The pain, which at first is localized sharply in the region of the extravasation, becomes generalized as the septic ma- terial spreads throughout the abdominal cavity. When the i>eri- tonitis becomes diffused and the bowel distention is excessive, pain usually subsides, and when it does so, it is a sign of grave signifi- cance (Richardson). Pain Due to Functional Processes. — When abdominal pain occurs, inquiry should be made concerning the following points: (1) The relationship, if any, to the ingestion of food. If 'Lennander explains the diffuse abdominal pain present in the early stages of so many infectious processes in the abdominal cavity as being due to: (1) An increased sensitiveness of a large portion of the parietal perito- neum, owing to lymphangitis or peritonitis. (2) A considerable increase and irregularity of peristaltic action, which, in addition to pain, often produces a feeling of sickness and vomiting, and leads to one or more actions of the bowels at the commencement of these ill- nesses. (3) On account of increased sensitiveness, the movements of the stomach and intestines against the parietal peritoneum, and the stretching of their re- spective mesenteries, are felt as severe pains. (4) In most cases, however, the general peritoneal irritation soon passes away; only the part more especially infected remains in a condition of inflam- mation, and the abdominal pain becomes localized at this spot. EXAMINATION FOR PAIN 401 there is any such relationship examine (a) the stomach and in- testine for a gastric or duodenal ulcer, or for adhesions, or the intestine for a volvulus or obstruction, in which case the pain, at first, is periodic and paroxysmal, and, later, continuous and of an aching, dragging character. If the pain is sudden and intense, especially if it commences in the umbilical region and gradually becomes localized to the right side, examine for appendicitis. If the pain is continuous and increasing, it indicates that the local peritonitis is spreading. This is especially the case should there be a synchronous increase in the tenderness, (b) In pancreatic disease it may indicate a rupture of the duct or an acute hemor- rhage and inflammation, (c) Biliary disease, as a rule, causes a pain which comes on about the first or third hour after eating, at the time of the gTeatest intestinal activity, and is especially marked when percystic adhesions are present. (2) Relationship of pain to defecation indicates: (a) hem- orrhoids, which generally are associated with bleeding; (b) fis- sures of the anus, which often are associated with itching; (c) carcinoma of the rectum, in which bleeding is very marked and sometimes is present previous to the onset of pain; (d) ulcera- tions of the rectum, which, as a rule, are not painful, unless the sphincter region is involved. (3) If the pain occurs in conjunction with menstruation, the genital organs should be examined, the uterus, tubes and ovaries all being subjected to a close inspection. If they are affected, the pain, because of the congestion then present, becomes worse during the menstrual period. Sudden abdominal pain is often premonitory of a miscarriage. Pain Due to Intestinal Diseases. — A few facts worthy of attention are: That increased peristalsis of the bowel may, in case of obstruction, be a potent cause of abdominal pain. This pain is located across the middle of the abdomen ; never below the umbilicus in obstruction of the small intestine, but generally above in lesions of the large intestine (Mackenzie). In obstruction of the large intestine painful states arise. These are the result of the obstruction to the forward peristalsis, and are called colics. 402 DIAGNOSIS OF ABDOMINAL PAINS Of intestinal colics, there are those due to acute indigestion, in which the pain is usually accompanied by vomiting; those due to poisoning as by lead or brass. (These metals irritate and cause constriction of the blood vessels in the intestinal walls, thus indirectly irritating the sympathetic nerve filaments and causing muscular contraction and colic. Pal claims that in lead fcolic the blood pressure is increased from one-half to twice the normal, and that this increased pressure irritates the terminal filaments of the sympathetic, and thus causes pain) ; those due to hernia, which are generally accompanied by vomiting; those due to uremia, which may precede other uremic symptoms by a considerable interval (Musser) ; those due to gall-stones, which are probably the most frequent cause of colic (here the pain, as a rule, is located in the right ejDigastric zone, but may be felt in the right lumbar zone anterior) ; and lastly, those due to renal calculus, which are very severe, and sometimes are mistaken for intestinal obstruction, chiefly because of the intestinal distention and inability to move the bowels, a condition often the result of large doses of morphia which ■ the patient has been given. In children painful paroxysms frequently occur in the course of purpura. This disease, according to Guinon, is due to a toxic infective agent, with special action on the nervous system ; so that it seems very probable that the colicky pains are due to intestinal cramps, the result of a deranged peristalsis, which in turn is the result of malactivity of the nervous system. The ordinary colics of children are accompanied by a great restlessness, throwing about of the body, and interrupted cries. Relief comes on the expulsion of flatus (Kerr, 861). Perforation in typhoid is a cause of very severe and acute abdominal pain. In Manges' series of nineteen cases of typhoid perforation, abdominal pain was the first symptom to appear in fourteen. In two of them, however, it was accompanied by a chill, and in two others by vomiting. Though not the initial symptom, it was present in seventeen of the nineteen cases. One of the best descriptions of the pain due to typhoid perforation is that given by Selby. What he says applies to perforation of any EXAMINATION FOR PAIN 403 hollow abdominal viscus. He says that abdominal pain is a most constant and reliable indication of perforation, depending, to be sure, on the mental condition of the patient and his appreciation of the sensation. The pain varies in degree, character and location. It may be so severe as to force a cry from a comatose patient, and, on the other hand, so mild as to attract but slight or no attention from a conscious patient. It may begin as a sudden, sharp, stab- bing and agonizing sensation, or may come on gradually. Its duration varies also. It is usually circumscribed and is lo- cated in the lower part of the abdomen near to the median line, or towards the right side, and, generally speaking, the more cir- cumscribed it is, the more keenly it is appreciated. Occasionally it is referred to the umbilicus and other parts of the abdomen, and even to the penis. If it be general at the start, as it some- times is, it may, in the course of a short time, become confined to the lower part of the abdomen. On the contrary, if primarily it is localized, and later becomes generalized, it strongly suggests progressive peritoneal infection. The value of pain, however, as a symptom, lies not so much in its limits, its severity, the manner of its appearance, and its persistence, as in the fact that it itself is present. Its modifying features, when present, may be weighed in proportion to their degree, but when absent may be ignored in arriving at a diagnosis. In one case of typhoidal perforation there was sudden pain in the lower abdomen, causing the patient to cry aloud ; soon after- ward there was intense pain in the penis (Allaben). The rela- tion of this penis pain to the perforation is difficult to determine. Abdominal pain may be caused by adhesions, for a discussion of which, see under Peritonitis. Abdominal Tenderness. — Tenderness on pressure, being close- ly allied to pain, may be considered in the light of a less-marked manifestation of that sensation. It usually accompanies pain, and not infrequently is present when actual pain is absent. It is found within the same areas as is the associated pain, but is con- fined within more narrow limits. Thus, diffuse pain is occa- sionally associated with a localized tenderness. This feature 404 DIAGNOSIS OF ABDOMINAL PAINS renders tenderness of value in the determination of the approxi- mate location of the lesion. However, as such, it is not without fallacy. A widening of the tender area may be taken as an indi- cation of a spreading- peritonitis, and, as such, is an indicator, of greater reliability than an increasing diffusion of the pain. "The value of tenderness as a symptom is enhanced, needless to say, by its characterizing features, but, as is true of pain, its real value lies in its mere presence." Pericholecystitis F'eriappendicitis Spreading pel- vic peritonitis Perisalpingitis Pelvic peritonitis Extension of the tenderness Morris's points McBurney'spoint Pressure over this area will cause pain if the ureter is inflamed Fig. 85. — Areas of Local Tenderness, when the Inflammation of the Appendix, Gall Bladder, and Fallopian Tube and Ovary Has Spread to ihe Peritoneum and Has Produced a Localized Peri- tonitis. Morris's points are also shown, as well as the area in which pressure is made best over an inflamed ureter. When abdominal pain is present, tenderness should always be sought over the areas associated with the gall-bladder, the pylorus, the appendix, and the hernial openings. Abdominal tenderness is sometimes due to a hypersensitiveness of the abdom- inal musculature, such as is produced by prolonged coughing. This tenderness is generally in the epigastrium in the region of the recti muscles. Percussion is of value in determining abdominal tenderness. It often happens that, in percussing the abdomen, attention is drawn to a particular region by the wincing and involuntary EXAMINATION TOR PAIN 405 shrinking of the patient from the percussing finger. This always indicates tenderness. After the attention is drawn to a particular area of the abdomen, more refined means of defining the degree and extent of tenderness (palpation and pin-prick pressure) may be used. Such measures have been described in earlier chapters. Types of Tenderness. — Tenderness is of two types : tempo- rary and permanent. Tenderness which is present temporarily over an organ may be due to the distention of the organs (stom- ach or intestines) with air or gas. As soon as the distention is relieved pain and tenderness cease. Chronic tenderness is more likely to be caused by inflammatory changes, especially in those in whom the abdominal wall or the parietal peritoneum is involved. Should the tenderness be superficial, and so acute that even the lightest pressure causes pain, it is probable that the condition is one of superficial neuralgia, such as is common during infec- tious diseases. On the other hand, deep tenderness is only of relative value, since even in many normal cases the forcing of the hand deep into the abdomen will cause pain. Reflected Tenderness.— Tn the consideration of tenderness the fact must not be lost sight of that tenderness is not always present over the organ causing it ; for in many cases pressure on or over the inflamed or diseased organ will cause pain at some distant area, and pressure over this area is painful, even though it is at a distance from and has no direct connection with the organs causing the pain. This is a most important point in the diagnosis of disease, and should never be forgotten. A point of tenderness in cases of pelvic adhesions is given by Cumston, who says that "a symmetrical point of tenderness on the opposite side of the abdomen from McBurney's point will be found in pelvic adhesions." This point of tenderness, as given by Cumston, closely approximates the point of tenderness defined by Morris as being present in pelvic lesions. Morris gives his point as being one and one-half inches from the navel on a line running from the navel to the umbilicus. He claims that when this point is tender on the right side alone, appendicitis is present, and that when it is 406 DIAGNOSIS OF ABDOMINAL PAINS tender on both sides, pelvic disease is present. This view has been controverted by Hubbard, who ascribes to these areas of tenderness, even in cases of chronic appendicitis, only secondary importance. McBurney's point, which is also a point of tender- ness in appendicitis, is situated in the lower left quadrant of the right lumbar zone anteriorly, on a line drawn from the umbilicus to the anterior-superior sj)ine of the ilium, and one and one-half inches from the anterior-superior spine. It has not the signifi- cance formerly ascribed to it (see Appendix). POSTURE IN ABDOMINAL DIAGNOSIS The posture of the patient, in cases of severe abdominal dis- ease, is characteristic. The patient assumes two general positions: in the first, the posture of abdominal protection, the patient is alert, and while with one hand he attempts to ward off any ab- > W^.. Fig. 86. — Posture of Abdominal Protection Present in Peritonitio. In cholecystitis and appendicitis, the hands maj^ be the reverse of what they are in the figure : the right hand acts as guard and the left as pro- tector. In salpingitis, the protecting hand is over the lower abdomen. dominal interference (touch, palpation), with the other hand he covers (without making pressure) the painful area. In the second form the j^atient, instead of warding off abdominal pressure, seems to find relief when pressure is applied to the abdomen. He is, as a rule, doubled up, with the limbs flexed on the abdomen, POSTURE IN ABDOMINAL DIAGNOSIS 407 Fig. 87. — Position in Abdominal Colic, A.ssumed on Lying. and the belly muscles tightly contracted. In some cases the pa- tients make pressure on the abdomen with the hands, while in other cases they use for this purpose some other object (pillowSj bolsters). In the first posi- tion inflammation of some of the abdominal organs is indicated, and if the sensi- tiveness is markedly in- creased peritonitis probably has already set in. The sec- ond position indicates some variety of colic, the parox- ysms of which are indicated by the exaggeration of the position which the patient assumes when the pain comes on. The patient, as a rule, lies down, or, if this is impossible,, assumes a sit- ting posture, with the arms folded and the body bent, so that pressure is made on the 1 1 Fig. 88. — Position in Abdominal Colic, Assumed on Sitting. 408 DIAGNOSIS OF ABDOMINAL PAINS FORMS OF ABDOMINAL PAIN To complete this chapter a brief discnssion of some of the most common forms of abdominal pain is necessary. Among those most frequently encountered is renal colic, the pain of which is generally on the affected side, passes downward toward the pelvis, and is often very acutely felt in the testicle on the side of the disease. In the purpura of infants painful abdominal paroxysms are common (455). According to Musser, abdominal pain is often a precursor of uremia. This pain is usually situated in the right or left hypochondrium, and, when in the left hypo- chondrium, has been mistaken both for gastritis and gastric per- foration. Enteroptosis, particularly gastroptosis, may produce pain in the suprapubic region (Deaver). Keen reports a case of rupture of the rectus muscle, in which, at the time of the rupture, sudden, sharp pain was felt in the abdominal wall. Such a rupture may occur in a typhoid patient who is convalescing, and generally follows some sudden exertion. The symptoms of rupture are sudden, sharp pain and tenderness localized to the point of rupture. The rupture is generally accom- panied by vomiting. Examination shows a depression in the course of the muscular fibers, later accompanied by ecchymosis and swelling. If the pain is in the rectum, it may be caused by a pro- lapsed colon. Arteriosclerosis of the abdominal vessels also causes abdomi- nal pain, which generally is severe and paroxysmal. For a full discussion, see under Arteriosclerosis of the Mesenteric Arteries. A condition is described by Depage in which pain is due to a displacement of a rib. Examination will show that the eleventh and in some cases the tenth rib is projecting over the iliac crest. The pain is intermittent and is worse when the patient walks or moves about. Pressure over the ends of the tenth and eleventh ribs is painful, and pain is also experienced if the angles of the ribs are brought one over the other. The condition is most fre- quent on the right side. rORMS OF ABDOMINAL PAIN 409 A rather rare and frequently overlooked cause of abdominal pain is anemia (Musser, 5). Functional Pains. — Richardson speaks of neuralgia of the ab- dominal organs as a cause of abdominal pain. This term, as a rule, is a misnomer, for nearly all cases of supposed abdominal neuralgia are due to some condition having a more definite patho- logic basis than is found in neuralgia. The only reason that these lesions are not properly diagnosed is that the search for their path- ology has not been sufficiently prolonged nor assiduously enough pursued. While neuralgia may and does occur as a cause of ab- dominal pain, it is much less frequent than is supposed. The so-called functional pains are frequently classified as neu- ralgic, but in nearly all cases these pains can, by patient search, be shown to be due to organic lesions, sometimes obscure, but present nevertheless. Under functional pains, Richardson gives gastralgia, nephralgia, oophoralgia, and simple intestinal colic from gas. All except the last are recognized entities, but not in the same manner as is generally understood. Gastralgia is only a term, usually applied to a painful state of the stomach, having an unknown basic cause. In some cases, when it is due to a painful condition of the muscular structure, it should be called gastromyalgia ; on the other hand, if the nerves are affected, it should be termed gastroneuralgia. However, all painful conditions of the stomach, whatever the etiology, may be classed under the generic term gastralgia. So likewise painful states of the kidney and ovary may be called nephralgia and oophor- algia. But often, alas, when we suffix "algia" to the name of an organ, it means that we are but adding a cloak to conceal our ignorance of the real cause of the pain which is present ; it means that we are naming the diseased state from a symptom instead of from the pathology. The careless use of these terms cannot be too strongly condemned, and they would be seldom employed if it were borne in mind that they frequently are but the indicators of ignorance and sloth. The presence of abdominal pain in neurasthenics should always be a subject of considerable investigation before a defi- 410 DIAGNOSIS OF ABDOMINAL PAINS nite diagnosis is made. The neurasthenic is frequently subject to the delusion that there is sometliing radically wrong in the abdomen, and even though operation and removal of an ovary or of an appendix may relieve the symptoms for a time, the pain soon returns, and is found in a new location, so that it is almost an impossibility to relieve this class of people, either with or with- out operation. Psychotherapy in the form of reeducation ia probably at the present time the most efficient means at our com- mand of producing relief. After the review of pain, as given in the previous pages, it may be well to consider the time of life at which the different pains are most frequent. For this purpose, life may be divided into four periods : infancy, childhood, adult life and old age. In- fancy, with its sensitive and helpless condition, offers a double hardship to the examiner, for he not only has to elicit symptoms, but has to derive them without the patient's help. For this rea- son, pain, as a symptom of disease in infancy, is a factor of almost negligible value. It becomes important only as the infant grows older, and, by intelligent cooperation, is able to tell the examiner something of the type and character of the pain which he experiences. Yet, with all these drawbacks, even in infancy pain is of some little value. When the infant continuously cries and cannot be hushed by its mother, as a rule, it is suffering from some form of pain. The most common causes of pain in infancy are colic, gastroenteritis, and intussusception. In children one should look for these conditions, and, in addition, spinal caries, gall-bladder disease, appendicitis and pneumonia. In adult life all of the above, with the addition of gall-stones, gastroduodenal ulcer, pancreatic disease, hernia strangulation, and, if the patient is a woman, ovarian, tubal or uterine disease may be present. As old age comes on, the tendency to malignant growths increases, and in case of persistent pain one should seek for cancers. Care in Diagnosis. — As previously mentioned, tabes dorsalis, caries of the vertebric and tumors of the spinal cord cause pain. These three conditions should always be thought of in those cases in which an abdominal pain is present without sufficient and definite FORMS OF ABDOMINAL PAIN 411 cause. So often are they mistaken for disease of the intraab- dominal organs that the physician must be very careful to exclude them before he arrives at any definite conclusion. Howell (111b) speaks of cases of tabes dorsalis being mistaken for cases of appen- dicitis and operated upon. Lead poisoning should also be sought, and when the patient with colic is a painter, the gums should be inspected at once, to ascertain if the blue line at the edge is present (Burton's blue line). In lead colic, the abdominal cutaneous hyperalgesia is absent (Robinson, 265). Intercostal neuralgia causes pain which is referred to the an- terior abdominal wall, and is likely to be mistaken for an intra- abdominal lesion. The presence of the pain points is a differen- tiating symptom (see Neuralgia). Pneumonia frequently refers its symptoms to the abdomen, and in some cases so strongly that an abdominal lesion has been diagnosed. In many cases appendicitis operations have been performed ivith negative results for appendicitis, and the oper- ator, to his chagrin, has found pneumonia symptoms developing during the course of the next few days. All cases of acute ab- dominal pain, with rapid pulse, rapid respiration, and high fever, should at once direct the attention to the chest. The ten- derness, also, is characteristic, in that in pneumonia the skin over the abdominal area in which pain is complained of is very tender, but deep pressure is well borne (Howell, Hood, Bennett). This is the opposite to the rule in severe abdominal diseases. Pleurisy has also been mistaken for abdominal disease, and a case is cited by Bennett (144, p. 1005), in which operation would have been performed for appendicitis had it not been that a band of tenderness extending around the abdomen above the umbilicus drew attention to the pleural involvement. Hilton claims that the abdominal pains of thoracic visceral disease are due to involvement of the parietal nerves, and a subse- quent reference of the irritation to their distribution area. He says that the pleura is supplied by the intercostal nerves, an opin- ion which is disputed by Mackenzie. (See pleura.) Abdominal pain may also occur with obstinate constipation. lain of a colic s depending for instance, iates around apula of the » or:: § = a i.s'i O 03 3 persists for attack. o jing; the p direction he colic; pain rad th the sc S cuts si.s a ''S 0) c 3 O ■> o ft 3 .2 .,-^ a) =3 X "o o O d agon ifferent tion of •olic th ndernc d o e o B-O is '^ 3 S-c ft >> . 1 .2 acute a es in the loc l-stone ! back side. ftO-a .at: g 0) -a 3 t time, lly ah i C3 c£ 03 c dj: V -r! cT " • o £ ^2 3S2g lasei colii and wall tops a sh lene CO w M 1 " SJ 0, C 0) 1 O C O .1 t: s along th algia of th h the pai h interspac the abdom isur ca: erv tei a ca pres 'ain he n the T3 +i" -^ M T3 1 §1 : ■3 nerally radiate ve, as in neur erve, in whic from the tent istribution on sligh pain, re up tes al 1 < s •< a a Z der. The ruciating by pressu pain radia a ■p E 3 ■> £ ft 13 o <- c^-o c ^-0 ^ • 03 acute, g of a ne dorsal : ;s aroum area of all. sively tei •es an ex produce and this branches 3 Sharp, course tenth radiate to the inal w 0) Ssi2-Z 1 ute. y no Sft-ila u C3 cute jive. The med ^' 03 £ 03 a m S .« C3 'cgfe-Sb « matio els is harac im the sriphe 3 z ES^ga u d if the infla ent of the ve a throbbing 3 to radiate f towards the ft ■< S s a '3 ft c3 '-' a g _T3_, » s aching, cngorg pain h also te outwa i c 1 — ., a 03 '§ C c 3 Cj3 03 C j^=3-ac3 a c a o 03 z '■B 05 < I' CL, ■a a o c 03 g _c >> "fl s t .2 H C K 412 CONDITIONS ASSOCIATED WITH ABDOMINAL PAIN 413 When it does so occur, it may come on rather suddenly. It gradu- ally increases with little or no* increase in the temperature; finally vomiting of stercoraceous material occurs and the diagnosis is made clear. CONDITIONS ASSOCIATED WITH ABDOMINAL PAIN Spasm and Rigidity of Muscles. — Spasm of the abdominal muscles nearly always accompanies abdominal pain, especially if the pain is severe. This symptom is lacking in those who have very lax or atrophied abdominal walls, and it is also much less marked in women than in men, because their muscular develop- ment is generally much less than that of men. On the other hand, severe rigidity of the abdominal wall may, in those of a very muscular build, supervene upon a very slight intraabdominal irri- tation. Localized rigidity is a good indicator of the region of the abdomen involved, for the contraction generally takes place im- mediately over the diseased viscus. Should abdominal rigidity gradually become lessened, while the toxic state of the patient gradually increases, it indicates that the lesion, whatever its nature, is increasing in virulence, and is becoming dangerous to the patient. This is particularly so if the leukocytosis, which has been present, decreases to, or even below, the normal level. Spasm of the abdominal muscles is of diagnostic value in differentiating abdominal from pelvic lesions, it being marked in abdominal lesions, and almost, if not entirely, absent in pelvic lesions. Visceromuscular Reflex. — In abdominal lesions, also, the so- called visceromuscular reflex (Mackenzie) may be present and render the diagnosis more difficult, especially since, in the abdomi- nal parietes, the muscles have the power of segmental contraction over an area of inflammation or irritation. These segmental masses of muscles are very deceiving to the palj^ating hand, and have been mistaken by the examiner for: (1) enlarged ovaries, (2) an enlarged and inflamed appendix, (3) tumors, intraab- dominal and parietal, (4) inflammatory exudates, and (5) intes- tinal tumors, due to volvulus, intussusception, etc. 414 DIAGNOSIS OF ABDOMINAL PAINS During every abdominal examination, the possibility of con- fusing these reflex muscular contractions with tumors, etc., should always be borne in mind, and, since the rectus abdominis is mostly at fault, its nodal points should be carefully mapped out. One of these points occurs at the umbilicus and another between the um- bilicus and the costal arch. Any swelling due to contraction of the rectus would occur between these points and would be somewhat oblong in shape. In the diagnosis between these phantom and true abdominal tumors it is well to observe: (1) that a tumor may vary in its relative position to a fixed point (umbilicus) on the abdominal wall, but a contracted part of the rectus muscles does not so vary ; and (2) that while the tumor, which is the result of contraction of the muscle, may be so persistent and constant that sometimes, even under chloroform, it yields with difficulty, yet it always does yield; while a tumor which is the result of organic disease is more clearly defined when, as a result of the anesthetic action of chloroform, relaxation of the rectus muscle occurs. Toxemia also has a restrictive action on pain perception, and if it is pronounced, abdominal pain is perceived very slightly, or not at all. As Musser remarks, when a hyperleukocytosis is present, with associated severe toxic symptoms, even though pain is absent, a serious lesion should be considered. Indicanuria, as an accompaniment of pain, is of considerable value in localizing the lesion to the small bowel. Polyuria. — Many painful conditions of the abdomen are asso- ciated with polyuria, and Osier has remarked on the frequency of polyuria in the later stages of typhoid fever. Relationship of Hysterical to Abdominal Pain. — Hysteria as a cause of abdominal pain is only mentioned to be condemned. It seems to be a term with which many clinicians hide their ignor- ance and diagnostic distress. The more a physician sees of ab- dominal pain, and the more frequently he follows his case to operation or to autopsy, the less seldom he makes a diagnosis of hysteria. It seems that nearly all so-called abdominal pains of hysteric origin have for their basis something more than a disor- CONDITIONS ASSOCIATED WITH ABDOMINAL PAIN 415 dered nervous system. Under the shadow of this name are hid- den many cases of gall-stones, appendicitis and gastric ulcer. Many are the patients who go on to chronic invalidism or lie in too early graves because of the ignorance or inattention of their physicians to these facts. Abdominal incisions are frequent causes of abdominal pain. Since this is of vital importance to the surgeon, I quote from Maylard, who, to avoid pain as a result of abdominal incisions, recommends that the ''incision be made in the most favorable part of the abdomen ; that is, the part that has the fewest nerves, and that, during the operation, as little irritation or destruction as possible to the tissues of the wound be made." Post-operative abdominal pain, according to Maylard, is caused by irritation of the nerve endings. If it follows immediately after operation, it is due either to tight suturing or to the pres- sure exerted by encircling ligatures. Tension is generally indi- cated by a throbbing pain or ache. When the pain is due to tight suturing or to the ligatures, it follows almost immediately upon the operation, and generally is of a stinging, stabbing character. In some cases a nerve may be transfixed with a suture or ligature, and be a constant source of pain production. If the pain follows twenty-four to forty-eight hours after operation, it is due to in- flammation, with consequent swelling and pressure. When the inflammation is mild, little or no pain results ; but should it be so extensive that exudation is present, the pressure from the exudate upon the terminal nerve filaments is productive of pain, in some cases very severe. The distress which at first was intermittent is now continuous, and should a rise of temperature occur suppuration will generally be found to be present. Inflammation of the skin or subcutaneous tissues generally produces pain in the first twenty- four to forty-eight hours, while inflammation of the deeper struc- tures does not produce discomfort for longer periods. In case the inflammation is of the peritoneum or subperitoneal tissues, discomfort and pain do not make their appearance until about the eighth day after operation. If the patient is very obese, a con- siderable amount of effusion takes place into the wound, and, as 416 DIAGNOSIS OF ABDOMINAL PAINS Maylard remarks, unless drainage is provided, tension, inflamma- tion, and consequent pain will follow. Pain Referred to Extraabdominal Regions. — In disease of abdominal organs the pain is sometimes referred to an extraabdom- inal location. For instance, it is common to have pain in the shoul- der in diseases of certain abdominal viscera. This pain has been described as due to irritation of the phrenic nerves, which convey the stimulus to the roots of the cervical nerves, to whose cu- taneous distribution the pain seems to be referred. This pain, along with an area of hyperesthesia of the skin of the shoulder in lung inflammation, has been attributed to diaphragmatic irritation by Mackenzie, although he also suggests that it may be due to the vagus terminations being involved. It is probable that the shoul- der pain, which is found associated with gall-stone and gall-blad- der disease, is due to involvement of the diaphragm in the in- flammatory process. Likewise, in certain cases of rupture of extrauterine pregnancy, Ave find that pain is present in this area. In these cases the pain may be due to pressure upon the diaphragm by the accumulation of extravasated blood (for it is a peculiar fact that, on standing, the pain often disapj)ears). Absence of Pain. — Should abdominal pain be absent when nat- urally it should be expected, or if it should disappear before the natural termination of the disease would warrant its cessation, the patient should be examined for: (1) perforation of the viscus involved, (2) gangrene of the diseased organ, and (3) increase of toxemia to such an extent that the jiatient's faculties are dulled so that he is unable to perceive pain. When perforation of a viscus occurs, pain is temporarily re- lieved ; but the relief is due only to the incapability of percej)tion which accompanies the shock produced by this condition. When perforation takes place the pulse generally increases in rapidity and becomes weak and thready. The temperature first falls and then rises, as infection and a generalized peritonitis ensue. Any localized tenderness which may have been present before the perforation now becomes diffused, and muscular rigidity, which before was restricted to one area, now becomes general. Should CONDITIONS ASSOCIATED WITH ABDOMINAL PAIN 417 gangrene of aii abdominal viscus occur, the temperature, because of consequent toxemia, may fall. That this fall is not beneficent, may be seen from the j)ulse, which is constantly increasing in rapidity, and from the increasing stupor and somnolence of the patient, whose aj)pearance indicates that he is suffering from a most severe disorder. The disappearance of the pain as an indicator of im- provement is of value only if all associated symptoms improve con- comitantly with it. In many, though not all cases, the rapid dis- apj)earance of the cutaneous hyperalgesia occurs simultaneously with the onset of gangrene (Bennett, 142, p. 1005). Toxemia can be easily diagnosed by the increasing stuj)or and coma associated with it. However, even in the most advanced stages of stupor and coma, while the patient does not complain or cry out from pain, a close examination will disclose the facial expression of the most severe distress. CHAPTER XXII PAINS OF THE ALIMENTARY TRACT Lips. — It is very rare for the lips to be afflicted with pain without noticeable organic change, although sometimes neuralgia of either the second or third branch of the fifth nerve seems to be particularly confined to either the upper or the lower lip. In this case we find that the lips are normal in appearance but ex- ceedingly tender to pressure. The pain also comes in paroxysms, between which there is no pain and absolutely no tenderness. The principal organic changes in the lips producing pain are in- flammation and fissure. Inflammation of the lips is generally due to infection, which has entered either through an abrasion or a pustule. When it is present there is considerable swelling, and the pain is of a constant, throbbing character. The involved area is very tender to the touch, and motion is almost if not entirely abolished, so that it is very difficult to take food. When fissures are present linear abrasions may be seen running across the mu- cous membrane of the lip, and at the angles of the mouth, where they are very common. Opening the mouth is very painful, and the contact of the denuded surface with salty or acid substances is also very disagTeeable, so that the patient is averse to eating. Herpes of the lips is very common in the early stages of in- fectious diseases, and, as a rule, the vesicles are exquisitely ten- der. Herpes of the lips is frequently complicated by infection. Cheeks. — Pain in the cheeks may be due to inflammation or to neuralgia. Inflammation is generally not of local origin, but is the result of an extension from adjacent areas, such as the gums, or alveolar processes. When it is present the cheeks are kept at rest. They feel as though they were stiffened, and are 418 TEETH 4iy hard and board-like. There are also considerable swelling and a glossy appearance of the skin. Neuralgia (trigeminal) here is not different from neuralgia in other locations, and gives rise to the same signs and symptoms. A condition of the cheeks that is very painful is a vesicular formation on the internal mucous mem- brane surface. This is very disagTceable and, though it does not cause any subjective pain, the least irritation, such as the rubbing against it of the tongue, or of solid or liquid food, causes a very disagreeable sensation. These vesicles are either the result of nerve involvement, such as is found in trigeminal herpes, or are but the reflex herpetic eruptions of digestive disturbances. If on the tongue an ulcer that is free or almost free from pain is found, syphilis or tuberculosis should be sought. In mild inflammations, such as those w^hich accompany stomatitis, there is moderate pain, which is increased on the ingestion of food. At the same time there are thick, sticky saliva, impaired taste, and often a slight rise of temperature. Teeth. — Sometimes, in cases of toothache, the aching may be due to hyperesthesia, a common accompaniment of pregnancy. Ordinary toothache is due to an irritation of one of the branches of the trigeminus by products of dental caries. At first the pain is more or less localized to the point of origin, but it gradually may become so accentuated that a general neuralgia results, and the entire side of the face may become affected. This may increase until the entire side of the head and neck is tender and painful. This extension can be explained by the rich collateral association of the trigeminus with the cervical nerves. Because of this close rela- tionship it is easy to understand how an excessive stimulation of one nerve can produce reactions in adjacent nerves. In some cases, after the extraction of teeth, pain may persist for several days, especially if gum-boils are present before the extraction, in which case the pain may persist for five or six days (Vosper, 896). The most sensitive part of a tooth is the pulp and the agents causing the greatest reaction are heat and cold. Head claims that, until the pulp is involved, the pain remains local, but as 420 PAINS OF THE ALIMENTARY TRACT soon as it is affected the local is changed into referred pain. Thus, in the course of destruction of a tooth three different vari- eties of jiain are encountered: (1) The local, sharp pain, associated with destruction of the enamel and involvement of the dentine. It is easily produced by the sensitive dentine coming into contact with very hot or cold substances, drinks, etc. (2) The referred pain from involvement of the pulp cavity. It seems that each tooth has a separate area of pain reference; for instance: Tooth Kefeeence Area Upper Jaw (1) Incisors Frontonasal region (2) Canine Nasolabial region (3) First bicuspid Nasolabial region (4) Second bicuspid Temporal or maxillary (5) First molar Maxillary region (6) Second molar Mandibular region (7) Third molar Lower Jaw Mandibular region (8) Incisors Mental (9) Canine Mental (10) Bicuspid Mental (11) Second bicuspid Hyoid or mental Hyoid — also in ear and just be- (12) First molars hind angle of the jaw. The (13) Second molars tip of the tongue on the same side is also tender. (14) Lower wisdom Superior laryngeal area (3) After the pulp is destroyed the referred pains cease and there are only local pains, due to involvement of the periodontal structures. For more detailed information, see Head, Brain, 1904, pp. 406-415. Central trigeminus pain (tic douloureux), either from in- TONGUE 421 volvement of the ganglion itself or its internal roots, or as a re- sult of pressure (cerebello-pontine angle tumor, neuroma), often leads to a faulty diagnosis of teeth pains. Many patients suffer the loss of one tooth after another in the vain search for the aifected one. After the sacrifice of the teeth the dentist or physician wakes up to the fact that the disorder is central, and that a grave mistake has been made. Tongue. — The lesions of the tongue which are apt to give rise to pain are inflammation, fissures, ulcers, new growths, and vesicles. Inflammation can generally be traced to some abrasion or injury, or to an extension of inflammation from some adja- cent area ; however, tliere is a unilateral inflammation (hemiglos- sitis) which is probably of neurotic origin. Fissures in the tongue, as in all sensitive mucous membranes, are apt to be very painful, because of the exj)osure of the sensory terminal filaments. This is also true of ulcers, which in this location likewise are very painful. New growths in the tongue give rise to a sensation of discomfort rather than to one of pain. Vesicles due to her- petic disturbances may appear on the tongue, and when they do, they cause great distress owing to their extreme sensitiveness. They generally are an indication of a central lesion, central herpes, though they may be, as are similar vesicles on the cheek, but a manifestation of disturbed digestion (reflex herpes). When due to herj)es the vesicles generally appear on the posterior half of the tongue, which derives its sensory supply from the glosso- pharyngeal nerve. Tuberculosis and syphilis of the tongue are not painful unless there is a breaking down of the lingual tissues, with a consequent exposure of the sensory nerve filaments. In many cases a hyperalgesia of the tongue is an indication of hysteria, which, when present, generally gives rise also to para- gusia or gustatory paresthesia (disturbances of the sense of taste), the patient complaining either of the disagi-eeable taste of that which would otherwise be agi-eeable, or of the persistence of a bitter or of a sweet taste in the mouth when nothing has been tasted. This is a fairly frequent condition in neurotics, particularly those suffering from neurasthenia. 422 PAINS OF THE ALIMENTARY TRACT The presence of small, painful lesions of the tongue may be the first indication of a nocturnal epileptic attack. There is an extremely painful condition of the tongue, due to a papillitis, in which nothing abnormal can be found on the sur- face; but, on magnification, small, ulcerating points are seen hidden in the folds of the mucosa about the fungiform papillae of the tip and the margin of the tongue. Moeller's glossitis, or chronic superficial glossitis, is charac- terized by bright red lines or patches at the margin or tip. The pain, which is the principal lesion, is out of all proportion to the, local involvement, and is much increased in chewing and speak- ing. According to Riesman (113b), pain in the tongue (glosso- dynia) which arises without any apparent organic lesion, may be divided into the following, which is the classification of Chaveau (112b). (1) Glossodynia secondary to trigeminal neuralgia, especially the inferior dental branch of the trigeminal. (2) Glossodynia of the insane, starting as a local paresthesia. (3) Glossodynia of tabes, corresponding to crisis in other organs. (4) Glossodynia of hysteria. (5) Rheumatism of the lingual muscles, or rheumatic glosso- dynia. (6) Glossodynia due to local causes. These may be classified into the extrinsic and intrinsic. The extrinsic causes are: (a) dental affections and artificial teeth, and (h) granular pharyngitis and hypertrophy of the posterior pillars and of the lingual tonsil. Among the intrinsic causes are: (ft) lingual varices; (&) chronic glossitis from tobacco, alcohol, spices, iodin, lead or gout, and (c) papillary hypertrophy of the follicular region of the tongue. Reference Areas in Diseases of the Tongue. — Disease of the anterior portion causes pain to be referred to the mental area ; of the lateral portion, to the hyoid area ; of the dorsum, to the superior laryngeal and the occipital area (Head). Salivary Glands. — The salivary glands are subject to the ordi- PHARYNX AND TONSILS 423 nary glandular pain-producing diseases, as inflammation, etc. There may be present also, in the ducts of the glands, some ob- struction which gives rise to an intermittent colic with an asso- ciated swelling and tumefaction of the gland. This condition may sometimes be diagnosed by running the finger along the course of the ducts, when an obstruction, if present, generally may be felt. The most common form of obstruction is a salivary calculus (Ranulus). The parotid gland sometimes becomes in- flamed, and is very painful, giving rise to the entity called "mumps." It also becomes tender after oophorectomy, and in some cases where orchitis is present. Pain beneath the angle of the jaws, in those who are convalescent from typhoid, should always lead to investigation of the parotid as the possible cause of the pain. Phaxynx and Tonsils. — Pain in the pharynx may be present, either objectively, on swallowing, or subjectively, without any provocative ' act. In the first case we find that the causative factors are slight, such as small ulcers and superficial inflamma- tions; but when the infectious agents extend deeper, and the surrounding connective tissues are involved, the pain is felt with- out any exciting productive factor, and is continuous. This is well exemplified in parenchymatous tonsillitis, in which the pain extends to the angles of the jaws, also to the ears, even down the neck, and in phlegmonous pharyngitis, which is extremely pain- ful, there being a constant burning or aching pain, which in some cases assumes a throbbing character. In the latter, the pain may be of such magnitude that the patient lives a miserable existence, being unable to eat or to sleep until the abscess which has formed ruptures and relieves the pressure. The tonsils and posterior pharyngeal wall may be extremely tender in certain forms of streptococcic sore throat, and the pain often persists for a long period after the cessation of the acute inflammation, A so-called gouty throat causes a similar painful condition of the pharynx and tonsils. There are few signs of inflammation ; the mucous membrane, however, is lax and edematous. Various types of pharyngitis, gra:iular, follicular, etc., cause 424 PAINS OF THE ALIMENTARY TRACT pain. The diagnosis depends upon a special knowledge of the various pictures. All of these conditions cause a certain amount of referred pain. The pain in front of the ear, complained of so much by patients with tonsillar aifections, or by those who have some tonsillar traumatism, operative or otherwise, is in the hyoid reference area of Head (for which, see Fig. GO, p. 291). The pain may also be referred to an area in the neck in the submaxil- lary triangle. Palpation here will disclose an enlarged gland. Esophagus. — The esophagus below the cricoid cartilage was formerly considered to be non-responsive to tactile and other stim- uli, but now it is known to be sensitive to heat, cold, tactile and chemical stimuli, and it is also held that many apparent stomach sensibilities are, in reality, esophageal sensibilities. Inflamma- tion of the esophagus is, if severe, productive of considerable pain. The pain is of a deep, burning character, and is felt along the course of the esophagus. Pain is also felt on move- ment of the esophagus, which occurs when the head is bent for- ward or backward, and is also present when external pressure is made through the overlying tissues upon the esophagus. Pain on swallowing is very severe. In the severest cases of corrosive esophagitis there may be no pain. Pain felt in the esophagus, without any objective lesion, may be due either to a hyperesthesia or a paresthesia. In the former, pain is produced by factors which cause irritation, such as in- flammation of the esophagus, or a neuritis of the nerves supplying it. The latter (neuritis) gives rise to a perversion of sensation; for instance, the act of swallowing, which ordinarily gives rise to no sensation, is, in this condition, interpreted as painful. In stenosis of the esophagus pain, as a rule, is absent. In cancer of the esophagus there may be only a feeling of distress or of dis- comfort under the sternum, generally localized to the area of the growth. Sometimes severe pains, confined to the area of the growth, or referred to the region of the xiphoid cartilage, may also be present. They generally are of a '^tearing, piercing char- acter, and radiate widely to the back, neck, or shoulders." They accompany the deglutition of food, but may be independent of it, ESOPHAGUS 425 and are often nocturnal. Thongli generally present only late in the disease tliej may be the earliest manifestations of it (McCrae). Referred pains may be present in the intercostal spaces be- tween the shoulder blades, in the epigastrium, in the throat and head, in the ear, or in the extremities (Rosenheim). Dyspnea and attacks of pain resembling angina pectoris also occur. These are duo to pressure on the trachea or upon both re- current laryngeal neryes. ■'■■ Localization ^yithin the esophagus is fairly accurate. Lamy, in his study of one hundred and thirty-four cases of carcinoma of the esophagus, found that four-fifths of the patients were able to locate the lesion ^vithin an inch or two of the correct site ; but in the remainder a correct localization was impossible ; often a carcinoma of the lower third would be located by the pain-sensa- tions in the upper third, or vice versa. Obstruction gives rise to sensations for the most part in the middle line, deeply seated, beneath the sternum, or, if the obstruction is low down, in the epigastrium. CHAPTER XXIII THE STOMACH After the review of the pain-prodiicing diseases which are located in the alimentary passages leading to the stomach, it is next in order to consider the pains and pain-producing disorders of the stomach. Of late years there has been considerable contro- versy as to whether the stomach has pain-sensation or not. The weight of the argument seems to be on the side of those who claim that it has not. It is claimed that the sensations which are felt in disease of the alimentary viscera are bnt referred sensa- tions or impulses, carried to the cord in the sympathetic path- ways, and thence referred again to the periphery through the cerebrospinal nerves. From the researches of Hertz in particular it would appear that the gastric mucosa does not respond to tactile nor to chemi- cal stimuli by pain. The stomach mucosa does not register thermal stimuli, and the sense of warmth and coolness following the ingestion of hot or cold liquids is largely due to the sensi- bility of the esophagus to these forms of stimuli. The sensation of fulness in the stomach is due to the deep-pressure sensibility of the muscular coat, and is brought about by tension. The sensation of hunger and emptiness is largely a matter of habit, associated with malaise and weakness. It is conditioned by the disturbance in the periodicity of the muscular hypertonus and of neuronic excitability, normally the result of regular eat- ing. ^ ^ According to W. B. Cannon and A. L. Washburn (Amer. Jour, of Phy- siology, March, 1912, Vol. XXIX, p. 455), hunger is due to the contraction not only of the stomach, but also of the lower part of the esophagus and the intestines. They were able to prove a relationship between rhythmic contrac- tions of these organs and pain sensations, 42e PAIN CAUSED BY STOMACH DISORDERS 427 However, even though pain in the stomach is not, as a rule, regarded as true visceral pain, yet it is closely related to it, for it may be due to the tension already spoken of or to the spread of the disease to surrounding sensitive structures, or to the traction of the peritoneal connections. The accompanying tenderness is most often due to hyperalgesia of the skin, voluntary muscles and con- nective tissues supplied by that segment of the spinal cord which receives the incoming stimuli from the stomach itself and its con- tiguous structures. AREAS OF REFERRED PAIN CAUSED BY STOMACH DISORDERS The areas to which the pain of stomach disorders are re- ferred are, first, the epigastrium, and (in many cases) the back, in an area which, according to Cumiston and Maylard, is between the posterior borders of both scapulae and opposite the spinous Fig. 89. — Areas of Referred Pain as Given by Head. A. One of the commonest situations for pain. B. One of the commonest sites of gastric pain. C. Maylard gives this point opposite the 5th dorsal spine as one of the commonest locations of gastric pain. process of the fifth dorsal vertehra. The pain also often circles around from one of these areas to the other, and they are often tender to the touch. The area spoken of by Cumiston and May- lard as opposite the fifth dorsal spine is given by other authori- ties as opposite the ninth or tenth dorsal spine. This agrees with 428 THE STOMACH my own observations and coincides more closely with the deduc- tions of Head, who places the maximum points of tenderness in the seventh or eighth dorsal segments, opposite the ninth and tenth dorsal spines. Boas, on the other hand, locates the area of.maximum tenderness as opposite the eleventh and twelfth dor- sal spines. When pain is produced in stomach disorders, it may be felt in any of the areas supplied by the seventh, eighth, or ninth dorsal segments, but it is more apt to be felt, and felt PYLORIC PLEXUS -RIGHT VAGUS SUPPLIES POST SURFACE STOMACH. I , LEFT VAGUS SUPPLIES ' ( ANT. SURFACE STOMACH. CORONAY PLEXUS --GA5TRO-EPIPL0IC 5IN15TER- FiG. 90 — Nervous Supply of the Stomach. more severely, in the maximal points of tenderness of these areas. In the accompanying drawing is shown the nerve supply to the stomach. It is seen to be both sympathetic (splanchnic, celiac ganglion) and cerebrospinal (vagus). True visceral pain is con- veyed through the vagus, but it is of the deep-pressure sensibility (tension) type allied to Head's protopathic system. The areas of tenderness are of great diagnostic significance. The hyperalgesic areas (Head) affected in stomach diseases are the seventh, eighth, and ninth dorsal. The seventh and ninth areas are those most frequently affected. The u^^per one, the seventh dorsal, seems to be associated particularly with the stom- ach diseases causing vomiting. AYhen it appears, as a sequel to vomiting, it is frequently accompanied by pain in the area next to and above it, namely, the sixth dorsal. The sixth dorsal area is associated with disease in the lower part of the esophagus ; PAIN IN GASTRIC AREAS 429 consequently, when both the sixth and seventh areas are affected the disease is somewhere near to and probably involves the esopha- gus. In the same way the ninth dorsal area is shared by both the stomach and the intestines, and when both are affected the lesion is probably in the neighborhood of the pylorus. When the seventh dorsal is involved, the pain, as a rule, comes on within half an hour after taking food ; while, if the eighth dorsal is in' volved, the pain generally comes on at least an hour later. By stimulating the area in the hypogastrium, which is hyper- algesic, a reflex contraction of the upper segment of the recti takes place. While in some cases only a segment, in others the entire rectus is thrown into contraction. That the area in which pain is felt in stomach diseases does not necessarily correspond to the site of the gastric lesion, may be seen from the drawing (Fig. 98), where the projected outline of the stomach is shown, with the dark circle indicating the area of tenderness in gastric ulcer, the tenderness in no case being directly over the stomach. PAIN IN GASTRIC AREAS When pain occurs in the gastric areas, it is necessary to in- quire into the following : (1) the character of the pain; (2) the time and manner of its appearance; (3) its relation, if any, to the ingestion of food; (4) the duration of the pain; and (5) pre- vious attacks. Character of Gastric Pain. — Certain types of gastric lesiois have characteristic pains; for instance, that of gastritis is bur:.- ing; that of spasm of the pylorus is sharp and sudden; that of ulcer is very severe and is sharply circumscribed; that of per- foration is sharp and agonizing, and quickly spreads from the site of its original location; that of acute dilatation is severe and constant, and is accompanied by symptoms of collapse. It should also be borne in mind that the severity of the pain has no proportionate relation to the gastric conditions, but often, as in pain caused by lesions in other organs, dejjends upon the 430 THE STOMACH susceptibility of the nervous system and the sensitiveness of the pain-receptive centers of the individual patient. Time and MaJiner of Its Appearance. — Should the onset be sudden, without any apparent exciting factor and without any previous history of pain, perforating ulcer or pyloric spasm is to be considered. In perforating ulcer associated symptoms of collapse and spreading peritonitis, with a diffusion and constant increase of the pain, would be present, while in pyloric spasm irregular paroxysmal pains that are sharply localized with no tendency to spread or to become generalized would be present. Acute gastritis is associated with the vomiting of indigestible or fermenting substances ; this generally tells the tale. If the pain is of slow onset, and there are at first discomfort, and then a gradually increasing distress until well-marked pain is present, particularly if the pain is associated with the vomiting of blood (coffee-ground vomitus), it is necessary to examine for gastric carcinoma. Relationship to Ingestion of Food. — If the pain comes on at a definite time after eating, and is relieved by vomiting, gastric ulcer is thought of. If it comes on immediately after eating, the cardiac end is affected ; on the other hand, if it does not appear for an hour or two after eating, ulcer of the pylorus is to be con- sidered. If, instead of coming on immediately, it makes its ap- pearance one-half to two hours after eating, carcinoma or hyper- chlorhydria should be considered. In carcinoma the coffee- ground vomit is distinctive, while in hyperchlorhydria the excess of hydrochloric acid, with the absence of blood, is sufficient to make a diagnosis. In early carcinoma, pain and coffee-ground vomit are absent. Hyperchlorhydria may occur from gall-blad- der disease, duodenal ulcer, or be purely functional. Duration of Pain. — The duration of the pain in any of the gastric disorders is variable. It seems to be present more con- stantly and for a greater length of time in those disorders which have an organic basis for their production. In carcinoma the pain is steady and persistent, while in hyperchlorhydria and pyloric spasm it is associated with the ingestion of food, LESIONS or STOMACH CAUSING PAIN 431 Previous Attacks. — A. history of previous attacks of pain may be of value, in that it often is confirmative of the diagnosis vehich the present symptoms would suggest. Associated Symptoms. — Constipation is generally associated with gastric ulcer, hyperacidity, and carcinoma. Pain Reflected or Referred to Gastric Areas. — When pain is present in the gastric areas, it may be not of gastric but of nervous origin (intercostal neuralgia) ; or it may be projected from the cord (locomotor ataxia, general paralysis, disseminated scle- rosis), or it may be a reflex from other organs, as the uterus, kid- ney, intestines, appendix, gall-bladder, pancreas, heart, or prostate. LESIONS OF STOMACH CAUSING PAIN The commoner lesions of the stomach causing pain are: (1) displacement; (2) gastralgia; (3) hyperchlorhydria ; (4) cardiac or pyloric spasm; (5) acute dilatation; (6) acute gastritis; (7) chronic gastritis; (8) gastric erosions; (9) gastric ulcers; (10) perforating ulcer; (11) new growths, and (12) perigastric ad- hesions. Displacement of the stomach (gastr ©ptosis) generally causes no pain until it induces a dilatation. Then the sensation produced is rather a disagi'eeable, nauseating feeling than a true pain. It is increased by eating or by standing, and is decreased on lying down or on supporting the abdomen by a bandage judiciously applied. Gastralgia or Gastromyalgia. — By many gastralgia is dis- claimed as a misnomer, because it is said that there is no such pathological entity. But why ? The stomach is an organ whose walls consist of muscular tissue, and why should not this tissue, even though it is involuntary, be subject to the same metabolic disturbances as are the muscles of the back, which under abnor- mal metabolic changes give rise to lumbago? The only differ- ence is that in the affected back muscle the changes act princi- pally on the terminations of sensory nerves in the muscles, while in the stomach walls the nerve terminals affected are not sensitive in the meaning that they convey pain or touch sensation. There- 432 THE STOMACH fore, for this irritation to be perceived as harmful, that is, painful, it must be carried to the cord, where, irritating some sensory neuron, the stimulus is carried to the brain, where it is perceived as coming from the area of distribution of this neuron. That such a changed metabolic and at the same time pain-producing lesion may exist in the stomach is in accord with the opinion of the majority of observers. The. condition, instead of being termed gastralgia, which is only a general term, should be called gastro- myalgia, although the term gastralgia is still in general use. Schmidt claims that "the existence of true gastralgia result- ing from purely anatomical and functional disturbances is as cer- tain as the pain of dental caries." Maylard describes it as "oc- curring generally in those of a neurotic taint ; and the pain may be of the most excruciating character, seizing the patient in the epigastrium, and striking through to the back, radiating some- times round the chest or waist." It is most erratic in the time of its appearance. Sometimes it follows the ingestion of food, while at other times it appears without any kno^\Ti cause. It may sometimes appear periodically at night, and at other times it may follow upon any excessive draft upon the nervous system by worry or excitement. The pain is "generally out of all proportion to other physical symptoms of any suggestive physical disease. The patient may also compkin of a beating sensation, pulsating sensation, a feeling of heat or cold. Periods of pain generally alternate with periods of complete freedom from it." ^ The symptoms usually associated with this condition are flatu- * This consideration of the subject differs markedly from that given by Schmidt, who classifies all gastralgias as neuralgic in origin. While it must be admitted that stomach pain depends upon the irritation of nerve terminal fila- ments for its production, yet, as mentioned above, in a somewhat though not entirely similar condition in the voluntary muscles, the term myalgia is used. It seems that an analogous term, such as gastro myalgia, should be used for pain having its origin in the stomach musculature. The general term gastral- gia, therefore, is ill-fitted, and is only to be used in a general way to include those pains originating in the stomach, the etiology of which cannot be defi- nitely determined. On the other hand, neuralgia of the stomach is entirely different in its etiology from gastromyalgia, but is included, as are all stomach-productive pains of unknown etiology, under the generic term ' ' gastralgia. ' ' LESIONS OF STOMACH CAUSING PAIN 433 lence, distention, anorexia, cravings for food, vomiting, and py- rosis. The stomach j)ains frequently alternate with attacks of migraine (same as in angina pectoris), neuralgia of the head, and asthma. Women are more j^rone to gastromyalgia than men, in the proportion of two to one, and it is most common between the ages of twenty and forty-five. In an entirely different class, but slightly related to the pains we have just described, are those due either to a secretory or a motor disturbance. These will be considered later under their proper headings. In the meantime it is well to remem- ber, in considering the cause of stomach j)ain, that the lessened resistance of the nervous system to pain-production is of mani- fest importance. Some people, owing to disease or inherited pre- disposition, are abnormally sensitive to pain, so that the percep- tion of sensations, wdiich in others ordinarily would not even be disagreeable, w'ould be felt by them as sensations varying all the way from distress to actual ^^ain. In this connection it is helpful to know that gastric pains not of purely nervous origin are influ- enced by the ingestion of food and the position of the patient, while those of purely nervous origin are not. The diseases acting as predisposing causes of gastromyalgia or gastroneuralgia are about the same as those which cause a lessened resistance in the nervous system, and which are pro- ductive of cerebrospinal neuralgia. Among them may be men- tioned anemia (chlorosis), infectious diseases, rheumatism, syph- ilis, influenza, tuberculosis, excessive use of stimulants (alcohol, tea), sexual over-indulgence, gout, diabetes, uremia, and physical depression. The reflexes which are sometimes felt as pain in the gastric reference area, and which in some cases are even accompanied by vomiting, will be considered under the reflex pains of the appro- priate viscera, though for clearness of conception they will also be described in our consideration of the diagnosis of stomach pains. These reflex pains in the epigastrium, associated with vomiting are due to disease of the gall-bladder, pancreas, appen- dix, uterus and appendages, etc., should not, as is done by some 434 THE STOMACH authors, be placed under gastralgia, but should be considered under the lesions of the different organs producing them. This is sometimes very difficult, for, in many cases, it is not easy to distinguish the origin of the different pains; for instance, gall- stone colic is often confused with gastric pain, yet it may be dis- tinguished from it by its paroxysmal character, its tendency to become localized to the right and to extend around the right side to the area underneath the right scapula. At the same time it is associated with localized gall-bladder tenderness, and often there is a well-marked enlargement of the gall-bladder and sometimes a generalized jaundice. Angina jDectoris has also been confused with gastric pain. Here the pain, as a rule, follows exertion, and radi- ates into the left arm and hand. The heart may be tumultuous in action, and frequently there are severe depression and a fear of death. The appendix, also, has in many cases been found to cause epigastric pains; but here epigastric pain, with no tender- ness over the epigastrium, but over the appendiceal region, is present. There may also be a palf)able mass in the same region, and the pain and tumor are associated with vomiting, eructation of gas and constipation. Of diagnostic importance in differenti- ating pain of local origin from referred pain is the administra- tion of local anodynes, as cocain, alypin, menthol, and f)henol. These generally cause the pain to lessen or cease when it is of local irritative origin, such as occurs when the lesion is in the mucous membrane, namely, in ulcer, carcinoma, etc. When no effect is noticed, after the administration of the local anodyne, neurotic lesions should be considered. Of considerable diag- nostic importance is the fact that gastromyalgia is frequently relieved by pressure. Hyperchlorhydria. — Hyperchlorhydria is the only secretory neurosis of the stomach which j^roduces pain. This pain comes on one-half to two hours after eating, and lasts a few hours, or until more food is taken, being particularly relieved by the in- gestion of proteids, and also by alkalies. It is much less after large meals, especially those containing much meat and eggs and deficient in carbohydrates. The pain differs from that due to LESIONS OF STOMACH CAUSING PAIN 435 gastric ulcer in being diffuse and extending over the entire abdo- men. It seems to be frequent in persons of neurotic tempera- ment, and is commonly associated with gall-stones, Hyj^er- chlorhydria is also frequently associated with neurotic motor disturbances. The pain produced by it often is accompanied by This substernal pain represents the esophageal component of the pain symptoms / Tenderness on deep pressure 'Area of hyperalgesia to pin point pressure. Over this area there is J also pain to deep pres- sure. It lies about the junction of the 7th left costal cartilage with the 7th rib Fig. 91. — Location of the Pain Symptoms in a Case of Hyperchlor- HYDRIA. a considerable belching of gas, generally preceded by a burning sort of pain, which seems to run up under the sternum to the throat, and is accompanied by the regurgitation of acid-tasting fluid. The pain may also radiate to the back, to the axilla, and to the scapula. In some instances the pain seems to be due to the presence, even in small quantities, of hydrochloric acid. In these j3atients there is a peculiar antipathy of the stomach to the presence of any acid. The examination of the stomach contents often shows a normal or even a subnormal percentage of acid. Hertz has shown that the gastric mucosa is not painfully stimulated by excess of hydrochloric or other weak acids. It is probable that the heartburn of so-called hyperchlorhydria has nothing whatever to do with acid production, and that the term is a misnomer. The hot sensation is closely related to that felt following the ingestion of alcohol, and is felt most often following slight regurgitation due to the presence of excessive amounts of gas. Hertz maintains that heartburn is an esophageal sensation, 436 THE STOMACH not a gastric one, and is due to the stimulus of excessive carbo- hydrate fermentation (hot bread — biscuit — causing the so-called pudding heartburns). This causes the jjroduction of alcohols, ethers, and organic acid in the stomach, which by regurgitation Fig. 92.— Pain Radiation. Crosses indicate the sites of pain and the Unas with arrows indicate the direction of the pain radiation. act upon the lower end of the esophagus, thus giving rise to the classical heartburn erroneously interpreted as a hyperchlorhydria. For a further interpretation of the causes of pain in hyperchlor- hydria, see gastric ulcer. Pyloric or Cardiospasm. — The stomach resembles other divi- sions of the hollow abdominal viscera in that it is subject to colic; but the j)arts chiefly affected are the pylorus and the cardia, as the intervening portion has so great a lumen that it contracts en bloc less readily. Then, too, this part of the stomach is so situated, and its attachments to the adjacent viscera are so arranged, that it may undergo considerable distention without any symptoms being produced ; but as soon as the distention becomes excessive and trac- tion is made on its peritoneal and diaphragmatic attachments, pain results. The same is true, when, owing to the contraction of. the pylorus or cardia, a change in the relationship of these two parts to the surrounding viscera results, and a pull on their peri- toneal attachments occurs. LESIONS OF STOMACH CAUSING PAIN 437 By reference to the anatomy it is seen bow the cardia of the stomach is immediately below the opening in the diaphragm, and how, when it contracts, especially when the stomach is full, there must be a stretching of the gastrophrenic ligament, with resulting pain. The same is true of the pylorus, but here the pull is made on the gastrohepatic omentum, and possibly also on the gastro- colic omentum. Hertz claims that the pains in pyloric or cardiac spasm are really tension pains, due to distention of a seg-ment of the stomach. In pyloric si:>asm a persisting contraction of the pylorus occurs as a reflex from the j^rcsence of an excess of HCl in the stomach. The peristaltic wave in the stomach, being ex- cessive from the HCl stimulation, pushes the food onward i::itil it reaches the prepyloric part of the stomach ; from here, owing to the closure of the pylorus, it cannot advance further, and tension is made upon the stomach walls at this point. From this it would seem that not only is the small part of the stomach at the pylorus involved, but that also a large part, if not the entire stomach musculature, is involved in the contraction. It is hardly probable that the contraction of the constricted part of the bowel at the pylorus could so alter the relationship of this one part to the gastrohepatic or gastrocolic omentum that the stretching of it would be gTeat enough to cause the severe and widely diffused epigastric pain which is sometimes present. Another argument in favor of the participation of the muscular wall is that the pain is relieved by vomiting. A somewhat similar cause exists for the pain in hour-glass stomach. Here a portion of the stomach is contracted, and an hour- glass stomach results. The food entering the upper compartment is pushed forward by the peristaltic waves until it reaches the place of contraction; here it is unable to jirogress further, and at this point tension is made on the gastric walls, and pain results. As would be exjiected, the jiain is not felt when the stomach is empty, but results only after ingestion of food and drink. It is relieved by vomiting. The cause of pain in cardiosjoasm is the dilatation of the ter- 438 THE STOMACH minal portion of the esoiihagus. This is the result of stasis of food, due to spasmodic closure of the cardiac sphincter. In cardio- spasm the pain comes on immediately after eating, is fairly con- stant, and seems to be located beneath the costal margin at the left seventh costal cartilage, while in pyloric spasm the pain is localized in the midline, about midway between the umbilicus and ensiform, and comes on two or three hours after eating, i. e., at the time of the passage of the gastric contents through the pyloric opening. Both pains have a typical paroxysmal grijDping or twisting character, and are equally severe. The pyloric spasm generally is relieved by vomiting, while cardiospasm gradually passes off, no vomiting, as a rule, occurring. In both midnight attacks are very frequent. It seems also that in some cases the contraction of the cardiac and pyloric sphincters alone can cause reflected pain, this pain being due to the unusual squeezing of the nerve terminals in the muscular tissue, the result of the abnormally severe contraction. For the production of pyloric spasm pain it is not always necessary that the stomach be full, for in many cases when it is empty the irrita- tion of the gastric secretions (which in this condition are often highly acid) will produce it. Also, it can be relieved by washing out the stomach. A similar contraction of the musculature of the pylorus and, in some cases, of the entire stomach and duodenum is the cause of hunger-pain. This differs from card i a and jiyloric spasm in that it can be relieved by the ingestion of food, provided the stomach mucosa and musculature are intact. The ingestion of food will not relieve the associated hunger-pain present in ulcer or carcinoma of the stomach, because the food, of itself, is an irri- tant in such conditions, and aggravates instead of easing the spasm. In all these conditions, after the pyloric spasm has persisted for some time, a dilatation of the stomach results. This dilata- tion, in turn, causes gastric pain, because of the traction and pull of the gastric walls on the omental attachments. The pain is of the same kind as described in acute dilatation of the stom- LESIONS OF STOMACH CAUSING PAIN 439 ach, only in dilatation the result of pyloric spasm the pain is added to the previously existing spasm pain. In acute dilatation also, the pain is more generalized, and becomes constant, while the pyloric-spasm pain is paroxysmal. In case of dilatation of the stomach the epigastrium is distended, the outlines of the stom- ach are plain, and visible gastric peristalsis can be seen; also, on listening, borboryg-mi and bubbling noises can be heard. Succussion sometimes gives rise to a splashing sound. Eructa- tions of sour-tasting fluid are also present. These associated symptoms generally come on when the pain is most severe. If vomiting occurs, and the spasm has been of some duration, large quantities of gastric contents are expelled. Sometimes the attacks of colic are accompanied by a mild chill of nervous origin, elevation of the temperature being entirely absent. Pressure on the distended stomach is well borne, and is fre- quently applied by the patient, because it seems to aid in the forc- ing on of the stagnated stomach contents. The pain is increased by the eating of indigestible foods. According to Schmidt, cold applications to the epigastrium seem to be better borne than hot ones, and to be more beneficial to the patient. Acute Dilatation of the Stomach. — Acute dilatation of the stomach frequently is a cause of the most severe pain. It is prone to occur after operations, especially those in which there has been considerable handling of the abdominal viscera. It comes on, as a rule, three or four days following the operation. By many it is held to be only a symptom of a peritonitis, which, it is claimed, is present in every case of such vomiting. At first there is a feeling of distress in the epigastrium, which soon increases until severe pain is felt. This is generally accompanied by the vomiting of a greenish fluid, and by a gradual abdominal disten- tion, with rise of pulse rate, and signs of severe systemic distress. This state, unless relieved, is rapidly fatal. Acute dilatation also occurs in many patients who have not been subjected to operative interference, but generally it is not of as severe a form as in the 440 THE STOMACH operative ones. In both of these conditions the pain is of a diffuse nature, and is located in the epigastrium. Because of the acid con- dition of the stomach contents, the pain may be partially relieved by the ingestion of alkalies; but the only sure relief is from re- peated stomach washing. Should stomach distention be suspected, it can be confirmed or disproved by percussion and palpation, as well as by the stomach tube, by which, if gastric dilatation is present, large quantities of greenish fluid may be removed. In some cases distention of the stomach may be associated with distention of the duodenum, and, when this occurs, as in a case reported by Torrance (577), there may be pain under the right shoulder and over the eighth and ninth ribs to the right of the spinal column. The pain of gastric dilatation is also partially due to the trac- tion which the diaphragm exerts on its costal attachments, owing to the upward force exerted upon it and its consequent displace- ment by the distended stomach. Acute Gastritis. — Although the stomach has no special tactile sensory nerves, it reacts painfully to inflammatory lesions. When inflammation is present in the stomach walls, the adjacent lymphatics become involved, lymphangitis results, and this in- flammation spreads to the parietal peritoneum through the im- mediate attachments, and causes it to become hypersensitive. At the same time the inflammation of its walls causes the stomach to become very irritable, and to react much more strongly than usual to stimuli; so that, on the entrance of food and drink, it contracts to a greater than normal degree. This produces trac- tion much greater than normal on the inflamed mesentery, and at the same time causes tension within its own muscular coat and pressure upon the nerves of deep sensibility with resultant pain. In gastritis the subjective pain is felt in the epigastrium, and at the same time the gastric areas of hyperalgesia (Head) may be present. The subjectiv^e pain is of a dull, aching character, increasing to a sharp, burning on the ingestion of foods. Another characteristic of this pain is that it seems to run directly through LESIONS OF STOMACH CAUSING PAIN 441 to the back, this being most probably the result of the irritation of the inflamed peritoneum around the cardiac opening, which lies very much closer to the back than it does to the anterior abdominal wall. On making pressure over the epigastrium, pain is elicited; light pressure bringing out, in many cases, the hyper- rPain in epigastrium goes directly through to the ■< back. Pain between shoulders is also some- Ltimes present Fig, 93. — Figube Illustrating the Location of Pain in Acute Gastritis. algesic areas of Head, while deep pressure brings to light the tenderness of the subserous peritoneum, which, because of its lymphatics, is frequently involved in the inflammatory process. This pain varies in intensity and seems to have some relationship with the severity of its lesion, so that the extent of the gastric inflammation may partially be judged from the magnitude of the pain. The pain of acute gastritis is fairly sudden in its onset. It may follow a night of alcoholic indulgences, or occur after the eating of indigestible substances, and is associated with nausea and vomiting. It may be so severe that morphin is required to relieve it. In some cases there is an elevation of the tempera- ture as high as 104 ° F. and an increased rapidity of the pulse. The recti muscles of the upper abdomen are also contracted (es- pecially on the left side) and are slightly tender on palpation. 442 THE STOMACH Chronic Gastritis. — Chronic gastritis is generally not painful, though after eating there may be a feeling of discomfort. Rie- gel, according to Gilbride, claims that in the atrophic forms of gastritis the pain resembles that of the gastric crisis of tabes. Gastric Erosions.- — Gastric erosions, as pathological entities, occupy a position intermediate to gastritis and ulcer. Pathologi- cally they are less extensive than ulcers, and more intensive than gastritis. The pain produced is of a dull aching character, and seems to extend throughout the entire stomach area. It is not affected by pressure or by change of position. It generally comes on after eating, persists an hour or two, and then gradually sub- sides; but it may be present irrespective of the intake of food, and intervals may be present in which there is absolutely no pain. The course of the disease is prolonged. Emaciation, loss of appe- tite, and, in many cases, hematemesis may result. Gastric Ulcer. — Gastric ulcer, in its pain production, depends upon practically the same factors as does gastritis. The lesion in ulcer is circumscribed, w^hile that of gastritis is diffuse. Both are associated with lymphangitis, and it is this lymphangitis which contributes greatly to the pain that is produced. That the pain and tenderness which are felt on palpation are not present in the stomach but in the abdominal wall can be demonstrated from the following premises : (1) The ulcer, in most cases, is on the posterior wall of the stomach, and pressure upon it through the abdominal wall, rigid because of the contraction of the rectus, is almost impossible. (2) The pain and tenderness are constant, while the relative position of the ulcer is always varying, depending upon move- ment of the stomach due to respiration, peristalsis, distention with food, liquids, gas, etc. (3) On exposure of the stomach by exploratory laparotomy the ulcer may not be found immediately beneath the area in which the pain and tenderness had been felt. In the following drawing, Mackenzie (586) illustrates the relative position of the pain and the site of the ulcer. In his LESIONS OF STOMACH CAUSING PAIN 443 cases the site of the ulcer bore no relationship to the site of the pain; but when the ulcer was near the cardiac end of the stom- ach the localized pain and the cutaneous and muscular hyperal- gesia were situated high in the epigastrium, while if the ulcer was situated near to the pylorus it caused pain low down in the epigastric region. It is claimed that in some cases it is the contraction of the pylorus which causes pain; in others that it is the contraction of the bundle of fibers which surrounds the prepyloric region of the stomach and separates the antrum pylori from the rest. In one case Moullin reports a cure from the ulcerated condition and the pain by section of these fibers (Mansell Moullin, 578). In this case neither ulcer nor scar could be found when the stomach was opened, so that it was probably only a case of hypertrophied pylorus. That the pain in gastric ulcer is not due to hyperacidity of the stomach contents can be de- duced from the fact that increase in the hyperacidity, due to the ingestion of acids, produces no increase in the pain. It has also been shown that pain cannot be produced by irritation of the nor- mal mucous surface of the stomach. The researches of Hertz also tend to show that an ulcerated surface is insensitive to acids in the strength found in the stomach. In some patients an ulcer of the stomach causes no pain. When this occurs the ulcer is generally situated on the anterior surface, near to the cardia, no adhesions having formed between it and the parietal peritoneum. C. W. Habershon, in 1859, was Fig. IN 94. — Location of Pain Gastric Ulcer. In the figure the area A shows the area of pain when the ulcer was at the cardiac end of the stomach a; B when the ulcer was in the middle of the lesser curvature b; C when the ulcer was at the pylorus c. 444 THE STOMACH one of the first to show that ulcer confined to the mucous mem- brane alone was not painful. He likewise claimed that cancer and other diseases, while restricted to the mucous membrane, produce no pain. The pain of gastric ulcer can generally be distinguished be- cause of its several characteristics, as follows : (1) Time of Onset. — Pain generally begins immediately on the entrance of food into the stomach, and gradually increases until it reaches a climax (at the time the pyloric end is at work), and then, as the stomach empties itself, it becomes less and less, and gradually disappears. It is also relieved by vomiting, and in many cases by the ingestion of alkalies. After an hour or two it ceases. The longer the interval between the time of ingestion of food and the appearance of the pain, the farther away from the cardia and the nearer to the pylorus is the ulcer. If it has occurred immediately after eating, the ulcer is probably near the cardiac orifice or the lesser curvature ; if two or three hours after, it will be at the pylorus; and, if four hours after, and relief ensues on taking food, the ulcer is probably in the duo- denum. (2) Character. — The pain, as a rule, is of a dull, boring char- acter, and is generally localized to a small area in the epigastrium. It may radiate to the back. Sometimes, instead of a pain, there is present in the epigastrium a dull, disagreeable, constant sensa- tion. When this is present, adhesions, peritonitis, and increased continuous secretion of gastric juices are likely to be found. The statement that the ulcer can be mapped out by percussion is mani- festly absurd, as can readily be understood from a study of the origin and propagation of gastric pain. A peculiarity worth noting is that the pain is most severe when the ulcer is located on the posterior surface, because, in this location, it is nearer to the parietal peritoneum, upon which there is more drag than would occur if the ulcer was situated upon the anterior surface. In some cases there may be a burning sensation after eating, and the pain may radiate to the sides of tlie chest and shoulder. The sensation varies from a feeling of distress, that is hardly notice- LESIONS OF STOMACH CAUSING PAIN 445 able, to a pain of the gi*eatest severity. This pain has been described as cutting, gnawing, piercing, or burning. The pain of pyloric ulcer is, as a rule, greater than that of cardiac ulcer. A very strong reason why this should be so is that the pylorus is relatively a fixed portion of the stomach, and in distention or contraction of the stomach it does not change its position according to the change in the position of the remainder of the stomach, con- sequently pull is made upon it, and it is this pull upon the already irritated structures that causes pain. This pain seems to occur most frequently in the mid-hours of the night. In some cases psy- chical disturbance, as anger or great emotion, seems to be conducive to its onset. (3) Tenderness. — In gastric ulcer, the tenderness which is in the epigastrium, in many cases to the right of the median line, may, because of adhesions, be localized in other parts of the abdomen. Ulcer of the stomach differs from gall-stone and all other colics, in that the patient is very sensitive in the upper abdomen, so that in many cases he will not bear even the slightest pressure, which is exactly the opposite to what occurs in colic, for here pressure seems to give relief. The tenderness to palpation and percussion associated with ulcer seems to vary according to the degree of distention of the organ — the greater the distention the more severe the associated pain. The tenderness elicited on palpation is of two types, super- ficial and deep. The superficial tenderness is merely an expres- sion of the hypersensibility of the skin, while the deep tenderness expresses the hypersensibility of the muscles, subserous perito- neum, and the peritoneum (parietal) in immediate association with the ulcer. When the tenderness is due to a hypersensibility of the rectus muscle, it will be found that the muscle is in a state of contraction, and that this contraction is localized to the upper segment. The contraction is more marked, generally, on the right side than on the left. This localized contraction, the so- called visceromotor reflex of Mackenzie, has, in some cases, been mistaken for a tumor. Sometimes, if the patient is very stout, io < a> o 02 . >> g ^?^-r H - 0> >-:^s3 H c . Z « a> a C5 1^ ^ 1— 1 Z H G . H cc o r? H Ix, -"^ :; o cs >'2 - X C bC O c3 fl rt ^ > Coo S3 .S J2 P-l 0) c cu ii <« "S 'O ■^ ^ p, ■*- 03 03 O 0) a ° « 5 ^ o fe 0) a> ^ 'is ts > o3 T3 a3 .2 =3 ^ ^ .S g a 3 3 03 3 'S 13 c3 H U o o 2 •.22 & -S • — *" ^^ fl r^ '^ 1 o C - § ^ Is s-o J'B !>, -i^ T3 3 a> 3 t ^ 2 i a § g 1 .2 1 ^ ? a o -Q : 1- o oj o O a a o a^ g § o 1- a fi fl o oj S . 11 J 1 ^ ^ i^ a (P 22 n) oj fl « Mrs i 03 c3 OJ o o a '^ .y S o .3 CO ,3 !z; o % 1 t/3 03 O iz; 485 486 INTESTINAL PAIN nal wall, and hyperalgesia is i3reseiit in the cord zones associated with the intestine. In inflammatory states of the small intestine entrance of food into the stomach may, by stimulating and increasing the peri- stalsis, aggravate a pain already joresent, or initiate one, if none is present. This inter-relationship of the stomach and intestine can be explained upon the hypothesis of the close nervous connec- tion between the two organs, so that a stimulation of gastric peri- stalsis will likewise cause an increase of intestinal movements. A confirmatory symptom of value in the diagnosis of inflam- mation of the bowel is diarrhea, which in acute enteritis or colitis is due to irritation by indigestible or fermenting substances. It is of a foul odor and contains frothy material. In tuberculous enteritis the stool is also foul, and contains blood and shreds of tissue. The diarrheal stool of an inflammatory intestinal lesion (enteritis) is generally acrid, and produces intense irritation around the anus and buttocks, while other diarrheal stools, as a rule, do not excoriate. Since many of the inflammatory processes are accompanied by fermentative changes in the intestinal canal, it follows that a considerable distention of the bowel from gas frequently is a con- comitant symptom. When it occurs, the pain of the distention is engrafted on to that of the 'inflammatory process. In some cases of inflammation of the bowels the inflammatory process is very severe and extends to adjacent structures. In this event, because of the involvement of the peritoneum, the sub- jective pain is associated with considerable local tenderness, and if the cecum or lower end of the ileum should be involved it may be confused with appendicitis. This is all the more likely to happen when the abdominal muscles over these areas are in a state of rigidity, and vomiting and rise of temperature are present. If the inflammation should be in the duodenum the abdominal pain is constant, and there is an increased sensitiveness to pres- sure in the right hypochondriac region. Duodenitis generally oc- curs in a patient suffering from an acute gastritis, and in the stools, mucus, with or without blood, will be found. Duodenal LESIONS OF THE INTESTINES CAUSING PAIN 487 digestion, according to O'Connell, occurs about three o'clock in the afternoon and two in the morning; therefore, at these times the pain would be most severe. Ulcers of the Intestine. — The pain in ulcers of the intestine is felt most often in the region of the umbilicus, though the exact localization of the pain depends largely upon whether the lesion is in the small or in the large intestine. In intestinal ulceration the pain is more restricted than in inflammation, and the area or point of tenderness does not move about, as it does both in the latter condition and in colics which are the result of eating indi- gestible food. The pain of ulcer is frequently accompanied by diarrhea, and occult blood can, in some instances, be demonstrated in the stools. A factor of importance in the diag-nosis of the loca- tion of the ulcer is in the relationship of the attack of pain to the time of the ingestion of food. Should the pain come on a few hours after eating, the duodenum is most likely to be involved ; while if the interval is longer the lesion is apt to be lower in the bowel. When an interval of seven or more hours elapses before the commencement of the pain, the lesion is probably in the large intestine. Another point of importance in diagnosing the loca- tion of an ulcer is that the lower it is in the bowel the less is the likelihood of diarrhea. If the pain becomes constant, and is asso- ciated with a steadily increasing distention of the intestine, stenosis of the bowel following an ulcer can be diagnosed. In intestinal ulceration there are, at first, intervals of freedom from pain ; but as the bowel lumen becomes narrowed from stric- ture formation, tlie intervals of freedom become less and less, un- til finally the pain is almost constant. This pain is relieved by the passage of the gas' present in the occluded bowel. Some- times rubbing and massage, although they may temporarily in- crease the pain by the extra intra-intestinal pressure which they produce, will finally cause a jjassage of the gas and consequent relief. Vomiting also appears, and, as the lumen continues to narrow, gradually becomes worse, until complete obstruction oc- curs. It is violent, persistent, and stercoraceous. In ulcer of the intestine, food, particularly that which is hard 488 INTESTINAL PAIN to digest, may act as a local irritant and increase the contraction of the howel, with a consequent drag and pull upon the ulcerated area, and thus cause j^ain. Unrijje fruit or vegetables, such as corn and cabbage, are very likely to act as irritating factors. It is claimed by Schmidt that the application of cold com- presses to the abdomen will relieve the pain of intestinal ulcer, while application of heat will increase it. The pain of ulcers of the intestine generally is not very severe, except when they occur in the duodenum, the sigmoid, or the rectum. Large areas of ulceration in any portion of the bowel are very painful, esj)ecially if the ulceration be deep enough to involve the peritoneuin. In these eases the areas of local tender- ness over the abdomen are proportionate in size to the area of the peritoneum which is involved. In ulceration of the rectum tenes- mus is frequent. The different varieties of intestinal ulceration are tuberculous, typhoidal, syphilitic, catarrhal, uremic, trophic ulcers and those following burns. Tuberculous Ulcers. — jSTon-progTessive tuberculous ulcera- tion of the intestine is often painless. Should the ulceration pro- gress pain is lu-esent. It may be caused by an associated enteri- tis, intestinal distention following a stenosis, a fermentation, or peritoneal involvement. Tuberculous ulcers of the duodenum, be- cause of the frequent location of the pain in the epigastrium, are often confused with pyloric spasm or gastric ulcer. A diag- nostic point of value between the two is that in pyloric spasm the vomitus never contains bile, while in lesions of the small or large intestine usually it is at least tinged with bile. Diarrhea of a very oifensive odor is frequent in tuberculous ulceration. Tubercle bacilli may, in some cases, be found in the stools. Reaction to tuberculin, signs of emaciation, night sweats, and probably some lung involvement can also be detected. Typhoidal Ulceration. — Typhoidal ulceration is generally painless, though in typhoid fever it is common for the patient to complain of discomfort in the lower abdomen, and in some cases of tenderness in the right iliac fossa. If the onset of the fever is sudden, there may be generalized body pain and headache. If LESIONS OF THE INTESTINES CAUSING PAIN 489 the development is slow and gradnal, and no acute toxic condition is present, the only pain-phenomena may be a zone of tenderness over the tenth or eleventh dorsal visceral segments. Syphilitic Ulceration. — Syphilitic ulcers of the bowel, as a rule, are painless. Should constant pain in the abdomen occur in a syphilitic, and be accomjmnied by diarrhea, and, in some cases, by vomiting, a diagnosis of syphilitic intestinal ulcer would be tenable. Catarrhal Ulceration causes no pain, unless the ulceration is very deep. The same is true of the ulceration the result of uremic and troj^hic changes. Ulcers Following Burns. — Ulcers following burns are common. They are most frequent in those cases in which the burn is on the abdomen. When they occur they are most likely to be in the duodenum (see Duodenal Ulcer), and give rise to no special symptoms, other than those which occur in simple intes- tinal ulceration. The pain produced by them is apt to be over- looked by the patient, because of the much greater j^ain which is the direct result of the burn. Duodenal Ulcers. — The pain of duodenal ulcer, like that of gastric ulcer, is jDaroxysmal. It may be of intense severity, or may be felt merely as a dull discomfort coming at certain inter- vals following the ingestion of food. In other cases, whether severe or dull, it is more lasting, and sometimes a constant sense of burning or of sharp pain is experienced. This in many cases is relieved by the ingestion of food, therefore it received the name "hunger-pain." The pain is situated to the right of the middle line, and usually a little above the level of the umbilicus. It may radiate toward the right or the left side. Sometimes it is described as having a deep-seated location, being rather unlike ihe characteristic pain of gastric ulcer in this particular. The time of its appearance varies. It may follow immediately after the taking of food, but most often does not api^ear or, if it does appear, does not reach its maximum of intensity until two, three, or four hours after eating. The character of the ingested food has 9, certain relationship to the intensity and occurrence of the 490 INTESTINAL PAIN pain. Generally speaking, heavy meals occasion a pain of greater severity, although the pain is later in appearance than after light meals. The drinking of copious draughts of water, or the taking of other liquids, such as milk, beer, and wine, or the ingestion of alkalies, may relieve the paroxysm for a time. Tenderness and rigidity of the abdominal muscles in the right upper segment of the abdomen may be met with. Pressure usually increases the painful paroxysms, although not invariably. That the site of the ulcer bears a relationship to the site of the pain cannot be doubted, though the idea that the pain, localized tenderness, and muscular rigidity occur directly over the site of the ulcer is not tenable. The pain in duodenal ulcer may be situated in the epigastrium, near the mid-line, and may extend to the right so that it lies be- tween the crest of the ileum and the ribs. In this condition there is also often a tender spot to the right of the lower dorsal vertebra. It is claimed by many (Deaver, among others) that the pain in duodenal ulcer shows a tendency to periodicity, so that it may be absent for long intervals and then occur in an attack of varying intensity. The pain of duodenal ulcer is increased by moving, eating, or pressure. In many cases there is also present in the abdomen a feeling of gnawing or of boring. Many theories have been advanced to account for the pain in duodenal ulcer. Three suppositions underlie all these theories, namely: (1) That the HCl, because of its reflex excess of secre- tion, directly irritates the ulcer and thus causes the pain. But, if this is so, there must be many exceptions, for a duodenal ulcer, without an excess of HCl in the stomach, is frequently found. In fact, it seems that the ulcer is the cause of this increase of secre- tion, and that the only effect of the excess is that by irritating the surface of the ulcer, it causes a reflex contraction of the pylorus. This leads us to the second supposition, so actively championed by Hertz, (2) that the pain is nothing more than a tension pain, due to localized distention of the stomach walls, the result of excessive stimulation from the HCl. It is known that the pylorus remains closed while the duodenal contents are acid, and that it LESIONS OF THE INTESTINES CAUSING PAIN 491 relaxes only when the contents become alkaline. In duodenal ulcer the duodenal contents are, because of the excessive secretion of HCl in the stomach, seldom, if ever, alkaline. Consequently the stomach is always in a state of hypertension, the result of abnormal peristalsis. This hypertension, however, exists only on the prepyloric portion of the stomach, because it is into this por- tion that the food is forced by the peristalsis and, being unable to advance because of the closed pylorus, accumulates and causes the increase of tension and the so-called ulcer pain, which has about the same location as that described under pyloric spasm. (3) A third supposition is that advanced by Bier, wdio holds that a stomach when empty has a tendency to pull to the left, and traction (in case of duodenal ulcer) is made upon the ulcerated area, while, on the contrary, a stomach, when full, is displaced to the right, and the traction is diminished, with a consequent diminution of the pain. Which of these (if any, or if all three) is the active factor in tha production of pain in duodenal ulcer is rather diffi- cult to decide, though it seems as though all three may have a more or less important influence. Distention of the Bowel. — Uncomplicated distention of the bowel will cause considerable pain, especially when the distention is sudden in onset, such as is found in acute obstruction, strangu- lated hernia, etc. In chronic intestinal distention, pain, as a rule, is not a promi- nent symptom, and only becomes so when there is a sudden in- crease in the distention. The pain of distention is relieved by the expulsion of gas, and frequently the patient feels a change in the location of the pain following a gurgling and the forward movement of the gas. Distention of the bowel is denoted also by tympany, localized over the area of the bowel segment involved in the distention. It frequently happens that when the large bowel is distended its segments can be defined by palpation, and if the abdominal wall is fairly thin, peristalsis, if at all active, may be seen. In idiopathic dilatation of the colon (Hirschsprung's dis- ease) pain is usually absent. Adhesions. — Bands of adhesions, which are a common cause 492 INTESTINAL PAIN of distention, occur most frequently in connection with the small intestine, and are there a more common cause of obstruction than in the large intestine. They usually do not produce pain unless so placed as to cause, during intestinal digestion or on active movements of the body, a pull or drag upon the parietal peritoneum. They may also cause pain by causing obstruction of the bowel. Obstruction of the Intestine. — Intestinal obstruction is more common in the small than in the large intestine. It may be acute or chronic. Acute Obstruction. — There are two varieties of pain due to acute bowel obstruction : the primary and the secondary. Primary pain is sudden in onset, very severe, and of a griping character. It is generally referred to the middle of the abdomen, and is due to the change in the relationship of the parts of the bowel, with a consequent drag or pull upon the mesentery or mesocolon. Following this is the secondary pain. , It is more continuous than the primary pain, and, owing to the violent peri- stalsis of the cut-off bowel, is interrupted with paroxysms of great intensity. Gradually, as the result of paralysis, from exhaustion, or from toxemia due to poisons generated in the obstructed seg- ment, the pain becomes less. If the pain has a tendency to spread from its primary location and is accompanied by concentric spreading tenderness, it is an indication that the peritoneum has become involved and that a spreading peritonitis has ensued. When this occurs the pain is sharp, stinging, and more constant. The cause of the bowel obstruction may be one of the follow- ing: (a) causes acting external to the bowel, (a) twists, volvulus, (&) adhesions, (c) intussusception, (d) hernial bands (see Her- nia) ; or (b) those acting within the bowel, as (a) contractures, (&) fecal contents, (c) foreign bodies. In twists and intussusception the onset is sudden and the pain is most severe. There is also present a well-defined and painful tumor. This tumor, depending upon the part of the intestinal tract which is involved^ is located in different parts of the- abdp- LESIONS OF THE INTESTINES CAUSING PAIN 493 men. If the sigmoid is the part involved, the swelling first be- gins in the left iliac fossa, and then gradually extends upward, with a central tendency, towards the umbilicus. From the very beginning there are pain and tenderness, which become more severe as the lesion progresses. The pain gradually extends until the entire abdomen is involved. The pain in intestinal obstruction is due: (1) to inflammation of the peritoneal surfaces and the consequent involvement of the lymph nodes; (2) the traction which the inflated gut exerts on the mesentery and mesocolon; and (3) irritation of the nerves in the affected segment of the bowel by (a) pressure from the ob- structing agent, (&) pressure from violent peristalsis. In acute intestinal obstruction the history of a previous attack of peritonitis would indicate that the obstruction might be due to adhesions. The pain in these conditions at first is very great, but gradually subsides if the obstruction persists. The tempera- ture and pulse are both variable, though, as a rule, no remarkable change is noted in either. Vomiting, though not constant, gen- erally is an accomj^animent of obstruction. Sudden, ad^ite abdominal pain, periodic in character, associ- ated with the i^assage of blood per anum, occurring in young children, should always lead to a consideration of intussusception as a cause. Obstruction accompanied by periodic pain generally means that a volvulus is the cause. This gives rise to almost the same symptoms as intussusception, though the tumor has, as a rule, a different shape and location. In the early stages of intestinal obstruction light pressure upon the abdomen will often give relief. If during the course of the disease the pain suddenly subsides without improvement in the pulse and the general condition, the case is serious. If, after having ceased, the pain again commences and becomes rapidly generalized, it is a sign that a generalized peritonitis has developed. Cheoxic Obstkuctioi^. — Chronic intestinal obstruction is due to adhesions, contractures, new growths, foreign bodies (gall- stones, fecal concretions), and inflammatory processes. In these the development is slow^ and extends over long periods, At first 494 INTESTINAL PAIN there is oiilj a sense of discomfort, which gradually becomes worse until it is merged into pain. This pain is intermittent and occurs in cramp-like paroxysms. These pains arise suddenly, and are relieved as soon as the stagnated fecal matter and gas have been forced beyond the point of obstruction by the pressure from the rear. The patient is also conscious of the "pain" beginning in a certain spot and working in a screw-like fashion up to another sjiot where it ends (Maylard). If the degree of obstruction suddenly becomes greater the pain immediately in- creases in intensity, sometimes so markedly and suddenly that the diagnosis of an associated acute obstruction is made. What really happens is that only an exacerbation of an existing condition has occurred. After a time the pain again subsides, owing, perhaps, to fatigue or to relief of the local conditions (Stengel). Early in the course of intestinal obstruction the jDain is mild, paroxysmal and infrequent ; but as the obstruction becomes more complete, attacks of j^ain are more frequent, and are of greater severity. Associated with the pain are tympanitis, vomiting (pos- sibly fecal), visible peristalsis (should the abdominal walls be thin), tumor, which is tympanitic, obstipation, and generally an absence of fever. Previous attacks of localized peritonitis or the history of an abdominal operation will suggest a band or kink of the intestine as a cause of the obstruction. The history of a tumor will suggest pressure and faulty position of an intestinal coil ; emaciation in middle life suggests malignant disease ; ascites should lead one to suspect tuberculosis (23, p. 220). Maylard claims that pressure by hardened feces will also cause pain, and he cites a case where severe pain and tenderness were present in the right iliac region, and, on exploratory laparotomy, only hardened feces could be found in the cecum. Lesions of the sigmoid colon often cause pain of the most racking kind. It is felt at a point usually about two inches to the right of the umbilicus and at the upper part of the iliac fossa at the level of the crest of the ilium. Overloading of the colon does not seem to be the cause of any LESIONS OF THE INTESTINES CAUSING PAIN 495 special pain. Constipated individuals rarely suffer from pain due to this cause (see Constipation, p, 509). The presence of indican in the urine is a point of considerable diagnostic importance in locating the site of the obstruction. Should indicanuria be present early in the disease, it is an indi- cation that the obstruction is high up, generally in the small in- testine. At the same time, in high obstructions there is a reduc- tion in the quantity of the urine due to the loss of water from vom- iting, which is much greater in lesions of the small than in those of the large intestine. In all cases of obstruction vomiting is constant, and i& not accompanied by nausea. The vomitus at first consists of the contents of the stomach, then of the bowel, and finally becomes fecal. The period at which the fecal transition occurs varies, depending upon the segment of bowel involved. The lower the involvement the longer is the fecal vomit in making its appearance. Should the obstruction be as low as the ileum, one or two days may elapse before it appears ; lohen it does appear it is pathognomonic of obstruction. The absence of pain in bowel obstruction may be due to the obstruction being the result of paralysis of a portion of the bowel distal to the obstruction, as in a case reported by Musser. Here, the patient, five days after an operation for intussusception, de- veloped vomiting, which was of increasing frequency and finally became fecal, though no pain was present. On operation the cause of the obstruction was found to be a paralyzed portion of the bowel. In resume it may be recalled that obstruction of the bowel may bo due to: (1) functional spasm (colic), the result of (a) irritation, organic poisons, bacteria, and cathartics, (b) inorganic poisons (lead) ; (2) obstruction of the lumen by (a) lodgment of some substance, as enterolith, gall-stones, indigestible or fecal material, foreign bodies, as gall-stones, (b) change in the relation- ship of the parts to each other, as in twists (volvulus), invagina- tion (intussusception), dragging and pulling (hernia) ; and (c) 496 INTESTINAL PAIN the presence of new gi'owths, which may be inter-, intra-, or extra- mural. Volvulus. — Pain in volvulus comes on as a sharp, sudden, severe pain (cramp) in the epigastrium, or in the region of the umbilicus. It is continuous, and at first is of a constant in- tensity; but as soon as fecal stasis occurs, and distention of the bowel segment proximal to the obstruction occurs, the constant pain is interrupted by a series of cramp-like exacerbations. These exacerbations are indications of the severe contractions taking place in the intestine, in its effort to establish a passage through the obstruction. Gradually, as the obstruction to the circulation in the affected bowel becomes complete, inflammation and gangrene supervene, and a generalized peritonitis, with its accompanying pain and tenderness, occurs. As the gangrene progresses, and the peritonitis becomes more severe, sepsis ensues, and the patient, becoming toxic, complains less and less of pain, until, in a state of somnolency and forgetfulness, the shadow of death hovers over him and he passes into the land of eternal rest. There is no relief for volvulus, unless the knot is reduced either by natural or surgical means. Associated with the pain of volvulus, as described above, there is also present in the abdomen a rounded tumor mass, either tym- panitic or dull on percussion. Obstinate constipation and vomit- ing are also present, and generally, though not invariably, a rapid pulse. If these symptoms are found, they are of sufficient mo- ment to demand a laparotomy. Volvulus is most frequent at the sigmoid. When the condi- tion is acute and the obstruction is complete, a distention greater than that which occurs with any other lesion of the bowels rap- idly develops. Therefore, when sudden pain is followed by a rapid distention, without signs of peritonitis, volvulus should be considered. It is more frequent in men than in women, but constitutes only about one-fortieth of all cases of intestinal ob- struction. Intussusception. — This is very frequent in infants, and, while pain is undoubtedly pronounced, yet we are not able to LESIONS OF THE INTESTINES CAUSING PAIN 497 make a definite assertion, because the infants, on account of their immature age, are unable to express their distress. There- fore, should evidence of colic occur in a baby (who, as frequently happens, has had a previous diarrhea), followed, within a short time, by the development and gradual increase in size of an elongated tumor, with an associated constipation, a tentative diag- nosis of intussusception may be made. If the disorder should happen in those of more mature years, a more detailed account will be given of the onset and the nature of the accompanying pain. Bearing in mind the manner of production of this disor- der (the sudden, acute invagination of one part of the bowel into another part, with consequent pull and possible twist of the mesentery), the reason for the sudden acute pain is apparent. It is commonly stated that the pain in intussusception is directly over the site of the tumor mass, but the fallacy of this is clearly proved in the introductory remarks to this chapter. The pain, which at first is of a well-defined, colicky type, gener- ally is confined to the umbilical region or lies immediately below it. Since the lesion is located most commonly in the cecum and the lower part of the ileum, the pain may finally become localized in the right iliac fossa. This location of the pain can be ex- plained from the fact that, when intussusception occurs, consid- erable pull is made upon the mesenteric attachments of the ileum and is reflected as pain to the anterior abdominal wall, generally in the region of the umbilicus. As the intussusception progresses an added pull is made upon the cecum, and through it traction is exerted upon the parietal peritoneum, with pain referred to the right iliac fossa, or to the lumbar region on the same side. Later in the disease, owing to restriction of the blood supply and to pressure, the inclosed segment of the bowel becomes necrotic. Inflammation of the proximal segment then occurs, and is com- municated to the adjacent peritoneum, with the production of pain. This pain is referred to the area below the umbilicus and across the lower portion of the abdomen. In pain-production the pull and tension on the mesocolon also are of considerable mo- ment. 498 INTESTINAL PAIN In intussusception the lumen of the bowel is obstructed, and the forward movement of feces hindered. Backward stasis occurs, and distention of the bowel proximal to the obstruction takes place. This distention then acts as an additional cause ol pain-production. In invagination of the ileum into the cecum the etiological relationship of the lesion to the region where the pain is felt is illustrated in the accompanying drawings. 3 Ro STAGE Fig. 103. — Pain Areas in Intussusception. First stage: Pull upon the mesentery. Second stage: Pull on mesentery and traction on parietal peritoneum connected with the cecum and colon. Third stage: Inflammation has supervened and pain is also referred to the colon area. Figure shows where the pain is felt as the bowel pro- gressively becomes involved in the invagination. After the intussusceptuni has sloughed off, provided the pa- tient survives, there is formed a considerable number of adhe- sions which, because of their traction, are always a source of an- noyance and pain-production. The bowel is also shortened, and the mesentery is constantly on the stretch ; and, though in time it may accommodate itself to its changed relations, at first every little LESIONS OF THE INTESTINES CAUSING PAIN 499 (intestinal) distention is noticed much more and produces more pain than it would iij. a normal subject. If in the sloughing stage a generalized peritonitis supervenes, the pain becomes much more acute and is diffused over the entire abdomen. Tympanitis also becomes more marked, and tenderness is excessive. In eliciting the tenderness, the pressure exerted upon the abdominal wall must be such that the parietal peri- toneum is irritated ; pressure must be light but not deep. That there is a somewhat intimate relationship between peri- stalsis and the production of pain, and that an absence of peri- stalsis may lead to an absence of pain, is seen from a case re- ported by Musser, in which an intussusception was present with an entire absence of pain. At the same time, peristalsis was absent. At operation the intestines were found as limp and as motionless as they are in a cadaver. ^ Hernia. — The obstruction due to hernia was considered under hernia of the abdominal wall (q. v.). New Growths of the Intestine. — Xew growths of the intestine frequently occur without the production of pain, especially in the early stages. When pain does occur, it is due: (1) to interference with the local circulation, causing congestion, edema, inflamma- tion, and adhesions; (2) obstruction to the bowels; (3) pressure on the nerve filaments in the wall of the bowel or pressure upon adjacent nerves; and (4) dragging and pulling on the mesentery. Interference wath the local circulation does not produce any pain until an active inflammation ensues; then pain becomes a most marked symptom. It is localized to the region over the affected bowel, and is of a peritoneal type. If obstruction to the bowel takes place the pain is of the type described under intesti- nal obstruction. If it is due to pressure on the nerve filaments in the intestinal w^all, the pain may be reflected to the abdominal wall, and be felt in the areas of distribution of the ninth, tenth, eleventh, and twelfth dorsal visceral segments. The higher the point of pressure in the bowel the higher the visceral segment which is involved. If pressure should also be made upon adjacent but extramural nerves, the pain is referred to the area of distribu- 500 INTESTINAL PAIN tioii of these nerves, either in the anterior abdominal wall or in the lower ]imbs. If a dragging and pulling on the mesentery occur, aching is felt in the area of distribution of the related dorsal visceral seg- ments. Pain Due to Colonic Involvement. — The colon is supplied by nerves derived, from the superior and inferior mesenteric plexi, which receive their supply from the solar and aortic plexi, re- spectively. These, in turn, receive their supply from the ninth, tenth, eleventh, and twelfth dorsal segments of the cord (accord- ing to Wilson (89G), from the seventh dorsal to the sec- ond sacral) ; the segments most commonly involved are the tenth, eleventh, and twelfth dorsal. The pain in colonic diseases seems Area in which pain is felt when the inflamma- tion progresses along the gastrocolic omentum and causes inflamma- tion of the stomach and adjacent tissues Area in which referred pain is present Fig. 104. Fig. 105. Figs. 104 and 105. — Areas of Pain in Diseases of Colon. I.; to be much more pronounced the nearer the lesion is to the anus. When the lesion is high up, the pain is not very severe unless in- flammation has extended to the peritoneal coat on either side of the mesentery. If this has occurred, the infiltration may pro- gress to the parietal peritoneum and thus cause pain, which, in lesions of the ascending and descending colon, is felt in the right and left lumbar regions respectively, or, in those of the trans- verse colon, in the center of the abdomen. Should only traction of the mesocolon occur, the pain is felt in the abdomen in the hypogastric area. This hypogastric pain comes under the class of reflected pains. It is in the zone of distribution of the eleventh and twelfth dorsal LESIONS OF THE INTESTINES CAUSING PAIN 501 visceral segments. The affections of the colon giving rise to pain are: (1) acute and chronic inflammation, (2) displacements, (3) obstruction, (4) new growths. Inflammation of the Colon. — In inflammation of the colon the pain is referred to the lower abdomen, and, in involvement of the sigmoid flexure, generally to the left side. This reference can only be explained bv the fact that, because of the shortness of the mesocolon and its intimate association with the peritoneum of the left side, inflammation of the colon is quickly communicated to the parietal peritoneum of the same side. The increase in local tenderness on this side can also be thus explained. Inflammatory diseases of the colon causing pain are of two classes: (a) acute and (h) chronic. Acute infective states of the colon are always painful, and the pain is of a griping, burning, or boring nature. Pains the re- sult of acute inflammation have a greater tendency to localize themselves to the region of the affected bowel than do the pains produced by chronic disease, which, as a rule, are reflected or referred to distant areas. In inflammatory states of the colon the patient is sometimes conscious of a relief of his pain follow- ing movement of the bowels or the passage of flatus. Mild inflam- matory states of the colon, as a rule, are not painful ; but if the irritation is prolonged, and the inflammation increases and be- comes phlegmonous, a septic and generalized bowel involvement or ulceration, with its somewhat mild but persistent symptoms, may occur. In some cases of painful colitis the ingestion of food brings on an attack of pain. This is due, probably, to activity of the colon incited through sympathetic nerve connections. According to Tuttle, there is in ulcerative colitis a "sudden onset of sharp, lancinating pains in the course of the colon, attended with griping and a tendency to frequent movements of the bowels. These pains last for a short time, then disappear, and the patient may have nothing more of the kind for several days or weeks, when they again occur. They sometimes last an hour or more ; at other times they continue for two or three days." If the attack is persistent, pus and blood finally appear in the 502 INTESTINAL PAIN stools. The attacks are periodical, and the pain, which in the early attacks was not severe, increases in severity with each at- tack. The amount of the pain bears no relationship to the extent of the ulceration, and is not influenced by the ingestion of food. The cause of the i:)ain seems to be the irritation of the ulcer by the intestinal contents, which incite irregular peristaltic or spas- modic movement of the bowel. In follicular colitis there may be tenderness over the lower end of the spine, with vague pains shooting down the legs. In chronic colitis pain comes on at irregular intervals. It is of a grij^ing character, and generally precedes the passage of a stool consisting chiefly of mucus or of shreds of membrane. After the stool the pain may persist for several days. The onset of the pain bears no relationship to the ingestion of food, nor does it seem to be influenced by diet. Tuttle thinks that the formation of the membrane is the result of a localized increase in the secre- tion of mucus, this being the result of a localized hyperemia, which, in turn, is due to a slight intussusception or volvulus. When the spasm (localized), which has been the cause of the intussusception or twist, relaxes, the mucus or membrane which has formed is rapidly discharged. The patient, because of the synchronicity, associates the jDassage of the membrane with the relief of the pain. Pain may be produced by spasm of the colon without any in- flammatory lesion at the same time. Schiitz thinks that these cases are most probably primary neuroses. Any systemic crisis, such as that occurring at the menstrual period, may bring them on. The pains occur as cramps in the sides and across the abdo- men, at first only at stool, but gradually they become more con- stant and are interrupted by exacerbations of agonizing intensity. Constipation is pronounced. Loss of appetite, associated with nausea, is present. This condition is found usually in those of" anemic and neuropathic tendencies. The lower in the colon the disease is located the greater is the tendency to pain-production. The reason for this is that, filaments of the cerebrospinal nerves are distributed to the lower part of the colon, so that, when this LESIONS OF THE INTESTINES CAUSING PAIN 503 part is involved, pressure will be exerted upon these nerves and pain will be produced in the area of their distribution. It is for this reason that in diseases of the sigmoid flexure of the colon pain has a tendency to be localized in the left lower abdominal quadrant. In sigmoiditis the patient flexes the left limb; the abdomen over the sigmoid is very sensitive to pressure, and the lower segment of the left rectus abdominis is in a state of contraction. These symptoms are but indicators that the inflam- matory process, localized at first to the walls of the lower bowel, has spread by means of the lymphatics to the adjacent peri- toneum. Such an extension would be very easy, for the sigmoid is without a mesentery, and is connected to the body wall by a loose meshed tissue. When peritonitis occurs all movements of the body, especially those producing stretching or traction of the abdominal wall, are very painful. These painful syndromes are present only in acute cases, the chronic ones being entirely or almost entirely free from pain. Often in cases of mucous colitis considerable pain is present previous to the discharge of casts of the bowel or of large shreds of mucus. This pain is relieved as soon as the bowel dis- charge commences, but abdominal tenderness persists for some time. Colicky pains in the lower part of the abdomen, on the left side, followed by tenesmus and mucus-stained stools, are pathog- nomonic of sigmoiditis. Inflammation of the sigmoid is very rare without, at the same time, an associated inflammatory state of the rectum. The latter produces symptoms similar in some par- ticulars to those of inflammation of the colon and sigmoid, but differing in many important details, because the lower position and the nearer relationship of the rectum to the spinal nerves cause the pain to be more that of a referred spinal type. The rectal pain-producing diseases will be considered in a later section. Displacement of the Colon. — A rather poorly understood cause of pain in colonic disorders is displacement. That pain is caused by displacement of the colon cannot be doubted, though, at the same time, the opinion is widely held that displacements, even of a major degree, may be present without producing the 504 INTESTINAL PAIN slightest pain. The manner of the pain-production varies widely, depending upon the portion of the gut involved. Should the dis- placement occur on either the right or the left side, the pull is upon the lateral mesocolon, and to some extent upon the kidney, through the nephrocolic ligament. If the displacement on the left side is gTcat enough, a pull upon the spleen also occurs through the splenocolic ligament. If the lesion is on the right side, traction is made upon the li\er through the hepatocolic liga- ment. When any of these conditions occur, aching and distress are present in the regions associated with the organs secondarily involved. Should the transverse colon be affected, the pull is exerted upon the stomach and the organs closely connected with it, as the pancreas, liver, and gall-bladder, and indirectly upon the diaphragm, thus producing a symptom-complex involving all these organs. As they are all supplied by the solar plexus, a general aching and distress, sometimes amounting to actual pain, with an ill-defined localization in the lower abdomen, result. As a sequela, associated with displacement, is distention. It occurs from the lodgment of fecal matter at one of the low places in the distended gut with a consequent obstruction and distention of the proximal segment of the bowel from gas. In some cases, owing to the weight of the fecal matter, the bowel sags and a kink results. The onward progTess of the feces and gas is obstructed, and, as a consequence, dilatation of the bowel occurs on the side proximal to the obstruction. The signs and symptoms of disten- tion (which are described under that heading) then appear. In a brief resume it may be stated that the localized pull upon the peritoneal attachments due to displacement produces signs referable directly to the organs involved, while the pull upon associated organs produces pain and symptoms referable to those organs. The consideration of the causes of colonic displacements is beyond the scope of this work, but a brief review of the effects of change of position, etc., upon the production and character of the pain may be permissible. If the displacement is of either the ascending or the descend- LESIONS OF THE INTESTINES CAUSING PAIN 505 mg colon, the position of the patient lying upon the side opposite to that in which the bowel is displaced will often cause consider- able and lasting pain. The pain is of a dragging, aching charac- ter, and may continue until the patient turns upon the opposite (affected) side, and allows the displaced bowel to assume its natural position, and permit the gas and fecal matter to have f\n unobstructed passage. Displacement also causes a tumor formation, which, as a rule, is tympanitic, and varies in size, depending upon change in the position of the patient. It can often be reduced by pressure, the reduction being accompanied by audible gurgling, and by a relief of the distress. An alteration of the diarrhea and constipa- tion often occurs. When this symptom-complex is present it should at once attract our attention to the colon. For other signs, consult Distention (cf. p. 491). Should the displacement be due to the drag of a tumor, pal- pation will reveal the abnormal formation, and, at the same time, the type of the displacement. Obstruction. — Obstruction of the sigmoid by hardened feces is a common cause of pain. In this condition there also may be an alternate diarrhea and constipation. New growths cause pain as a result either of displacement or of obstruction. The Rectum. — Rectal pain is of two classes: (a) local and (&) referred. Local pain is due to ulcers, new growths, strictures, etc. The pains produced by these lesions are more frequently the result of involvement of the neighboring structures than of direct irrita- tion of the nerves ending in the walls of the rectum. In all these conditions there is, in addition to the local pain, a referred pain, which may be felt in the lower lumbar or sacral regions of the back, on one or on both sides. These regions are supplied by the fourth sacral nerve, which is distributed both to the rectum and to the skin over the sacrum. In some cases, owing to associated nerve involvement, the pain may be referred to the perineum, down the back part of the thigh, and even to the penis, or to the 506 INTESTINAL PAIN labia. The upper part of the rectum is without pain, and can be greatly distended without distress. Because of its non-sensibility it becomes the receptacle of the hardened feces. Pain may be referred to the rectum from adjacent organs, as the uterus, tubes, ovaries, prostate, posterior urethra, or trigone of the bladder. In these conditions the pain has more of an aching character, and there is a constant desire to go to stool. ISTervous disorders also cause pain referred to the rectum. The following nervous disorders, it is said, cause rectal referred pain: epilepsy, locomotor ataxia, neuralgia, and hysteria. It is, however, a disputed question if any nervous derangement can, without some definite rectal pathology, cause local rectal pain. The nerve supply of the rectum includes both sympathetic and cerebrospinal nerves. The sympathetic supply is derived chiefly from the inferior mesenteric and pelvic plexuses and from the nerves accompanying the superior and middle hemorrhoidal ar- teries. The cerebrospinal nerve supply is derived from the second, third, and fourth sacral nerves, which enter the sacral plexus and are distributed to the rectum through the following nerves: (a) the inferior hemorrhoidal, which supplies both the rectum and the anus; (6) the superficial perineal, a branch of the pudic, which supplies the levator ani and the skin in front of the anus. The skin around the anus is supplied by the inferior hemorrhoidal branch of the jitudic (Piersol). The pudic nerve is derived from the same segment of the cord as is the sciatic. Therefore, irrita- tion of this nerve by ulcer or fissure of the lower rectum or anus may be referred as pain down the leg along the course of the sciatic. The central origin of the nerve supply of both the rectum and anus is located about the level of the first lumbar vertebra. This is about the same level as that for the bladder and genitourinary systems. Thus we have the explanation of the close sympathetic bond existing between the two systems. Inflammation of the Rectum. — Inflammation of the rec- tum, called proctitis, as a rule, is of little moment, unless it passes LESIONS OF THE INTESTINES CAUSING PAIN 507 tlie catarrhal stage and becomes of a dysenteric type. Proctitis of the catarrhal type may give rise to no symptoms except a sense of distress in the rectum, and, in some instances, an aching referred to the back over the sacrimi. Pathognomonic of catarrhal proctitis are griping pains in the lower abdomen, with constipation, and, in some cases, nausea and vomiting. In addition to these symp- toms, there is at times the occasional passage of a small quantity of blood-stained mucus. Should constipation be pronounced, the stools hard and dry, and tenesmus and sacral pain marked, trophic proctitis is most likely. Rectal tenesmus is present in all vari- eties of proctitis. In proctitis hemorrhoids are almost constantly present, and should not be mistaken for the disease ; nor should pruritis, which often is severe, lead one astray in making the diagnosis. Dysenteric proctitis is the most severe form of rectal inflam- mation. It causes the most pronounced aching in the pelvis and about the anus, and also produces ''burning and heat in the lower . part of the rectum, severe tenesmus, constant diarrhea, and rapid exhaustion." Xew Geowths. — The new gTOwths of the rectum causing pain are carcinoma and giimmata. Carcinoma of the rectum, if it is above the mucocutaneous folds, is generally painless. One of the unfortunate things about this dread disease is that its onset is so insidious and symptomless that its cryptic advance is not suspected until it has progressed so far that treatment is of no avail. Yet, because of the morning diarrhea and the discharge of pus and blood, attention should be focused early upon the rectum as the seat of the trouble. Gummata of the rectum are painless. At the anus they are inversely as frequent as are the primary lesions in the same loca- tion. The probable reason for the lack of pain in gummata of the rectum lies in the fact that they are seldom accompanied by inflam- matory reactions, and pain, if it is "present, is chiefly caused by distention, and, because of the laxity of the tissues at this place, is very hard to produce. Another reason for the absence of pain 508 INTESTINAL PAIN is that gummata rarely suppurate, and, therefore, the nerves are but seldom involved in an inflammatory process. Ulceration. — The most common cause of rectal pain is ul- ceration, and I cannot do better than quote from Tuttle, who so thoroughly covers the subject. He says that in this condition "pain is a very sharp, unreliable, and indefinite symptom. Cer- tain individuals suffer greatly from it, while others have no pain at all. If the ulceration is high up in the rectum, a sense of weight and aching in the sacral region is the chief discomfort of which most patients complain, while, if it is situated lower down. within the grasp of the sphincter and involves the mucocutaneous fold, which is rich in sensory pain-receptors, pain of a sharp, lancinating, burning character will be the chief complaint. This pain is the result of contraction of the internal sphincter, which makes pressure upon the exposed sensory receptors. The amount of the pain varies considerably with the character of the ulcera- tion. Tuberculous ulcers are almost entirely free from pain. Syphilitic ulcers vary considerably in the amount of pain which. they produce. Sometimes they are very sensitive; at other times the patient is almost entirely free from pain. This freedom de- pends, to a considerable degree, upon the location of the ulcer. As a rule, ulceration of the rectum is not an acutely painful affec- tion." Varicose ulcers of the rectum, because of their location above the mucocutaneous fold, are a rather negligible quantity as a cause of acute pain. However, there is present a dull aching in the back, and sometimes shooting pains run down the leg or around the pelvis. Should the sphincter be involved, the pain, because of the excessive contraction of this muscle, becomes very acute. If the varicosities are large enough to be termed hemor- rhoids, the pain is much more severe. It is especially marked should the hemorrhoid be of such a size that it can prolapse through the anus and be grasped by the sphincter. Hemorrhoids may cause pain referred over the sacrum, in the back, and down the limbs. LESIONS OF THE INTESTINES CAUSING PAIN 509 Ulceration accompanying Bright's disease usually is without pain. Ischiorectal Abscess. — In ischiorectal abscess the infec- tion is generally ushered in by a well-defined chill, and a feeling of discomfort which is soon followed by a throbbing pain. Ex- amination reveals an induration around the anus ; redness may or may not be present, depending upon the extent and severity of the infection. The patient generally has difficulty in urina- tion, and defecation may be and usually is extremely painful. In some cases a hematoma may simulate an ischiorectal abscess, but on opening the swelling the only thing found is a collection of blood. As soon as this is evacuated the pain disappears. Pain Due to CoxsTiPATioisr. — ISTeuralgia is often associated with constipation. This is due in large part to direct pressure by the fecal mass upon a nerve or a nerve plexus. Continued pressure causes traumatism, and leads to a pressure neuritis. Lowered vitality of the nerve-stem, due to pressure, also permits infection. Thus, there may develop an infectious neuritis, as well as a pressure neuritis. Constipation. — Colicky pains are produced by constipation, and are the result of the distention of the bowel by gas or fecal matter, or they may be the result of enterospasm, due to irritation from the stagnated feces, or their contained toxins. These pains are, as a rule, localized in the central part of the abdomen. The abdominal muscles are sometimes associated in the symptom-com- plex and are strongly contracted. Frequently the contraction of the muscle is confined to the portion which lies over the area of the involved bowel. The Anus. — The lowest part of the rectum, the anus, is the part most subject to painful reactions. These are the result of two factors : ( 1 ) the gi'eat sensitiveness of the sensory receptors in tliis location, and (2) the presence of two powerful, constant act- ing sphincters, whose contraction produces severe pressure upon the exposed and irritated nerve filaments. Because of these con- ditions, the slightest ulcer in this area is provocative of the most extreme distress. The nerve stimuli from the anus areas are con- 510 INTESTINAL PAIN veyed in the fifth sacral nerve, which also supplies the integu- ment over the sides and the tip of the coccyx. This accounts for the referred pain felt over this area in anal disorders. H«nonhoKla\Alnte(3. Around ^* ^ Sphincter Fig. 106. -Irritation at External Sphincter Referred to Skin over Coccyx. Anal Fissure. — The most painful of the anal affections is a narrow and deep ulceration of the mucocutaneous junction, the so-called anal fissure.^ The pain produced by this lesion is of two types, depending upon the stage of development. In the early stages the nerve endings are exposed on the ulcerated surface, and the pain is of a cutting, burning type, most marked after defeca- tion. Later, as the sensitory fibers which have been exposed are destroyed, the pain is more dull and constant. During the course of the ulcer, owing to infection, and possibly traumatism of the adjacent nerves, a peri- and, in some cases, an interstitial neu- ritis may develop. There is then present a dull, throbbing ache, which radiates to the back and down the legs. This pain may persist even after the ulcer has cicatrized, because, even though the ulcer may heal perfectly, the neuritis will still remain. ^ In anal fissure pressure upon the margin of the anus, just below the ulcer, is always painful. A large part of the distress may be prevented, should the patient lie down immediately after defecation. When the pain has persisted for some time it may be permanently relieved by forcible divulsion of the sphincter. The relief of pain by this means seems to be due, as de- scribed by TuttJe, to the release of the nerves from inflammatory adhesions with which they were surrounded, and to the removing of the pressure which had previously been exercised by the tightly constricting sphincter. LESIONS OF THE INTESTINES CAUSING PAIN 511 The descrij^tion of the pain of anal fissure given by Tuttle is worth quoting. He says, ^'The pain is very variable in time, nature, and duration. It may come on at stool, immediately thereafter, or half an hour or an hour after. It may be acute, cutting, tearing, as if a wound were being pulled asunder, or it may be a burning, hot, irritating feeling, accompanied with spasm and bearing-down sensation. Finally, it may have none of these characteristics, but assume a dull, heavy ache, with throbbing and distress similar to that of an aching tooth. The time during which the pain lasts is also as variable as its nature. Sometimes it lasts for only a few minutes, and the patient is then able to go about his business without any further disturbance till the next stool. At other times the pain and smarting are so severe that he is unable to move from his position at the toilet, or he must seek his bed, and lie there from one-half to three-quarters of an hour until the acute agony has passed away. After this he is comparatively comfortable for the rest of the day. In others, the pain does not come on for some little time after the fecal move- ment, when smarting and burning are felt in the anal region. This sensation gradually changes to a throbbing, aching distress about the anus and the sacrum, which may last for several hours, or even, in some cases, all day long. Certain patients are never entirely free from discomfort. There is a pretty clear relation- ship between these pains and the character of the fissure. "The acute j^ains, lasting only for a few moments, are ordi- narily due to superficial fissures which involve the uppermost layers of the mucocutaneous tissues, healing partially from day to day, and recurring with each hard stool. They can be pro- duced by forcibly stretching the anal folds apart. Such fissures are frequently associated with atrophic catarrh and late syphilis. The pains, which come on just after stool and last for one-half an hour or more, are ordinarily due to an ulceration between the radial folds of the rectum, especially in the posterior com- missure. There is a slight red granulated base, thickeniug of the edges, with a sentinel pile, or two little teats at its lower end. The dull aching or throbbing pain, which comes on some time 512 INTESTINAL PAIN after stool, is geiieraliy due to a fissure or ulceration in the upper part of the anus, and involves the internal and the upper fibers of the external sphincter. It is ordinarily of long standing, deeper, and more indurated than the previous variety, hut its edges are not so elevated and thickened, and it does not involve the skin at all, and can only be seen by the use of the speculum, or by forcibly stretching the anus apart. The late pains, occurring some time after a fecal movement, indicate that the ulceration is high up, while those occurring immediately thereafter would indicate a lower situation. In general, however, it may be said that the acuteness and severity of the pain are in direct propor- tion to the nearness of the ulcer to the anal margin. The more the mucocutaneous tissue is involved the greater is the pain. The reason of this is probably that the sensitive nerve fibers approach the mucous membrane from below, and are distributed in a gradually decreasing ratio as we ascend into the anal canal, disappearing almost entirely after the mucous membrane has been reached." ^ The reflex pains associated with anal fissure are: (1) Dysuria. — This generally occurs at the time of or shortly following defecation. This association is easily understood when it is considered that the anus and the lower urinary system re- ceive their nerve supply from the same segment of the cord. (2) Uterine and bearing-down pains (in women). (3) Backache and neuralgic pains shooting down the leg. (4) Facial and occipital neuralgic pains. The neuralgia may be but an indication of the reaction of the nerves to the toxins which are circulating throughout the system, because, in anal fissure, the bowels, on account of the pain, are inactive, and the fecal matter accumulates, giving rise to a toxemia. Perianal Abscesses. — Some perianal disorders are ex- tremely painful. Of these abscesses are the most painful. Should an abscess be present in the subcutaneous tissue around the anus, and no pain be felt, it is a fairly good indication that the condi- tion is due to tuberculosis. In such affections there is very little *" Diseases of the Anus and Pelvic Colon," p. 300. LESIONS OF THE INTESTINES CAUSING PAIN 513 inflammatory reaction, and swelling and redness are absent. The discharge, thin and watery, passes out of a small opening which leads from a boggy central mass. All cases of fistula, abscess, and ulcer around the rectum, which have developed insidiously with- out pain, are generally tuberculous. Should the abscess not be tuberculous, but the result of an infection from a pyogenic organ- ism, there is at first a preliminary feeling of discomfort, quickly followed by sharp and severe pain. Examination will, in this case, disclose a small, round, inflammatory area, which is hot and red, and exquisitely tender to the touch. The patient also has fever and an increase in the pulse rate. CHAPTER XXV THE APPENDIX The appendix is located in the right iliac region at a point about two inches from the umbilicus on a line running from the umbilicus to the anterior superior spine of the ilium. It gen- erally lies deep in the abdominal cavity, and has no direct connec- tion with the abdominal wall. As a rule, it and the adjacent loops of the bowels are covered by the omentum, which hangs over and protects them from injury, either traumatic or infective. It is, in the majority of cases, free, although its excursions and movements are somewhat restricted by a short mesentery which joins the right leaf of the mesentery proper and is called the mesoappendix. Through this mesoappendix the appendix derives its blood and nerve supply. The blood supply is derived most frequently from the posterior branch of the iliocecal artery, formed from the junction of a branch from the iliocolic with one from the colica dextra. The nerve impulses are carried through the superior splanchnic of the sympathetic. The researches of Neumann (127b) have definitely shown that the splanchnics convey painful sensations to adequate (tension) stimuli. The pain ^ in appendicitis is, in the early stages of the attack, found to be general, or, as it is termed, diffuse, being distributed over the entire abdomen, though frequently it is first perceived in the epigastric or umbilical region. Then it becomes localized to the region of the appendix and, as the peritoneum becomes in- volved, it again spreads. In gangrenous appendicitis there often ' The nervous system of woman reacts to pain more readily than does that of man (265, p. 408). 5U THE APPENDIX 515 is lack of i^aiii, assumed to be due either to benumbing of the pain receptors by the toxemia, or possibly because there are no peristal- tic waves set up in the appendix. The diffuse pain is probably due to an explosion of nervous impulses, which are produced in the appendix by the sudden distention and consequent traction thus Right side shows cuta- neous distribution X Thoracic nerve xi Thoracic nerve xii Thoracic nerve Left side shows muscu- lar distribution Fig. 107. — Cutaneous and Muscular Distribution of 11th and 12th Thoracic Nerves. It is seen that the eleventh thoracic supphes principally the lower segment of the rectus abdominis muscle. Thus since this segment is the one usually connected with the appendix it is easy to understand the reason for the local and segmental contraction of the rectus muscle in appen- diceal inflammatory states. induced upon the mesoappendix.^ It has been stated by Lennan- der ^ that all pain arising from intraabdominal changes is due to peritoneal traction produced by these changes. The secondary pain, which becomes localized to the region of the appendix, may be due 'Moullin (226, p. 515) claims that the initial pain of appendicitis is due to the "peristaltic action of the cecum or of the appendix dragging upon the attachment of the cecum to the abdominal wall." When the inflammation spreads to the muscular coat the latter can no longer contract, and as a conse- quence the pain ceases. Moullin also claims that such a relationship is shown by the fact that the cessation of the umbilical pain is coincident with the formation of a local swelling "due to distention of the bowel and the thicken- ing of its walls by inflammatory exudate." ^Lennander's explanations, however, as has been repeatedly pointed out, are not valid, because of the oversight of what constitutes an adequate stimu- lus for the internal viscera. 516 THE APPENDIX to involvement of tbe terminal sensory filaments of the spinal nerves distributed to the appendix.^ These refer the sensation to their terminal somatic filaments and the abdominal wall and, since the eleventh spinal segment (Deaver) is connected with the appen- dix, the pain will be referred to the filaments of distribution of this segment. The principal points of emergence of these nerves are near McBurney's point, thus accounting for the pain in this neigh- borhood. It is also possible for an appendix to be inflamed and give rise to no symptoms. For example, in many cases I have exam- ined appendices where strictures were present, indicating an old inflammatory reaction, and yet the patient was unable to recall any attacks of pain resembling an appendicitis. Varieties of Appendiceal Pain. — Pain in appendicitis may be divided into the following classes ; I. Local pain due to: (1) (a) Obstruction. (&) Inflammatory swelling. (2) Inflammation: (a) Mural. (h) Extramural. (3) Adhesions: (a) To other abdominal viscera. (6) To the peritoneum. II. Distant pain, which may be: (1) Referred pain: (a) To the abdominal wall of the same side. (h) To the tunica vaginalis testis and also to the sacroiliac region. (2) Transferred pain: (a) To the abdominal wall of the same side, at a higher or lower level. (h) Crossed to the abdominal wall of the other side, at the same or at a higher or lower level. ^ It is questionable whether the terminal filaments of any spinal nerve ever really reach the appendix. VARIETIES OF APPENDICEAL PAIN 517 (3) Keflex: (a) Headaches. (5) Reflected pain. Local Pains. — (1) Obstruction. — The local pains are due to: appendiceal colic, the result of obstruction of the lumen of the appendix by (a) some indigestible food, (&) a foreign body, (c) a kink in the appendix, or (d) constriction by adhesions. (a) In some cases indigestible food, as the chaff of the wheat grain, or of any other cereal, or the seeds of various fruits and berries lodge in the appendix, and, because of diminished muscu- lar power, it is unable to extrude them ; consequently, they re- main in its lumen and are a source of irritation. This irritation is the signal for the gathering of germs which produce a mild grade of inflammation; and, as a consequence of it, fermentation and a slight dilatation of the lumen occur ; this in turn stimulates contraction, and this causes the pain, (h) Foreign bodies may lodge in the appendix, as fecal concretions, or seeds, (c) Kinks may occur in the appendix. In these conditions the bend in the appendix hinders the emptying of its lumen; consequently, there is an accumulation of secretion and fecal material on the side distal to the obstruction. This causes distention, with a conse- quent tendency of the appendix to straighten out, and there re- sults a great pull and drag uj^on the segment of the mesoappendix to which the distended segment is attached. This either initiates a pain or adds to the pain which is already present. If the obstruc- tion is near the end of the appendix, and the appendix is unable to contract, there is little, if any, pain from the obstruction, (d) The active causative factors of pain due to constriction by ad- hesions are the same as when kinks are present. Obstruction may be due to an inflammatory swelling, which causes a blocking of the lumen of the appendix, distal to which the distention occurs, with consequent pain production. (2) Inftammation. — The pain of appendiceal colic is, in many instances, due to an associated inflammation of the ileum, because of which the peristaltic waves become painful. This adjacent iu- 518 THE APPENDIX flammation is more definitely indicated bj the close association of these attacks and the subsequent diarrheas. Inflammation of the appendix may be divided into three stages : (a) Inflammation which is confined to the mucous and the submucous coat. Often, in this condition, no actual pain is pres- ent; rather there is a sense of discomfort, which, as a rule, is referred to the region of the umbilicus. This is the class of cases in which the complaints are mainly digestive, such as pres- ence of gas in the stomach and intestines, distress after eating, and a tendency at times to nausea and vomiting. These symptoms are but the reflex indications of a sympathetic involvement. Should the onset of the inflammation be sudden, the shock to the sj'mjDathetic system is greater, tbe above symjDtoms are in- creased, and a well-marked, referred pain is present. (&) Inflammation of the muscular coat follows closely upon that of the mucous. To the above symptoms, well-defined local pains are now added. These, following closely upon signs of mucosal involvement, are a sure indication that inflammation is spreading. (c) Involvement of the peritoneal coat nearly always occurs if the inflammation is severe. This happens, as a rule, only in acute processes; that the peritoneal coat may be involved in a chronic inflammation is possible ; but by far the vast majority of peritoneal inflammations arise from an acute inflammation. If tlie attack is acute and the inflammation has advanced to the peritoneum, there is then present a greater intensity of the cuta- neous hyperalgesia and referred pain. Following the onset of the local pain, also, in some cases, in which the appendix is so situ- ated that it lies in close contact with the parietal peritoneum, this layer also becomes involved in the inflammatory process. The local peritonitis is then manifested by exquisite local tenderness. With peritoneal involvement the sympathetic reflex symptoms are increased; nausea and vomiting occur, local peristalsis ceases, constipation ensues, distention of the bowel comes on, and symp- toms of toxemia appear. These are accompanied by an elevation VARIETIES OF APPENDICEAL PAIN 519 of temperature and a rise of the pulse and respiratory rate. An- other sign of importance (reflex in nature) is the cessation of dia- phragmatic breathing as soon as the peritoneum becomes involved. It is of importance, in deciding the extent of involvement, to note the presence or absence of irritative peristalsis in the cecum. The manner of obtaining this is suddenly and lightly to palpate over the appendiceal region, having, at the same time, the bowl of the stethoscope over the cecal region ; should the peritoneum be in- volved, no peristalsis will take place; should the peritoneum not be involved, peristalsis will immediately follow. This sign has been elicited in many cases. (3) Adhesions. — Should adhesions from the appendix drag upon the parietal peritoneum, the pain is sharply localized to the area of adhesion, is of a dragging nature, and is worse when cer- tain positions are assumed by the patient. A right lateral recum- bent posture often seems to be conducive to the induction of this pain. Active movements, also, as bending forward or backward, will cause pain, if the appendix is adherent to the anterior abdom- inal w^all. Bowel distention, by dragging upon the adhering per- itoneum, will cause pain, which ceases upon the passage of the bowel contents. Adhesions between the appendix and the body of the psoas muscle are often the cause of the pain felt by those suffer- ing from chronic appendicitis when they attempt to climb stairs. Distant Pains. — Pain in appendicitis is sometimes felt at a distance from the site of the appendix. These pains are due to stimuli transmitted from the site of the original lesion through the nervous system to nerve collaterals. This stimulation is per- ceived as pain, and is felt as coming from the area of distribu- tion of the nerves originating in the centers irritated. The distant pains may be classed as referred, transferred, and reflected. Referred Pain. — Referred pain is due to the transmission of the stimuli along the splanchnics to the related spinal centers in the cord, and the pain seems to be produced in the area of dis- tribution of the latter. By a study of the figures following, the location of the transferred pains may be seen. It is also 520 THE APPENDIX shown how irritation to any division of the eleventh nerve will cause a contraction of the rectus, particularly the segment supplied by the eleventh thoracic nerve. Should the irritation be strong enough, the tenth nerve may also be irritated, and segments of the muscle above the part suj)plied by the eleventh may also be thrown into contraction. The figTires also show how dorsal cutaneous ten- • Posterior division of 11th dorsal nerve -Posterior division of 12th dorsal nerve Fig. 108. — Areas Supplied by the Posterior Branches of 11th and 12th Thoracic Nerves. The figure illustrates how appendiceal pain may be felt posteriorly in the distribution areas of these nerves. (Drawing modified from Toldt.) derness and lumbar jDain may be present, the areas in which they are found being marked off on the figure. Pain is, in some cases, also referred to the vaginalis testis of the same side, or it may be referred to the extreme lower j^art of the abdomen, or to the upper part of the thigh. This reference is through the first lumbar nerve, which is distributed to the lower abdomen and upper part of the thigh; also, through a small branch to the tunica vaginalis testis. Transferred Pain. — By transferred pain is meant that form of pain which is felt on the opposite side or at a higher or lower level of the body than the lesion causing it. It is due to the trans- VARIETIES OF APPENDICEAL PAIN 521 mission, upward or downward in the cord of the stimulus from the point of origin. In the following drawing, modified from Toldt, it may be seen how an appendiceal pain may be transferred across the cord and be felt on the opposite side, the arrows indicating the origin of the stimulus in the appendix, its conduction to the thoracic sym- pathetic ganglion, and thence its transference either to the ante- rior or to the posterior division of the nerve, the pain being felt PAtN l\^. 1/ \ V\ /^ PAIN PAlH ^AIN Fig. 109. — Aheas of Pain Referred from the Appendix. The arrows indicate the direction of the referred sensation. The two sets of nerves are the superficial and the deep nerves of the abdominal wall. At the point where they pass through the wall and become superficial pain is felt. (Drawing modified from Toldt.) either in the anterior or posterior abdominal wall. At its begin- ning the anterior division of the nerve lies in close relationship with the peritoneum, so that any irritation of the peritoneum would cause pain, which would be felt either at the point of pro- duction, or would be referred to the anterior abdominal wall. Irritation at this point would also stimulate the motor fibers in the nerve and segmental contraction of the rectus would result. Reflected Pain. — The sympathetic nerve supply to the appen- dix is derived from the superior mesenteric plexus, which re- 522 THE APPENDIX ceives its supply from the ninth, tenth, eleventh, and possibly the twelfth dorsal segments. It seems, however, that the origin is chiefly from the eleventh and twelfth dorsal segments, the eleventh being the one most often involved in appendiceal lesions. In case Fig. 110. FiQ. 111. Figs. 110 and HI. — Areas of Cutaneous Hyperalgesia in Appendicitis Corresponding to the 11th Dorsal Area of Head. of very sudden onset, with severe toxemia, reflected pain may be absent. It is also frequently absent in secondary attacks, because of the destruction of the nerve endings, which has occurred in the primary attack. In these cases of reflected pain the pain is due either to inflammation or to distention of the appendix. That the inflammation alone can cause it is well authenticated; while the fact that the reflected pain may suddenly cease on per- foration of the appendix demonstrates that it also is caused by appendiceal distention. Figs. 112, 113, and 114 represent a com- plete drawing of many of the reflected pains felt in appendicitis. Reflected cutaneous hyperalgesia is difficult, if not impossible, to elicit, should ice or counter iriitation have been applied to 'Z. h 3 a 3 o 'So < ^ ^ Cm t, O' o 03 (M z _^ ^ O ^i 'A 73 •S^ .J fa ■a o CO a P4 « 22 "* H 03 1— I o O o -^ d w Ph :i eb ^_ ? 3 S (N GiOS u, H 'S o , OJ bO "S 3 3 ^1 •r' fa g S, ^ W 02 ^ ^ P4 3 tH cc CO H 3 . O +J o 3 I— 1 O THE APPENDIX the patient a short time previously, because both reduce the cuta- neous sensibility. According to Maunsell Moullin (226, p. 516), "When hyper- esthesia is definitely associated with other evidence pointing to an inflammation of the appen- dix, it may be taken as a clear indication that the wall of the appendix itself is involved and that, therefore, though the in- flammation may subside, it will in all probability leave some permanent alteration in the ap- FiG. 115. — Location and Radia- tion OF Sympathetic Reflected Pain in Appendicitis. 1. Probably indicates some traction on the splenocoHc ligament from pull on the colon. 2. Appendix is probably directed to left side, mesentery being derived from left. 3. Appendix being directed up under the colon. 4. Referred pain in early stages of appendicitis. 5. Referred pain in early stages of appendicitis. Fig. 116. — Location and Radia- tion OF Sympathetic Reflected Pain. 1. Pain in this case was referred to the sacroiliac synchondrosis. 2. Pain was present over the sacro- sciatic notch and radiated down the leg. Appendix was found lying across the psoas muscle, being entirely retroperitoneal. No mesoappendix was present except about 3^ inch at extreme tip of the appendix. 3. Same as 3 in Fig. 115. 4. Pain over left kidney due to gangrenous appendix, no kidney lesion. VARIETIES OF APPENDICEAL PAIN 525 pendix, which later will necessitate operation. Sudden cessation of the hyperesthesia without at the same time any improvement in the other symptoms often indicates that the appendix has be- come gangrenous." Figaires 115, 116 and llY show the location and radiation of sym.pathetic reflected pain. Fig. 117. — Areas of Hyperalgesia in the Uth Dorsal Visceral Seg- ment Due to Appendicitis of the Catarrhal Type. The pain of appendicitis is well illustrated in the accompany- ing case, in which the acute pain, present in the right side, was associated with a well-marked hyperalgesia over the same area. As the subjective pain decreased, the hyperalgesia also decreased, so that when the subjective pain was gone the latter also was entirely absent. Deep pressure over the appendix area still caused pain, but no hyperalgesia, so that the patient was tender but not hyperalgesic. This illustrates tho independence of the two symptoms. On operation the appendix was found enlarged, swol- len, and very much inflamed. It extended along the right side of the abdomen, running up in the direction of the liver. Adhesions were not present. The following photographs are of a boy eight years of age. Qj a> ^ -*^ -^J •^ -2 ^ CD C o ■4J 3 e O eS S -*:> O g ^ o '3 « -C a, t^ -fj r^ « oT a -X ^ 3 a> o s m c ~ s a o O O .2 S "3 o 'm 3 +3 ^ w 03 ^ d. a "P o Oh b rt <11 03 1— 1 K C3 03 a ^ o O -If +3 o d o H -O (^ o -§ 2 E-i 2 ~ o O 12; "m C < o i -t^ g r- t^ -d -^ "tJ ^ G ^ Ah o "'^ »^ H ■" +3 O O o 05 02 "3 -^ w X ^ o IS I- rt 03 -2 "^ > "si 03 a s 2 H -ri is CO 2 fi r-4 o T-H H a a> 02 O 03 si < +3 S .2-^ «4-t « 't/2 y2 o o o '— Z ?■ o ^ '— «-(-. 03 1— ( "^ c> d o 02 < pj a ^ CO "^ <4-l o ^ 1. -tJ s 00 v-' .3 g ^ 11 o 3b d K "i J2 fe o ^ 1 1 c5 ^ ^ 3 ^ o 5 13 -G c G ^ o S 3 3 0) +3 "? .^ o <4-l o IS m f^ 03 ^§ fi «i 3 d 03a VARIETIES OF APPENDICEAL PAIN 527 who complained of severe pain in the abdomen. Examination showed the following area of tenderness (see Fig. 118) : the shaded portion, which indicates the area of sensitiveness to pain, such as to pinching; the cross-shaded portion, which indicates the area of sensitiveness to touch, and the dark spots, which indicate points of maximal tenderness (to touch), which were produced by deep pressure. The circle around the umbilicus indicates the region to which he referred his pain. At first there was thought to be a possibility of malingering in this case, as on a second examination the area of sensitiveness had moved slightly, and on a third examination the area of cutaneous hyperalgesia was much smaller than on the first exami- nation, being about one-half inch smaller at all points. This idea was dismissed later, as it was observed in several cases that the area of hyperalgesia may change according to the change in the position of the patient, and definitely according to that change ; also that it becomes smaller as the disease progresses toward a cure. Pain on the left side in appendicitis may, in some cases, be due to the position of the appendix on that side. Below are a few of the positions which the appendix may take, owing to a faulty rotation (Annals Surg., July, 1908, p. 137). Left-sided pain may also be due, in some cases, to an inflamed appendix situated in the pelvis on the left side. Sympathetic pain, such as headache or generalized aching, so common in appendicitis, is the result of the action of the toxins (produced in appendicitis) on the centers supplying the areas in which the pain is present. In connection with aberrant pains in appendiceal inflamma- tory states, it is a fact that, in many of these so-called pains, there is a separate anatomical basis for the pain-sensation. Appendicitis and colitis, says Lockwood (127b), are often closely related, and in those cases which had pain over various parts of the colon there was also associated a mucous colitis, which was the underly- ing cause of this most prominent and distressing symptom. In regard to involvement of the colon in appendicitis and its relationship to pain-production, the reader is referred to the sec- o 3.2 -2 528 TENDERNESS IN APPENDICITIS 529 tion on diseases of the colon, where the pain resulting from colonic involvement is carefully reviewed. In this connection it is well, also, to recall the fact that epi- gastric pain, occurring at some late stage of appendicitis, or dur- ing the course of the disease after the pain has been localized in the right iliac fossa, is almost pathognomonic of a peritonitis (W. D. Stanton). Tenderness in Appendicitis. — The following are Robinson's (265, pp. 414-415) conclusions in regard to the presence of super- ficial tenderness in disease of the appendix: "In disease of the vermiform appendix, or in disease originat- ing therein, cutaneous tenderness is sometimes present, most com- monly in the skin innervated from the eleventh dorsal segment of the spinal cord, but also sometimes in the territory of the ninth, tenth, and twelfth dorsal, and possibly the eighth dorsal and first lumbar segments. "According to Sherren (26G), there are three chief forms of cutaneous tenderness. The first is in the form of a broad band, extending from about the level of the first lumbar vertebra around the anterior surface of the body, having a general downward direction, and ending below the umbilicus. Its lower edge rides over the crest of the ilium. The entire band closely corresponds to the area of sensory distribution of the eleventh dorsal segment. The second area is triangular, its upper boundary being on a level with the umbilicus, its apex over the crest of the ilium, and its base on the right side, toward the median line of the body. The third area is found about the middle of a line joining the umbilicus and the anterior superior spine. A corresponding area is on the back just above the iliac crest. "A patient displaying an area of superficial tenderness of one of these three defined varieties is, in the gTeat majority of cases, suffering from appendicitis. ]^evertheless, many other diseases may resemble appendicitis in this respect ; for instance, renal colic, perforated gastric ulcer, intestinal colic and perime- tritis. . "Infiammation of nerve trunks is not the cause of this symp- 530 THE APPENDIX torn, for the latter may occur in skin supplied by the post-primary divisions of the spinal nerves. There is little evidence as to the immediate cause of this reflex tenderness, but it is probably due to irritation of the afferent nerves from the appendix. The irri- tant is possibly, in some cases, tension ; in others, it is almost certainly something different. The symptom is found in a minority only of the cases of appendicitis seen in hospital prac- tice. It may, while a case is under observation, vary in charac- ter or disappear altogether. During the progress of an attack, it may appear in a patient in whom it has not originally been present. "Cutaneous tenderness is found as frequently in subsequent as in first attacks of appendicitis. It may persist long after all other signs of the disease have disappeared. ''The prognostic and therapeutic significance of cutaneous tenderness, in cases of appendicitis, is slight. It is somewhat less often found in cases of abscess than in other cases. When the symptom and abscess coexist, the abscess is usually only a beginning process. "Cases of widespread peritonitis, set up by appendicitis, may display large areas of cutaneous tenderness over the right side, or over the whole of the abdomen." Tenderness as a Symptom in Appendicitis. — In two hundred and forty-seven cases, reported by Sherren (267), and Robinson (265), hyperalgesia was found in 66, or 26.7 per cent.: sixteen times as a complete band ; thirty-two times as a triangle ; four- teen times as a circular spot; and three times as a large, irregu- lar area. Sherren makes the statement that tenderness may be absent in attacks after the first, if the first attack was of sufficient sever- ity to destroy nerve tissue in the wall of the appendix (265, p. 398). The number of cases examined by Robinson was one hun- dred and twenty -three, and the proportion of positive and nega- tive cases was 21.1 and 78.9; but, as Robinson says, this does not invalidate Sherren 's statement, for the occurrence of previous attacks may dispose the sufferer to superficial tenderness, and so TENDERNESS IN APPENDICITIS 531 make up for the cases in which nerve tissue has been destroyed. He further says that the cases he has seen are the severe and neglected ones; and that in the milder cases, which are seen in private practice, the presence of pain is more common. During its disappearance, as the other symptoms of the dis- ease clear up, the areas of hyperesthesia assume many irregular and migratory shapes. Another conclusion of Sherren's is that the disappearance of cutaneous hyperalgesia, without improvement in the general con- dition of the patient, is a sign of perforation or gangrene, and should be the sign for immediate operation. Bennett (142, p. 1005) questions the entire accuracy of this statement. According to Sherren, also (265, p. 399), the presence of cutaneous tenderness is no contraindication for operation. Ab- scess may form and general peritonitis develop while it is pres- ent. Of twenty-six positive cases, Robinson found abscess in eleven ; gangrene in nine ; perforation in seven ; and general peri- tonitis in three. "However, absence of cutaneous hyperalgesia is of gTeat im- portance. Absence of cutaneous hyperalgesia in a patient coming under observation early in the first attack of appendicitis is a sign of gangrene of the appendix, unless the case is obviously mild and is getting well rapidly. (Robinson is in accord with this state- ment.) Cutaneous tenderness, as a rule, is absent in cases of abscess of the appendix. (This is true in two out of three cases.) The age of the patient and the position of the appendix have no influence on the cutaneous hyperalgesia. Cutaneous hyperalgesia is occasionally of use in the diagnosis of appendi- citis. Cutaneous hyperalgesia, in the area which is associated with appendiceal disease, generally is an indication of appendi- ceal involvement, though of necessity it is not a pathognomonic sign, for it has also been noted in other conditions, such as per- forated duodenal ulcer, intestinal colic, and peritonitis. In a case of perimetritis the area of hyperalgesia was in the form of the small circular patch, already described. This may be the same as Morris's point or area of tenderness" (Sherren, 265). 532 THE APPENDIX Varieties of Tenderness. — In acute appendicitis two varieties of tenderness are present: (1) tenderness to superficial irritation in which over certain areas light pressure, as the drawing of the point of a pin over the surface, produces pain. These areas of tenderness are but reflexes from the viscera, and correspond to the zones Head has worked out for the eleventh and twelfth dorsal segments. Recently Elsberg, of New^ York, has confirmed to a large extent the earlier observations of Head. The points of most exquisite tenderness are but the maximal tender points of Head. Robinson says (265, p. 392) that it is "remarkable, in all definite cases of appendicitis, how definite is the line of tender- ness between the tender and non-tender areas." This superficial tenderness generally occurs during the first attack, which may be a very mild one. In some cases the discom- fort may be the result of a mild inflammation of the mucosa, while in others for the pain production it is necessary that the perito- neum be involved. Sherren (267, 625, p. 390) thinks that a suj)erficial tenderness is due to stimulation of nerves within the appendix, the result of intralumenary tension. This statement is disputed by Robinson, who says that "inflammation and the products of inflammation are capable of acting just as well." He says further, that "tension may exist without tenderness, tenderness may be present without tension, and the mere destruction of the afferent nerve fibers or endings does not seem to abolish the symptom in all cases, any more than tension on them of necessity produces it." (2) Tenderness on deep pressure is always an indication that the inflammation has spread to the peritoneum. It is generally, also, an indication of an abscess formation, in which the parietal peritoneum takes part. Should the peritoneal involvement be con- siderable, subjective pain will also be associated with the tender- ness, and the muscles over the painful area will be contracted. This contraction is due to the beneficent reflex of Hilton, in which the muscles over an (inflamed) area supplied by the same nerve or nerves contract. In chronic appendicitis the tenderness is due chiefly to the TENDERNESS IN APPENDICITIS 533 adhesions which are present. In this condition palpation of cer- tain areas seems to be particularly painful. The increased pain is due to the much greater pull or drag upon the band of adhe- sions, resulting from the palpation. Peristalsis of the bowel will also cause pain. In examining patients for cutaneous tenderness see that no poultices, compresses, fomentations, or ice have pre- viously been used. Tenderness may also be found : (a) In the lumbar regions when the appendix is retrocecal. Here the tenderness is probably due to direct pressure exerted by the cecum upon the appendix. (&) Vaginal palpation may produce pain if the appendix lies in the pelvic cavity. It is very hard in this condition to distin- guish by palpation an appendix from an inflamed fallopian tube. However, the other signs and symptoms present in appendicitis aid in the diagnosis. Should the appendix be in the pelvis, defe- cation and micturition, due to the traction exerted upon the ap- pendix by the adhesions which bind it to the bladder or to the rectum, may be painful. Pain may also be present on bending and straightening of the thigh. When this is the case, the appen- dix lies on and is adherent to the psoas muscle, and the pain is due to pressure and traction, the result of movement and contraction of this muscle. (c) Transabdominal tenderness, — In many cases a typical ap- pendiceal pain can be produced in the area of appendiceal reflec- tion by making pressure over the colon at the corresponding point on the left side. This area corresponds rather closely with Mor- ris's point of tenderness in tubal and ovarian disease. Eovsing (Ref. 190) makes no mention, however, of the presence of tubal or ovarian disease, but states that in more than one hundred cases it was never found unless there was some affection of the cecum or appendix.^ ^ Dieulaf oy had first indicated the contraction of the abdominal musclea as an indicator of intraabdominal inflammatory states — the so-called muscular defense, defense musculaire. This symptom is a good indication that gan- grene or perforation, with beginning free or circumscribed peritonitis, has al- ready taken place. 534 THE APPENDIX Special Points of Tenderness. — The presence of pain at Mc- Burney's point lias long been regarded as symptomatic of appen- diceal involvement. This point is situated one and one-half inches from the anterior superior spine, on a line running from the anterior superior spine to the umbilicus. Pressure at this spot has been held to be iiroductive of pain in diseases of the appendix. This area of pain is not constant, but it may be said that in general its presence indicates appendiceal involvement, while its absence is of no significance. In no case is its presence in any way connected with the location of the appendix. In fact, Lanz has shown that, as a rule, the appendix is some distance away from the painful spot, and generally is below it. Morris, of !New York, has described a point of tenderness about one and one-half inches from the umbilicus, on a line ex- tending from the navel to the anterior superior spine of the ilium. In reference to this point and its diagnostic value, the con- clusions of Hubbard are pertinent. He says that, "this tenderness is due to a tender lymjDh-gland, which has drained the region of the appendix, and there is nothing absolutely diagnostic in its presence. In acute appendicitis tenderness at Morris's point is of less importance than the symptoms caused by the appendix itself. However, in chronic appendicitis tenderness at Morris's point may be of distinct diagnostic value. Tenderness at this Perman (80b) had in a report of appendix cases (appearing in the Hy- geia for 1904, p. 797) spoken of right-sided pain produced by pressure in the left iliac region in a case of appendicitis. At the present time this symptom- complex is known as Rovsing's sign. The best way to obtain the pain is to lightly tap the abdomen on the left side, while the patient breathes quietly and relaxes the abdominal muscles. Perman argues with Hofman and Hausman that the pain is not due to the stretching of the cecum due to the pushing up of the colon contents, but rather to the pressure carried directly from the palpated to the inflamed area. If the sign is present, in chronic or in interval attacks of appendicitis, it is due to adhesions. When present in acute attacks, the appendicitis is not simply a catarrhal form, but is a pathological case of the most severe kind, either a beginning phlegmonous infiltration or gangrene with threatening perforation. The sign may also be present in salpingitis. In a few of those cases and in pelvic peritonitis Perman (80b) has observed it. Lauenstein (53b) also doubts the value of this sign, and believes that Eovsing also will in the future change his mind regarding its absolute sig- nificance. SYMPTOMS ASSOCIATED WITH PAIN IN APPENDICITIS 535 point, even though the only physical sign, by the rule of chance, makes the diagnosis of appendicitis probable. When combined with tenderness at McBurney's point the diagnosis becomes more certain. Its absence does not rule out appendicitis, and its pres- ence does not make the diagnosis of appendicitis absolute, for it may occur in other conditions besides appendicitis. The point has by no means the importance given it by Dr. Morris." (See areas of reflex tenderness. Head's zones, in appendicitis.) In hernia of the appendix the pain is more or less diffused around the umbilicus, or lies in the lower abdomen. It is described as colicky in character, sometimes as a dragging sensation which in felt in the right iliac fossa. (See the relationship between the dragging and the location of the pain, which is the same as in an early case of appendiceal inflammation.) Symptoms Associated with Pain Production in Appendicitis. — Rigidity of the right rectus is an almost invariable accompani- ment of appendiceal inflammation. It is most marked in the muscular segments located immediately above the appendix. Should rigidity suddenly increase, and become general over the entire abdomen, with a sudden increase of pain, it is an indica- tion of a rupture of the appendix, or of a sudden spread of the inflammation, so that a generalized peritonitis has resulted. Constipation is one of the associated symptoms of appendi- citis. It is due to a reflex arising from the inflamed organ. Often the reflex peristalsis can be aroused in a normal intestine by the pressure of the bowl of the stethoscope. A weak or absent peri- stalsis is an indication of the spread of exacerbation of the inflam- mation. Motion is generally interfered with; climbing the stairs is a source of pain, especially when the appendix lies upon the psoas muscle. The reason of the much greater pain when the patient is walking or climbing stairs is that, in these conditions, there is a concomitant contraction of the psoas muscle and the abdominal wall muscles, and the appendix, caught between the two, is sub- ject to considerable pressure. Often the first indication of peri- toneal pain has occurred during the drawing on of the shoes. 536 THE APPENDIX Posture. — In appendicitis the patient usually assumes a re- cumbent dorsal posture, with one limb, usually the right, drawn up, and in some cases lies with the right limb thrown over the left. In many, especially after an abscess formation, or when adhesions are present and the bowel segments are bound to- gether, a left lateral posture is very painful ; this is due to the drag and pull upon the adhesions by the weight of the bowel in this position. It is common for patients with appendicitis, when walking, to bend the body forward and step lightly. Jarring, such as occurs in running and jumping, frequently causes pain. x\ny spasmodic movement of the diaphragm, such as takes place in vomiting, coughing, and sneezing, also gives rise to pain. Percussion of the abdomen also produces it, and it is claimed by Schmidt that often by this means the delimitation of pain is more accurate than by any other. The pain is greater when percussion is made directly over the median line than when it is made to either side, because here the protective action of the Muscles to the abdominal viscera is lacking. During appendicitis pressure on the abdomen is very painful, particularly so if to the appendicitis peritonitis has been added. When this ensues vomiting generally occurs. In some cases of appendicitis, pain can be produced by palpation upon the opposite side of the abdomen. Another means of diagnosing appendicitis is to distend the colon with gas. As soon as the gaseous distention reaches the appendiceal region, pain is produced by disturbance of the cecal relationship if peritonitis is present, or by appendi- ceal distention should only the appendix be involved. However, this is a dangerous procedure, and should be used, if at all, only in chronic cases. Sudden increase in the sensibility to pressure is indicative of extension of the inflammation. The sensibility may be so great that even the weight of the bed-clothes is unbearable. In some cases distention of the bowel may also cause great sensitiveness to pressure. Pain on pressure under the costal margin is chiefly of peritoneal origin. The pain of appendicitis, in many cases, seems to be induced DIFFERENTIAL DIAGNOSIS 537 bj peristalsis. Many a sufferer has been aroused in the middle of the night by the most severe cramps, Avhich the later progress of the case i^roves to be of appendiceal origin. These come on at the time intestinal peristalsis is most active, that is, from five to seven hours after eating. In some cases the ingestion of cold food or drinks will incite active peristalsis and thus cause pain (Schmidt). Differential Diagnosis. — The pain of appendicitis should be diagnosed from : colitis, which generally is not productive of pain; but if it is, the accompanying diarrhea, with its content of mucus, is sufficient for a diagnosis; intussusception, in case of tumor formation. It is very difficult, in many cases, particularly Avhen pain is very severe, to decide whether the condition is one of appendicitis or intussusception, especially so should the condi- tion be associated with vomiting and constipation. Gall-hladder and gall-stone colic pain may be diagnosed by the higher area of cutaneous hyperalgesia ; also by the area of local tenderness present in these conditions. Typhoid fever, espe- cially when it is of sudden onset and commences as an acute ab- dominal pain, has on more than one occasion been mistaken for appendicitis, and the patient has been operated on under that mis- taken diagnosis, in some cases with disastrous results. Generally, in these diseases (typhoid), the pain, while severe, is still bearable, and, as a rule, there is not present any considerable amount of abdominal rigidity. The temperature also is of the ordinary typhoidal type, high in the evening and low in the morning, while in appendicitis it is more constant. The blood count in typhoid is also low in leukocytes, while generally, in appendicitis, it is high. Should the pain occur later in the disease (about the third week), and be associated with abdominal rigidity, perforation should be sought and careful inquiry should be made as to the type and character of the pain. A constant, spreading pain, very sharp and severe, generally indicates a spreading peritonitis. Ovarian and Tubal Disease. — In the diagnosis of appendi- citis from right salpingitis or oophoritis, the presence on the right side of tenderness, which is increased and, at the same time. 538 THE APPENDIX is associated with subjective pain at the menstrual period, is a criterion of worth. In those conditions which closely simulate both appendicitis and ovarian or tubal involvement, it must not be forgotten that either or all may simultaneously exist, and that, if they do so, symptoms of one or of all three may be present. If all of these organs are acutely inflamed, adhesions will remain after the inflammation subsides, and these adhesions will be a potent cause for pain production in the future. A point of some importance to remember is that pains due to involvement of the genitalia are never, or very seldom, influenced by the ingestion of food. Vaginal examination may help to clear the diagnosis, though when the appendix is in the pelvis it may be difiicult to differentiate appendicitis from tubal disease.. Hydi'oneplirosis has been mistaken for appendicitis, but the urinary symptoms of the former, with the history of the disease, should render easy the diagnosis. Ureteral calculus has a pain that is very sharp and severe, and soon after the cessation of the pain, or, if the attack is pro- longed, during it, blood may be present in the urine. Sciatica could hardly be mistaken for appendicitis, though appendicitis with referred or reflex pain down the back of the thigh has been mistaken for sciatica. Carcinoma of the cecum is a condition associated with tumor, emaciation, and signs of a gradually increasing intestinal obstruc- tion. Lumbago can hardly be confused with appendicitis, even in those cases in which appendiceal referred pain is felt in the back. Peritonitis has been mistaken for aiDpendicitis. This can hardly happen with a careful observer, for the bilateral and deep tenderness, generalized, with tenderness on vaginal and rectal ex- amination cannot but be interpreted as due to peritoneal involvement. Tuberculous peritonitis, in which the lesions are confined to the cecum, is very difiicult to diagnose from chronic appendicitis. The more chronic course, the tuberculin reaction, the presence of a focus of tuberculosis elsewhere, the very slow DIFFERENTIAL DIAGNOSIS 539 onset, with no history of an acute attack, are diagnostic criteria of very great value. Extrauterine pregnancy has also been mistaken for appendi- citis, but the presence of fluid in the cul-de-sac of Douglas, the history of pregnancy, the presence of anemia, and the passage of some bloody discharge from the uterus help in the diagnosis. Erythema exudativmn multiforme sometimes causes a pain resembling ajDpendiceal crises. Sagging loops of intestine, or omentum, by pressure upon the external abdominal ring, jDroduce j^ains that closely resemble those experienced in chronic appendicitis. Cheinisse (454, pp. 1-12) describes a condition which is fre- quently associated with syphilis, influenza, or hysteria, in which there is considerable pain around McBurney's point. The diag- nostic differentiating points are : the absence of leukocytosis, fever, and raj)id pulse. Painful points may also exist at the exit of certain nerves. The abdominal wall, also, is not rigid, and the pain, as a rule, is not confined to one defiiiite location. A variable tumor is felt. CHAPTER XXVI THE LIVER, GALL BLADDER AND DUCTS GENERAL CONSIDERATIONS The liver is the largest gland in the body. It is subject to diseases similar to those of other glands, and also to additional disturbances, functional and anatomical, due to its different structure and function and to its intimate relationship with the digestive apparatus. The painful disorders affecting the liver as a glandular organ are congestion, inflammation, adhesion, and displacement. The painful disorders affecting the liver and gall-bladder be- cause of modified structure are inflammation of the gall blad- der, inflammation of the ducts, obstruction of the ducts by foreign bodies or new growths, adhesions, etc. Nerve Supply. — The nerve supply to the liver is sympathetic. It does not, as many have thought, derive through its convex sur- face a partial supply from the branches of the intercostal nerves distributed to the dome of the diaphragm, nor does it have any connection with the phrenic, Ranstrom being unable to trace a single branch of the phrenic nerve through the suspensorium liga- ment to the capside of the liver, also no twigs from the intercostals could be found extending to the surface of the liver. The sympa- thetic fibers are derived mostly from adjacent sympathetic plexi and ganglia (coeliacum, etc.), which in turn are connected with well-defined segments of the cord. The cord segments involved in diseases of the liver proper are the eighth and ninth, and some- times the tenth dorsal, while the fifth, sixth and seventh dorsal segments are involved in disease of the gall bladder. The outlines 540 GENERAL CONSIDERATIONS 541 of the segments, with their maximal points of tenderness, are shown in the annexed figures. The maximal points of tenderness Fig. 122. — Abeas of Referred Pain in Liver Disease: An- terior View. (According to Head.) Fig. 123. — Areas of Referred Pain in Liver Disease: Pos- terior View. (According to Head.) of these zones closely correspond with the areas in which pain and tenderness are felt in diseases of the liver and gall gladder. The vagus also assists in the liver innervation (Edgeworth). In some cases of common duct disease, especially when the area near the junction of the hepatic and cystic duct is involved, the pain-producing stimulus is carried through the branch from the adjacent sympathetic plexus to the left vagus, and thence to the fourth and sixth dorsal segments, from whence it is reflected to the chest wall in the distribution area of these segments. This explains why pain is sometimes felt in the left anterior wall of the chest, at about the level of the fourth or fifth costal cartilage. The accompanying sketch (Fig. 125) shows how pain irrita- tive sensation may be carried from the vicinity of the hepatic duct to the vagus, and thence be propagated through the sixth or fourth ganglia of the sympathetic to the adjacent cord section, 542 THE LIVER, GALL BLADDER AND DUCTS from whence it is carried to the brain, and is felt as coming from the somatic distribution area of these segments. The maximal points of tenderness in these segments are shown in Figs. 122 and 123. Pain in the right shoulder in liver disease is transferred through the right phrenic. This happens when the diaphragm is involved by a lymphangitis spreading from an inflamed liver or gall bladder. The draw- ing on the next page shows the paths of com- munication between the liver and the cord. The liver itself is not very sensitive to pain-producing stimuli, for Lennander was able to apply a strong faradic or galvanic current to the surface of the liver above the gall bladder without exciting pain. He also claims to have separated the gall bladder from the liver as far as the cystic duct with- out the production of pain. The sensations of pressure, cold and heat are absent from the liver, as well as from the stomach and „ io/« A intestines. However, tilting of the liver, or X IG* 1^4, AREAS OF Referred Pain in pulling on the common duct, will cause pain. Liver Disease: According to Mayo, the most sensitive LateralView.(Ac- . , T . . ... cording to Head.) ^^^^ ^^ ^^^ liver is m the vicinity oi the common bile duct about the neck of the gall bladder. This area receives filaments from the eleventh and twelfth dorsal, and the first lumbar nerves. These nerves also supply the diaphragm, and this relationship probably accounts for the spasm of the diaphragm so often associated with gall-stone colic. It also accounts for the disturbance of diaphragmatic action, even under deep anesthesia, when in operating in this region pres- sure is made on this area. Murphy's ^ sign owes its presence to this reaction; for as soon as the sensitive area around the gall bladder is pressed against the examiner's fingers, there is a sudden * For a description of Murphy 's method of eliciting this tenderness, se* r.Kiiti- GalJ Bladder Disease. GENERAL CONSIDERATIONS 543 restriction of inspiration, and the characteristic grunt or groan as described bv Mnrphj occurs. The liver, as has been shown, is supplied bj both the sym- pathetic and the cerebrospinal nerves. Its cerebrospinal nerve supply is derived from the left vagus through a communicating branch which passes from the nerve plexus on the anterior sur- face of the stomach; thence it is distributed to the substance of LE.FT VAGUS N. SPLANCHNIC MAJOR. N. SPLANCHNIC MINOR. COMf^UNICATlNG BR.TO LEFT VAGUS -SEr^lLUNAK. GANGLION COMMUNICATING BR. L HEPATIC PLEXUS Fig. 125. — Relationship of Nerve Supply of Liver to Cerebrospinal AND Sympathetic Systems. the liver through the ligamentum hepatico-duodenale to the trans- verse fissure. The nerves accompany the arteries and are dis- tributed in their walls. This is important to remember, for it has a definite bearing on the production of pain in congestive states of the liver. Examination for Pain. — The grade of intensity of pain is of little guiding moment in the diagnosis of diseases of the liver or of its appendages. In many of these cases the patient is abnor- mally sensitive and is most irritable, so that a variety of subjective symptoms, either painful or otherwise, are experienced. Under these circumstances, local tenderness is most useful in defining 544 THE LIVER, GALL BLADDER AND DUCTS diseases of these organs. It may be elicited by: (1) palpation, (2) percussion, and (3) sensibility examination. Palpation is of the most value and is the method universally employed, the use of the other two being, as a rule, confined to those who are accustomed to employ in their examinations the refinements of modern tech- nique. Palpation should be attemf)ted only with the patient reclin- ing, with the abdomen flaccid, and the knees drawn up.^ With the abdomen relaxed the hand is placed flat upon the an- terior surface with the finger tips directed tow^ard the liver. For this purpose it is best to use the right hand and to stand at the right of the patient. The tips of the fingers may now be pressed into the abdominal wall below the costal arch at about the level of the ninth or tenth rib, and the patient is requested to take a deep inspiration. If, during or at the acme of inspiration, pain is felt, it is an indication of either a perihepatitis or a gall-bladder disordel". The fingers should then be removed to the area of the gall bladder ; the patient is raised to a sitting posture and another deep inspiration is taken. Should there occur a sudden stopping of the insj^iratory movement, accompanied by a grunt, gall-bladder disease is indicated. If nothing special is noticed on this proce- dure the patient is again directed to lie flat, and the right hand is placed on the back below the liver, while the left is placed above and over the liver. Firm pressure is now made between the two hands and at the same time the patient is instructed to breathe deeply. Should a perihepatitis be present the patient will com- plain of severe pain, which sometimes radiates to the front of the right shoulder. Nodular growths on the surface of the liver, tender on pressure, may often be felt in malignant disease of the liver. They are present along the lower margin and the convex surface. Percussion is of less value than is palpation as a means of eliciting pain phenomena in the diagnosis of diseases of the liver or of its appendages. If the liver is involved, percussion is pain- ful over the entire liver area, and, to a slight extent, beyond it. * Should the patient be unable to relax the abdomen, because, perhaps of an associated peritonitis, palpation is of no value. PAIN OF THE LIVER 545 If the gall bladder alone is involved diffuse tenderness extends around a much smaller area of maximum local tenderness as a center, the maximum tenderness corresponding to the location of the gall bladder. The cause of this considerable extension of tenderness is probably to be explained by the range of vibration produced by the percussion stroke; for even though the blow is made over an area which is not diseased the vibration may be communicated to an adjacent diseased area, and thus cause pain. In congestion of the liver, percussion in the epigastrium is productive of pain. This pain extends from the ensiform cartilage to the lower margin of the liver. Sensibility Examination. — Examination to light touch, pin- point and related sensory tests are of value in localizing the areas of hyperalgesia, which are identical with the areas of re- flected pain, as elucidated by Head. These areas are particularly useful in defining lesions which do not give rise to any acute symp- toms, such as abscess of the liver, cholecystitis not involving the peritoneum and cirrhosis. In some cases of liver, gall-bladder and duct disease the pain persists after the removal of the pathological lesion originally causing it. This persistence, the so-called habit-pain, is, no doubt, due to some pathological change in the nerve supply to these parts, by which the excitability to stimuli is increased to such an extent that reaction to a painfully excessive degree occurs on the slightest irritation. This excitability, which was originally due to the pathological lesion, remains for some time as a habit-state after the original cause has been removed. PAIN OF THE LIVER Character of the Pain. — In disease , of the liver the pain, if present, is generally of a dull nature, while in involvement of the ducts the pain is of an intermittent, colicky character, and is much more intense and severe than it is in disease of the liver proper. Relation to the Ingestion of Food and Drink.— The ingestion of food does not seem to have such an intimate relation to the 546 THE LIVER, GALL BLADDER AND DUCTS production of pain in disorders of the liver and its appendages as it does in disorders of the gastrointestinal tract proper, but that it is not entirely without influence is apparent. In nearly all of the diseases to which the liver, the gall bladder or its ducts are subject the movement of peristalsis and the augmentation of the circulation, which the ingestion of food produces, cause pain. The degi"ee of pain from these factors depends considerably upon the extent to which the liver structures are involved and particu- larly on the manner of the involvement. Should a perihepatitis be present or adhesions have formed, increased peristalsis and increase in the portal blood pressure in the liver will cause more pain than if an abscess or a cirrhosis constitute the entire pathology; consequently it is in the lesions of most acute and recent formation that the pain variation is most influenced by food ingestion. The ingestion of food also causes pain in a simple inflamma- tion of the gall bladder or of the ducts. The manner of the pain production may be explained on two hypotheses : (1) That there is an intimate nervous connection between the gall bladder, its ducts, the stomach and duodenum, so that when peristalsis is excited in the latter organs there is, at the same time, a reflex peristalsis produced in the gall bladder and ducts. Should the ducts or gall bladder be inflamed pain is likely to result. (2) Owing to the intimate relationship of all the structures in the upper abdomen, an increase of peristalsis in the stomach or the duodenum will, by pressure or dragging (from adhesions already formed), produce pain in the neighboring inflamed blad- der and ducts. Therefore, if pain in the liver, gall bladder or duct areas or zones is present after the ingestion of food, inflam- mation or adhesions should at once be sought. Schmidt (p. 215), in speaking of the relationship of food to the production of pain in liver, gall-bladder, or gall-duct disease, says that ''the taking of food is important only in those cases where we are dealing with delicate, anemic individuals, often with some degree of enteroj^tosis, esiDecially those with gastroptosis and PAIN OF THE LIVER 547 general atony of tlie stomach." It does not seem that the kind and character of the food, except when it is so indigestible that it leads to vomiting, have as much influence on the production of gall-bladder and duct pains as does the quantity, where it acts more as a mechanical agent, producing pain from its proximal pressure. In case the pain is of inflammatory origin, cold drinks seem to ease it. Relation to the Movement of the Body. — It may be stated as an axiom that when, in disease of the liver or its adnexa, pain is produced by movement, such as bending, stooping, and rapid or forcible breathing, inflammation is present; while, should these movements, including change of position, not produce or increase the pain, it may be accepted as a fact that inflammation is absent and that any si^ontaneous pain which may be felt is due to stone, or to some disease causing a slow tissue change, as cirrhosis. It seems that in inflammatory diseases of the hollow viscera deliber- ate movements and change of position are not particularly pain- ful, but that rapid movements, especially those involving a jar, are productive of great pain. Movements such as occur in running, jumping, riding horseback, traveling in springless wagons, going up or down stairs, and some movements connected with respira- tion, such as sneezing, coughing, and yawning, are very painful. Positions causing intraabdominal pressure are also painful ; for example, the bending of the body, stooping, and defecation. Position of the Body. —In inflammatory diseases of the liver the patient tries, as much as possible, to inhibit motion and to avoid everything which causes dragging upon the liver and its attachments, as this causes pain. To do this he generally lies in bed upon his right side. It might be urged that this is a very poor position for him to assume in order to acquire ease, for in it the pressure from the abdominal viscera is greatest upon the inflamed liver, gall bladder, and ducts, and consequently one would think that the jjain should be greatest. It is very true that in such a posture there is great pressure on the liver, etc., but it should be recalled that the assumption of the left lateral posture would put considerable traction upon the ligaments, which, being inflamed. 548 THE LIVER, GALL BLADDER AND DUCTS would cause pronouncod })aiii. This pain is so much greater than the pain produced by the intraabdominal pressure, when the patient lies upon the right side, that naturally he assumes the posture of relatively greatest ease. In general, it may be said that more comfort is obtained in reclining than in the upright or sit- ting posture. This, according to Schmidt, is due to the much better draining of the liver when the body is in a reclining posi- tion. Likewise in malignant disease of the liver, or in hepatic hyper- trophy or enlargement from any cause, the patient has the greatest ease in the right lateral position, for turning upon the left side causes a great increase in the pull and drag upon the ligaments by the enlarged and weighty organ. This is especially noticeable in multipara^, because of the relaxation of the abdominal wall. Generally, in these conditions, the patient likes to lie upon his back, because this is the posture of greatest ease. If nausea and vomiting also occur on change of position, some additional patho- logical process in the stomach or intestine should be sought. Relationship to Other Diseases and Processes. — Gall-bladder colic is often initiated by psychic and emotional disturbances. It is also suggested that it may be reflexl}' started by impulses arising in other organs, such as the kidney, genitals, stomach, or intestines. Constipation also seems to initiate an attack. Should pain occur in the liver area during pregnancy, or shortly after its termination, either the gall bladder or the liver may be affected. It seems to be fairly common that the gall bladder, im- mediately after labor, becomes intolerant of its gall-stone contents, and tries to force them out through the narrow duct, thus produc- ing pain and distress, the so-called gall-duct colic. During preg- nancy, also, the liver is subject to metabolic and toxic changes. A degeneration of liver tissue leading to atrophy may result in the well-known yellow atrophy. While the pathologic changes asso- ciated with this disease are, as a rule, painless, yet in many cases, because of parenchymatous or peripheral inflammation, pain may be a prominent symptom. Typhoid fever, at times, in its early stages produces symp- PAIN Oi' THE LIVER ' 549 toms resembling- cholecystitis, and, in some instances, gall-bladder inflammation very likely is present. When symptoms of cholecys- titis do occur in typhoid fever they last only for a few days, and then become merged into those typical of the fever. During con- valescence pain and tenderness over the gall-bladder area may also occur, and in these circumstances they indicate gall-bladder infection. Should the inflammation become so severe as to re- quire operation, the gall bladder is found to be inflamed, and in many cases filled with pus. Liver disorders occurring during the course of dysentery, par- ticularly that due to amoeba coli, should at once cause a search to be made for liver abscess. Enteroptosis may be associated with gall-duct disease, and the pull and drag upon the liver and its appendages, produced by jarring, running, or jumping, may, especially if a movable right kidney is present, incite a gall-duct colic in one who is subject to such attacks. Time of Appearance of Pain. — Liver and appendage pain i& generally incited or at least made worse by the onset of digestion, particularly after the food passes through the pylorus and enters the small intestine. This, as a rule, occurs from two to four hours after eating. Gall-stone pain generally occurs in paroxysms. The pain paroxysms may be incited by vomiting and by excesbive motion.^ Should a colic resembling gall-stone colic appear in a person of advanced age, it is more likely that the condition is one of carci- noma of the gall-bladder than a cholelithiasis. Gall-stone colic, like all other colics, seemingly has a tendency to occur most fre- quently at night. This possibly is only a supposition (see Diurnal Variation of Pain). If the pain is due to a hepatitis it may last for a long time, the constant pain being interrupted by exacerba- tions, which indicate the flaring up of a dormant infection. In gall-stone colic, on the other hand, the pain is not so continuous, ^ Gall stones may lie latent in a gall bladder for years until, suddenly, the patient has an attack of indigestion and the latent disturbance at once becomes active. The violent retching and vomiting which accompany the indi- gestion have dislodged the calculi from their resting place in the bladder and one or more are forced into the cystic duct, thus causing the pain. 550 THE LIVER, GALL BLADDER AND DUCTS but occurs in paroxysms, which disappear on the passage of the stone or on its retrogression into the gall bladder. In these cases there is generally a history of a previous attack, with a similar pain, accompanied by vomiting, jaundice, light-colored stools, bile in the urine, and constipation. A history of gastric disturbances, associated with pain in the right hypochondrium, should, in all cases, lead to the suspicion of gall stones as the cause of the dis- order. Neuralgia. — Sometimes the nerves supplying the liver, it is said, are subject to what is called neuralgia. Allbut describes such a state of the liver, but Maylard doubts its existence. The latter observer quotes a case, but the signs and symptoms which he noted seem to be rather those of a hepatitis than of a neuralgia. The case quoted by Maylard from Allbut is as follows: "Mr. W. A. , aged 32, whose habits are temperate, whose health is exceptionally good, and who presents no obvious disorder of function, has called upon me at intervals for three years. Four months before his first visit he was taken with a pain which he refers precisely to the seat and extent of the liver. This pain has often recurred, and observes no period of recurrence, except that it' always attacks him at night. It is a 'miserable pain.' He arises and paces the floor for hours. He maps out the liver, of whose seat he was previously ignorant, with curious ex- actness. He has had no jaundice, nor does he suffer from consti- pation. The i:)ain does not stab nor radiate as spinal pains do. On bromid and arsenic he recovered and was well for twelve months, when worry and overwork recalled the attacks. The family history j)oints to rheumatism." Pains Due to the Disturbance of the Liver Substance Proper. — The pains due to disturbance in the liver proper are either extra- or intraparenchymatous in origin. (1) Extraparenchymatous pains are caused by (a) distention of the capsule; (b) inflammation of the capsule by inflammatory products, etc. ; (c) traction from adhesions joining the capsule PAIN OF THE LIVER 551 to adjacent organs, or to the parietal peritoneum; (d) traction by the liver on adjacent organs through its ligaments, because of dis- placement. (2) Intraparenchymatous pains are produced by irritation of the nerves in the liver substances by inflammatory products, tumors, etc. The stimulus is carried by means of the sympathetic fibers, whence, depending mostly upon the strength of the stimu- lus, it is generally reflected to the body wall and is there per- ceived as pain. Intrapakenchymatous Paix. — Distention of the live)' causes pain, especially when the enlargement is acute. Chronic disorders of the liver causing an increase of the parenchyma (of substance mass) are, as a rule, not painful.^ The principal causes of acute distention of the liver are passive and active congestion. Passive congestion is due to a backward stasis, either in the blood circulatory system (hepatic or portal vein), or in the bile circulatory system, such as is pro- duced by closure of the lumen of the bile ducts from inflammatory swelling or gall stones. Acute distention, the result of active congestion of the liver with involvement of the parenchymatous nerves, occurs in abscesses (toxic or pyemic), in rapid-growing cancer and sarcoma, and in acute generalized inflammation of the liver substance. In these conditions there is present an inter- stitial hepatitis, and this adds considerably to the pain content by irritating the local nerves. Acute distention of the liver may also be caused by active hyperemia of the liver, the result of over- eating. Patients subject to a hepatic congestion, due to a stasis, gen- erally complain of a sense of pressure in the liver region. Pain, if present, is more of a dull ache around the costal arch of the right side. Referred pains are not common in this class of dis- orders. The pain is made worse by any exertion of the patient, such as going up stairs, running, and walking, while it markedly ' It is claimed by Schmidt that distention of the liver capsule is a cause of pain production in malaria, pernicious anemia, paroxysmal hemoglobinuria, leukemia, and diabetes. 552 THE LIVER, GALL BLADDER AND DUCTS decreases when the patient, and consequently the heart, is in a state of rest. The pain is also worse when the patient is in an upright position, and is increased by deep breathing, by the inges- tion of certain kinds of food, such as albumins, and by the drink- ing of alcoholic liquors. It is also made worse by a sudden change of position and by lying on the right side. According to Murchison there are ^^resent in congestion of the liver: (1) a feeling of tightness in the liver region; (2) more or less tenderness, rarely acute on pressure below the margins of the ribs on the right side; (3) a pain which may extend up to the right shoulder and which is increased after meals. According to the same author, lying on the left side produces a feeling of drag- ging or weight in the hepatic region. Pressure on or percussion over the liver area is painful. According to Schmidt the maximum pain is felt in percussion along the linea alba and extends in this line from the tip of the ensiform down to the liver margin. He also claims that the tenderness to percussion, in a case of back- ward congestion from a non-compensating heart, will, when under treatment with digitalis, become less as improvement occurs. Another differential point is that the pain of congestion, un- like that of hepatitis, is rarely referred to the right shoulder or scapula. When acute congestion occurs the liver becomes larger and harder. The patient may be aware of this change, the exact nature of wliich he does not understand, for he often complains of the increasing hardness of the abdomen. In passive congestion of the liver, pain and tenderness are not prominent factors, unless the congestion is sudden in its onset, for the passive congestions of slow onset gradually distend the cap- sule, which, without pain, accommodates itself to the increase in the intracapsular bulk, A pathognomonic sign of backward (stasis) congestion is expansile pulsation of the liver, systolic in time. A liver which already is afflicted with cirrhosis cannot become congested. Therefore, if passive congestion is general and it does not appear in the liver a diagnosis of cirrhotic liver may be made. Should perihepatitis ensue during passive congestion of the liver PAIN OF THE LIVER 553 the pain of the congestion is aggi'avated by the much more acute and severe pain of the perihepatitis (q. v.). Besides the congestion due to the backward stasis of blood, a, biliary stasis may also occur, but this is not of such a type that pain is common. The pressure from the retained bile generally is not sufficient to distend the liver capsule and cause pain. It acts especially as a j^redisposing cause for pain production, for the biliary stagnation produces a condition favorable to inflammatory reaction, which may ensue and turn the passive congestion into an active inflammation. Congestion due to acute inflammatory lesions causes both a distention of and an irritation of the capsule. This irritation may be productive of a very mild or a very severe inflammation, which in turn may result in the formation of adhesions. There is also a great tendency for infectious inflammatory diseases of the liver to form abscesses. The abscesses are of two types: (a) pyemic and (b) tropical. The pyemic abscesses are generally small and multiple and are painful only because of the secondary changes which they induce. Some of the abscesses are near the peritoneal surface, and as a consequence they involve this membrane. Adhesions quickly form, and much of the pain is due to the traction exerted upon them by the liver. A description of the pain due to a single abscess and its complications is given by Hotchkiss, Kew York Surgical Society, March 10, 1909. He says: "The onset of the condition Degan as a pain in the epigas- trium, which lasted for two days without relief; but after this it was less severe and lasted for two years, being modified by the kind of food which the patient ate. It came on in the morning when he woke up, was confined to the epigastrium, did not radiate, and was often relieved by a cup of hot fluid, such as tea. The pain always returned after the other meals, but was not as severe, and generally was relieved by pressure and hot drinks. It was worse when lying on the side ; also, after the taking of solid food and after exercise. On physical examination there was an area of tenderness and muscular spasm over the upper segment of the 554 THE LIVER, GALL BLADDER AND DUCTS right rectus muscle. An abscess was found in the central part of the liver, adhesions to the diaphragm being present." The pain in these conditions in which the liver is bound to the diaphragm or to the abdominal wall by adhesions is increased by coughing, sneezing, and deep breathing. The respirations, because of the pain, are generally short and rapid. Tenderness over the abscess area is, as a rule, present. Tropical abscess is generally free from pain; because, in the first place, it is of slow development and is in the interior of the liver; and, secondly, because it is free from inflammatory re- action. Should it progress toward the surface and the peritoneum become involved, pain is produced. If it is on the convex surface and involves the diaphragm pain over the right shoulder is also a prominent symptom. In cirrhosis of the liver the pain, if present, is due chiefly to an associated neuritis, which may be caused either by previous alcoholism or by the toxemia which is associated with this disease. This neuritis is confined principally to the arms and the legs. In biliary cirrhosis there is generally a sense of weight in the right hypochondrium ; and periodic attacks of pain with tender- ness over the liver and spleen occur. New Growths. — In new growths of the liver pain production seems to depend upon two factors: (1) the location of the growth in reference to the capsule of the liver, and (2) the rapidity of the growth. Growths which involve the capsule are generally more painful than those which occur in the substance of the gland. When the growth is superficial a certain amount of perihepatitis is to be ex- pected, and this not only causes pain directly, but also indirectly, by the adhesions which are produced. According to Rolleston the pain due to malignant disease may be almost constant in the right hypochondrium, but often is especially marked in the back, in the shoulder, or in the loin. It often occurs in paroxysms, frequently radiates to the right shoulder, and is worse at night (characteristic). Early in the disease there is only a sense of discomfort or dragging, pain being a later result of the process. PAIN OF THE LIVER 555 Should the gi'owths occur arouud the common duct symptoms re- sembling gall-stone colic are produced. Tenderness is well marked in growths of rapid development. This tenderness is fre- quently a sign of the associated perihepatic inflammation. Cysts, especially hydatid, in the liver and its appendages are causes of pain. The pain in these conditions is not marked, unless the growth is rapid or the peritoneum is involved. In the first instance the pain is dull and aching and is due to distention of the liver capsule. In the second it is the result of peritonitis, is sharper and more acute, and is definitely localized to the upper abdomen. In cystic formation the abdomen over the margin of the liver -is tender and often the irregular nodosities of the cystic gi*OT\i;hs can be felt. Sometimes the passage of small cysts through the cystic and common duct produces a typical gall-duct colic (Schmidt). These attacks, like those of calculi colic, are most common during the night, and the pain is worse in the left lateral posture. The onset of hiccoughs indicates diaphragmatic involvement. Syncope is common. The presence of booklets in the fluid removed by exploratory puncture is confirmative of the condition. Tenderness is generally a sign of suppuration. When this occurs there are a rapid pulse and an elevation of temperature. In some cases, owing to pressure on the stomach and intestines, symptoms of obstruction of either one or of both of these two organs may supervene. The rapidity of the growth influences to a great extent the intensity of the resulting pain. Growths of slow development generally are painless, because with the slow increase in size the adjacent liver cells, having had an opportunity to adjust themselves to changed surroundings, give rise to no physical or economic disturbances. In growths of rapid development, however, this does not occur, nor has the capsule had an opportunity to adjust itself to excess of pressure, and so pain is produced. Secondary (metastatic) gro\\i:hs in the pleura and the perito- neum also cause considerable disturbance. The pain and local ten- derness, the results of these conditions, generally follow, by a iiotic^able interval, the pains and tenderness due to the primary 556 THE LIVER, GALL BLADDER AND DUCTS growth. Sometimes the common or cystic duct may be partially occluded by the growth. Then biliary colic is added to the symp- toms already present. In some cases gall stones are present as a complication, and these add their own particular syndrome to the symptom-complex. Rapid progress of the disease is an indication that the growth is probably of a primary nature. This belief is strengthened if the pain first complained of was in the liver region. Should the cancer be primary death generally occurs in three or four months. Even in growths involving the liver secondarily, death generally occurs Avithin six months of the involvement. Malignant disease of the liver, which, as a rule, is painful, is fre'^r^ntly confused with cirrhosis, which is painless. Other diagnostic points are: that in cirrhosis the spleen and liver are both enlarged ; also in cirrhosis the liver enlargement is more uniform than in malignant disease and cachexia is less marked. If in malignant disease of the liver pain should be felt in the epi- gastrium and vary with the ingestion of food, a secondary in- volvement of the stomach is very likely present. Growths in the liver, secondary to cancer of the stomach, or of the intestine, are generally more painful than secondary growths in other locations, because the accompanying inflammation is much greater. In the secondary involvement of the liver the pain follows that caused by the primary growth, wherever that may have been. Should the primary growth have been in the stomach the primary pain would indicate stomach involvement ; and this, in case of liver metastasis, would be followed in an appreciable interval by pain in the region of the liver or gall-bladder. Syphilis of the liver is indicated by attacks of pain, rapid in- crease in size of the liver, and by fever. Tlie enlarged liver is tender, and has an uneven surface. The left lobe is more fre- quently affected than the right, therefore the left-sided localiza- tion of the pain under the left hypochondrium. There is also a certain amount of inflammatory reaction accompanying all syphi- litic growths, and this in turn causes inflammation of the cover- ing of the liver (perihepatitis) and of the adjacent peritoneum. PAIN OF THE LIVER 557 In view of these facts, it is hardly necessary to add that in all cases of pain in the liver area, with enlargement of the liver, syphilis should at least be considered and the Wassermann reac- tion determined. ExTRAPARENCHYMATOus Pain. — PeriJicpatitis. — Intimately associated with the foregoing disorders, and generally following as the result of one or the other of them, is inflammation of the capsule of the liver, the so-called perihepatitis. Of these, there are two varieties, the acute and the chronic. The acute variety as a primary condition is never met with in the temperate zone, It has been found as a primary disorder in the tropics, because the congested state of the liver in inhabitants of these regions easily lends itself to an inflammatory process. The inflammation originates from local extension of a diseased process, either from within the liver substance (acute hepatitis, abscess, new growths) or from some adjacent viscera. In both the acute and chronic form of j)erihepatitis a friction rub is generally heard over the liver region on auscultation. It may also be felt on palpation over the same area. The extrahepatic disorders from which perihepatitis may re- sult are : peritonitis in the lesser or greater peritoneal sac ; rup- ture of viscera adjacent to the liver, as the gall bladder, stomach, or duodenum; and inflammation of adjacent viscera. Here the inflammation is communicated to the peritoneum, or to the con- necting ligaments, and thus is transferred to the liver capsule (Roberts). In any of these conditions the character of the pain present previous to the perihepatitis may give some idea of the primary source of involvement. In some intrahepatic lesions pain is not present, although, as a rule, some discomfort is experienced. Acute Hepatitis. — The pain in acute hepatitis is quite sudden in its onset, while that of the chronic variety is of a more gradual develoj)ment. In either case the pain is directly over the liver and is made worse by such motions as occur in respiration, in changing the position of the body, or in contraction of the abdomi- nal muscles. The liver is also tender to the touch. A method of 558 THE LIVER, GALL BLADDER AND DUCTS palpation suitable to define this condition is to place one hand on the hypochondrium over the liver and the other on the back under- neath the liver. Kow make a to-and-fro motion with the two hands, when, if hepatitis is present, pain will result. Besides this local pain there is also present a referred pain, felt in the right shoulder, in the area between the clavicle and the acromion process of the scapula on the front of the chest (Cantli). Displacement of the Liver. — A further cause of hepatic pain is traction on adjacent organs by an enlarged liver through its ligaments. These ligaments are five in number: the falciform or suspensory ligament, the round ligament, the two lateral liga- ments, and the ligamentum venosum. Any or all of these may be stretched or pulled upon in liver displacement. In liver displacement (hepatoptosis) the liver may be rotated in one of two directions: around the transverse axis, so that its upper, convex surface becomes anterior ; or around the vertical axis, either to the left or to the right. The latter is the more common. In this the right lobe becomes inferior, and the inferior surface is turned to the left. In a left-sided rotation the left lobe becomes the lower, and the inferior surface is turned to the right. Rotation to the left will produce more traction on the ligaments connected with the left lobe of the liver, while rota- tion to the right Avill cause traction to be exerted on the ligaments connected with the right lobe. In either case the pull is chiefly upon the diaphragm and has about the same degree of force, irre- spective of the direction of the turning. The traction due to rota- tion will produce the same diaphragmatic symptoms as a down- ward displacement of the liver (q. v.). Downward displacement of the liver will produce: (1) a pull on the diaphragm; (2) a pull on the left vena cava; (3) a rotation and angulation of the portal vein, hepatic artery, and common duct; (4) a slight rotation of the upper pole of the right kidney; and (5) a compression of organs below the liver. The pull on the diaphragm which is exerted through the falci- form ligament, which is almost in the center of the diaphragm, ?ind through the coronary and triangular ligaments^ which are to PAIN OF THE LIVER 559 the right of the median line, will produce traction on the right half of the diaphragm, and thence through the diaphragmatic attach- ment, on the right ribs. This is felt as a dragging sensation, or discomfort, in the right lower chest at the points of insertion of the diaphragm on the six lower ribs. Because of the pull on the vena cava, traction is propagated up into the chest underneath the sternum, even as far as the base of the heart. Here the inferior cava, because of its intimate asso- ciation with other structure, is firmly fixed, and, as a consequence, it is at this point that the greatest traction is made and the pain, which is referred to the anterior chest wall, is produced. In other cases the pain is propagated further, being transmitted through the cervical fascia and is felt as high as the base of the neck. Owing to the rotation of the liver, a twist or angulation of the portal vein, hepatic artery, or the common or cystic bile duct may occur. A twist and partial occlusion of the portal vein or hepatic artery may not, of necessity, be provocative of pain, though an occlusion of any of the bile ducts, provided it is acute, is almost sure to be. When an occlusion of the ducts occurs, the pain may be due directly to the occlusion, or the occlusion may lead indirectly to pain production from the tendency, when stag- nation of bile takes place, to the formation of gall stones. The rotation of the kidney may cause the renal colic some- times present in hepatic displacement. The liver, when it is dis- placed, causes, through its ligamentous attachments to the upper pole of the right kidney, a downward and inward rotation of the upper pole of the kidney, with a tendency to, and sometimes an actual, kinking of the ureter. This is the cause of the pain. All the pains due to hepatoptosis are relieved when the patient assumes the reclining posture and are increased in the upright position. When the pain is not relieved by lying down it can be assumed that some permanent pathological change has taken place in adjacent organs, such as cholecystitis in the gall bladder, colitis in the colon, and chronic intestinal disturbance in the small bowel, or that, in the reclining posture, either traction or pressure is exerted on them by the enlarged liver. 560 THE LIVER, GALL BLADDER AND DUCTS Brown (Osier's "System") describes tlie pain of liepatoptosis either as spontaneous, or as being brought on by jumping, walk- ing, raising the right arm, sneezing, coughing, and yawning, while sometimes paroxysms of pain occur without apparent cause. The pain is usually relieved by having the patient lie on the back or on the right side, or by manual replacement of the organ. The pain is commonest in the right hypochondriac and epigastric regions, radiating thence toward the right shoulder or to the flank. Pressure, though rarely painful, often produces peculiar sensa- tions in various portions of the body, especially in the right arm and shoulder. Adhesions. — Following perihepatitis, and a result of it, adhe- sions take place between the liver and the adjacent structures. Adhesions between the liver and its associated structures, gall bladder and bile ducts, may be present without the production of pain, though pain is likely to occur when the patient changes his position, or during some phase of digestion. Should the pain be- come prominent on change of position, the area in which it is felt is a good indication of the location of the adhesions, provided they lie between the liver and the parietal peritoneum. Should ad- hesions not be present in this location, but between the liver and some intraabdominal organs, the pain, or rather discomfort, will be referred to the area to which this organ refers its disc6mfort and distress. Should adhesions, for instance, be present between the liver and the stomach or intestine, the reference will be to the somatic area associated with the stomach and intestine, and not to the area associated with the liver. In cases in which dense ad- hesions exist between the stomach and the gall bladder the pain may be in the epigastrium or over the ensiform cartilage. It is somewhat acute and is more or less severe, especially on movement. Should the pain be especially prominent at the time of gastric digestion it is reasonable to assume that the adhesions involve the stomach. Should it occur at the time of the colonic passage of food it is most probable that the colon is the adhering organ. In all cases of adhesive formations there is a history of previous acute pain, the result of infection of the liver, gall bladder, ducts. PAIN OF THE LIVER 561 or adjacent viscera, with a gi'adually developing chronic (ad- hesive) pain. Universal chronic serositis, a disease in which all the serous membranes are involved, is generally free from hepatic pain and is slow in its development. Its principal symptom is ascites. Essential Diseases of the Liver. — Pain is absent in amy- loid enlargement, fatty liver, leukemic enlargement, adenoma, cysts (simple), angioma and fibroma. Pain is present in the cirrhoses, hepatitis, acute yellow atrophy, syphilis and new gi'owths, hydatid, etc. In chronic atrophic cirrhosis the pain is dull and heavy in the first stage. There is also present tenderness due to intermit- tent attacks of perihepatitis. In hepatitis the pain is over the liver and is propagated to the area between the clavicle and the acromion process of the scapula on the front of the chest. The liver is very tender on pressure. In portal cirrhosis pain is absent in the last stages. In the early stages there is a dull, heavy pain. Tenderness in the right side (hypochondrium), intermittent in character, is also present. In biliary cirrhosis there are periodic attacks of pain with fever and jaundice. Tenderness is found over the liver and spleen. In acute yellow atrophy pain is nearly always present and is often spontaneous. Tenderness is so marked that it can be elicited when the patient is unconscious. In syphilis there is no pain, unless the gi'owth is tertiary and a perihepatitis has resulted with inflammation of the capsule ; in this condition |)ain is common. In lymphadenoma pain is absent. In hydatid cystic disease the only discomfort may be a feeling of weight or of dragging in the abdo- men. If the peritoneal covering of the liver is inflamed pain is present on respiration. Tenderness is also a marked symptom. In fatty liver there is no pain. The enlargement is slow and the liver surface is smooth. Lardaceous disease is generally secondary to other conditions. The enlargement is constant, slow, and pain- less. Simple cysts of liver are rarely large enough to cause any special disturbance. In adenoma, angioma, myxoma, fibroma, and lipoma there is no pain. 562 THE LIVER, GALL BLADDER AND DUCTS GALL BLADDER General Etiology. — The pain of gall-bladder disease is due to over-distention of the walls, excessive contraction of its muscular coat, or irritation of the mural nerves from either of the above, or from inflammatory processes, which may be intra- or extramural. Intramural inflammation aifects only the mucosa and musculature, while extramural inflammation affects the peritoneum. The drag- ging by adhesions also produces pain. Over-distention of the gall bladder is the cause of pain in such disorders as hydrops of the gall bladder, but only when the condition is acute. It is most likely that over-distention of the gall bladder does not of itself cause pain, unless there is an obstruction to the onward flow of bile, such as may be produced by either a stone in or an inflammation of the cystic or common duct. The obstruction hinders the flow of the bile and the muscu- lature of the gall bladder, attempting to force it on, is thrown into a series of painful sj^asms. In gall-bladder colic the pain is generally sudden m its onset and persists for some time, when it either gradually fades away, or, owing to the passage of the stone or the removal of the duct obstruction, it disappears, sometimes quite suddenly. In either case it leaves a legacy of tenderness over the site of the lesion. Over-distention of the gall bladder may occur from obstruc- tion of the cystic or common duct by (a) inflammation, (b) stone, (c) pancreatic lesions, (d) pressure from adjacent viscera, (e) tumors, or (f) excessive contraction of the muscular coat. The gall bladder is similar to many other abdominal viscera in the method of its pain production. This pain is of a colicky character, and, at the time of its production, palpation in the gall bladder region will reveal a hard tumor mass, due to a spasmodic muscular contraction of the gall bladder. Should this spasmodic muscular contraction be relieved, either because of the opening of the gall duct passages or of exhaustion of the musculature, the pain will be eased and the hard tumor mass will disappear. If the bladder is GALL BLADDER 563 not emptied the mass persists, but soon loses its hard con- sistency. One of the commonest lesions of the gall bladder is inflam- mation. In addition to the local pains (the result of local j)erito- nitis), inflammation of the gall bladder causes well-marked re- ferred pains. The inflammation is generally of a very active type and is very violent. It j^roduces a well-marked tenderness. If this tenderness suddenly becomes general and is associated with signs of a spreading peritonitis, perforation of the gall bladder should at least be thought of and searched for. Inflammation of the gall bladder (cholecystitis) is invariably due to infec- tion. The common causes of gall-bladder infection, probably in the order of their frequency, are colon bacillus, typhoid bacillus, and influenza bacillus. The pneumococcus and tubercle bacilli are only rarely found as causative agents. Pregnancy seems espe- cially to be a predisposing factor for gall-bladder infection. Diar- rhea is a prominent symptom of infection of the bile passages. It occurs after eating or, in some cases, in the middle of a meal. At the time of the diarrhea severe pain is felt in the epigastrium. This pain is probably synchronous with, and due to, the contrac- tion of and the emjDtying of the gall bladder. Following the inflammation adliesions form, but these, unless they are attached to the anterior abdominal wall, are not particu- larly painful. Should they be so attached breathing becomes very painful, and the pain is of a dragging character. Should adhe- sions exist between the gall bladder and the stomach or duodenum, the pains are associated with digestive activity. In these cases there is some history of a previous acute attack, in which the pain was confined to the gall-bladder region. Diagnosis. — The means of eliciting gall-bladder pain are palpation and percussion. Tenderness on palpation is generally most pronounced beneath the costal margin at the level of the ninth or tenth costal cartilage. There is here present a point of most exquisite tenderness, and around this an area which is not quite so tender. In some cases, where there is an associated ap- 564 THE LIVER, GALL BLADDER AND DUCTS pendix involvement, the hyperesthesia extends down to the neigh- borhood of the aj)pendix, over which there is another point of maximum tenderness. In lesions of the gall bladder, if pressure or percussion is ap- plied over any portion of the abdomen, the pain is felt in the Area of greatest tender- ness in cholelithiasis General area of tender- ness in cholelithiasis and appendicitis Area of greatest tender- ness in appendicitis Fig. 126. — Area of Greatest Tenderness in Diseases of the Gall Bladder and Appendix. The upper X indicates the point of maximum tenderness in gall-bladder inflammation; the lower X that of the appendix. In both, though the entire area indicated may be tender, the points of maximum tender- ness will differentiate the two disorders. gall-bladder area or region. This is one method of differentiating gall-bladder disease from appendicitis. For the purpose of differentiating gall-bladder (direct) tender- ness from that due to lesions of other organs, Murphy elaborated a special technique. His method of eliciting the tender points in gall-bladder disease is as follows : Having previously removed all clothing from the part to be examined or from its neighbor- hood, place the patient in a sitting position, bent well forward, with his hands resting upon his knees. The examiner now stands behind the j^atient and places his hand, with the palm flatly DIFFERENTIAL DIAGNOSIS. DISEASE OF THE LIVER AND ITS APPENDAGES Symptom Hepatitis ' Perihepatitis Gall Bladder Gall Duct G^™,cU.c.n Pyloric Spasm Pancreatitis Renal Colic Appendicitis Pain, type. Dull aching, constant. Referred areas may be present. More sharp than in hepatitis, increased on breathing, on movement and on sitting down with the knees drawn up. Rub present on palpa- tion and friction sound pres- ent on auscultation over the liver region. Colic, ^generally of a paroxysmal type, suddenly reaching an acme and then suddenly disap- pearing, leaving only a feeling of soreness in its place. In some cases instead of being paro.xys- mal the pain may be constant. Long intervals of freedom from pain may be present. Generally some constant sore- ness in cholangitis, then, as the duct becomes blocked, the pain is paroxj-smal with a gradual disappearance, only a soreness remaining. The pain may be referred to the area of the fourth costal cartilage on the left side. Long intervals from pain may be present. Sudden, sharp, referred to one special point on the abdomen. Reheved by vomiting; is rather constant, always follows the ingestion of food. Sudden onset, occurs a few hours after the ingestion of food, when it is passing through the pylorus. The spasm is relieved by Vomit- ing. Attacks generally occur at short intervals. Principally in epigastrium. Very severe. Generally sudden onset. Radiates down the groin in the direction of the ure- ter, sometimes as far as the testicle. Attacks arc spasmodic and there may be a long period of free- dom between individual attacks. May in case of coUc be of sudden onset. Finally is localized to the right inguinal fossa. At first, because of the locaUzation of the appendix pain in the epigas- trium, it may be confused with cholecystitis. In some cases, gall-stone eoUc may be confused with appendiceal colic. Relationship lo the ingestion of food. Worse at the time of in- testinal digestion when the blood content of the liver is greatest. Same as in hepatitis. No special relationship to the ingestion of food. None except in cases of inflam- mation of the duct (common), when it seems that intestinal peristalsis may set up an asso- ciated peristalsis in the duct. Follows immediately upon or a short time after the ingestion of food, depending upon whether the ulcer is at the cardia or the pylorus. Eased by local anal- gesics. Follows two to four hours after the ingestion of food. No special rela- tionship in the acute variety, but in chronic is made worse by the ingestion of food. No relationship. May follow four to eight hours after taking food. Rather eom- nion during the night. Tenderness. Present over liver region. Present over liver region. Present over margin of gall bladder. Murphy's sign pres- ent. Shght tenderness in epigastrium, then over the gall bladder and liver area, as the duct becomes occluded and the gall bladder and liver distended. Present in a circumscribed area. .\rea is constant, and is generally located in the epigastrium im mediately below the ensiform cartilage. In epigastrium. Epigastric. Over the kidney region 1 Over McBumev's point, in the loin. Jaundice. May be present. .\bsent. Ab.sent. Present. Absent. .\bsent. SUght amount may be present. Absent. 1 Absent. Nausea and Not specially marked, vomiting. Not specially marked. Generally present. May be con- stant and severe. Bile present. Generally present, constant. Bile is present when the duct is blocked. May ease the pain. Generally occurs. Some blood in it at times; the pain is generally eased by it. Bile present. Frequent; eases the pain; no bile. Present and, as a , Not so common, rule, persistent. Bile generally | present. Nearly always present. Temperature. SUght rise. Slight rise. Septic in cases of inflammation. In cases of colic no rise. May have a Charcot's intermit- tent fever, but generally no rise in gall stone colic and only a slight rise in cholangitis. No rise. No rise. Rise or if the shock be too great a fall. Nu rise. Rise, if the severity of the dis- ease increases, the temperature continues to rise and may assume a septic t>'pe, if abscess forma- tion results. Pulse. Slight increa.'ff . Slight increase. Considerable increase in cases of inflammation ; very slight, if any, increase in cases of colic. Generally slight increase. Shght increase. Shght increase. Very rapid. Generally rapi •5 .5x! 5 o|5 SI'S S " a >- g o « t. t-J -tj -fj > 10 CO t^ \A K K < Z •z ^ 1 (M CO r— 1 l^ (N CO s to J3 ^ ,, a s .fl (S ^•9 a . a Jr. :! C -H i; c3 ^ ^ " ^ "^S -c m a «^ a 2 3 a ■a a a> a; a 3§ S « 590 DISEASES OF PANCREAS CAUSING PAIN 591 pain of a typical duct-colic type is more likely to be due to ob- struction of the gall ducts than to obstruction of the pan- creatic ducts, for gall stones are four or five times as common as pancreatic stones. In some cases of pancreatic calculi pain may be absent, with only a soreness in the epigastrium, or an aching in the upper lumbar region. When at its height the pain may be associated with hiccoughs, vomiting, rigors, cold sweats, and collapse. In one case in which pain was j)resent in the left iliac fossa considerable free fluid was found in this fossa. In another case pain was present after the first six or eight hours only in the region of the ninth and tenth costal carti- lages on the left side. Cystic Disease of the Pancreas. — The distress in cystic disease of the pancreas may vary from a feeling of uneasiness and dis- comfort in the epigastric region to one of the most severe pain. It also may bo broken by acute exacerbations, probably due to the sudden increase of tension in the cyst walls, which, in turn, is caused by a sudden increase (frequently due to hemorrhage) in the volume of the cyst contents. Like other varieties of pan- creatic pain it is generally confined to the upper abdomen, but may radiate to the back and has been known to strike down into the testicles. Cancer of the Pancreas. — The pain of cancer of the pancreas is the result of pressure on the neighboring structures or on the pancreatic tissues. It may be very mild or very severe, continu- ous or intermittent. It frequently starts under the costal cartilage of the left side and gTadually extends toward the midline, low in the epigastrium, radiating around one or both sides to the shoul- der or to the back (generally to the left side). It is worse at night ; paroxysms are frequent and give a corset-like constriction. Because of its pressure on the gall duct, over-distention of the gall bladder occurs, producing a most severe gall-bladder colic. Pressure on the pylorus may be the inciter of a pyloric or gastric spasm. Curtin speaks of a case of cancer -of the pancreas in which the pain radiated to the inguinal canal, back of the testicles 592 THE PANCREAS and perineum, and down the thighs as far as the knees. In his case the most prominent symptom was a girdle sensation about the level of the tenth costal interspace. In cancer of the pancreas the patients generally assume a posture in which the body is bent forward and the knees drawn up. CHAPTEE XXVIII THE SPLEEN GENERAL CONSIDERATIONS Anatomy. — The spleen is the largest ductless gland in the body. It is situated in the left hypochondrium and is in intimate anatomical relation to the digestive apparatus. There- fore, it is particularly prone to enlargement in diseases of the liver, stomach and intestines. Any acute enlargement is painful. A small part of the superior surface of the spleen is in inti- mate contact with the diaphragm in the vicinity of the esophageal opening. The contact is very firm and so close that any disturb- ance in the spleen would cause some related change in this part of the diaphragm, so that disorders of the spleen may exert trac- tion on this section of the diaphragm and so cause irritation to the peripheral branches of some of the intercostal nerves distrib- uted on its lower surface, with consequent pain, which is referred to the body Avail. Nerve Supply. — The spleen receives its nerve supply from the sympathetic. The fibers accompany the blood vessels to the ultimate divisions and supply the parenchyma of the gland. They are derived from the splenic plexus, a division of the celiac plexus. From the celiac plexus collateral branches connect with the right vagus, which, in turn, is in communication with the right spinal accessory and the cervical plexus. Thus we may account for the shoulder pain on the right side. Embleton believes that "the splenic nerves are derived from each side of the semi-lunar ganglion and from each of the mem- bers of the par vagum, and thus, by receiving nerve twigs from 593 594 THE SPLEEN each pneumogastric, the shoulder jDaiii of the right side may be accounted for." This is probably not true. (See Bechterew, "Funktionen der ISTervencentra," I, p. 376.) According to Lyon, "The spleen is supplied by nerve fibers from the left splanchnic nerve, through which a control of the size of the organ is obtained. Stimulation of the splanchnics causes contraction of the organ, whereas cutting them causes splenic enlargement." The splanchnics carry both sensory and motor stimuli. Pain in splenic disorder may therefore also be due largely to irritation of their terminal branches from increase in tension of the splenic capsule. Character of the Pain. — Many of the lesions of the spleen progress entirely without pain, though in nearly all cases, even when pain is absent, there is present a feeling of dragging or of pulling in the left hypochondrium. Sometimes there is also a feeling as of weight in the epigastrium, or a sense of tension in the splMiic area. These pains and discomforts generally extend from the left side around into the epigastrium. They may be spontaneous, but most frequently are felt only on mechanical irri- tation, such as comes from running, jumping, or from trauma on the left side. In splenitis and ^perisplenitis the pain is generally worse about four hours after eating, because at this period digestion is at its height, and the blood supply to the spleen is at its maximum. Consequently it is at this time that the spleen has reached its greatest size, the tension on the capsule is greatest, and the pain is most severe. From then on the pain gradually decreases until about the twelfth hour, when it ceases, for the spleen has returned to its normal size. The reason for this splenic enlargement is that the spleen is supposed to act as a resen'oir for portal blood, which, during the active stage of digestion, is gi^eatly increased in quantity, with a consequent increase in the quantity present in the spleen. This increase in size is the result of a vasomotor dila- tation of the blood vessels of the spleen, with a general relaxation of the musculature of the orgaxu GENERAL CONSIDERATIONS 595 A very significant feature in splenitis is tenderness of the left pneumogastrie. Of ten cases of splenitis (Embleton), in six cases the left pneumogastrie was found tender on pressure^ while in two cases this condition was found in the right pneumogastrie. Localized point of ten- derness Signorelli's spleen point Fig. 133. — Points of Pain and Tenderness in Diseases of the Spleen. Pain present in epigastrium, upper part along the costal margin. Localized point of ten- derness Fig. 134. — Points of Pain and Tenderness in Diseases of the Spleen. Pain in interspaces, especially those lying directly over the spleen. 596 THE SPLEEN Position of Patient. — A patient suffering from splenitis gen- erally finds the dorsal position and tlie left-sided position painful. Tenderness. — Localized points of tenderness are found in the shoulder over the acromion process, and at the "junction of the upper and middle third of the upper edge of the trapezius muscle." SigTiorelli's spleen point is near the intersection of the Fig. 135. — Method of Palpating for Splenic Tenderness. The patient is placed in a reclining posture with the knees flexed on the thighs, and the thighs on the abdomen; the abdominal muscles are also relaxed. The examiner stands to the right of the patient and introduces his right hand deep under the left costal border and the left hand makes pressure over the left hypochondrium. The patient now takes a deep breath and if the spleen is tender, pain is complained of when it comes in contact with the examiner's hand. In case of enlargement the deep inspiration may not be necessary. left fifth intercostal space and the mid-clavicular line. Tender- ness is also felt, both on palpation and percussion over the splenic area. Factors Influencing Pain. — Factors influencing the onset of pain are motion, pressure, and circulation. Motion is a cause of pain, especially should the movement be in the form of quick, sharp jerks or jars, such as occur in running, jumping, and horse- back riding. Change of position of the organ, such as happens in turning the body from the dorsal to the left-lateral position, GENERAL CONSIDERATIONS 597 causes a sense of tension or of pain in the left side. Tkis is most prominent when the stomach is full. Diaphragmatic movements, such as occur in sneezing, cough- ing and hiccoughing, also cause pain. Pressure on the organ also very frequently produces pain. Such pressure is exerted by the patient himself when he bends forward or backward. In either case the spleen is caught in the recess of the diaphragm and is squeezed considerably. If it is not enlarged the force of the pressure may not be great enough to cause pain ; but should it be enlarged the least amount of pressure is very painful. For the same reason, straining efforts, such as take place in. defecation and in lifting, are very painful. Pressure may also be exerted by »■ A, ^- / Spleen 1 Kidney — ww> f- . -I |:' fcg \ Fig. 136. — Location of the Kidney. (Campbell.) the descent of the diaphragm ; thus, deep breathing is productive of pain. This is markedly so should perisplenitis be present. Palpation, especially when bimanual, causes, in a tender spleen, considerable pain. The method of palpation is shown in Fig. 135. Percussion is also painful, particularly if the percussing blow is rather heavy. "Both palpation and percussion are made in the splenic area, which is marked out upon the back, by drawing two horizontal lines from the spinous processes of the ninth dorsal and the first lumbar vertebrse; these are joined by a vertical line one and one-half inches to the left of the midline of the body, and another corresponding with the left, midaxillary line" (Monyhan). Within this quadrilateral space the spleen lies obliquely between the ninth, tenth, and eleventh ribs. Circulatory changes during digestion also produce and modify spleen pains ; at this time there is present a secondary hyperemia 598 THE SPLEEN in the spleen. If pain is already present, it is increased; or, if it is not present, it is initiated. Should the spleen be inflamed, or adhesions be j^resent, the pain is all the more pronounced. Adhesions between the stomach and the spleen, or the spleen and the colon, are the most painful because, in these cases, during cer- tain stages of digestion, enlargement of both organs occurs and the jniU is doubly severe. Drugs, such as quinin and arsenic, lessen splenic pain, because of the decrease in the size of the spleen which they cause. Symptoms associated with a painful or tender spleen are : Enlargement,^ which is almost invariably present. Very often the pain and tenderness seem to vary directly with the size of the spleen. In nearly all cases of diseased spleen there is present an inflammation or some congestion of the capsule. This causes a deposit of fibrin on the peritoneal surface, or at least a roughening, which gives rise to friction when, during respiration or deep breathing, a to-and-fro motion occurs between the spleen and the diaphrag-m. This friction rub can be heard on auscultation, and be felt on palpation. Sometimes, in severe, active congestion, a systolic murmur can be defined on listening over the sj)lenic area. DISORDERS OF THE SPLEEN PRODUCING PAIN Displaced or Movable Spleen — Gleuard states that a mov- able spleen may be present without any special symptoms, though generally a dragging or a sense of pulling in the back or sides, referred along the line of attachment of the diaphragm to the ribs, is present. Other organs may be affected by the displaced spleen; their circulation becomes disturbed, congestion results, and pain is produced. When the displacement is excessive the splenic pedicle may be twisted and the splenic circulation inter- rupted. Pain now becomes a prominent symptom, the character and severity depending upon the completeness of the circulatory ' The spleen is increased in size, should its anterior border lie below the line extending from the middle of the sternal notch to the tip of the eleventh rib on the left side. DISORDERS PRODUCING PAIN 599 obstruction. Should the veins alone be obstructed, congestion results. The pain is very severe and the spleen is increased in size. Should the obstruction be complete, both arteries and veins being blocked, the spleen at first is not increased in size, and con- sequently pain is not prominent. In gradual venous obstruction the pain is not as severe as it is in venous obstruction of sudden onset. In either case, whether the obstruction is complete or incomplete, complicating perisplenitis, with secondary, pain, re- sults. The diagnosis of movable spleen can be made from the shape of the tumor mass, which is oblong, with an indented border and pulsating artery on its inner surface. The absence of the spleen from its normal position, and the ability to replace the tumor mass in the cavity the spleen should normally occupy also assist in the diagnosis. Displacement of the spleen is very rare, Glenard having found only two in one hundred and sixty cases of enteroptosis, a condi- tion with which, naturally, one would suppose it would be asso- ciated. Congestion. — Congestion of the spleen causes pain in nearly every case. This is well illustrated in the infectious diseases, which are almost invariably accompanied by a congested spleen and have pain in the left hypochondrium. The presence of a tumor below the left costal arch, moving with respiration, and tender to the touch, is a sine qua non of splenic involvement. In some cases of acute splenic congestion, accompanied by cardiac disease, pulsation may be felt. In these cases the pain may be localized to the splenic area, or may radiate in different directions. An acute congestion of the spleen, originating in the presence of a gastric ulcer, may be due to a thrombus of the splenic vein, the thrombus, in turn, being caused by necrotic tissue or blood clot arising from the ulcer. The spleen, which in infectious diseases is enlarged and con- gested, may also show signs of acute inflammation. In this it does not differ from the lymphatic glands, which in the presence of infection become enlarged, and, in some cases, acutely inflamed. However, the sjileen especially, because of idiosyncrasy and 600 THE SPLEEN special peculiarity of function, seems particularly liable to in- volvement in all acute infectious processes. Several factors may account for tins tendency, namely: (1) because of the great amount of lymphatic tissue in its substance it acts as a producer of leukocytes, and at the same time, (2) because of its relation- sliip to the circulation, it performs the fimction of a filter for a portion of the blood. Thus, infections and septic conditions, by casting detritus and bacteria into the circulation, are particularly prone to cause splenic disease. The infectious diseases causing the most marked enlargement are typhoid fever and malaria. In both diseases the spleen is enlarged and tender, and pain is com- plained of beneath the left costal arch. The enlarged spleen fre- quently compresses that jDortion of the lung between the dia- phragm and the thoracic wall so that, on deep breathing, a fine crepitation may be heard. This, at times, has led to a confusion of the splenic lesion with pneumonia. Such a mistake is most likely to happen if the onset of the disease causing the spleen in- volvement occurs with a chill. Deep breathing in the presence of an enlarged and tender spleen is very painful. Because of the associated splenic congestion, paroxysmal hemoglobinuria also causes splenic pain. In brief, it may be said that the causes of active congestion and inflammation of the spleen are due: (1) to acute factors, as microorganisms and their toxins (typhoid fever, malaria, syphilis), drugs (acetanilid and other coal-tar derivatives), trauma, and local and morbid processes in the spleen (hemor- rhage, embolism) ; (2) to chronic factors, such as anemic states (pernicious anemia, chlorosis, infantile anemia, splenic anemia, chronic cyanotic polycythemia, rickets) ; or (3) to passive con- gestions, which may be due (a) to disease of the heart and lungs (producing obstruction to the general circulation), (b) to diseases of the portal area (causing obstruction to the portal circulation), such as cirrhosis of the liver and pyelophlcbitis, or (c) pressure on the portal or splenic veins by tumors, adhesions, and sometimes by an enlarged and inflamed gall bladder (Lyon). Perisplenitis. — In perisplenitis pain is almost invariably pres- DISORDERS PRODUCING PAIN 601 ent, especially if the inflammatory process is acute. The pain varies from a feeling of discomfort to one of the greatest distress. All movements of the spleen initiate and aggravate it, particu- larly those movements associated with breathing, turning or twist- ing of the body, and bending forward or backward. Of diagnostic importance, if the lesion is acute, are the fric- tion sounds, which may be heard over the splenic area on auscul- tation. Great tenderness, also, is present on pressure over the same area. In cirrhosis of the liver perisplenitis frequently occurs. It is found in syphilitic, Banti's and Hanot's cirrhoses, while Laennec's cirrhosis rarely causes pain. The causes of perisplenitis, according to Lyon, are: (1) local- ized splenic involvement, as infarct, gumma, hemorrhage, abscess, cysts; (2) generalized involvement of the splenic parenchyma in the acute or chronic splenitis of the infectious diseases; and (3) extension of inflammation from disease outside of the spleen, as pleurisy, pneumonia, local or general peritonitis, tumors or cysts. Abscess of the Spleen. — Abscess is most frequently caused by lodgment of a septic embolus ; but so long as the abscess is con- fined to the parenchyma it gives no indication of its presence. It is only when the capsule is involved, and perisplenitis occurs, that pain is felt. The pain of central abscess and other crypto- genic forms of splenic involvement miglit be of great diagnostic value ; but, unfortunately, as yet the pain equivalent has not been defined and correlated to the different varieties of splenic disease. Infarct. — In infarct of the spleen sudden, severe pain is felt in the splenic area. Tenderness due to perisplenitis is also pres- ent and is localized over the area of the infarct. After the first acute pain, following the lodgment of the embolus, the pain syndrome is that of a perisplenitis. The emboli causing these infarcts are most commonly due to vegetative endocarditis, in which a portion of these vegetations has been carried away in the blood current and has lodged in the splenic artery or its branches. Such a lodgment is very common, because in the spleen the ar- teries are end-arteries and have no anastomoses ; therefore, lodg- 602 THE SPLEEN ment always cuts off the circniation to a limited area and causes an infarct. Should the embolus be septic an abscess of the spleen results. Rupture of the Spleen. — Pain in the splenic area, following a blow or a sudden trauma in the region of the spleen, particularly if it be associated with collapse and signs of internal hemor- rhage, is an indication of sjDlenic rupture. The patient, in addi- tion to the pain, has, at the time of the accident, a sensation as of something being torn or of giving way in the abdomen. However, pain does not at once, in all cases, occur, for immedi- ately after the injury the patient may seem but little hurt. He may be able to walk for some distance or to engage in some work before the pain comes on. A rupture may also occur sponta- neously, as has been observed in a few cases of very large and congested spleens. Tumors of the Spleen. — Tumors of the spleen, according to Monyhan, are, as a rule, painful, the pain in some cases being so severe as to prevent the slightest movement. On the other hand, the enlarged, amyloid spleen, found in septic diseases, is apt to be overlooked, because it rarely produces a pain-complex. Cysts of the Spleen. - — Likewise, cysts of the spleen, unless of very great size, are generally free from pain, though from their size they may cause a sensation of weight or of fulness in the epi- gastrium. Pain, when present, is in the area occupied by the enlarged spleen. Hydatids, as a rule, are painless. They usually grow from the upper surface of the gland and give a character- istic thrill on palpation. Kala-azar, a rare disease of the spleen found in certain tropical countries, produces a splenic enlargement, which, as a rule, is painless. Of the blood diseases causing splenic enlargement, myeloge- nous leukemia always causes pain. This pain, due to distention of the capsule, is frequently the first symptom of the disease. Pseudoleukemia and polycythemia also cause splenic pain, but this is rare in chlorosis and pernicious anemia. The reason for DIFFERENTIAL DIAGNOSIS 603 this may be that the spleen is enlarged in only about sixteen per cent, of cases of pernicious anemia and chlorosis (Schmidt). It is only in the cases of enlarged spleen that pain is present. SPLEEN. DIFFERENTIAL DIAGNOSIS.' Symptoms Spleen Pleurisy Pneumonia Pain. Felt in right side or is referred to the ab- domen. Worse on respiration. Localized to diseased area; not such a great tendency to be referred. Localized over area \<'hen pleura is involved. Re- ferred pain over the chest wall is also present. Tenderness. Splenic points of ten- derness are present. Pressure on i he lower border of the spleen (bimanual) is painful. No splenic points of tender- ness. Tender- ness maybe pres- ent in the inter- costal spaces over the affected area. - No splenic points of tenderness. Tenderness a s a rule is present over the affected area. Rales. May be present, due to pressure atelecta- sis of the adjacent lung. May be present, due to the asso- ciated involve- ment of the sub- pleural p n e u - monic tissue. Present. Enlargement of the spleen. Present and spleen is tender on pressure. No enlargement. Enlargement, sep- tic in origin, may occur late in the disease. Friction rub. May be present; gen- erally absent. Present. Dis- appears when effusion occurs. Frequently pres- ent. Cough. Generally not pres- ent. Present. Present. Sputum. None. Frothy or dry. Rusty. Temperature. Generally that of the causative lesion. Generally none, or very slight. Generally p^-esent and vcy high. * Splenic disorders have been confused with acute rheumatism, especially so when the splenic pain is referred to the left shoulder; but in rheumatism some of the joints are almost invariably affected, while in splenic disorders there is no joint involvement. CHAPTER XXIX THE KIDNEY GENERAL CONSIDERATIONS It is said by Howard Kelly, in what is probably a fair esti- mate, that over 60 per cent, of the patients with ill-defined, right- sided pain have disease of the kidney. In view of this, it is easy to understand the importance of being thoroughly conversant with kidney pains, the rationale of their production, and the method and manner of their perception. The kidneys, unlike other abdominal viscera, are entirely retroperitoneal and do not come in intimate relationship with the other intraabdominal viscera. Their position, however, brings them into more intimate contact with the parietes and conse- quently with the nervous supply of the abdominal walls, which is cerebrospinal. It is extremely doubtful if any cerebrospinal fibers convey ner\'e impulses from the parenchyma of the kidney.^ Yet the capsule and some of the pericapsular tissue contain cere- brospinal sensory fibers. In this way the localization of the aching pain felt in all capsular or pericapsular affections can be explained. Sympathetic nerve fibers supply the parenchyma. They are collected into the renal plexus, which in turn communi- cates, through the solar plexus, the lower and outer part of the semilunar ganglion, and the aortic plexus, with the lesser and the smallest splanchnic. Nerve Supply. — The nerves supplying the kidney are derived 1 According to the latest researches the cortex of the kidney is derived from the mesoblastic tissue of the posterior abdominal wall; consequently there must have been, at least in the early stages of development, some slight distribution of the terminal branches of the spinal nerves to the kidney sub- stance. Whether these persist in later life is problematical. 604, GENERAL CONSIDERATIONS 605 from the tenth, eleventh and twelfth dorsal, and the first lumbar segments of the cord (Head). How important these areas are to kidney pain production, and how necessary the knowledge of their location is for a cor- rect and satisfactory diagnosis, will be shown. Etiology of Kidney Pain. — The direct cause of kidney pain is, as in all painful lesions, an irritation arising somewhere in the course of the nerve supply. Since the nerve fibers supplying the kidney are related directly and indirectly with other organs, irri- tation arising in their course may be referred to any or all of these related organs. Therefore, since a lesion of the kidney will cause pain and disturbance in other organs, and a lesion of other organs will cause pain and disturbance in the kidney, it requires more than the pain syndrome to make a diagnosis of a kidney lesion. An exception to this probably could be made in favor of the local tenderness which occurs upon pressure in the costal-vertebral angle, when the kidney or the surrounding areolar tissue is in- flamed. The causes and the locations of nerve irritations causing kid- ney pain are varied ; yet it is most probable that nearly all of the kidney pains owe their origin to stretching and pressure ex- erted upon the nerve filaments terminating in the capsule. In this connection, Watson reports a case of apparent renal colic, in which the kidney was opened and no stone was found, but the capsule was thickened. Complete relief followed the oper- ation. Keyes also reports relief from the splitting of the capsule in a case of chronic granular kidney. Even in a simple congestion the pain is eased by capsulotomy. However, it is probable, in all cases, that the pain is the result of an acute process, for in chronic and slowly progressing disorders, like granular nephritis or new growths of the kidney, pain is absent unless the tension of the capsule, from any cause, is suddenly increased. The pain of a severe and a colicky type instantly results. Indeed, it is claimed by Bcvan and others that the pain of renal calculus is the result of a sudden increase in intracapsular tension. Bevan re- ports a case in which, j)revious to a nephrotomy, severe pain had 606 THE KIDNEY been present, but was entirely absent after operation, although a stone, which was present in the ureter, had not been removed. After the operation its progress down the ureter could be watched with the X-raj. At no time in its descent was the slightest pain present. This is only one of the many instances which seem to show that kidney pain, that is, direct pain, is due to tension on the renal capsule. Should the capsule be thickened and non-elas- tic any increase in the mass of the kidney would be painful, be- cause of the resistance to stretching offered by the thickened cap- sule. For this reason, it may be, that old people and rheumatics can, by the aching which they have in their backs (in the kidney areas), foretell changes of weather. The lowering of the baro- metric pressure may induce a kidney hyperemia, which produces tension of the capsule and thus causes pain. In cases of intracapsular tension, in which the renal pelvis is distended wath exudate, splitting of the capsule and opening of the pelvis will let out the exudate and relieve the primary pain ; but a secondary congestion in the pelvis may result and produce a secondary pain. An example of the insensibility of the kidney parenchyma to pain production is given by Cartwright (Lancet, 1888, Vol. II, p. 403). He says that, when in China, he was shown a speci- men of a kidney removed from a Chinese cooley by an American physician. Before its removal it had extended through an open- ing in the loins and had suppurated from the treatment of bird dung, saliva, etc., with which it had been daily dressed ; and yet, during all this time, no pain had been present. The kidneys are in close relation with the upper parts of the lumbar plexus on either side and enlargements of their substance, new growths, or perinephritic abscesses will sometimes press upon certain of these nerves and cause pain. This pain is referred to the distribution area of the nerves upon which pressure has been made. A more complete discussion of these pains will be entered into under the heading of referred pains of the kidney. The ureters and their nerve supply will be considered in their respective sections. GENERAL CONSIDERATIONS 607 Character of Renal Pain. — In some cases, especially early in the renal involvement, a well-defined pain is not present ; rather, there is exjDerienced a sense of discomfort and distress in the cor- responding iliac fossa or lumbar region. This distress may gradu- ally increase, so that in time it becomes a well-defined pain. If the pain, when present, is of a dull, aching character, it indicates that the tension on the capsule is not of any considerable moment, but rather that the lesion involves the surrounding renal struc- tures or is of some slowly progressing, intranephritic nature, such as that which occurs in the large white kidney of nephritis. If there is also considerable tenderness on palpation an extrarenal complication may be suspected. An aid of value in the diagnosis of intra- or extrarenal lesions is that intrarenal lesions generally give rise to areas of referred hyperalgesia, while extrarenal lesions do not. In some cases of wandering kidney, from kinking of the ureter, there is a sudden elevation of the intracapsular pressure, vritli a very severe, colicky pain. These attacks go under the name of Dietl's crises (see TTandering Kidney). They are accompa- nied, at the time of the attack, by a considerable decrease in the quantity of urine. This is followed, on the reestablishment of the urinary channel, by the voiding of a considerable quantity of clear urine which may be slightly tinged with blood. During the attack palpation will disclose a swollen and tender kidney. A calculus blocking the ureter will produce similar symptoms. Botli a kinking of the ureter and the blocking of the same by a calculus are accompanied by vomiting and chills, and, in some cases, by a mild fever. A kidney in a state- of hypertension from arterial hyperemia has a peculiar rhythmical, pulsating pain, most pronounced in the lumbar region. The pain is synchronous with the cardiac systole and is the result of the increase in the intranephritic ten- sion, which occurs during each systole. Localization of Kidney Pain.- — In kidney disorders, as well as in disorders of all other organs, there are two classes of pain manifestations, namely: the subjective, in which the pain is pro- 608 THE KIDNEY duced without any apparent external means of causation, and the objective, in which pain is produced by manipulation, pressure, etc. Tenderness comes under the class of objective pain. The subjective pains may be divided into the following divisions: (1) local, (2) referred, and (3) reflected. Local Pains. — Local pains, as the name would imply, are those which are produced directly in the kidney area. This area is bounded by (Gray) : (1) A line parallel with, and one inch from, the spine be- tween the lower edge of the tip of the spinous process of the eleventh dorsal vertebra and the lower edge of the spinous proc- ess of the third lumbar vertebra. (2) A line from the top of the first line outward at right angles to it for 2f inches. (3) A line from the lower end of the first transversely out- ward for 2f inches. (4) A line parallel to the first and connecting the outer ex- tremities of the first and third lines just described. The kidneys are therefore opposite the last thoracic and the upper two lumbar vertebrae and reach to within 2.5 to 3.5 cm. (1 to lYz in.) of the highest part of the iliac crest (Piersol). (See Fig. 136.) Thus, any pain felt in this region should lead at once to the suspicion of disease of the kidney, especially eo when the pain is associated with local tenderness. If the pain is sharply delimited, and if referred or reflected pains are absent, a perinephritic in- flammatory lesion should be sought. ''This is most important to a correct diagnosis in infants and children, because in them, on account of lack of development, the ability to localize pain is defective. In any case, either in them or in adults, a severe abdominal pain, of unknown etiology, espe- cially when associated with the drawing up of the limb, etc., should always direct attention to the kidney." Beferred Pain. — By referred pains are meant those pains which are felt at a distance from the place where the irritation producing them is located. The irritation may occur at any point in GENERAL CONSIDERATIONS 609 the course of the affected nerve, but the pain is perceived as com- ing from its peripheral distribution area. In kidney lesions this is well exemplified, for pain due to the kidney may be felt in the lower iliac region, the suprapubic, the outer, middle or the inner Renal I Prostate and seminal vesicles, sexual excess Bladder Prostate Seminal vesicles Prostate Disease of base of blad- der Fig. 137. — Akeas of Referred and Reflected Pains in Disease of the Urinary Apparatus. (Modified from Fenwick.) Unilateral pain of one fimb is often a premonitory sign of brain hemorrhage. part of the thigh. Pain, Avhen felt in any other part of the thigh, if it is produced by lesions of the genitourinary tract, is generally due to those lesions which are located in the ureter above the bladder; while pain felt in the penis, scrotum, or in the lateral margin of the perineum and the inner aspect of the thigh, or over the lower part of the sartorius muscle (involvement of the obtura- 610 THE KIDNEY tor nerve), generally indicate involvement of the ureter adjacent to the bladder. A differential point of value in the diagnosis of the location of lesions of the kidney or ureter is that in high ureteral in- volvement the skin of the scrotum is not painful to pressure, but the deeper tissues are ; while the reverse is true in low ureteral involvement. When the involvement is adjacent to the bladder the pain may be referred through the inferior hemorrhoidal nerve to the skin around the anus or through the perineal branch of the pudic to the skin of the scrotum. It may also be referred through the dorsal branch of the pudic to the glans penis. When, in cases of renal calculus, pain is felt in these areas it js a good indication that the stone is in, or almost in, the bladder. This is especially true should referred pains in the lower areas follow those in the upper areas, particularly those supplied by the eleventh and twelfth dorsal, the ilioinguinal, iliohypogastric, and the genito- crural nerves. The anterior crural nerve, because of its position behind the psoas muscle, is fairly well protected from pressure from any kidney or ureteral disorder, and therefore referred pain is seldom, if ever, found in the region which it supplies. Another diagnostic point of great value is that involvement of the lower third of the ureter produces increased frequency of urination, but no pain during urination. In this it differs from lesions of the bladder, which cause both increased urination and pain. The zones of Head are also of particular value in determining the exact location of the lesion. In some, but not in all cases the progress of the descent of a calculus, and the distention of the ureter above it, can be noted by the referred and reflected pains which are present. These pains commence above in the area of the tenth dorsal and pass down through the areas of the iliac, suprapubic and the ilioinguinal to the scrotum and the penis, at which time, as a rule, the stone is in the bladder. Referred pains are also felt in the thigh. These Schmidt regards as being due to pressure upon the twelfth dorsal nerve and upon branches of the lumbar plexus by thickening of the :; '-'3 hi ^. S =3 B — > c B 15 -r (3 ■3 « a 3 M — M 2 OS o C3 x> go a o > Ul >> 3" 5 2 o l.=: s ^ a i c u o oJ s 3 3 X "^iJ" C c h M ^ ,2 1^ W ►q a 3 "o 1= a) 13 > U a "3 .2 2 1 u a E c °-3 ^ ^g Ti 3 a ■3 Sa u !3 e §.2.2 c^ c '5 41 ^i ^■^ 3 2_5 a •■^ *^ »— < M CO ■* < e u ■G W 611 612 THE KIDNEY capsule. Such a causative agent is a far-fetched possibility, for though the amount of capsular thickening may be excessive it would not by any means interfere with the surrounding nerve structures, unless there was, at the same time, an extensive peri- nephritic inflammation. For emphasis, even though it involves a slight repetition, it may be permitted to recall that the nerves involved in referred pain from the kidneys, and the areas which they supply, are: (1) the twelfth dorsal, which supplies the skin of the lower ab- dominal and lumbar region; (2) the iliohypogastric, (a) iliac branch, supplying the integument of the anterior gluteal region, (b) hypogastric branch, which is distributed to the integument of the suprapubic region; (3) ilioinguinal, supplying the integu- ment of the upper inner portion of the thigh; (4) genitofemoral, which is divided into (a) genital branch, which gives branches to the skin of the scrotum, the thigh adjacent to the scrotum, and the labia majora in the female, and (b) the crural branch, which supplies the upper anterior part of the thigh, between the regions supplied by the external cutaneous and the ilioinguinal, and ex- tends down as far as the middle third of the thigh; (5) the ex- ternal cutaneous, dividing into (a) an anterior branch, supplying the integument over the anterolateral aspect of the thigh as far as the knee, (b) posterior branch, supplying the skin over the tensor fasciae femoris and lower portion of the gluteal region; (6) the obturator, which subdivides into (a) the anterior branch, supplying the integument of lower inner third of the thigh, and (b) the posterior branch, which by a branch supplies the knee joint; (7) the anterior crural, dividing into (a) the middle cutaneous, which, through its (1) external branch, supplies the integument over the rectus femoris as far as the knee, and (2) the internal branch also, which supplies the integument over the rectus femoris as far as the knee; (b) the internal cutaneous, supplying the integument over the anteromedian aspect as far as the knee; and (c) the internal saphenous, which gives sensation to the integument over the anterior internal portion of the leg, and the posterior half of the dorsum, and mesial side of the foot ; GENERAL CONSIDERATIONS 613 (8) the small sciatic, dividing into (a) the gluteal cutaneous, supplying the skin of the inferior gluteal region, as far externally as the great trochanter, and internally as far as the coccyx; (b) inferior pudendal, supplying the skin of the upper mesial por- tion of the thigh and also the perineal body and anus; (c) the Cord Zones Dx Dxi Dxii Li 9th dorsal 10th dorsal 11th and 12th dorsal ihohypogastric ilioinguinal genitocrural ext. cutaneous middle cutaneoua int. cutaneous obturator Nerves FiQ. 139. — Distribution of Cord Zones (according to Head) and of Nerves. femoral branches, supplying the skin of the posterior aspect of the thigh; (d) the popliteal branches, which are distributed to the popliteal space, and at times extend as far as the ankle; (9) the pudic, which, through its superficial branch, supplies the lateral margin of the perineum and inner aspect of the thigh, and the integument of the scrotum or labia majora ; and through the inferior hemorrhoidal branches supplies the external sphincter 614 THE KIDNEY and the interment of the anal region (Piersol, "Anatomy," 1st ed., pp. 1320 to 1352). Reflected Pains. — In the lesions of any visens Head's zones should be investigated. Their presence is of very great positive, though their absence is of little negative, value. It seems to be a rule in kidney disease, as in disease located Fig. 140. — Areas of Reflected Hyperalgesia, in 10th, Uth, 12th Dor- sal, AND 1st Lumbar Visceral Segments According to Head. These are the areas affected in. kidney lesions. elsewhere, that the first acute attack of inflammation almost in- variably produces reflected pain, but that later attacks are not so prone to do so, because, during the first attack, the nerve termina- tions are so much injured that their ability subsequently to react to pain stimuli is very much impaired. This is the reason why hyperalgesic zones are not found in all cases of acute or chronic, recurring inflammation. According to Head, "The kidney is par- ticularly associated with the area of distribution of the tenth GENERAL CONSIDERATIONS 615 dorsal segment, and to a lesser degi'ee with that of the eleventh and twelfth dorsal and the first lumbar segments. Disease of the kidney, of the renal pelvis, and of the ureter seems to be par- ticularly associated with the eleventh and twelfth dorsal and the first lumbar segTxiental areas." The testicle receives its nerve supply from the same segment of the cord as does the kidney, and therefore re"«l lesions fre- quently give rise to pain in the testicle. It sometimes happens that the pain may be felt entirely in the distribution area of the lower cord segments, commonly associated witli kidney disease, Fig. 141. — Method of Palpation in Eliciting Tenderness in the Kidneys. and not at all in the upper, so that a lesion of the kidney may sometimes be mistaken for one of the bladder. Renal pain also is frequently transferred across the cord and is felt in the distribution area associated with the opposite kidney, the so-called renorenal reflex of Morris, though Prout was prob- ably the first to draw attention to this phenomenon. Tenderness. — Tenderness is present to a greater or less extent in nearly every case of kidney disease. The only exceptions are new growths, which may be entirely free of tenderness. The technique for examination for kidney tenderness is as follows : Have the patient's bowels tho^-o^g^ly cle^Tised by a purgative previous to the examination; cause the patient to recline on the back; and have the limbs dra%vn up, and raise the shoulders (preferably on a pillow), so that the abdominal walls may be re- laxed (Fig. 141). Place one hand, palmar surface, over the lum- 616 THE KIDNEY bar region. Place the tips of fingers of the other hand in the subcostal space anteriorly; then, have the patient take a deep breath, and at the same time make simultaneous pressure with both hands. If the kidney is displaced it can be felt slipping between the fingers. If it is not displaced it cannot be felt. When pressure is a2)plied in this way to a healthy kidney no pain, though sometimes a sense of discomfort, is produced; while, on the other hand, if the kidney is diseased the patient immediately complains of severe pain. Ransohoif palpates simultaneously on both sides, with the thumbs along the last rib from within outward, and thus finds the tender foci. E. H. Thompson gives a som.ewhat similar method for eliciting tenderness in kidney lesions, especially in renal calculus. ''He stands behind the patient and places the thumbs of ^loth hands under the last ribs and then so spreads the fingers over the abdo- men that when the jiatient relaxes the abdominal walls, by bend- ing forward, tlie kidneys are pushed up toward the spine; then, as the patient straightens up, the thumbs are strongly pressed in. If a renal calculus is present the patient will quickly bend over to the affected side." In some cases it occasionally happens, in kidney lesions, that contraction of the psoas muscle may cause pain. This may be demonstrated by having the patient, after having flexed the thigh upon the abdomen, suddenly straighten the limb. The pain, so produced by this maneuver, is deep down in the iliac region of the side involved. The points where tenderness are most marked are (1) in the subcostal angle, between the margin of the erector spinse and the last rib; (2) on the outer surface of the thigh, about the iliac crest; and (3) on the abdomen, below the free margin of the tenth rib. The tenderness may be divided into tlie superficial and the deep. Superficial tenderness and hyperalgesia are useful in outlin- ing the zones of Head, while deep tenderness is a means of prac- tical value in the diagnosis of deeply situated lesions. Should tenderness be associated with edema it is almost pathognomonic of GENERAL CONSIDERATIONS 617 a deep-seated inflammation. Percussion is very useful in exactly localizing the boundaries of renal tenderness. Tenderness of the lower segment of the ureter can be deter- mined by palpation through the vagina or rectum. In case of inflammation, pressure exert- ed upon it produces pain, which is referred to the same areas as is the pain due to in- volvement of the lower seg- ment of the bladder. Tender- ness is very marked in tuber- culosis of the ureter, or in ureteropyelitic inflammations. In some cases a stone, if lodged in the lower segment of the ureter, can be felt from the vagina or rectum by the palpating finger. The upper segment of the ureter cannot be satisfactorily palpated. Factors Influencing Pro- duction of Pain. — Factors in- fluencing the production of pain in kidney and ureteral lesions are : (1) The Position of the Patient. — The patient always assumes the posture of great- est ease. In inflammatory lesions he may lie on the side in which the lesion is lo- cated, although as a rule he lies upon the opposite one. However, in nephroptosis the patient is most comfortable when lying upon the healthy side. During an acute renal attack he reclines in a semi-prone position, with the back slightly arched. Fig. 142. — Position Assumed in Kidney Disorders, Ureteral and Kidney Colic, Lumbago, Uterine AND Tubal Adhesions and Drag on Back, Enteroptosis, Espe- cially after Removal of Corset. 618 THE KIDNEY and the limbs flexed upon the abdomen, so that the abdominal muscles are relaxed. When standing the patient generally bends forward and grasps the side of the body, pressing in on the lumbar region with the thumbs, and on the iliac region with the flat of the hand. (2) Motion of the Patient in B elation to Pain Production. — In all diseases of the kidney or ureter due to obstruction of the ureter, or to an inflammatory process, motion of any kind is more or less painful. This is especially true of those movements asso- ciated with shock (vibration), as horseback riding, or movements in which the kidney is subjected to pressure; for instance, cough- ing, sneezing, deep breathing, rowing, bending, stooping, or the lifting of heavy weights. All of these movements throw great pressure upon the sensitized kidney and so produce pain. In some cases forcible flexion of the thigh causes pain. This is due to the contraction of the psoas muscle, causing either a dragging or a pressiire upon the affected kidney. (3) Duration of Kidney Pain.— Pain that is sharp, sudden and spasmodic, coming quickly and passing away just as quickly, generally indicates a lesion of transitory activity, probably a calculus. Pains of greater severity and more constant duration indicate a lesion of more permanence and greater gravity. The persistence of tenderness for some time after the pain has ceased is characteristic of infarct. Absence of Pain in Kidney Lesions. ^ — Pain is generally absent in the following lesions of the kidney : n'ew growths, acute and chronic nephritis, and fatty and amyloid degeneration of the kidney. Symptoms Associated with Pain Phenomena. — Symptoms as- sociated with pain phenomena in kidney lesions are: (1) muscu- lar rigidity, which is frequent on the affected side; (2) frequency of urination; (3) urinary tenesmus; (4) the presence of patho- logical products in the urine; (5) the presence of a tumor in the kidney region; (6) the presence of edema, both localized and general. Edema localized to the kidney area is present in cases of peri- GENERAL CONSIDERATIONS 619 nephritis, inflammation, and abscess formation. Should edema be present nnder the eyes of those who complain of pain in the lumbar region it is a fair indication of nephritic trouble. Gener- alized edema only occurs late in nephritic processes. Pain in Diagnosis of Kidney Lesions. — After a review of the anatomy, relationship, and pain-producing factors in kidney disease, it is well again to recall to mind, in a brief summary, the value of pain in the diagnosis of kidney lesions. Besides pain the principal means that are of use in diagnosing lesions of the kidney are the presence of a tumor and the character of the urine. (1) Should pain be present in the kidney areas without tumor, ' and at the same time pus should be found in the urine, and this be accompanied by a cystitis, with or without hematuria, it indicates a renal tuberculosis. If pus is present in the urine, without cystitis, and with or without hematuria, renal calculus is probably present. The X-ray, as a rule, will disclose the stone. In calculus the pain is made worse by movement and may be referred to the neck of the bladder. Should no pus, but, instead, blood, be found in the urine, the following should be considered as causative factors : cancer, hematuric nephritis, papillomata or angiomata of the renal pelvis, and renal congestion. (2) If pain is present in the kidney areas and is associated with tumor, the following should be inquired into: (a) the presence of pus in the urine, accompanied by a cystitis, with or without hematuria, indicates a hydronephrosis; (b) the absence of pus in the urine and freedom from cystitis and hematuria are almost pathognomonic of aseptic hydronephrosis or of floating kid- ney, with or without moderate retention of urine; (c) the pres- ence of a hematuria with neither pus in the urine nor a cystitis, most frequently points to cancer, especially if the hematuria usually occurs at night or on awakening. In all cases of kidney involvement the cystoscope should be used to tell which is the affected kidney. Pain in the lumbar region may be due to lesions of other organs, as Avell as to those of the kidney, and these should be diag- 620 THE KIDNEY nosed from kidney lesions. The lesions sometimes so mistaken are iliosacralgia and iliomyalgia, and are distinguished from kidney lesions by the following: (1) they produce no enlargement in the lumbar region and no tumor can be felt by transabdominal palpa- tion; (2) stooping and bending of the body are painful and, as Cathelin has pointed out, those afflicted by the above-named condi- tions are unable, upon arising in the morning, to button their boots or to pick up anything from the ground; (3) gross urinary changes are absent. DIFFERENTIAL DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN After a general consideration of kidney pains, it is necessary to particularize and to review separately the different lesions. The order in which they will be considered is as follows: (1) movable kidney; (2) renal infarct; (3) congestion; (4) inflam- mation, acute and chronic; (5) peri- and paranephritis; (6) rupture of the kidney; (7) tuberculosis of the kidney; (8) new growths of the kidney; (9) pyelitis; (10) hydronephrosis; (11) renal calculus. Movable Kidney. — This is a very common lesion. Out of two hundred patients it was present eleven times, but in only one case were there any symptoms referable to it (Johnston). It is thir- teen times more frequent on the right side than on the left. Even allowing for its rarity in the usual class of patients, it cannot be denied that it is the cause of a large proportion of the abdominal discomforts usually encountered. However, frequency of this con- dition is probably slightly exaggerated by Kelly, who says that sixty per cent, of the cases of ill-defined, right-sided pain are due to trouble in the kidney, which trouble is usually a displacement, with a kinking of the ureter and retention of the urine in the renal pelvis. Anatomical Considerations. — Normally, the kidney is a mod- erately movable organ, slight elevation and depression being asso- ciated with the up-and-down movement of the diaphragm in o -< m S < 2 ■< (» Attacks are only brought on by movement, are much worse in the morning, but as the day advances, and the muscles are exercised, tl.e pain and soreness gradually become less. 3 S o -a m ■^ 0) =i -« S -0 a If .■S a m ° •-I a "^ 2 S 3 "a 1 em a ■§• o a 1 "3 _o . So as s-S o •^ at. £> i: li 1- . 0) a'o i.i g a ■«"a £ a 3 o i-3 3 a a _3 O a) "3 a O I-, Z a' •3 a a> .♦^ 1 C3 tc a 'a a 03 1 a 3 a '3 a » V 13 _o a .2 Oh !2 03 _>. 13 la _>. a £ "3 a a _a a ca >. 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S 9 °.9 a^ II a ■" '3 2 a 3 M a '.3 t a ii T3 .9-- a 0) 03 03 >, "a S -0 a ■3 a i> +J 0) ■3 _o a ta 0- ai. •" 3 ■g.9 3 v a XI . 03 Sg "03 9-S g-g . ?m 03 v ja .2 "a^ >.« a fell _a a < a Ji , SS .9| S'oa _a •5 a ao ^« -a 03 _a 1 a) a a (U a 03 o s M a '3 t3 £ 3 2 a i 3 i N 621 622 THE KIDNEY breathing. This freedom of motion is permitted by the rather loose connection of the kidney with the surrounding structures. It is retroperitoneal and is in close relationship Avith the dia- phragm. Both kidneys are inclosed in perirenal fascia which divides into two layers. The anterior layer passes across the great vessels and nerves (such as those from the renal plexus, the solar, eleventh and twelfth dorsal, ilioinguinal and iliohypogas- tric), and joins the homologous layer of the opposite side. The posterior layer passes behind the kidney and is attached to the spine. Above, both fuse into the diaphragm, while below they merge into the fatty subperitoneal tissue of the iliac fossa. This structural formation jDermits considerable up-and-down move- ment, while anterior or posterior displacement is limited: The kidneys are joined on the right side to the liver, colon, and duo- denum, while on the left the colon and the spleen are in intimate relationship. It is because of these connections that displace- ment frequently produces symptoms of xliscomfort and even of pain in these associated organs. Pathology. — In displacement of the kidney most of the pull is made upon the diaphragm and the lumbar fascia. These are supplied by the tenth, eleventh, and twelfth intercostal and the first lumbar nerves. Therefore it follows that the pain and discom- fort in displacement will be radiated over the lower abdominal wall and the back. Such is the case. Yet every person having a mova- ble kidney does not complain of pain. Indeed, in many people a considerable amplitude of movement and of displacement are pres- ent without any symptoms; it is only when the displacement be- gins to cause disturbances in other organs that the patient be- comes aware of the pathology. From this time on the unfortunate individual has entered the realm of the nephroptotic, and is subject to constant distress and discomfort. The first distress from which he suffers is that of a pulling and a dragging in the lower lumbar region. The discomfort may become so gTcat that the patient walks in a stooping posture, though this posture is more characteristic of the enteroptosis, with which, as a rule, nephroptosis is associated, the nephroptosis being but one symp- DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 623 torn of the generalized condition. In renal displacement other causes for later pain production are due to kinking or twisting of the renal pedicle, which causes: (1) distention of the renal pel- vis, because of conij)lete or partial obstruction of the ureter, and (2) distention of the renal parenchyma, because of renal conges- tion, which is the result of partial obstruction of the venous flow. In both these cases the pain is due to the sudden increase of intra- capsular pressure. Both simulate, in severity and suddenness of onset, the pain of renal calculus. In some cases a movable kidney may also be the seat of calculus, pyelitis, tuberculosis, or inflam- mation, and these give rise to their owti typical symptoms, in addi tion to those of the displacement. A differential point of value in the diagnosis is that a diseased kidney is tender on pressure, while one which is only displaced is not tender. Location of the Pain. — Local pain is generally absent in mov- able kidney, though there is present a constant sensation of pull- ing or of dragging in the lumbar region. In contradistinction to local pain is the frequency with which referred pains (the so- called radiating pains) are found. They are due to the drag and pull upon the nerves, which lie in close relationship to the kidney, such as the eleventh and twelfth dorsal, the ilioinguinal, iliohypo- gastric, and, at times, even the crural or the sciatic. Pulling and dragging on these cause pain and discomfort in the lower abdomi- nal wall, the outer and inner side of the thigh, or, in some cases, in the genitalia. The pain in the shoulder, which Kelly states is sometimes present, probably is due to traction on the diaphragm, the irritation being carried through the phrenic to the supra- acromial nerves, and thence to their distribution over the shoulder. True reflected pain is seldom found in displaced kidney, except when a state of very acute congestion, from venous stasis or inflammation, occurs in the affected organ. Then pain is felt in the kidney zones ; in some cases it is felt in the kidney zone on the side opposite to the one affected. This pain is probably trans- mitted through the sympathetic nervous system to the cord, and thence to the body wall on the opposite side. Kelly, quoting from Moullin, reports a case where the pain 624 THE KIDNEY was in the epigastrium, shooting around to the back and shoul- ders. It invariably came on one-quarter to one-half an hour after eating; solid food made it worse, vomiting was frequent, and seemed to relieve the pain. The reclining position eased the symptoms. Kelly quotes this as a case of referred pain from the kidney, but it is difficult to see why it is not one of gastric ulcer. The vomitus at times contained blood and all the symptoms, man- ner of pain production, its reference, and character would indi- cate the lesion to be ulcer of the stomach. The relief coming after the kidney suspension was due, it would seem, more to the rest in bed than to the operation on the kidney. In addition to the symptoms detailed above as resulting from displaced kidney, there also result gall-duct colic, jaundice, and other symptoms which are referable to the liver and its appendages, and are due to the pressure of the right kidney against the common bile duct. Character of the Pain in Displaced Kidney. — The pain may be of a constant, dragging, or aching character, and may be either mild or very severe. In certain cases it is so slight that the patient is not aware of its presence unless his attention is directed to the displacement. In other cases he is always in great distress. In all cases, when present, the pain is made worse by standing or by exercising, and is generally relieved by lying down. In some women the pain, as a rule, is worse during the menstrual period. In others it is worse at night time, after the removal of the corset, while in still others it may be present when the patient is lying in bed, but promptly disappears when, on arising in the morning, the corset is put on. Generally, though, reclining in bed relieves the pain. Paroxysmal pains are also frequent in kidney displacement. They were first described by Dietl in 1864, and are due to torsion or kinking of the ureter, with the consequent acute hydro- nephrosis. That such a twist or kinking is the causative agent in the production of the pain of this condition would seem to be verified from the fact that similar pains may be produced by arti- ficial distention of the pelvis of the kidney by sterile water. In addition i« the hydronephrosis, it is likely that torsion o'f the re^al DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 625 vessels (especially the vein), by causing a sudden increase of the intracapsular tension, may also be a partial factor in the pain of the so-called crises. The attack is generally accompanied by nau- sea and vomiting. It frequently takes place as a sudden increase of existing symptoms and, as a rule, follows excessive or violent motion, either in the form of exercise or in the jolting incident to riding horseback, or journeying in springless wagons over rough roads. In some cases indiscretion in diet may induce the pains. Generally, the attack subsides as quickly as it began, though soreness in the loin may persist for some time. The at- tack, as a rule, is associated with a weak and rapid pulse, cold, clammy perspiration, and signs of collapse. It generally passes off in a few hours, but may last for days. Should the pain be due to torsion of all the renal vessels, wath consequent renal conges- tion and increased intracapsular pressure, it does not at once pass off on relief of the condition, but persists as a soreness in the kidney region for some time (Johnston). A transient polyuria follows each paroxysmal attack. Associated Symptoms. — The symptoms associated with mov- able kidney are : (1) The Urinary Changes. — The urine varies greatly in the daily quantity. During the time of the acute torsion the quantity of the urine is decreased and blood, albumin, and casts may be present. Immediately after the attack the quantity of the urine is greatly increased and it becomes clearer, though blood is occa- sionally present, as well as albumin and casts. Painful urination also is present at times. (2) A tumor due to hydronephrosis may be noted during the attack. It disappears after the hydronephrosis is relieved. In some cases the tumor may represent only the kidney. If such is the case, the kidney can be replaced by manipulation and the tumor then disappears. (3) Digestive disturbances, such as (a) flatulence, which is the result both of pressure by the kidney on the intestine and of the transmission of nervous stress from the kidney to the intes- tines, the latter being due to the intimate association of the two 626 THE KIDNEY organs through the nervous system, (b) nausea and vomiting, which are very frequent. (4) Constipation may be due to pressure on and obstruction of the bowel by the kidney. Tenderness. — When a movable kidney is pressed between the fingers the patient feels a peculiar, sickening sensation, similar to that felt when pressure is made on the testicle. If, instead of the sickening sensation, pain results, some inflammatory lesion of the kidney or some condition producing increased intranephritio tension is present. Factors influencing tlie production of pain in movable kidney are: (1) the position of the patient; standing, especially if corsets or kidney pads are not worn, is provocative of very severe distress. Lying down immediately relieves the pain. (2) Motion; all violent motions cause painful or distressing symptoms. Such motions as are present in jumping, running, and swimming are the most active. Lesions associated with movable kidney are: (1) enteroptosis, which is a commonly associated condition, and often is the primary cause of the kidney lesion; the tympany, which may be present in nephroptosis, is more a sign of the general enteroptosis than of the movable kidney; (2) neurasthenia frequently accompanies mov- able kidney, and is probably due to the pressure and pull upon the abdominal sympatlietic by the displaced organ. Renal Infarction. — In renal infarct pain is of gi-eat value in forming a diagnosis. The .infarction may be either septic or aseptic. In the septic variety the embolus is infected and is pro- ductive of much more pain than is the non-infected type. Should the embolus be infected, after the infarction has occurred there is a slow increase in the pain. Pain and chills of gi-adually increas- ing severity, arising in a case in which they previously have been absent, are signs that infection has occurred. Causes. — The causes of pain in infarction are, according to Halperin : (1) insult to the renal plexus, (2) perirenal inflamma- tion or inflammatory reaction, and (3) tension on the kidney capsule (Halperin). 2: a g 3 6 K s :0 < Si O D H o s P-, Pain is of a dragginK nature. Present around the crest of the iliimi. Generally not severe and is referred to lower abdomen or to the iliac region. 3S g.s.- |:l fe ° g S-S in 2'E M ^§:- c3 0. a 1 11 >>§ H '3 a u >. 1 ■6 m •3 C 3 2 0" 03.2 ^1 a E£ 3 t. "3g si 2.20 -° .2 C3 a S •|5§ a "3 1 Z a _C Z c < a 03 ,- rt " =; M a . a — _o ^^ -^ "S cr a -"^ ■n « a — IS CT3 il >J= C3 >- a «^ 2 S I'S ^ 2.2 -S S""'3) «-3 a CMC 03 3 03-5 1|' = ^•^ a C a*— cj 2 ^'m 2 1] li J= t. c ■^ =3 ^ Is'a |li 4) 2 ^~. >> CO - > *J ■3 01 > C z a a a 3 s >, c 03 3 C S Z _>, c 0) 3 cr £ fa a =3 .a 1 c a z Q J m •0 *^.H • a J S||| --; ^ — ja — a „ a « 2 !« fl £ ■" ^g 2 " r/i a § rt a 5-1 2 .ssg -3 a '3 C S cS 2 = § fa "3 a tH a a .-, § §.2 = . . gil-a 71-3-3^ II c ac C 0)"~ ©5g - S-S a i: 3 &p a _a a 3 > a d z 3 ^a •3 03 n a § "a a'2 c a 2 oi ja _2 .£ ■ if g " 3 « ■3 a g.2 o 0. g C .3 X -» 2 P 3 2 a' 1 S • q| .2Ph tn'3 'S a 627 628 THE KIDNEY Type of Pain. — The pain is sudden, burning, or stabbing in character, and is entirely free from any tendency to paroxysms. It may be felt in the central part of the abdomen (Johnston) or may be without any definite localization. A point of value in the diagnosis of renal infarct is that in no case does the pain radiate into the inguinal region or to the genitalia. Violent motion of all kinds, such as running, jumping, coughing, and sneezing, in- creases it greatly. The position of greatest ease is one in which the patient reclines on the side of the lesion. Tenderness is present over the affected kidney, particularly toward the back in the costo-vertebral angle. Anteriorly, the abdominal muscles are contracted and render difficult deep palpation, so that deep ten- derness is hard to elicit, although the diffuse tenderness which is present is easily defined. Percussion is a valuable means of diagnosis in this disorder and more definitely localizes the tender- ness than does palpation. Dijferential Diagnosis. — Conditions causing pain from which renal infarction must be diagnosed are: (1) appendicitis, (2) gastralgia, (3) perforative peritonitis, (4) acute ileus, (5) gall stones, (6) lead colic, (7) embolism of either of the mesenteric arteries, (8) gastric crises, (9) lesions of the kidney or of the ureter, such as (a) torsion of the ureter, which may occur in wan- dering kidney, (b) paroxysmal exacerbations of chronic 'nephritis, (c) calculus colic, (d) pseudocalculus colic, from plugging of the ureter with debris, of either tuberculous or neoplastic origin, blood clots, or hydatids, or from obstruction from catarrhal swell- ing of the mucous membrane, or from functional spasm of the ureter. Associated Symptoms. — Symptoms associated with renal in- farct are : changes and variations in the quantity of the urine. In the early stage of the attack the secretion of urine may be greatly diminished or may entirely cease. The urine also always contains blood, which, in the non-infected cases, may be present alone, but, if the infarct is infected, pus and bacteria are also to be found. Considerable albumin and epithelial casts are present in the urine during the early stages of the infarction. Vomiting and hiccough- DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 629 ing are also common. Frequently there is a history of an asso- ciated or of a previous infectious disease. Hematuric Nephralgia. — Hematuric nephralgia (Sabattier) is a term used to designate a pain of the kidney that is without a definite causative lesion. In many cases it seems to be an essential neuralgia. That there is most probably some definite organic basis for this variety of kidney pain can be judged from the association of the pain with a hematuria. The productive agency seems to be a congestion of the active type. The absence of albumin in the urine in this disorder does not argue against the presence of a congestion, for the kidney may be extensively diseased without the presence of albumin in the urine, as has been proven time after time by examination of kidneys removed for nephralgia. In hematuric nephralgia one or both kidneys may be affected. In some cases, however, hematuria may be present without any accompanying pain. This usually occurs when coagulation of the blood has not taken place in the renal pelvis. When it has occurred, spasmodic pain, typical of ureteral obstruction, is felt. This variety of hemorrhage and pain production is frequent in renal tuberculosis, renal tumors, and the like. A part of the pain present in renal hemorrhage owes its origin to distention of the renal pelvis with blood. The presence of pain and tenderness in association with well- defined Head's zones may be of inestimable benefit in helping to decide whether one or both kidneys are affected by the inflam- matory process. The definite localization is of very great prac- tical value in the operation of capsulotomy or suspension. Should only one kidney be displaced it is necessary to sling up only one, and it is most important to know which one. Inflammation of the Kidney. — Inflammation of the kidney may be considered under two divisions: (1) congestion, and (2) inflammation, which, in turn, may be divided into the acute and the chronic. Congestion. — Preliminary to inflammation of any kind is congestion, which is very common and is frequently encountered 630 THE KIDNEY during ordinary colds and in various infectious disorders. It is of two types, (a) passive and (b) active. Passive congestion, as a rule, is not painful, only the active variety being so. The cause of pain in active renal congestion is the hyperemia (induced by local irritants) and the resulting tension on the capsule. It is of a dull, aching character, and is made worse on movement. Deep breathing seems to cause more distress than does simple motion. A characteristic point, differentiating congestion pain from lum- bago, is that in lumbago the pain is worse in the morning and im- proves as the day advances ; while in congestion the pain is better in the morning and is worse in the evening. Also, the pain of lum- bago is increased on pressure and is eased by fixation, while the kidney-congestion pain is not eased by fixation with adhesive straps and is very severe on deep pressure. In acute congestion disturbances of sensation in Head's zones are present; the urine also shows the effect of the circulator}^ disturbances and contains albumin and casts (blood) to a variable degree. The quantity daily eliminated is also diminished. The use of digitalis eases a passive, while it increases an active congestion. There are all degrees of congestion. Some may be so slight that they cause but the slightest of transitory disturbances, while others may be of such severity that they produce symptoms as severe as those found in inflammation. A case illustrating the pain phenomena in congestion of the kidney is that of a young man who, at the time of the taking of the history, had a congestive inflammatory lesion of the kidney, with an associated pleural effusion which extended as high as the fifth dorsal vertebra. He had a well-marked hyperalgesic zone extending from the spine around the body to the right iliac region. This hyperalgesic area was thought to be due to the kidney. If it were due to a nephritis, tlie hyperalgesia would probably be bi- lateral; consequently the areas of hyperalgesia would be present on both sides and would he somewhat symmetrical in outline. The areas of hyperalgesia in this patient were present only on one side and strapping did not ease the pain. (If the pain was due entirely to pleurisy, strapping the chest would probably havA DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 631 eased it.) Consequently, it would seem that the condition was one of unilateral congestion. The figure below is an outline in which the cutaneous hyperalgesic area is defined. IxFLAMMATiox (Xephkitis). — Acuto inflammation of the kidney invariably causes pain, the intensity of which depends upon the degTce of the kidney congestion and the time which the kidney has had to adjust itself to the circulatory changes. The Area of hj-per- aigesia Area ot maxi- rcum tender- ness 12th rib Area of maxl mum tender- ness Area of hyper- algesia A B Fig. 143.- — Area of Hyperalgesia in Congestion of Kidney. pain is a much agg-ravated form of the aching present in the kidney areas when the kidney is acutely congested. Inflammation is one of the disorders of the kidney in which sensory disturbances in Head's zones are very plainly marked. Their presence should lead, with almost a certainty, to the correct diagnosis. In renal inflammation the urine contains casts and is loaded with albumin. An interesting and valuable point in the diagnosis of this condi- tion is the co-relation between the extent of the Head zones and the intensity of the pain and tenderness for, as the hyperalgesia (in Head's zones) becomes less extensive, the pain and tenderness also gradually diminish. A peculiarity of inflammatory kidney pains is that they never become paroxysmal, but are always char- acterized by dull, constant aching. Stooping is not painful, but local tenderness is marked. A good way to elicit tenderness is by percussion, and the best way to percuss is with the whole hand, the blow being delivered by the ulnar edge of the open hand. The 632 THE KIDNEY referred jDain is not constant. In a bilateral lesion it may be pres- ent only on one side, and in a unilateral disorder it may be on the side opposite to the one involved. The zones of Head are of particular value in deciding which of the two kidney's is involved, because they are jjresent almost invariably only on the involved side. If the subjective pain should be on one side and Head's zones should be present on the opposite side, the latter would be the side involved. Tenderness may be present on both sides, even when only one kidney is diseased, or it may be found in the side opposite to the one in which the diseased kidney is located. Referred pain due to inflammation of the kidney parenchyma is uncommon. When present it shows that the inflammation has extended outside of the capsule into the adjacent perirenal tissues, and that a perinephritic abscess has formed. In some cases of nephritis pain is felt in the epigastrium. Sometimes, also, a dull aching is present across the loins. Rayer has observed that in acute nephritis there is never any retraction of the testicle or radiation of the pain into the groin, such as are so frequent in renal calculus. In kidney disease should the pains become generalized it is very often a signi of an early fatal termination, because general- ized pains are the result of a generalized toxemia rather than of the local process, and a generalized toxemia occurs only in the most severe and usually fatal cases. Chronic Inflammation. — In contradistinction to acute inflam- mation, chronic inflammation, as a rule, produces no pain that might be of value in forming a diagnosis. Chaeactee of Pain iisr INFepheitis. — In many cases nephritis may be present for years, and not produce the slightest discom- fort, while in other cases, very shortly after its origin, pains of great severity, generally ])aroxysinal in type, may ensue. These paroxysmal pains are due to an intermittent congestion of the kidney. At the time of these congestions blood, as a rule, is pres- ent in the urine. Other pains associated witn nephritis are the neuralgias and the pains due to neuritis. Headache is the most frequently aeso- DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 633 ciated pain. It comes on periodically (at fairly regular inter- vals) and, like migTaine, may be limited to one side (hemi- crania). It is located in various regions of the head. It may be frontal, occipital, temporal, or occipito-frontal, the occipital form being the most common. Frequently it is of a throbbing char- acter. Associated Sympto:ms. — The s^nnptoms accompanying neph- ritis are: (1) the presence of albumin, casts, and blood in the urine, (2) nausea and vomiting, (3) edema, (4) dry skin, and (5) slight fever and (6) a rapid pulse. Illustrative Cases. — The following cases are intended to illustrate the sensory disturbances in Head's zones and their bear- ing upon the diagnosis and prog-nosis of nephritis. Case 1. — The first case is that of ]\Iiss A. ^I. K., a school girl 15 years of age, suffering from subacute parenchymatous nephritis. The illness of which the patient complained began about six weeks previous, with shortness of breath, vague pains, headache, palpitation, coldness of the extremities, digestive dis- turbances, eructations of foul gases, fetor of the breath, consti- pated bowels, pains immediately after eating, nausea, and occasionally vomiting. The patient says she has been voiding urine, as a rule, only once a day for the past six months and sometimes not at all for more than twenty-four hours. She says that her eyes puff up in the morning and that the feet and ankles are edematous. There is also some disturbance of vision. She has had measles, chicken-pox, whooping-cough, and had scarlet fever when seven years of age. Tonsillitis is frequent. The family history has no bearing on the case. On physical examina- tion the patient was found fairly well nourished, eyes bright, pu- pillary reaction normal; puffiness of the lower lids, lips normal, tongue coated; tonsils appear normal, pharynx bulges slightly; adenoids are present, respiratory disturbances are absent. The pulse rhythm changes; otherwise it is full and rapid. The heart beats are normal in tone ; no valve lesions are present ; the abdomen is tender and slightly tympanitic; the liver and spleen are normal in size, but somewhat tender; gi-eat tenderness is 634 DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 635 present over both kidney regions; the glandular system is normal, with the exception that the postcervical glands are enlarged ; the urine discloses hyalin and granular casts, albumin, a few cells, and has a specitic gTavity of 1.018. The patient complains of subjective pain sometimes in the back and in the side; at other times in the epigastrium. The blood pressure has remained at 140 mm. Hg. (Stanton). The general symptoms are probably due to the high vascular tension in the abdominal organs. A B Fig. 146. — ^Akeas of Hyperalgesia in Kidney and Liver Congestion. Case 2. — In the case of A. B., seen in consultation with Dr. P., the kidney areas of nephritis are well defined and are almost typical. The liver area is also present, because, at the time of examination, the liver was in a state of passive con- gestion. The disease began with a tonsillitis about three weeks before the examination was made. For the past two weeks the patient has had no chills nor fever, though the tonsillar ulceration per- sists. Vomiting was absent at the time of the tonsillitis, but dur- ing the past week has been severe, especially in the morning. Headache is present over the right eye. It is a steady, dull pain. Nose-bleed occurred about six or seven days ago, and a slight discharge of blood from the nose has since been constantly pres- 636 THE KIDNEY ent. Dizziness is present at times. Buzzing or ringing in the ears also is constant. The bowels are freely movable. The urine, at first, was very slight in quantity, though at the present time about two quarts are voided daily. The patient cannot rest lying down and is compelled to assume the sitting posture. The entire body is very much swollen and the swelling is worse in the morn- ing. Figure 146, A, shows the area of hyperalgesia, A being that of the liver, which is greatly enlarged and tender; B and C the Hyperalgesia, not very marked Areas of hypersensitiveness Fig. 147. — Areas of Hyperalgesia in Nephritis. The letters do not correspond to the letters in Fig. 146. areas of the right and left kidneys respectively. In Figure 146 B, the areas A, B, and C correspond to those for which A, B, and C stand respectively in Fig. 146, A. Notice that the areas do not meet in the median line; also notice the notch on the lower border of the kidney area, and how the lower border extends over the crest of the ilium. In the back the hyperalgesic areas meet over the median line. Examination of the eyes shows them to be normal, with the exception of an internal squint of the left eye. The tongiie is coated. Examination of the chest exhibits a normal heart. Fluid in the pleural cavity is absent. DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 637 Fig. 1-iT shows the areas of hyperalgesia about one week after the previous drawings had been made. The area A in Fig. 147 A is becoming smaller, the diminu- tion in size being more marked in the upper boundaries than in the lower, because these boundaries mark the upper limits of the liver hyperalgesia and, at this time, the liver was much smaller and its congestion much less; therefore, its areas of hyperalgesia would be less. The other areas are not as well defined as they were in the last drawings, but they show a concentric, though ir- regailar diminution in size. In Fig. 147, area B indicates the hyperalgesic zone of the liver. This area lies above area C, which was more hyperalgesic. This, in turn, was bordered below by an area D of much dimin- ished sensitiveness, though still hyperalgesic ; circles in the fig- ures indicate the points of greatest sensitiveness. In a general way the patient is much improved ; the edema is becoming less and the urine is increasing in quantity. The throat is also better. The presence of the referred liver zones would indicate that con- gestion of itself can produce a Head zone. The gTadual disap- pearance as the edema became less would also be another indica- tion of potency of congestion as a causative factor in the produc- tion of a Head zone. Why the area D, which was not present a week ago, should be developed is rather hard to explain, unless the adjacent cord cells became irritated, because of their proxim- ity to those which were originally involved. This argument would seem to be strengthened from the fact that the hyperalgesia in this area was not as acute as in the mid-area C. Perinephritis. — Perinephritis is the name given to the con- dition in which inflammation is present in the perirenal con- nective tissue. This inflammation generally progresses to the point of abscess formation. It is in this lesion that the most pro- nounced symptoms of any renal disorder appear. The most con- stant and important of these symptoms is pain with its associated tenderness. Charade?' and Location of Pain. — The pain is always severe and is found in the lumbar region. Owing to the location of the 638 THE KIDNEY inflammation the lumbar plexus of nerves and the psoas muscle are frequently involved in the inflammatory process. When the lumbar plexus is involved, the pain is referred to the distribution area of the nerves connected with it, viz., in the cutaneous distri- bution area of the iliohypogastric, the ilioinguinal, the anterior crural, the obturator, and the other branches of the lumbar plexus. The distribution area of these pains is illustrated on page 6Y7 (q.V.). The pain in some cases of perinephritis is referred to the knee. This is apt to cause the perinephritic abscess to be mis- taken for a diseased hip. A reference of this kind is very fre- quent when the abscess originates at the lower pole of the kidney, for abscess formation in this region is more likely to make pressure upon the anterior crural or the obturator nerves; these nerves are distributed to the skin of the lower part of thigh (ant.) and the knee, and when irritated anywhere in their course refer the irritation (pain) thus produced to these areas. When the abscess is at the upper pole of the kidney, the in- tercostal nerves may be involved and pain may be referred to their area of distribution. W^hen the sheath of the psoas is in- volved the abscess progresses downward and consequently affects the external cutaneous, the anterior crural, and the genitocrural ; and the pain is referred to their area of distribution. At the same time, owing to the functional relation of the psoas to the thigh, pain on flexion and extension of the hip results. In fact, motion of all kinds is very painful, especially those movements in which pressure is exerted upon the kidney and the inflamed, sensitive tissues adjacent to it. Thus, bending forward or back- ward is almost impossible. Tenderness. — Palpation and percussion are disagreeable to the patient. The tenderness elicited by these procedures is most marked over the renal area, the point of greatest tenderness in perinephritic abscess being over the fascial triangle of Grynfelt and Lesshaft, or, as it is called by Miller, the kidney triangle. It is bounded by the erector spinse, the twelfth rib, and the internal oblique. Here the kidney is nearest the surface, and consequently tc.o il History of a very severe I)ain. Generally at the time the patient comea under observation the pain may be so severe and resembles perirenal ab- scess. Pain may be pro- duced by the taking of food. For further pain see Appendicitis. > "o >) '5b . 2^ May be slow or rapid. Follows an acute attack of appendicitis. o H 3 % O a O Not very severe. Tenderness is most marked on pressure made over the affected ver- tebra. Very little tenderness is felt on pressure through the anterior abdominal wall. Pain may radiate down to hi{); when the abscess reaches the psoas muscle it runs along this muscle to the hiji. Fixity of vertebra?. In tuber- culous disease of the vertebra kyphosis is present as a late symptom. o o 3 '^- a 3 CO 3 a No tumor, unless an abscess has formed to one side of the vertebra, in which case it is present. The appearance may closely resemble the tumor mass of a perinephritic abscess. CQ PQ < a a 2 H Rather severe. Tenderness is most marked on pressure made in the subcostal angle. Tenderness also is felt on pres- sure made through the an- terior abdominal wall. The pain is eased by flexion of the vertebra. The pain radiates down in the direction of the ureter. CI 03 I -§ > >> 'a S3 ID Pus; blood generally found if examinations are persist- ently and carefully made. c o £ c o U Presents below the ribs on the side affected and causes a bulging outward on that side. The tumor can be felt some- times through the anterior abdominal wall. fL| 1 £ a 'o % •n £ a £ o > -3 i CD u o a 639 640 THE KIDNEY pressure at this point is made more directly upon the diseased tissue. Pain is also felt in other inflammatory diseases of the kidney upon making pressure at this point, but not to the same degree as in perinephritic abscess. Tenderness on palpation and percussion is also present between the crest of the ilium and the last rib, in the midaxillary line, or somewhat posterior to it. Should a localized peritonitis occur over the inflamed kidney a marked tenderness to transabdominal pressure will be found. Ac- cording to Ransohoff, a perinephritic abscess may be diagnosed from a kidney lesion proper by its exquisite tenderness on super- ficial pressure, because, on the contrary, in affections of the kid- ney proper, it requires deep pressure to cause discomfort. A further point of diagnostic importance is that, in suppuration of the kidney parenchyma, pressure made from in front through the abdominal wall causes considerable pain, while in perinephritic abscesses the greatest tenderness to pressure is in the loin just below the last rib. Posture. — As a rule the patient stands with "thighs flexed on the pelvis. In order to relax the psoas he walks with body bent forward and with the hand of the affected side resting upon the upper part of the hip. To relax the part the trunk is some- times bent laterally, so that the ribs approach the iliac crest" (Roberts, 127, p. 392). Roberts believes that flexion of the thigh is an accompaniment of perinephritic abscess, especially if the abscess is located at the lower third of the kidney. The flexion may be so slight as to be hardly noticeable ; in other cases it may be so severe that it resists all efforts at extension. All other motions of the thigh may be painless. Associated Symptoms. — Other symptoms of value in the diag- nosis of a perinephritic abscess are : (1) The presence of a localized, fluctuating swelling in the lumbar region. The three cardinal features of this swelling, which render its identification as a kidney lesion easy, are as follows: (a) it lies entirely on the posterior wall of the abdomen and, even when very large, does not approach the anterior ab- dominal wall; (b) it is diffuse and is not confined to the region DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 641 of the kidney proper; its limits, also, cannot easily be defined; (c) it is not influenced by respiration (a kidney enlargement due to disturbance in the parenchyma of the kidney will move with respiration). (2) Aspiration of the tumor mass generally reveals pus. (3) Gastrointestinal symptoms, such as vomiting, tympany, and constipation, are present. (4) Jaundice sometimes occurs in perinephritic abscess on the right side. (5) There is frequently a history of an injury or of a renal infarction. In the first, trauma is followed at first by renal ten- derness, then by chills, and fever, and lastly by the tumor. (6) In some cases there is a fixation of the lumbar spine with scoliosis, the concavity being on the side of the diseased kidney. (7) When the sheath of the psoas is involved extension of the limb on the affected side is painful, while at the same time all other movements can be made without pain. This differentiates it from hip-joint disease. (8) A characteristic of perinephritic disease is the high white blood count (Morris, Booth, Miller). (9) Painful breathing, coughing, sneezing, etc., are some- times present and may be due to involvement of the pleura. Retraction of the testicle tow^ard the affected side has been given as an important sign; but according to Xieden it does not occur unless a calculus nephritis is present in addition to the peri- nephritic abscess. This statement is doubted by Roberts (127, p. 392). When it occurs the retraction is due to involvement of the genitocrural nerve (Roberts, p. 405). Differential Diagnosis. — Perinephritic inflammation may be confused with pleurisy. Hepatitis should be differentiated from perinephritis on the right side; splenitis from perinephritis on the left. Pneumonia also is sometimes mistaken for perinephritis. It should also be diagnosed from osteomyelitis of the vertebra and appendicitis with abscess formation. Rupture of the Kidney. — While rupture of the kidney with- out pain has been reported, it is almost inconceivable how this 642 THE KIDNEY severe lesion could occur without producing at least some pain. The rupture may tear into the perinephritic tissue ; when it does so there is felt a sudden, sharp pain, not restricted to any area, but generalized and diffuse. If the rupture is such that hemor- rhage takes place into the pelvis of the kidney severe pain, paroxysmal in type, ensues, and is due to the passage of blood clots down the ureter. At the same time there is a transitory hydronephrosis. One of the surest of the confirmative signs of rupture is hematuria ; however, there is an exception in slight rupture of the cortex, in which, unless there is a concomitant injury to the pelvis, blood may not be present in the urine. Following the rupture, if it has not proved fatal, a perineph- ritic abscess generally develops. Tuberculosis of the Kidney. — Tuberculosis of the kidney may or may not be painful. In some cases pain is present only in the terminal stages of the disease, while in others it may be one of the earliest symptoms. According to Maylard pain is absent as long as the lesion is confined to the parenchyma, and, when pain is present in the early stages, it is more vesical than renal in origin. When present it occurs before and after urination and is associated with increased frequency of tlie urinary act. In these cases the symptoms are such that even in a normal bladder cystitis might be diagnosed. In all advanced cases, however, it is found, and should it be present in the absence of gonorrhea, trauma, instrumentation, or stone, it must be looked upon as jore- sumptive evidence, especially in the young, of renal tuberculosis (Ransohoff). Character of the Pain. — When the disease is fairly well ad- vanced pain is a most important symptom. It is localized to the side of the kidney and may radiate to the inguinal or to the iliac regions. It may be i:)roduced spontaneously or be felt only on pressure. According to Brazy, the three points on the anterior abdominal wall where, in renal tuberculosis, pain is most likely to be produced on pressure are the paraumbilical, the subcostal, and the lumbar (Figs. 148 and 149). If the tuberculous process advances beyond the capsule and invades the paranephritic tis- DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 643 sues, the pain and tenderness in the costovertebral angle become excessive. In tuberculosis of the kidnej Head's zones of reflected hyperalgesia are sometimes present. When present they are, as a rule, synchronous with the so-called ureteral colic, due to the pas- sage of detritus, blood clots, pieces of necrotic tissue, etc., through the ureter. The tissue and clots block the ureter and distend the pelvis of the kidney either with urine or with blood. The intra- nephritic pressure now becomes excessive and it is to this, and not to spasm of the ureter, that the jDain, paroxysmal in type, is due. Areas of tenderness in renal tuberculosis Areas of tenderness in renal tuberculosis Figs. 148 and 149. — Areas of Tenderness Present in Renal Tuber- culosis. There are two types of pain in renal tuberculosis. The first is the constant, steady, aching pain, which may be interrupted by the paroxysmal pains, the second type. In some instances, sud- den, acute, paroxysmal pain may be present without obstruction of the ureter by clots or by pieces of necrotic tissue or other ele- ments. It is, then, probably due to an acute congestion of the kidney, with a great increase in the intracapsular tension. For- tunately for the comfort of the patient, these paroxysmal attacks are rare. In kidney tuberculosis tubercle bacilli often can be discovered in a centrifugalized specimen of urine obtained by ureteral cathe- terization. 644 THE KIDNEY In many eases the tubercnlons disease of the kidney may not produce any well-marked pain, bnt rather a diffuse aching, discom- fort, or a dragging sensation in the lumbar region. As sometimes happens in other varieties of kidney disease, the pain and distress may be referred to the kidney area on the side opposite to the one affected. Diagnosis. — Pain in the kidney region, in those cases in which tuberculosis is present in other parts of the body, should always lead to the suspicion of a probable tuberculosis of the kidney. The diagnostic signs of tuberculosis of the kidney are : (1) The presence of the characteristic pain. (2) The discovery of blood, pus, cells and tubercle bacilli in the urine. In some cases the presence of blood in the urine may precede other symptoms of the disease for many years. Precipi- tancy of urination is frequently present. (3) Elevation of temperature is present in a fair proportion of cases. (4) Increased rapidity of the pulse is common. It generally varies with the fever and is of a hypotension type. (5) Lung symptoms, or signs of tuberculosis in other regions of the body, are often found. (6) Enlargement of the kidney is generally an early symp- tom. The kidney is tender to pressure, and since the enlarge- ment is commonly due to pyonephrosis it varies with the painful crises. (7) V. Pirquet, subcutaneous, and Calmette reactions for tu- berculosis are, as a rule, present. New Growths. — New growths of the kidney are of two types, the benign and the malignant. In either case, pain is not a symp- tom of much value. The benign growths causing pain are cystic in character, and may consist of simple cysts, polycysts, or hyda- tids. The malignant growths are sarcoma, carcinoma, and hyper- nephroma (Grawitz' tumor). Etiology. — The pain in all of these conditions is due: (1) To the dragging upon the surrounding tissues by the kid- ney, because of its increased size and weight. DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 645 (2) To an increase of intracapsular pressure, from (a) a hydronephrosis, the result of a kinking of the ureter from a ptosis of the kidney, or a blocking of it by a blood clot or a par- ticle of the malignant tissue; (b) increase in the size of the growth (a slow and gradual increase in size is not painful, it is only when the increase is sudden that the pain is pronounced) ; (c) a hemorrhage into the substances of the growth or into the parenchyma of the kidney. This occurs more frequently in sar- coma and carcinoma (Johnston) than in other growths. Indeed, it is claimed that in these growths pain is not produced unless an intracapsular hemorrhage has occurred. Sometimes, when the new growth penetrates the pelvis, hemorrhages ensue and hema- nephrosis, with its consequent pain, results. (3) Contracting abdominal muscles, also, may, by pressing upon tender kidneys, cause pain. Chakactek of the PAijf IX Xew Growths of the Kidney. — The sensation present in these disorders is rather an aching and discomfort than actual pain, though at times, when the intracapsular tension is greatly increased, the pain becomes most acute and assumes a paroxysmal character. Because as a rule only one kidney is involved the pain is unilateral. It may be caused, and in most cases is aggTavated, by violent movements, such as jarring, the lifting of heavy objects, or the carrying of a heavy weight. The pain may radiate to the thigh. This radia- tion is due to the pressure exerted upon the lumbar plexus by the enlarged and heavy kidney. Vaeieties of jSTew Growths. — Cystic Disease. — (1) Simple Cysts. — In these conditions the pain has been known to precede the formation of the cyst. When the cyst has formed the pain is of a dull aching type, and is varied with sharp paroxysms, which are associated with enlargement of the kidney. These exacerba- tions are probably due to a hemorrhage into the substance of the cyst. (2) Polycystic Disease. — In this disorder, if only one kidney is diseased, the pain is on the diseased side. Should both kidneys be affected the pain is bilateral. It may be constant or intermit- 646 THE KIDNEY tent, is less when the patient rests in bed and is quiet, and is very much increased upon movement. As in simple cysts, hemorrhage may occur into the substance of the growth and produce great pain. Considerable tenderness on pressure is present in the costoverte- bral angle. The diagnostic symptoms associated with a polycystic growth of the kidney are (a) the presence of a tumor (kidney), which is mobile and contains knobs on the surface, and (b) the character of the urine, which is increased in quantity, is of low specific gravity, and contains a slight amount of albumin, casts, and blood. It also contains bodies resembling those found in the prostate. (3) Hydatid Disease. — In this, as a rule, pain due to sti*uc- tural kidney change is absent ; but in its stead is colic, due to blocking of the ureter by the booklets. These booklets can some- times be detected in the urine. (4) Sarcoma of the Kidney. — This gives rise to pain of a dull, dragging character, referred to the lumbar region or to the thigh. Paroxysms of colic occur when the ureter is temporarily blocked by blood clots or by pieces of sarcomatous tissue. (5) A hypernephroma may be without pain. Its onset may be so insidious that its presence is not discovered until the size of the tumor draws attention to the condition. Then pain may ensue and aggravate further the discomfort and distress of the patient. The pain may be constant, dull, and aching, or it may be paroxysmal, the paroxysms occurring when the kidney capsule is subject to considerable intranephritic tension, either from back- ward stasis of the urine (a clot in the ureter) or from hemorrhage either into the parenchyma of the kidney or of the tumor. The pains may radiate into the pelvis or down into the thighs. Both the kidney and the related tumor as a rule are very tender to pressure. Hematuria is the most frequent associated symptom. Diagnostic Symptoms. — Tumors of the kidney have the following diagnostic symptoms (Piersol and Morris) : (1) The large intestine is in front of the tumor. This does not happen with liver or splenic tumors. If the colon is distended with ga'^ it produces a tympanic mass anterior to the tumor, while DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 647 if collapsed it can often be felt as a roll of tissue beneath the fingers. (2) Eenal tumor causes an anterior bulging into the abdo- men. A posterior bulging generally indicates a periuephritic abscess. (3) 1^0 area of resonance, such as is found in tumors of the spleen, is present between the dulness of the tumor mass and the vertebrae. (4) A kidney tumor retains somewhat the shape of the kidney. (5) It generally does not reach the midline. (6) There is an area of resonance on the right side between the dulness of the liver and that of the kidney. (7) Varicocele is often present on the side of the tumor. (8) The tumor generally does not extend into the pelvis, and generally does not move, to any considerable degree, with respira- tion. Associated symptoms may also be produced from obstruction of the colon and also from traction on the spleen, the liver, or the diaphragm. Pyelitis. — Character, Causation, and Localization of Pain. — In pyelitis pain may or may not be present, although in about seventy-five per cent, of the cases it is manifested at some time during the course of the disease. The pain is more severe in the acute varieties, or in exacerbations of the chronic forms. These exacerbations are sometimes the result of cooling of the surface, such as occurs in getting drenched, or even in having the feet wet or damjD, and in being exposed to drafts or to chill' ing. The chilling of the surface drives the blood inward and pro- duces a congestion of the already inflamed kidney, with an exacer- bation of the pain. The pain usually is felt in the back (in the kidney areaj, and has a tendency to radiate to the thigh, the peri- neum, the genitalia, or upward to the epigastrium or shoulder. It is generally increased by pressure. It is possible that pyelitis of itself does not produce pain un- less there is a concomitant involvement of the kidney paren- chyma. When such involvement occurs a slight tensiot* of the Q I— ( W w O O H O o K 3 w '/: s Generally dull aching in the back. Spasmodic, colicky pains mi ay also occur. They are due to the passage either of blood clots or of tumor tissue through the ureter. Blood is nearly always pres- ent. This is most n arked when the growth has invaded the renal pelvis. 03 .2 Q S o Pi o Present, generally very large. Often the kidney can be felt on the lower pole of the mass. i O -i Ci bC c3 03 bC > a o a a o « in 1 .a s •^ -< & a 3 § ^ S g to _>> C a; O o ^^ . 1-5 fcC 'E o P^ o a a3 bC <5 > t 648 DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 649 capsule may result, and both subjective and objective pain be felt. The pain may appear in the form of an aching in the back, or of tenderness over the diseased kidney. These renal pains may be followed or accompanied by ureteral colic, due to the blocking of the ureter by debris. This variety of ureteral colic is hard to differentiate from calculus colic. A means of distinguishing it is by the X-ray, which defines a shadow if a stone is present ; or by the wax-tipped catheter, which shows a scratch should stone be encountered. If the pain changes to a dull, constant, or possibly throbbing type and chills and fever appear, it is an indication that a pyelonephrosis or a renal abscess is forming or has formed. Pyelonephrosis and Parenchymatous Infection. — In- flammation of the kidney pelvis of itself may not produce pain symptoms until some secondary complication such as (1) pye- lonephrosis or (2) parenchymatous infection takes place. The former, pyelonephrosis, produces symj^toms that resemble in their complex the paroxysms of ureteral colic. Both have the same etio- logical relationship to pain production, which is due to ureteral obstruction. This obstruction may be caused by blood clots, fibrin, pus, necrotic tissue, inflammatory swelling, or organized exudates. A peculiarity worth remembering is that pyelonephritic pains generally precede the parenchymatous ones. Parenchymatous in- volvement also causes pain symptoms which we have learned to associate especially with kidney involvement. It is likely that the irritation of the parenchyma gives rise to sensory signs in the Head zones, Avhile the capsule tension, also due to the paren- chyma involvement, causes the achings so constantly found in the lumbar region. Therefore, in pyelonephrosis or in hydronephrosis, the p9,in is due both to ureteral spasm and to capsule stretching, and Head's zones will be absent, while in parenchymatous involvement Head's zones and the capsule tension pains will be present, while the col- icky pains are almost invariably absent. Differential Diagnosis. — One is likely to err in the diag- nosis of lesions of the kidney or of the upper part of the ureter. 550 THE KIDNEY because involvement of the upper part of tbe ureter causes the pain areas to be so distributed tbat they correspond to tbe kidney zones. Yet if it is borne in mind tbat a ureteral colic cannot be due to a lesion of tbe kidney witbout ureteral obstruction, tbe con- clusion may be reacbed tbat tbe lesion is of sucb a nature tbat it involves both tbe kidney and tbe ureter. Sbould pain be present in tbe kidney area prior to its presence in tbe ureteral area, and sbould tbe latter become manifest only during a severe colic, or sbould pain in tbe ureteral area disappear after tbe colic, witb tbe persistence of a kidney zone, a lesion of tbe kidney, wbicb causes intermittently a renal colic, may be diagnosed. Among sucb lesions are tbe following: (1) Pyelitis or Pyonephrosis. — In tbese conditions colic, due to tbe passage tbrougb tbe ureter of masses of exudate, sucb as collections of fibrin, or pieces of kidney substance wbicb bave be- come disorganized and cast off, is sometimes present. Kidney and ureteral zones are both present. Tbe kidney zone persists after tbe obstruction bas been removed, wbile tbe ureteral zone disappears. (2) Penal Calculus. — Here tbe pain comes on quite sud- denly, and tbe ureteral zone and tbe kidney zone from tbe asso- ciated bydronepbrosis are botb present. Wben tbe obstruction is removed, and tbe dammed-up fluid escapes, tbe kidney and ureteral zones disappear simultaneously. In pyelitis, pyonepbrosis, and ureteral calculus an intermit- tent bydronepbrosis occurs, and on bimanual examination tbe physical signs associated witb it are found. Sucb signs are: (1) tumor, wbicb is in tbe kidney region, and wliicb increases in size during tbe period of colic, to rapidly decrease in size on tbe subsidence of tbe colic; (2) subjective pain in tbe back over tbe location of tbe kidney; (3) tenderness to deep pressure over tbe kidney region, tbe tende'rness being especially well marked at tbe time of tbe bydronepbrosis. It is easy to understand bow difficult it is definitely to decide from tbe pain complex tbe character of tbe Iddney involvement, and tbe stage at which it rests. But with constant endeavor aric DIAGNOSIS OF KIDNEY DISEASES CAUSING PAIN 651 close application in nearly all cases it is possible to do so. For a proper realization of tlie non-importance of their absence it must be recalled that disturbances in Head's zones are not constantly present, esj)ecial]y so should the attack under observation be only one of a series which has preceded it. During the preceding attacks the nerve filaments may have been destroyed to such an extent that subsequently they are not able to carry stimuli. Thus they are not able to respond to irritation. This is the reason why the Head zones are so often absent in parenchymatous involve- ment. Pyelitis in Pregnancy. — Pyelitis is frequent in pregnant women, and is due to the pressure of the pregnant uterus upon the ureter, with a consequent stasis and infection of the urine. As a rule the infection comes from the adjacent colon. In these cases pyonephrosis accompanies the pyelitis, and all the signs and symptoms usually associated with the former are present. However, inflammation of the renal pelvis itself does not cause pain unless there is a concomitant obstruction of the ureter by the pregnant uterus (Pilcher). To produce pain it is not necessary that the pyonephrosis be severe ; in some cases a very slight distention will cause the most severe pain. A pelvis containing only one ounce of pus has been known to produce con- siderable pain. The reason for this is that the existing inflamma- tion of the pelvis has penetrated to the parenchyma, and has caused it and the capsule to be more sensitive to stretching, and to react with pain production to a lesser threshold pressure than they would in their normal condition. The hydronephritic symp- toms may be intermittent. They may disappear for a time only again to reappear with increased intensity. Symptoms Associated with Pyelitis. — In pyelitis a careful examination of the urine is most essential to the making of a proper diagnosis. The presence of pus cells in the bladder urine is not of such special diagnostic import as are pus cells found in a specimen of urine catheterized from the ureter. Ureteral catheterization also gives a clear indication of the kidney which is involved. The temperature in pyelitis, as a rule, has a typical 652 THE KIDNEY septic curve. In some cases the temperature curve is present for some days before the attack of pain. Chills are generally coin- cident with the paroxysmal pains. They are due to the absorp- tion of septic material from the dammed-up urine. Owing to the sympathetic relationship of the bladder and the kidney, secondary bladder symptoms, or rather preliminary bladder symptoms, since in nearly all cases they precede the other symptoms, are frequent. The symptoms especially associated with the bladder are frequency and difficulty of urination. Pyoneijhrosis is an advanced type of pelvic inflammation in which a retention of urine from ureteral obstruction has taken place. In the very early stages of this condition the pain is not different from that present in the lesion from which the pyone- phrosis originated. Later, pain typical of a hydronephrosis occurs. The inflammatory process now travels through the tubules into the parenchyma of the kidney and a general inflammation of the kidney structures ensues, the so-called pyelonephritis. However, a hydronephrosis does not always precede the formation of a pyonephrosis; the preceding condition may have been a pyelitis, without any accumulation of fluid in the renal pelvis. When pyelitis is present without pelvic distention, pain is absent, and only comes on when the pelvis of the kidney begins to dilate, and tension is made upon the kidney capsule, when a diffused, dull aching in the back is felt. At the same time disturbances in the kidney (Head) zones may become prominent, so that in many cases they are a sign of value. Should the disease still further progress and become extracapsular, tenderness to pressure is excessive; breathing becomes difficult, and motion of all kinds is greatly limited. At this time a perinephritis may develop. Urination becomes painful and frequent, and pain is referred to the glans penis and down the thigh (p. 609). The patient walks or re- clines with the body bent toward the affected side, and in many cases the thighs slightly flexed on the abdomen. . Pain may also be present on pressure anteriorly over the abdomen, and posteriorly over the flank ; in some cases the anterior pressure may cause pain and the posterior pressure may give relief. DIAGNOSIS OF KIDNEr DISEASES CAUSING PAIN 653 Symptoms associated with a pyonephrosis are: (1) The presence of pus in the urine. It may be present only occasionally in intermittent pyonephrosis, being absent at the time the ureter from the diseased kidney is blocked, but appearing again as soon as the obstruction is removed. Its reappearance is concomitant with a gi-eatly increased urinary flow. Pyelonephritis can often be diagnosed by the presence in the urine of casts com- posed of pus cells. It may be distinguished from pyonephrosis in that in the latter condition cellular casts are absent and large quantities of urine and pus are passed at intervals, at which time the symptoms referable to obstruction are relieved. (2) Chills and fever, usually associated with a septic infec- tion, are present. Hydronephrosis. — Causes. — Hydronephrosis is due to an ob- struction of the ureter. It is of two types, constant and intermit- tent. Constant hydronephrosis is the result of forces acting con- stantly. Intermittent hydronephrosis is the result of some cause acting intermittently, and is due to the blocking of the ureter by a stone, blood clot, or piece of necrotic tissue. Character of the Pain. — Pain in hydronephrosis is not marked, except when the intranephritic tension is suddenly raised. Should the obstruction be complete pain at first is very severe, then gradu- ally ceases, because, as a rule, under such circumstances the secre- tion of urine soon ceases and pelvic distention does not persist. The pain in the majority of cases of hydronephrosis is of a drag- ging or dull aching type, and may be continuous or intermittent. The intermittency indicates that the ureteral obstruction is not complete, and that at times there occurs a partial relief of the pressure from some of the urine being forced through the semi- patulent canal. Sudden and severe pain may occur if the hydronephritic sac should rupture into the abdominal cavity. Peritonitis then results and the pain assumes the character of the pain associated with that condition. It may radiate to the back above the pelvic brim, or around the side to the external genitals. . Sudden subsidence of the pain in hydronephrosis indicates 654 THE KIDNEY that the obstruction to the onward flow of urine has been removed, either because it has been forced into the bladder, or because the material (calculus) which was acting as a valve at the entrance of the ureter has been forced back into the pelvis of the kidney, thus allowing the passage to be free (ball-valve action). Associated Symptoms. — Associated signs of hydronephrosis are: (1) the presence of a tumor, located below the costal margin. It is round, smooth, or lobulated. The colon is anterior to it or is on its inner side ; in this particular a tumor or enlargement of the kidney differs from that of the gall bladder, intestine, omen- tum, or appendix, which are generally anterior to the colon. (2) Xausea and vomiting are very common in the cases of acute hydronephrosis. Points that lead to an almost positive diagnosis of hydro- nephrosis are: (a) the presence of a dragging pain in the back, (b) a tumor mass in the kidney region, and (c) a decrease or increase in size of this tumor mass, occurring simultaneously with an increase or decrease in the amount of the urine, (d) ure- teral catheterization and distention of the renal pelvis by meas- ured quantities of salt solution, (e) injection of collargol into the renal pelvis, and then a Roentgen picture (these will clearly indi- cate the lesion). Hydronephrosis in Pregnancy. — During pregnancy the uterus, because of unilateral enlargement, or because of its peculiar posi- tion in the pelvis, may make more pressure upon one than upon the other ureter. The consequence is that, if the pressure is great enough, a unilateral hydronephrosis results. This causes consid- erable annoyance to the patient and much anxiety to the attending physician, for, when the stasis occurs, violent pain, due to the in- creased tension in the pelvis of the affected kidney, is produced. Because of slight temperature, the presence of pus in the urine, the appearance of a mass which is tender in the lumboiliac re- gion, and the constant complaint of the patient, a condition of this kind sometimes is mistaken for a lumbar or perinephritic ab- scess; yet the normal leukocyte count, the marked remission fol- lowing a copious discharge of urine, the low position of the uterus, DIAGNOSIS OF KIDKEY DISEASES CAUSING PAIN 655 the relief which sometimes follows the assumption of the abdom- inal prone position, and the late stage of pregnancy, all point to a pressure hydronephrosis with a slight infection. After deliv- ery the condition passes off without any permanent ill results, A case illustrative of this condition is that of Mrs. M , eight months pregnant, who at times would have severe pain on the right side in the kidney region. The pain would be accom- panied by a lumbar enlargement on the same side. The pain and enlargement would both disappear synchronously with the ap- pearance in the urine of a considerable number of pus cells. At the same time the quantity of urine would be greatly increased. After delivery all the symptoms disappeared. Renal Calculus. — Renal calculi may lie in the pelvis of the kidney for many years without producing symptoms. Several cases have been reported where stones weighing as much as one ounce have remained quiescent in the kidney for long periods of time. In one case the presence of the stone was entirely unknown to the patient until an abscess formed and ruptured posteriorly. If these stones do not at times produce symptoms it is necessary to know what must occur before their presence becomes so intoler- able as to draw attention to them. Etiology of Calculus Pain. — From a long series of observa- tions it has been concluded that renal calculi do not produce pain symptoms unless a blocking of the ureter occurs. For a long time and by many observers it has been held that a spasm of the ureter is the cause of pain in calculus colic, and ic has only recently been determined that the pain of renal calculus is not due to spasm of the ureter, but is caused by tension on the renal capsule from back pressure of the urine. Many cases con- firmative of this could be cited, but Bevan's case, which is de- scribed on page 605, will illustrate the point exactly. Fenwick, in 1893, was one of the first to suggest this explanation of a calculus colic. That the distention of the ureter is not the only cause of renal calculus pain, and that the ureter itself has some place in the pain production, is seen in the changing position of the pain as the m O o P >^ CO O O < 1-3 I— t H o < m :^ o < o Pain is in the gall-bladder areas (q. v.). This pain can be produced by pressure on or by traction dragging on the tumor mass. Is on the right side. Rotates around a center located near the margin of the right tenth costal cartilage. o a m 1 "43 '-3 m K^ «3g o| 1 a o5 bC A A 3 El CO u a. < > O "3 & _43 -tJ -u 3 'd Sh 43 G 43 o Is more central. Arises out of the pelvis. Tym- jiany of the intestines Ucs above and lateral to it. (H ft c2 > 1 2 '0 o3 43 ^3 Generally attached to the tumor by means of ad- hesions. 43 bC G Sh O) o U ^ H ^H C3 Q l-H o 03 [X4 o 05 03 CO 03 CI o <; « H W < iz; XI2 -2 1 ij >> ', , "oi 3 O Tumor present some time after the development of the pain. Size of tumor not affected by renal catheterization. Very tender. CO o There may be no pain as long as the calculi remain in the pelvis of the kidney. Pain is felt only when the stone passes into the ureter. Then symp- toms of ureteral colic, sudden, sharp, paroxysmal, agonizing pains occur. The pain is the most severe to which man is heir. The severity is due to the| very sharp and jagged character of the calculus. Generally a diminution at the time of the cohc followed by a sudden increase on the re- lief of the cohc. 3 03 g Tumor may or may not be present. When it is present, it is due to a hydronephrosis. Passage of a wax-tipped cath- eter shows location of stone. Idem. M M O w » z o PS Q Considerable pain is pres- ent, especially so if the con- dition is one of acute origin. Generally the pain felt is due to the original cause of the disease. Generally but slightly changed. Blood is fre- quently profuse after re- lief of the occlusion. Sudden increase in the quantity of the urine causes a diminution in the size of the tumor. .2, 'c? a a Immediate formation. De- creased in size on ureteral catheterization of the pel- vis. Tumor can be pro- duced at will by fiUingthepel- vis of the kidney with fluid. Idem. H Generally very little in the early stages, and the pain that is present is due to a nephrectasis or to a spread- ing of the disease to such an extent that either the entire parenchyma or the peri- nephritic tissues have be- come involved. Generally turbid. Specific gravity is low. Blood fre- quent though not profuse. T. B. are present in the centrifugaUzed urine. In- oculation produces death in the guinea pig. Generally not present un- less secondary infection, with pus-forming bacilli, occurs. Early formation. On cath- eterization, no noticeable difference in size of the tumor mass may be found. Tumor not tender. CQ Hi a r/2 a Pu, i Tumor and catheter- ization and tender- ness. 669 CHAPTEE XXX THE UEETEE, BLADDER AND URETHEA THE URETER Pain associated with, ureteral involvement is due to : (1) Obstruction of the ureter. This is caused by muscular spasm, which produces (a) hydronephrosis, in which there is gen- erally a certain amount of associated infection, and (b) dilata- tion of the ureter. Obstruction may also be caused by calculus, blood clots, detritus, kinks, external pressure from tumors (aortic aneurysm) or growths in adjacent organs (as carcinoma of the bladder at the point of ureteral insertion), displacement of adja- cent organs (making pressure on the ureter), and stenosis of the ureter, which may be intralumenary from stricture, or extralume- nary from inflammation of the walls or of the surrounding tissues. (2) Inflammation (ureteritis) may also cause pain in ureteral disease. Obstruction to the ureter produces at first a muscular spasm and then a distention of the proximal ureter and renal pelvis. This causes a sudden sharp pain. To what extent the ureters are innervated by the cerebrospinal system is still a question for the physiologists, but it has been shown that the mucous and muscular coats are innervated by both medullated and non-medullated nerves, so that the spasm, which is produced by an irritating stone, would affect both cerebrospinal and sympathetic nerves, and thus cause both local and reflected pain. The local pain is due to the irrita- tion of the cerebrospinal nerves, and the reflected pain is the result of irritation to the sympathetic nervous system. Later, should inflammation ensue and the outer coat of the ureter be involved, the local is more prominent than the reflected pain ; and if the adjacent tissues are affected the local pain far outshadows the 670 THE URETER 671 reflected. Generally, however, such fine distinctions cannot he made in practice, yet if it were possible to follow a case of ureteral stone colic from its incipiency to its conclusion, such a transgression from reflected to local jDain might sometimes be found, and the presence or absence of inflammation exactly de- fined. This is easier if the obstruction is incomplete, but at the same time sufiiciently irritative to cause inflammatory reaction. According to Ashton, "When the ureter is inflamed pain is elicited at the brim of the pelvis, about one to one and one-quarter inches on either side of the promontory of the sacrum, and over the upper or renal portion by deep palpation." (See Fig. 1.55.) A reference pain due to stone in the ureter which would seem to be of value is given by Bennett. In this case a stone lodged in the vesical end of the right ureter, and caused more or less con- stant 'pain in the right groin. The pain was never acute and rarely was entirely absent. It was worse in the morning on leav- ing the bed, and again in the evening. Possibly a little increase of the pain was noted when the bladder was full. On removal of the stone the pain ceased (Bennett). According to Howell (287, p. 445) the pain in renal colic is felt at a point a little below the ninth costal cartilage in the mid-clavicular line, from which it runs downward to the testicle and along the inner side of the thigh, following the cutaneous distribution of the eleventh and twelfth dorsal and the first lumbar nerves. Should obstruction be complete the pain of distention occurs pari passu with that of the spasm. The distention of the renal pelvis first occurs, and therefore the first organ to be affected by the distention is the kidney. It reacts to it and causes a sense of aching, tenderness, and pain in the lumbar region. Tumors of the ureter as a rule are not painful unless they cause a sudden obstruction to the ureter, either from pressure, or from inflammatory swelling due to an acute infection. They may also cause pain by the pressure of the ureteral mass upon the sur- rounding structures. Depending upon the location of the mass, either local or referred pain, or both, may be produced. Piersol ("Anatomy," first ed., p. 1914) gives a good idea of 672 THE URETER, BLADDER AND URETHRA the route of pain reference in kidney, nreter, and bladder diseases. He sajs : ''The skin of tlie scrotum and penis is supplied with sensation from the same spinal segments as is the bladder, and therefore the referred pain in vesical irritation or inflammation is often felt in those regions in the distribution of the perineal branches of the pudic and the inferior gluteal nerves. The tick- ling or itching around the anus, or painful contraction of the sphincter, which may be present, is the referred sensation through the inferior hemorrhoidal nerve from the sacral plexus. Lumbo- sacral pain is felt through the communications between the sec- ond, third, and fourth sacral nerves and the hypogastric plexus. Pains in the area usually associated with the kidney disease are due to the junction in the spermatic plexus of filaments from both the renal and the vesical j^lexuses. Pain over the kidney region may also be due to the involvement of the spinal nerves. Pains in the lower limbs, especially in the foot (podod^Tiia), are produced by the irritation carried through the sacral nerves into the sacral plexus and the lumbosacral cord, which give off the great sciatic nerve." THE BLADDER GENEEAL CONSIDEEATIONS Anatomy. — The bladder is next to the last division of the urinary apparatus, and acts as a reservoir for the urine. It is very loosely attached to the surrounding structures, and can be subjected to great distention before it causes inconvenience to, or pressure on, adjacent organs ; but when it is so distended pain and discomfort are most marked. The urinary bladder is unlike most other abdominal viscera because of its great distensibility (in this it resembles the stomach), and its peculiar position (being almost extraperitoneal) and because its cavity is in almost direct contact with the external air. Because of this contact the bladder is much more susceptible to inflammatory diseases than are the abdominal viscera, which are entirely intraperitoneal. Nerve Supply. — The nerve supply to the bladder, being both THE BLADDER 673 sympathetic and spinal, grants to it attributes possessed by both these systems. The sympathetic system keeps it in harmony with the abdominal viscera, while the spinal system supplies its muscu- lar coats and acts as a finely sensitized apparatus which quickly responds to all harmful irritations giving rise to the sense of pain. The sympathetic nerves are distributed principally to the muscu- -[-- CONTRACTION IMPULSE FROM BRAIN INHIBITION IMPULSE FROM BRAIN WHEN THE LESION 15 ABOVE. THE SACIiAL 5ECMENTS. SENSATION WILL 13E CONVEYED TO BRAIN. BUT THE POWER. OF RETAINING URINE WltU BE DESTROYED. Fig. 157.- -Relationship Existing between Pain and other Sensa- tions Arising in the Urinary Bladder. lar coat. They follow the arteries and are derived from the vesi- cal plexi, which, in turn, arise from the pelvic plexi (Pier- sol). When the sjTnpathetic fibers are irritated the stimulus is carried to the cord, and thence is reflected to the body wall, where it may be felt as pain. When the spinal nerve filaments are irritated the pain is referred to the region of the bladder, although its exact localization is rather indefinite. The sympa- thetic nerve supply differs from the spinal in that, although deep pressure pain perception is carried through its fibers, it also car- ries stimuli to the cord, from which they are referred as pain to the cutaneous areas having their nerve supply derived from the same segment. 674 THE URETER, BLADDER AND URETHRA The sympathetic fibers are derived principally from the vesi- cal plexus, which is in direct communication with the second, third, and fourth lumbar segments of the cord, and it is through these communications that motor impulses are carried to the bladder wall. The vesical plexus communicates with the hj^po- gastric plexus, which, in turn, communicates with the second, I I' I It u Fig. 158. — Pain Areas Associated with Diseases of Bladder. (Accord- ing to Head.) The 2d, 3d and 4th sacral areas are the ones in which the bladder pains are usually referred. third, and fourth sacral nerves. This supply is sensory, as can be seen from the diagram. That the pain sensation is carried through the nerve fibers which are derived from the sacral segments is apparent, because, in a lesion of the twelfth dorsal segment, ordinary sensations from the bladder are lost; but if the lesion is below the first and second sacral segTaents sensation is not lost. The cord zones, in relationship with the bladder, are given THE BLADDER 675 above. These are not so useful in the defining of bladder lesions, because the intensity of the pain from almost every painful lesion of the bladder is so great that it overwhelms the localizing sense, so that it is almost impossible to define the zonal areas. The areas most commonly affected in bladder lesions are the second and third, and possibly the fourth sacral. It is possible also that sensation may be referred through the second, third and fourth lumbar nerves, though such a reference is very unusual. That it may occur is certain, as is maintained by Head, "who says that "in those cases where there is distention of the blad- der, and ineffectual attempts are made by the patient to evacuate, the pain is of a sharp, shooting character, radiating from the lower lumbar and sacral regions behind, around the ilium to the lower part of the abdomen just above the pubes, and also down the inner side of the thigh to the knee." The pain may also extend to the outer side of the thigh. The accompanying drawing (Fig. 159) illustrates the relationship of rectal tenesmus to ves- ical tenesmus and the method of reference of bladder pain into the penis. The reference areas of bladder pains have been nicely illus- trated in Figure 160, which represents the pain of cystitis, fol- lowing instrumental crushing for the removal of stone. These drawings, which were taken from Head ('^Brain," Vol. 16, p. 82), represent points of maximal tenderness, which were found, (1) over the ischial tuberosity, (2) over the lower part of the sacrum, and (3) over the tip of the glans penis. Fig. 159. — Relationship of Rectal Tenesmus to Vesical Tenesmus. The transmission is through the pudic nerve which also suppUes the prostate and the glans penis. When SLuy of these regions are affected it is common to have pain referred to any one, or all three, of the three regions. 676 THE URETER, BLADDER AND URETHRA Causes of Pain. — All direct bladder pains are, of course, due to irritation of sensitive spinal nerve filaments in the bladder walls. Some of the indirect pains are due to pressure, dragging or pulling upon the adjacent pcrivesicular structures. Generally lesions of the bladder proper are not painful unless they encroach directly upon the trigone, for this is the only part of the bladder which is Area of distribution in bladder case Sacral 4th / 'm': Sacral 3d - - -' Sacral 4th Maximum tenderness sacral 4th Area of maximum tender- ness sacral 3d Sacral 3d Fig. 160. — Areas of Referred Pains Usually Associated with Disease OF Urinary Bladder. (According to Head.) extremely sensitive. Even in the absence of inflammation, touch- ing of it by a sound or probe is provocative of the most intense dis- tress. How much more this distress is increased when the mem- brane is inflamed can easily be surmised. If it is inflamed, and there is also increased irritation associated with a sharp and jagged calculus, it is apparent that every time the bladder walls contract a sharp and agonizing pain is bound to result. If adhe- sions exist between the bladder and adjacent organs, pulling and ^ -¥. 1^ . -^ S ^ 'S 2 r- S o 52 ■^^ •§ <0 OS S S ^' O O o S g o — 5j l-H 'a ^ o < Ph Q W K « fa O c3 "^ « -^ oj r-i .-30 CS fl 0^ c3 -"5 ^ cu M « O -73-3 ^ ^ s Ji" 1=5 ■^ 5 CO a; o3 03 OSS J^ r^ a; -(-2 <1 « +3 03 Ph Q w Q Q 3 kJ ,— < ■ ^ K W .-, > 1 < ^ 'y^ 1-i +J W f^i C/J - ■^ Q cr! « « .-H %^ ->^ ' ^ ;^ Q Oj c:i ^ 02 Cf3 y| 0) 3 ^ g O IS o 'S o o :?: j3 S > =° fa J n fa TJ 03 a u< -Ti 3 (A) 3 S-> 03 Tl •" oj >. Si 3: fcfl o3 ^ -3 3 -►-' o3 f-i cj 03 9 w -3 c; 677 678 THE UKETER, BLADDER AND URETHRA dragging by these viscera at the time of the greatest activity will produce pain. Should the bladder (in the male) be adherent to the rectum, or to the sigmoid, all evacuations of the bowel will be attended with more or less urinary tenesmus and localized bladder pain. Likewise, adhesions to the uterus and tubes in a female will produce the most severe pain during the periods of menstruation, during pregnancy, or during sexual intercourse. In some cases the bowel and urinary bladder have become adher- ent. In these the pain occurs at irregular intervals, and is fre- quently accompanied by the gurgling noise which betokens bowel contraction. If the adhesions are to the adjacent tissues, pres- sure in the suprapubic region is painful, esjiecially so if the bladder is full. In woman the bladder can be palpated more easily than in man, and surrounding adhesions and inflamma- tion, because of the great tenderness they produce, are easier to define. However, adhesions never cause such severe pain as do intravesicular lesions. Character of Pain. — Pain due to lesions of the bladder is of two types: constant and paroxysmal. The constant pain is of a dull, aching character, and is felt behind the symphysis pubis. When present it indicates a rather severe inflammation of the bladder walls, for an inflammation that has not progressed beyond the mucous membrane will not produce this marked pain. The constant distress, associated with this lesion, is interrupted by paroxysmal attacks of pain occurring during micturition, slightly before and at the termination of the act, at the time when the two opposing internal surfaces of the bladder are brought into forcible contact with each other by the contracting walls. Should a stone also be present the most severe pain is felt at the end of the urinary act ; in fact, the pain may be so severe that urination is inhibited. This pain may be relieved b}'' changing or reversing the position of the patient; for instance, if during the attack of pain the patient lies do^Am, the stone may gravitate away from the urethral opening. The urinary flow is resumed and the bladder pain ceases. Location. — ISTearlv all bladder diseases, even those of the least THE BLADDER 679 magnitude, cause an aching in the suprapubic region. In some cases this aching is the only discomfort produced by the disease, while in others the aching progTesses into acute, severe, and well- marked pain, which may be local, referred, or reflected. If local the pain is due to injury of the terminal filaments of the sensory nerves of the bladder wall, which have become involved in the A — Congestion of penis B — Constant pain in glans penis in- dicates: 1, Fissure (mea- tus) 2, Prostatitis 3, Inflammation of the prostatic urethra 4, Ulcer of the urethra C — Constant pain in: 1, Chronic pros- tatitis 2, Commen cing senile enlarge- ment of the prostate 3, Encysted cal- culus at the base of the bladder Pain relieved by micturition in: 1, Acute prosta- titis Fig. 164. — Referred Pain in Dis- ease OF the Bladder Due to Involvement of the Pudic Nerve. 2, Tuberculous prostatitis (quiescent) 3, Tuber cu lous bladder Pain increased by micturition in: 1, Encysted pros- tatitis at base of bladder be- hind prostate 2, Ulceration (a) Catarrhal (b) Tuberculous 3, Local condi- tions (a) Sub-ure- thral abscess (b) Inflamma- tion of the post urethra (c) Impacted stone (d) Carcinoma of the bulb process. These nerves are spinal in origin, and the pain is perceived as coming from their distribution area. It sometimes happens, though, that the pain is referred to the distribution area of some other of the branches of the nerve involved, as may happen, for instance, in the pudic; where, although the only irritation which may be present is in the branch ■ supplying the lower part of the bladder, the pain may be felt in the glans penis, or in the anal sphincter (see Fig. 159). When the pain is reflected it is perceived as coming from the 680 THE URETER, BLADDER AND URETHRA distribution areas of the third and fourth sacral segments. These have been shown on page 677. In this connection it is well to remember that the areas in which these pains are most often found are: (1) in the kidney area (probably the result of the backward stasis) ; (2) over the sacrum, and (3) in the foot, fre- quently in the heel. Time of Pain Attacks. — There is no special time at which blad- der jDain is at its maximum, although from experience with quite a number of cases it seems that night, with its quiet and peace, is the time when the poor unfortunate cystitic feels and suffers the most distress. Often he fears the darkness more than the un- godly fear the evil one, for never does it bring sleep, but always anguish and pain. Why he should suifer so much more at night is rather hard to say; perhaps it may be that at this time the senses are more acute. During the night they are relaxed from general care, and perceive slighter irritations than otherwise would merit their atten- tion. Another reason is that at night congestion of the retro- prostatic plexus of veins occurs. This produces pressure upon the prostatic nerves and possibly also upon the sensitive trigone, and so gives rise to pain. It may also happen that the bladder is fuller at night than during the day, and thus pain is more apt to be produced. The above description applies to all cases except those in which a stone is j^resent in the bladder. When such is the case the pain is generally worse in the daytime because of the motion which then occurs. Position of Patient.' — The position assumed by the patient during urinary bladder pain when walking is one in which he stoops slightly forward, in a posture similar to that assumed in enteroptosis. When a stone is in the bladder the patient frequently bends forward, and, if a male, tugs at the foreskin of the penis. This, in some cases, seems to give relief. Why, it is difficult to say. Distention of the bladder also causes the patient to bend for- ward. THE BLADDER 681 The prone position is not so often sought by the person sub- ject to bladder derangement. As a rule he likes best to sit on a chair, bent forward, with his elbows on his knees. Sometimes he makes pressure over the region of the bladder, though if the in- flammation is severe he does so very carefully. Factors Influencing Production of Pain. — E elation of Urinary Bladder Pain to Motion. — One who is troubled with chronic blad- der disease is not very active muscularly. Slow, calm, and de- liberate in all his movements, he seems the perfect embodiment of caution. He will not run, jump, ride in springless wagons, nor in jolting cars ; even walking may become distasteful to him. His life is one living torment, for exevj motion hurts and injures him. Even rest in bed may be denied him, for it may prove to be only a snare with which to increase his pain. Yet he goes on hoping, always hoping for a surcease from pain. Relation of Food and Drink to Bladder Pain. — In food and drink lie hidden dangers, for the first may produce bowel dis- orders which are distressing, and the second may produce urine which burns and scorches. Both bring added discomfort to an already overburdened soul. Drugs sometimes cause an attack of bladder pain. Witness the frequency with which urotropin initiates one. Cold air and drafts produce a congestion that may stir up latent disease and cause old symptoms of pain and discomfort to appear again; or, in the presence of an active involvement, they may still further augment the distress. Tenderness in Disease of the Bladder. — Diseases of the blad- der, when they cause pain, are always accompanied by inflamma- tion, and inflammation as a rule produces tenderness. This ten- derness of bladder lesions is marked in the three locations in which it is possible to make direct pressure upon the bladder by the examining finger. The first and most prominent location is immediately above the pubes in the suprapubic region. Here the fingers can be pressed into the abdomen and then, by flexing, can be depressed deep into the pelvis. Should the patient be a child this latter 682 THE URETER, BLADDER AND URETHRA procedure is not necessary, as in children the bladder rides above the pelvic brim. The second location is the base of the bladder. In woman the base of the bladder may be palj^ated bimaniially between a finger placed in the vagina and the palmar surface of the other hand laid over the abdomen. If the bladder is in- flamed the patient will complain of pain on pressure between the two. A stone in the bladder or lower Ureter can often be palpated by this method. A rectal examination frequently is made in the male, but, as a rule, is not successful in eliciting symptoms of any value because of the gTeat sensitiveness of the prostate. The third location in which pain in inflammatory diseases of the bladder is particularly marked is the trigone. The pain here is elicited by the passing of a catheter, which when it enters the bladder produc-cs the most intense distress. Associated Symptoms. — The symptom commonly associated with disease of the urinary bladder is painful and frequent urination. Frequency of urination is one of the first signs of bladder disorder. Painful urination may also be associated with a new growth. In the urethra the growth may be a caruncle, which is a small rasjDberry mass lying to one or the other side of the meatus ; or a cancer (carcinoma or sarcoma). These are nearly always ulcer- ated and have acrid discharges, which give rise to severe itching. If the urination is painful and frequent, and pus, but no blood, is present in the urine, it indicates a cystitis, in which the pain is of a scalding nature and occurs during the entire time of the iiassage of the urine. It is most joronounced at the beginning of the urinary act, and difficulty is often experienced in starting the stream. Painful and frequent urination, with blood and pus absent from the urine, indicates: (1) vesicourethral fissure, in which the pain is constant and is increased during the urinary act, or (2) pressure upon the bladder by an enlarged uterus, ovarian tumor, or inflammatory mass. If painful and frequent urination occurs, with blood in the urine, the examiner should seek for: (1) tuber- THE BLADDER 683 culosis, in wliich the blood as a rule is found early in the disease and ceases as the disease advances; tubercle bacilli also may often, if persistently sought, be found in a centrifugalized speci- men, while in (2) gonorrheal disease, the gonococcus may often be found on a similar examination; and (3) vesical calculus, in which condition other signs and symptoms of the calculus are present. !N^on-painful and frequent urination, with hematuria, generally is the result of tumor, in which the pain becomes noticeable only late in the course .of the disease. Differential Diagnosis. — Bladder diseases should be diagnosed from involvement of the central nervous system. Here the "pain occurs independent of micturition and radiates to the rectum or to the genitals and thigh" (Schmidt). BLADDER AFFECTIONS CAUSING PAIN The bladder lesions causing pains are: (1) cystalgia, (2) vesicourethral fissure, (3) distention of the bladder, (4) rup- ture of the bladder, (5) cystitis, (6) pericystitis, (7) tumors, (8) tuberculosis, and (9) calculus. Cystalgia.— ^Montgomery speaks of a cystalgia. Reed is inclined to think that this condition should be described as a hyperemia. He says that while a neuralgia of the bladder may occur, gener- ally it is only a term used for hyperemia. Under the circum- stances a frequent desire to urinate is present, with a burning during or after the act. Most of the women so complaining are of a neurotic temperament, and are afflicted with displacement of the uterus, movable kidneys, etc. Fenwick seems to believe that neuralgia of the bladder may exist as a separate entity; and that it is probably produced by the toxins of infectious diseases, as those of influenza or of light septic infectious. In some cases pain apparently in the bladder is due to inflammation of the pudic nerve. The pain in this case is also referred to the penis, rectum, and perineum. The perineal pain may be so severe and the perineal surface so sensitive that the sitting posture becomes 684 THE URETER, BLADDER AND URETHRA almost imj)ossible. Traveling on cars also causes the greatest agonv. Pain "witli incontinence and frequency of urination should lead to the suspicion of tabes, general paresis, etc. Vesicourethral Fissure. —In this condition the pain as a rule is constant, but is more marked during the urinary act. The con- stancy of the pain is due to the irritation by the urine of the nerves exposed in the b3d of the fissure. It does not seem to make much difference ^vhether the urine is acid or alkaline, the pain (in many cases) being equally severe in both, though the neutral or slightly alkaline urine seems to produce the least pain. An- other cause of the constant pain is the steady pressure made upon the exposed nerves by the contraction of the sphincter. The pain of this condition differs from that of cystitis in that it is sharply circumscribed, while the pain due to cystitis is diffuse. Urination in cystitis gives relief from pain, while in vesico- urethral fissure the pain during urination is increased. Tender- ness, sharp and localized to the posterior urethra, is also present in vesicourethral fissure, while in cystitis the tenderness is dif- fused. Distention of the Bladder. — Distention of the urinary bladder is not very painful unless it is of sudden onset, when pain is a prominent symptom. Distention may be due to an acute urethral obstruction from a blocking of the urethra by a calculus or a clot. If the distention of the bladder is the result of lack of sensation or of muscular power in the bladder, it is likely due to a lesion of the brain or of the cord, and may be entirely painless. In some cases the bladder may be so encompassed by adhe- sions to adjacent viscera, the result of inflammatory exudates in the pelvis, that only two or three ounces of urine produce a pulling and dragging on the adhesions, and dull aching pain is felt in the areas and regions of the viscera secondarily involved. In these conditions pain is most severe during the urinary act because, by the contraction of the bladder, traction is made upon the sur- rounding adhesions and pain is produced. This pain is of a more THE BLADDER 685 severe type than the dull, aching, continuous pain of distention, and generally occurs as the acme of a pain of gradually increasing intensity. This type of pain is found as a rule only in the female, because a male is free from pelvic disease with its result- ing adhesions. The pain is most frequently felt behind the blad- der. The intervals between the periods of distention are free from pain. The pain Avhen present may radiate along the ure- thra to the (testicles) anus and perineum. The two latter, in common with the bladder, are innervated by the sacral plexus. The pain may also be propagated reflexly to the hypochondrium, to both thighs, or be referred to the regions innervated by the an- terior crural and sciatic nerves. This radiation is very common in prostate tumors. Rupture of the Bladder. — Rupture of the bladder is indicated by sudden severe pain in the lower part of the abdomen. It fol- lows a trauma, and is associated with a constant desire to urinate. On attempting to urinate no urine may pass, though the desire does not abate. If any urine is passed it is mixed with blood. In addition, tenderness over the lower abdomen in the prevesicular region is most marked. All cases of rupture of the bladder are not accompanied by pain. A case in point is related by Moullin (226, p. 514) of a man wdio twenty-four hours after an accident walked into the hospital and complained of his inability to pass urine. Examination disclosed a ruptured bladder. Cystitis. — Inflammation of the bladder is always accompanied by pain. The cause of this pain production undoubtedly ' is the irritation of the sensory receptors in the bladder mucosa and of the sensory fibers in the bladder wall structure. This irritation produces more pain when it occurs in the region of the trigone. When it is present there, the entire urinary act may be painful, though the pain is most marked at the end of the act. Character of the Pain. — In mild forms of cystitis the only annoyance may be a slight discomfort at the time of urination or shortly before it, or if pain is present it is more of a burning or scorching of the urethra after urination than a true pain. This peculiar sensation disappears between the urinary acts, to CO O HH CO W K^ Pi W Q P < CO O H Pi O & O 03 03 .1 a (-• cT.s .2 c bC« o &. •§s 0; 3 ^ O c ^ HH 03 Urine is bloody, or maj' be en- tirely absent, owing to the in- ability of the patient to urinate. Is present in the perineum and scrotum, soft and boggy to the touch. Ecchymosis is marked. O O 3T3 ^'^ g.s 03 o h •s S 03 O 03 3 H ?: Q ¥-* li. o a 3J D o +^ 03 03 .2 -3 Pi 3 O 'Sb S 3 P.a o SP No blood may be present. Urine less in amount. Urethral catheterization may disclose no urine coming from the injured kidney. Desire to urinate not so marked. Blood, when it is present, is evenly mixed with the urine. If urine is coming from the injured kid- ney and no blood is mixed with it, rupture has not occurred. Is present in the lumbar region, and produces a well-marked swelling. This formation fluctuates. If the rupture is intraperitoneal, no tumor formation will be present in the loins, but intraperitoneal fluid will be definable. u 03 T3 -a o 3 03 03 >> 1 Injury has been to lumbar region, or in some cases to the abdomen. A crush between bumpers of cars will cause it. Q Q < O a 6J H t) Pi 03 a CO O 3 O ;-! 03 '^ .s§ Contains blood. On catheterization, urine may be absent from the bladder. Frociuent and painful urination. Urine or blood may not be passed, though the desire to urinate remains. If the rupture is extraperitoneal, the tumor mass is in the lower abdomen and rides above the symphysis pubis, and fluctuation is present over the symphysis pubis. If the rupture is intra- peritoneal, tumor formation may be entirely absent, but fluctuation will be present in the abdomen. Catheter easily enters, but passes into peritoneal cavity or adjacent area be- cause of rent in bladder wall. Injury has generally been a crush, in which a fracture of the pelvis has been produced. Any sort of a trauma to the suprapubic region may cause rup- ture of the bladder. o 02 3 Pi 03 3 - u o a 3* o 3 '3 1— 1 "0 s .52 M 686 THE BLADDER 687 recur when the urine is passed. The severity of the pain varies with the intensity of the inflammation. In severe grades of in- flammation the pain is most marked. In some cases nrinary tenesmus is so great that the unfortunate sufferer is compelled to sit on the urinal for hours before he has relief from the in- sistent desire to urinate. In the severest forms of cystitis the patient's life is a living torment. Goaded by a constant and un- satisfied desire to urinate, with the most severe pain and local tenderness over the bladder, his existence may be said to be a li\dng hell. In chronic cystitis pain is not as severe as it is in the acute. Should the pain occur only at the end of the urinary act it indicates that the disturbance is in the trigone and the posterior urethra. The lesion most likely to cause this pain is inflammation, which in many cases is of gonorrheal origin. In some cases, spasm of the urethra ensues, and the patient is unable to urinate without the greatest pain. This pain may be so great that he is loath to perform the act, and a partial retention of urine results. However, in cystitis pain is not always present, and may be absent for considerable periods ; and even when pres- ent may at times be eased to such an extent that the patient is fairly comfortable. Then suddenly, often without any apparent cause, there ensues a very severe, painful and active paroxysm. Location of the Pain. — The pain of cystitis may be either local or referred. The local pain is felt both in the urethra and in the suprapubic region. In the urethra it is most severe during or before the urinary act, though, if the trigone is involved, it may be most severe at the end of the act. In the suprapubic region the pain is felt more as a dull, constant aching, increased at time of urination. Both of these pains are due to the irrita- tion of the terminal filaments of the cerebrospinal nerves supply- ing the bladder. When the base of the bladder is involved the inflammation may be communicated to the rectum, and severe rectal tenesmus may then result. The referred pain is present in the skin of the scrotum and the penis. These (Piersol) are supplied by the perineal branches of the pudic and inferior gluteal nerves, which are derived from the 688 THE URETER, BLADDER AND URETHRA same segment of the cord as are the nerves supplying the bladder, so that irritation from the bladder may be carried to the cord and thence referred through these nerves to their distribution area. The pain in the lower limbs and foot, especially the foot pain (podalgia), is due to the transmission from the sacral nerves, which form the pelvic plexus, to the lumbosacral cord, which is formed into the great sciatic. Tickling or itching around the anus and painful contraction of the anal sphincter (rectal tenesmus) are present at times, and are most marked when the trigone is affected. Lumbosacral pain is also present. In some cases of cystitis pain has been felt in the region of the umbilicus, w'ith at the same time an entire absence of bladder tenderness (Hilton). The pain may also be referred to the kid- ney region. In some instances pain due to a lesion at the fundus of the bladder may be referred to the head of the penis. Tenderness. — In cystitis tenderness, as a rule, is present in the suprapubic area; but Hilton reports a case in which the tenderness to light pressure was a little to the left of the umbili- cus, and pain to deep pressure was present toward the loin, no tenderness being felt over the bladder region. The superficial tenderness, it seems likely, was due to some other factor than the cystitis. The tenderness in bladder lesions is most marked at the time of the painful paroxysms. In examining for tender- ness, pain is more frequently produced by sudden withdrawing of the hand pressure than by deep palpation. If the tenderness is marked, and the point of greatest ten- derness is in the suprapubic region, cystitis is probably present. This area, in inflammatory states of the bladder, is very sensitive either to palpation or to percussion. In some it is so sensitive that they cannot bear to have the clothing touch it. Factors influencing attacks of pain in cystitis are: (1) Anything which causes a congestion of the bladder mu- cosa or musculature, such as exposure to cold, dampness, menstru- ation, diarrhea, constipation, or exposure to drafts. These mav produce an attack or cause an exacerbation of one already present, THE BLADDER 689 (2) Instrumentation, especially if it is at all rough, brings on an acute and severe attack of pain. (3) Digestion at times is also responsible for the production of an attack. The symptoms associated with a cystitis are: (1) frequency of urination, (2) alkalinity of the urine, (3) the presence of pus and bacteria in the urine (the bacteria found are those which have been the chief factors in causing the cystitis), and (4) blood in the urine. This last indicates a cystitis of considerable se- verity, and is nearly always found in gonorrheal and tuberculous cystitis, and in the later stages of the cystitis due to bladder tumors. Pericystitis. — Should pain and tenderness be present in the bladder region, and be associated with a mass either in the median line or to one side, and should this follow instrumentation or trauma to the bladder, it is a good sign that pericystic inflamma- tion has occurred. This lesion produces a constant, severe throb- bing or aching pain, made worse on urinating. If the process continues an abscess may form. Tumors of the Bladder. — Pain in tumors of the bladder is of no practical moment, either as an aid in the making of a diag- nosis or in deciding how far the process has advanced. It is more prominent in carcinoma than in other tumors of the blad- der, probably because, in this form of malignancy, the walls quickly become infiltrated and pressure is made upon the sensory terminal filaments. The infiltration also hinders the contraction of the bladder muscles. When under these circumstances cystitis develops it is very serious, and the pain incident to it is most severe. Tenesmus, out of all proportion to the size of the tumor, is nearly always present in malignant tumors of the bladder wall. Tumors of the bladder, because they may block the ureters, and thus cause a back pressure and distention of the renal pelvis, also at times give rise to kidney pain. As a rule the malignant tumors are the only ones which are very painful, the pain vary- ing in, direct proportion to the nearness of the growth to the trigone. The reason why malignant tumors are so painful is 690 THE URETER, BLADDER AND URETHRA that as a rule thej are very friable, and pieces of the tumor mass frequently slongh off. These pieces, and in some cases blood clots, are carried to the urethra. If they are not able to pass, a blocking occurs, and bladder distention, which is painful, results. In other cases the carcinomatous tissue invades the wall of the bladder ; when it does so, on each contraction of the bladder, pain is produced by the pressure made by the contractr ing muscles U2:)0n the terminal sensory nerve filaments in the bladder wall. The tumor cells may also progress beyond the bladder walls and involve neighboring structures. Then pain due to interference with their functions may be produced, and be referred to the distribution areas of the organs involved. The tumor cells may also infiltrate adjacent sensory nerves. When they do so, severe, continuous, dull, aching pain is referred to the distribution area of the nerves involved. Tuberculosis of the Bladder. — Causes of Pain. — In tubercu- losis of the bladder the greatest pain is felt in those cases in which the trigone, the prostate, or the deep urethra are involved. It may cause the most severe suffering. Infections of the upper part of the bladder are not so painful as those of the lower part. According to Fenwick, the pain of bladder tuberculosis de- pends upon the depth of the ulceration, the state of the phos- phatic deposit, the presence of exposed nerves, and the degree to which the eroded edges are stretched by the accumulating urine. ''Deep ulcerations may not produce any very severe pain, while in other eases congestion or slight ulceration of the mouth of a ureter, or a few miliary tubercles in the mucous membrane of the trigone may increase the frequency of urination and tenesmus, and pain may be excruciating." (Johnston, Surg. Diag., Vol. II, p. 440.) Character of Pain. — Pain occurs during urination. Gener- ally it follows a period' of increased frequency of urination, which as a rule has been present for a long period before the pain commences. Gradually the frequency of urination and the pain increase, so that finally the patient is in a stage of perma- THE BLADDER 691 nent discomfort, with constant urinary pain and tenesmus. The paiu is of a burning character. Time. — The severest pain is felt during the urinary act, and is most severe at the end of the act, when the sphincter closes down upon the posterior urethra. Sometimes the intervals be- tween the urinary acts are free from j)ain ; at other times j^ain is constant, being aggravated only at the time of urination. Location. — The pain may be local, referred, or reflected. Local pain may not be present, except at the time of urination. Even then the pain may not be localized to the region where it is produced, but may be referred along the urethra to the glans penis. It is especially severe at the end of the act, at the time the sphincter muscles close down on the sensitive urethra. The other referred pains have been described under the general con- siderations of bladder pain. The reflected pain is present in the (1) sacral region, (2) the kidney region, (3) the groin, and (4) the thighs. Factors Influencing Production of Pain. — Position does not influence either the onset, course, or severity of the pain. Motion also does not in the slightest degree modify or change the pain, except in the presence of a cystitis, when the slightest movement may cause the severest pain. Associated Symptoms. — Associated symptoms of bladder tuber- culosis are: (1) Hematuria, which is present in about ten per cent, of the cases (Johnson). It may precede the onset of pain by an appre- ciable interval. (2) Polyuria may be present. It also is frequent in renal tuberculosis. (3) Pus is commonly found in the urine, and, after a long and careful search of the urine, tubercle bacilli are also, as a rule, discovered. A confirmative sign of value in the diagnosis of bladder tuber- culosis is the presence of tuberculous foci elsewhere in the body. Foreign Bodies in the Bladder. — Foreign bodies may be pres- ent in the bladder without producing pain; however, this is 692 THE URETER, BLADDER AND URETHRA true onlj in those cases in which the foreign body has no sharp edges, or in those in which, by its position, it does not interfere with the emptying of the bladder. The usual way in which a sharp, pointed foreign body can cause pam is by penetration of the bladder wall and the starting of an inflammation, either of the perivesicular tissues or of the peritoneum. The peritoneal inflammation will produce signs of a peritonitis, while the peri- vascular inflammation will provoke the symptoms of a pericys- titis. (See under the appropriate headings.) A history of the introduction of a foreign body into the ure- thra, and its lodgment in the bladder, followed by vesicular pain, is presumptive evidence that the foreign body is the cause of the pain. If the body shoul(J lodge in certain parts of the bladder, such as the posterior prostatic space, especially if the space is ample, as it is in those W'ho are old and have large prostates, little pain results. In these patients the bladder walls, on account of the peculiar configuvation of the parts, will not be able to contract upon the object, and localized irritative pressure will be absent. One of the commonest foreign bodies present in the bladder is a calculus. Foreign bodies of the greatest variety may occasionally be found in the female bladder. Over a hundred different objects have been found in a single bladder. Such patients use such bodies deliberately for urethral titillation. During use they fre- quently slip into the bladder by accident or are placed there by design. Vesical Calculus. — Causes of Pain. — Stone in the urinary bladder generally causes pain, the amount, variety, and constancy of which depend on the position of the stone, its size and shape, and the condition of the bladder wall. If a stone is located at the opening of the urethra it always produces more pain than it would if it were located in any other part of the bladder. This pain is the result of interference with the proper emptying of the viscus. In these cases, the bladder walls, when they contract, are brought into contact with the stone, which, if sharp and irregular, causes the most severe pain. Often a small stone, if rough and irregular, will produce much greater THE BLADDER G93 distress and pain than a larger one witli a more regular outline.^ If the bladder wall is not irritable a stone may be present for long periods of time without causing the least annoyance. This also happens if the calculus, because of its fixation in a diverticu- lum, be immovable, so that it cannot irritate the bladder wall. Should the stone be rough and freely movable, and in constant contact with the trigone, it causes very severe and constant pain. This pain is very much increased during urination, especially toward the end of the act, but may be entirely absent if, because of incomplete contraction, the bladder does not make pressure upon the stone. If the stone lies in a pouch or depression of the bladder wall, or is lodged behind an enlarged prostate, pain may also be absent. It is also much less in the aged, because of the comparative insensibility of their bladder mucosa. Renal hyjDeremia and congestion generally accompany vesical stone; these cause parenchymatous enlargement of the kidney, and so produce pains which are referred to the kidney area, so that in some cases, even when the lesion is in the bladder. Head's kidney zones may be present. In such cases, also, the ureteral areas may be free of pain, while the vesicular and the kidney areas may be hyperalgesic ; also the typical colic of ureteral stone may be absent. Character of the Pain. — The pain of vesicular calculus, while it lasts, is very severe. If a cystitis develops, the constant pain may be interrupted by sharp, severe, spasmodic attacks, initiated by urination. The pain is most pronounced at the end of the act, and may persist for some time after. Some patients, while un- able to urinate comfortably in any other position, can do so with- out pain if they lie upon their backs. Sometimes the pain is of such a character that the patients seem to gain ease by pulling up the foreskin after urinating. The pain is always most severe in those in whom the bladder presses do\Mi upon and comes into direct contact with the stone. 1 Calculi of oxalate, of lime, or of phosphate are the roughest. Those of cystin and uric acid are generally more round and smoother than the former, and cause less pain. 694 THE URETER, BLADDER AND URETHRA Location of the Pain of Vesical Calculus. — The pain may be either local, referred, or reflected. The local pain is felt in the suprapubic region and in the deep urethra. Keferred pain is felt in the glans penis, the perineum, or the anus, the reference taking place through the respective branches of the pudic nerve. The pain likewise may be reflected through the nerve fibers arising from the third and fourth sacral and, in some instances, from the second sacral visceral segments. Through these nerves reflection occurs, so that the pain is felt as coming from the thighs, the hips, the sacral region and, in some cases, from the shoulders and the anus. A sensation is often felt as though a paper of pins were in the rectum (Keen). These referred and reflected pains are always worse when the bladder is full, or when the patient assumes the erect posture. In some cases the pain is radiated into the area of the distribution of the lumbar plexus. It is also said (Head quC'ting from Erickson) that in some cases there is a dragging sensation in the groins, and frequently a pain in the soles of the feet. Factors Influencing Pain. — Factors influencing the pain pro- duction are : (1) Motion. Kest is the choice of the patients. They are very cautious about making the slightest movement, for from experience they have learned that motion of all kinds results in pain. Riding in springless wagons, jumping and running are accompanied by pain; for the same reason, rapid walking, jar- ring, and, in some cases, going up and down stairs are distasteful. After such movements the urine is frequently tinged with blood. Upon rest and quiet the pain ceases and the blood disappears. Violent or sudden turnings or twistings of the body also cause pain. If the stone is small and is freely movable, turning from side to side, or rolling over in bed, generally causes severe pain. This pain is sharp and burning, and is frequently referred to the anus and rectum. Straining at stool will also cause pain. In some cases coughing and deep breathing also produce pain. (2) Position. The patient generally lies upon his back, since he has found that this is the posture of greatest ease. THE URETHRA 695 (3) Digestion. During the active stage of digestion pain is always greater than at other times. Absence of Pain. — Absence of pain symptoms, when a calcu- lus is in' the bladder, is due to : (1) Anesthesia of the mucous membrane of the bladder, the result of a cord lesion, such as tabes dorsalis. (2) Mechanical causes preventing the stone from falling upon the sensitive neck of the bladder, as (a) its adherence to the blad- der walls; (b) sacculation of the bladder walls, or (c) pouching of the bas-fond of the bladder, so that pressure cannot be made upon the stone by the contracting bladder walls. THE URETHRA Pain in urethral disease follows the course of the twelfth dorsal segment (Head). Urethritis will be considered in connection with the male genitalia. Here will be considered only those con- ditions connected with the urethra in its essential relation as a urinary organ. These are caruncle and stone. Urethral Caruncles. — Urethral caruncles, fouud only in the female, are very painful to the touch. They also give rise to very considerable pain on the passage of the urine. This pain gradually lessens after the act until, in the course of a few min- utes, only a slight burning or smarting remains. Intercourse may become impossible because of the very severe pain, or because of the vaginismus which is reflexly produced. In some patients friction from the rubbing of the clothing or from the contact of adjacent parts may become so distressing that moving or walking is hardly possible. However, in most cases, the pain is not so extremely severe. In some it is most distressing, while in others it is of such a slight degree that it may give rise only to a feeling of discomfort. The pain is probably due to irritation of the delicate nerve filaments exposed in the denuded surface of the caruncle. It may also be due, in a certain degree, to the gTeatly increased sensi- bility of the caruncle, owing to the increased nerve supply. 696 THE URETER, BLADDER AND URETHRA Calculus. — The passage of a calculus through the urethra causes a burniug pain, as though a hot iron were drawn along the pas- sage. If the stone is rough the pain is much more severe. At the same time urination is extremely difficult, and blood is gen- erally present in the urine. Rupture of the Urethra. — Rupture of the urethra in the mem- branous portion causes an extravasation of blood and urine into the tissue between the two layers of the triangular ligament. At the lateral aspect of this space are the dorsal nerves of the penis ; so that, when extravasation occurs, pressure is made upon them and the pain is referred to the glans penis, although the extrava- sated fluid collects in the scrotum. Transferred Pain in Urethral Disease. — Fenwick mentions a case of pain in the foot due to stricture of the urethra. He also records another case of pain in both forearms which occurred during urination. In this patient a prostato-membranous catarrh was found. Both patients were relieved of the pain by treat- ment appropriate to the urethral condition. Pain on Urinating. — Where pain is felt during urination exact information should be obtained as to the exact time in the urinary act at which it occurs. Pain at the beginning of urina- tion, without a continuance during the act, generally means some obstruction to the onward flow of the urine. This obstruction may be due to a mild urethritis, owing to which the lumen of the urethra is blocked by shreds of mucopus or mucus; or it may be due to a very soft stricture, or to an enlarged prostate that at first offers some obstruction to the onward passage of the urine. A clot or small stone may lodge in the opening of the urethra, and very severe pain and retention of the urine may tlius occur. This pain continues until the obstruction has been overcome, when it ceases and urination again becomes free. If pain be present during the entire time of the urinary act the following should be inquired into: The presence of irritating constituents in the urine itself, such as phosphates, eliminated drugs (cantharides), urates, glu- cose, and various ingested acids. The burning may also be due THE URETHRA 697 to a too great concentration of a normal urine, so that, owing to that concentration, substances which ordinarily do not irritate do so most severely. This burning may also be caused by inflammatory states (in- filtration, granular patches, etc.) along the urinary tract, either in the prostate or in the urethra. The burning sensation in those conditions is most severe, and at times does not end with urina- tion, but persists some little period beyond. A narrowed meatus also causes pain during urination. Pain during urination also may be due to inflammatory changes in the bladder walls, or to diseases of or changes in the adjacent organs, such as anteflexion of the uterus, which in a pregnant woman often, owing to traction on the bladder, causes severe pain during the urinary act. Abscess in the prevesicular space of Douglas and pregnancy itself, by its pressure on the bladder, causes pain. Adhesions to different organs by the blad- der are also a cause of painful urination, likewise are tumors of the uterine adnexa. The pain in these various lesions is probably due to the hindrance wdiich they offer to the contraction of the bladder musculature, or to the free exit of urine. Pain at the end of urination is due to prostatitis, urethritis, or to some disease in the bladder. At this time the bladder walls close down, pressure is made upon the trigone, and, if pain is present, it generally indicates an inflammation of the bladder wall or the presence of a calculus, which drops or is pushed into the triangular opening at the beginning of the ureter terminals, and thus, by pressing upon the irritated surfaces, causes pain. This pain is most excruciating. It frequently causes the patient again to attempt to urinate, even though the act has just been performed. Should the pain be present all through the act, and be continued beyond, as a dull, aching sensation in the rec- tum, it indicates that the prostate is probably at fault. Pain continuing beyond the urinary act may, in some cases, be due to urethral changes, as a blocking from a calculus, or a growth at the vesicular orifice, closing the urethra, CHAPTER XXXT THE MALE ORGANS OF GENERATION The male organs of generation are the testicles, epididymis, vas deferens, seminal vesicles, prostate, and penis. THE TESTICLES The testicles, when intlamed, become very tender, especially to deep pressure. In testicular affections the skin of the scrotum is not necessarily tender, the testicles and scrotum being supplied by entirely different nerves. The stroma of the testicle receives its nerve supply principally from the sympathetic segments, while the skin of the scrotum is supplied by the genital branch of the genitocrural. Irritative lesions of the testicle cause referred aching or discomfort in the reference areas (deep pres- sure sensibility) of the eleventh and twelfth dorsal segments. Pain sensibility in the testicle is also conveyed through the genital branch of the genitocrural nerves. The testicle and its coverings being supplied by different nerves, irritation of the different structures will produce pain in different areas, but al- ways in the area with which they have nerve connections. After the testicle has descended into the scrotum, the communication between the testicular sac and the j)eritoneum becomes abolished, and the testicle lies in a closed sac. The deep pressure pain produced in testicle disease is due to distention of the capsule. It is a type of sensibility quite similar to that found in other viscera. Should the distention be gradual pain may be entirely absent. In some cases the testicle grows to a great size, and does not produce any inconvenience other than the dragging due to its overAveight. The testicle is capable, however, of giving rise to severe pain 698 EPIDIDYMIS, VAS DEFERENS, AND SEMINAL VESICLES 699 when inflammation causes it to become greatly enlarged. At such a time it is very painful and is extremely tender. Pressure on it causes pain referred to the inguinal region and the inner side of the thigh. In some cases it may be reflected to the back or to the iliolumbar region. Trauma of the testicle may or may not be very painful. In a case of Mitchell's a wound of the testicle caused pain in the back alone. The deep pressure sensibility of the testicle has a peculiar quality, in that it is often associated with nausea and vomiting. EPIDIDYMIS, VAS DEFERENS, AND SEMINAL VESICLES The genital ducts are the epididymis, the vas deferens, with the seminal vesicle as a reservoir. In a comj)licated urethritis all of these may become involved, and gTeat inconvenience may result. Yet pain is not a promi- FiG. 165. — Areas of Cutaneous Tenderness in Disease of the Epi- didymis. A and B correspond to the points of maximum tenderness of the 11th dorsal segment. B and C correspond to the points of maximum tenderness of the 12th dorsal segment. nent symptom until the inflammation extends far enough to involve the epididymis. Then it is most severe, and is of a throbbing, aching character and, because of the increased blood stasis, is most intense in a standing position. The epididymis, at the same time, is exquisitely tender to the touch, and pressure 700 THE MALE ORGANS OF GENERATION upon it produces the peculiar sickening sensation that is as- sociated with deep pressure on the testicle. Pain when pres- ent radiates anteriorly into the distribution area of the crural branch of the genitocrural ner^^e, and posteriorly over the lower lumbar and the upper sacral vertebrae, which, according to Head, are the areas of the eleventh and twelfth dorsal segments. The pain may also be felt in the leg, as far down as the knee, and in the perineum. Figure 165 illustrates the places where cutaneous tenderness is generally found in inflammation of the epididymis. THE PROSTATE The prostate is the principal seat of pain in all acute infec- tions of the male genital tract. Ordinarily the passage of the urinary stream over it is without pain, but when the urethral surface is inflamed, the subepithelial tissue, becoming congested, swells and blocks the urethra. The urinary stream now causes a sudden separation of the urethral surfaces and compression of the tender tissues, with consequent pain production. This pain is most marked in the beginning, and persists during the entire urinary act, and continues for some short time thereafter. If the portion of the gland under the bladder wall is affected, and the inflammation is communicated to the mucous membrane of the trigone, frequency of urination, with severe pain at the end of the urinary act, comes on. Likewise, if that part of the pros- tate adjacent to the rectum is involved, defecation becomes very painful. Abscess of the gland in any of these regions acts about the same as does an inflammation, but has symptoms of much greater intensity. In prostatic involvement referred pain may also be present in the perineum (through the perineal nerves) and in the back and down the legs (because of the intimate as- sociation between the roots of the pudic nerve with the sacral and lumbar plexi) (Bryant, 895). Congestion and Inflammation. — Congestion of the prostate occurs at times without inflammation, . and is found especially in those indulging in sexual excesses. The sensation complained THE PROSTATE 701 of is more of an aching or dragging across the back in the lumbar region than an actual pain. However, both congestion and inflammation cause in the glans penis a pain not relieved by micturition. This glans pain is of the referred variety, the stimuli being transmitted through the dorsal nerve of the penis, a branch of the pudic supplying the prostate. The pudic also sends a branch to supply the perineum and the anus, and in both these regions referred pain may be felt. Lesions — Lesions of the prostate may also cause re- flected pain and hyperalgesia in the tenth and eleventh dor- sal, the first, second, and third sacral, and sometimes also in the first lumbar visceral seg- ments. The areas of distribu- tion of these segments are illus- trated in the accompanying figure. Fig. 166. — Areas of Distribution OF THE 10th and IIth Dorsal Segments, and the 1st, 2d, and 3d Sacral Segments on the Right Side. These areas are most frequently involved in prostatic disease. (Head, Brain, Vol. XVI, p. 85.) In some cases also the prostate may make pressure on the sciatic nerve and thus cause pain which is referred to its distribution area. The most common diseases of the prostate causing pain are: (1) congestion, (2) inflam- mation, (3) hypertrophy, (4) new growths. Hypertrophy. — Congestion and inflammation have been con- sidered. ISText and closely related to these two is hypertrophy. Generally it is wathout pain, or, in fact, symptoms of any kind, unless, owing to increase in size, the prostate encroaches upon the neighboring structures and causes some functional disturb- 702 THE MALE ORGANS OF GENERATION ance. For instance, no pain is felt in median lobe enlargement until the enlarged lobe causes retention of urine, with infection and consequent cystitis. Then the paii-. becomes most severe, but it is not the pain of the hypertrophy, but of the cystitis. Hyper- trophy of the prostate may cause pain in almost any region, de- pending upon the changed relationships, pressure, etc., which are produced in the neighboring structures. Some of the places where pain is felt are the glans penis, the back, the hips, the buttock, down the thigh and legs, the foot, and the suprapubic and perineal regions. Tumors of the Prostate. — The most common is cancer. In it prostatic pain may be complained of only when the bladder is distended with urine. As a general rule, in the soft varieties of cancer, pain is not a prominent symptom. It is usually only when the cancer is hard and the surrounding tissues become infil- trated that pain and discomfort ensue. In some cases, in which the cancer involves the vesicoprostatic portion of the bladder, pain of a spasmodic type occurs. It depends for its production upon the compression of the nerve filaments in the muscular walls of the bladder, particularly so if the lesion occurs in the vicinity of or involves the vesical sphincter. Tuberculosis. — Tuberculosis of the gland structure is not pain- ful unless neighboring tissues are involved. Calculi, likewise, may be present in the prostate without causing pain. Associated Symptoms. — Associated symptoms of prostatic in- volvement are: (1) Frequency of urination. This is one of the most charac- teristic symptoms. Commonly, when the prostate is not acutely inflamed, urination is frequent, but is entirely free of pain. (2) On passing a sound the most extreme agony is experi- enced by the patient as it passes over the prostatic portion of his urethra. THE PENIS 703 THE PENIS Pain felt in the penis may originate from conditions present in its substance, involving principally the uretlira, or it may be referred from distant lesions. Urethritis. — The lesion of the penis causing the most pain is, in the vast majority of cases, an acute inflammation, generally gon- orrheal, of the urethra. Inflammation of the urethra causes pain in urination, which, however, is more of a burning sensation, or, as some of the i^atients put it, "a feeling as though they were passing hot oil," than an actual pain. The irritation is often transmitted to the head of the penis, where it is felt as a severe stabbing. When the urethra and adjacent tissues are inflamed erection causes acute pain. Owing to the structure of the penis inflammation, when the spongy body only is involved, causes it, during erection, to be bent on itself. Many misguided individ- uals, ignorant of the true nature of tlie pain production, have attempted forcible straightening of the penis in such conditions, with resulting rupture of the urethra. Referred pains felt in the penis may originate in lesions of the kidneys or ureters, in prostatic diseases, in some spinal cord conditions, and occasionally from rectal disorder. Inflammation of the prepuce (balanitis) causes a pain that is especially marked on erection of the penis. In the state of erec- tion the prepuce is stretched, normally, without any special sen- sation, but should it be inflamed, pain results. Pain is also pro- duced by the rubbing of the clothing against the inflamed and eroded surfaces. Inflammation of Cowper's Glands. — Sometimes the glands in the bulbo-membranous urethra, known as Cowper's glands, become inflamed. When they do, pain is felt in the perineum, where, on palpation, a painful mass may be palpated. The pain is greatly increased by motion, such as walking; defecation and the sitting posture also increase the jiain, which is of a throbbing character. To cause this throbbing it is not necessary that the congestion be severe, for the glands lie between the two layers of 704 THE MALE ORGANS OF GENERATION the triangular ligament and are inclosed in perineal fascia, so that the least engorgement is resisted, and gives rise to pain. The glans penis itself, generally, is not painful. Examples of an ulcer of the glans being present without the patient's knowledge are common. Indeed, he may not be aware of any- thing abnormal until the skin is involved, or until lymphangitis or lymphadenitis occurs. However, the penis is not absolutely without sensation, for it is capable, probably more so than ordi- nary organs, of appreciating different degrees of pressure. (Head and Kivers, 86, p. 39.) CHAPTEK XXXII PAIN IN THE FEMALE GENITALIA GENERAL CONSIDERATIONS Anatomy. — The female genitalia consist internally of tlie uterus, Fallopian tubes, and the ovaries, and externally of the vagina. The internal organs lie deep in the pelvis, and are protected against traumatism by the bony wall which surrounds them. This wall, although it serves the purpose of a protection to the sexual organs at the times when the organs, enlarging for some reason, cannot accommodate themselves without making pressure on the surrounding structures, also is a cause of pain and distress. The free mobility of the uterus and adnexa helps to overcome, in a measure, the structural disadvantages of its loca- tion. The peritoneum, which covers the uterus, tubes, and ovaries, is reflected over the anterior and posterior surfaces of these or- gans, and on either side forms the two layers of the broad liga- ment. The uterus lies in front of the rectum and posterior to the urinary bladder. Any enlargement or distention of the rec- tum causes a displacement of the uterus, raising it up and throw- ing it forward. Normally this causes no discomfort, but when inflammation, with its accompanying adhesive formations, arises, this free mobility is curtailed, and change of position causes pain. Owing to the close anatomical connection and relationship of the uterus with adjacent organs, any inflammation or derangement of the economy of these organs has an unfavorable influence upon the uterus, either through the nervous system or the circulatory supply, and may lead to pain production. Nerve Supply. — The female genitalia receive their nerve sup- 705 706 PAIN IN THE FEMALE GENITALIA gu ply from both the sympathetic and the cerebrospinal systems, the sympathetic being distributed to the upper part of the uterus, the tubes and the ovaries, and the upper part of the vagina, while the cerebrospinal nerves are distributed to the lower uterine segment and the vagina. The ovaries and tubes are supplied entirely by the sympathetic, the nerves supplying the ovary and the distal extremity of the tubes being derived from the ovarian plexus, which, in turn, receives its fibers from the fourth and fifth lum- bar ganglia of the sympathetic. The proximal end of the tube and the upper part of the uterus re- ceive their supply from the uterine plexus, and this also derives most of its fibers from the fourth and fifth lum- bar ganglia of the sympathetic. At this point it is well to recall that the lumbar ganglia do not corresjiond with the lumbar visceral segments of the cord, as described by Head. The nerves which pass through the ganglia may arise from much higher segments of the cord than the ganglia through which they pass would seem to indicate. The segmental supply will be considered on p. 713. To understand better the nerve supply of the female genitalia each organ will be considered separately. The supply to the Fig. 167. — Nerve Supply of Female Genitalia. cu, spinal uterine center; plh, hypogastric plexus; nhy, hypogastric nerve; npc, nerves pudendres communis; nh, hemorrhoidal nerves; gu, peripheral ganglion in vaginal form; s, vagina; vu, bladder; vl, vulva; an, anus. (Bechterew's "Functionen der Nervencen- tren.") GENERAL CONSIDERATIONS 707 ovaries and tubes will first be traced, and then the supply to the uterus and vagina. The ovaries are probably supplied entirely by sympathetic fibers (Luschka, Van Hoerff), which are derived from a plexus surrounding the ovarian artery.' This plexus, in turn, is formed by nerves from the renal and aortic plexi, and thus is in inti- mate connection with the abdominal sympathetic ; so that any de- rangement of the ovaries may produce sympathetic disturbance! in the abdominal viscera. The plexus surrounding the ovarian artery sends fibers into the ovary, to form plexi surrounding the larger blood vessels. A plexus is also formed in the cortex and sends nerves to the periphery, to end on the surface between the germinal epithelial cells, or in the follicles, where they termi- nate in the walls of the blood vessels. Xone of the fibers pene- trate beyond the theca. In opposition to the view that the ovaries are supplied entirely by sympathetic fibers is that of Head and Kivers (86), who hold that the ovary receives a part of its nerve supply from the abdominal wall, its innervation probably being connected with the last dorsal and first lumbar nerves. However, this is likely true only of the peritoneal covering which the ovary has acquired during its developmental descent, for in early fetal life it lies close to the abdominal wall, beneath the peritoneum. The Fallopian tubes receive their nerve supply from the sym- pathetic. The nerves follow the arteries and reach the tubes from the ovarian and uterine plexi (cervical and corporal). After reaching the tubes the nerve fibers penetrate into the peritoneum and immediately beneath it form a plexus (the subserous), from which some nerves are given off to supply the muscular tissues, and others to form a subepithelial plexus, which lies in and supplies the mucous membrane. The uterus is supplied both by the sympathetic and the cere- brospinal systems. The sympathetic is distributed chiefly to the body of the uterus and is formed into two plexi, the smaller of which lies upon the upper and lateral surface somewhat pos- teriorly, and is distributed to the posterior and lateral surfaces of the uterus. The larger is distributed to the cervix and the 708 PAm m THE FEMALE GENITALIA vaginal vault. One of these ganglia is especially large, and is called the cervical ganglion. It lies behind and to the side of the cervix. The uterus, in addition to the sympathetic fibers, re- ceives medullated fibers from the second, third, and fourth sacral nerves^ (third and fourth sacral, Xovak), which also supply the vagina, and, through the pudic, are distributed to the perineum and the bladder. Therefore, when the lower uterine segment is affected, pain may be felt in the bladder and the perineum. ^ In the uterus the course of the sympathetic and spinal nerve fibers is different, the sympathetic fibers being distributed to the blood vessels, while the spinal fibers terminate between the muscle bundles and in the mucosa (Piersol), but are probably not found above the cervix. It is because of the intimate relationship of the cerebrospinal fibers to the uterine musculature that uterine spasm is so specifically localized to the uterus ;^ because, when the uterus contracts, the nerve filaments are caught between the individual muscle bundles and are tightly squeezed. This irri- tation produces the sensation peculiar to the uterine contraction^, and is called uterine "colic." The nerves of the uterus show great ability to adapt them- selves to changes in size of the uterus. This is well seen during pregnancy, when the uterus enlarges to many times its normal 1 Bechterew, quoting from Rein and Pisemsky. 2 According to v. Basch and Hofman (379), there are two sets of nerves in the uterus: the nervi uterini, reaching the uterus by way of the hypogastric and sympathetic nerves, and the nervi uterini sacralis, passing from the main sympathetic chain, and belonging to the pelvic splanchnics (Korner, Robling, 378). The stimulation of the hypogastric nerve causes a contraction of the circular muscles of the uterus. Stimulation of the cerebrospinal nerves causes the longitudinal to contract. 3 Since the stimuli carried to the brain over cerebrospinal tracts are definitely localized to the area in which they are produced, any stimuli occurring in the spinal nerves supplying the uterus would be referred to the area in which they are produced, viz., in the lower uterine segment. The localization of the pain is not as definite as it would be if some of the somatic nerves were involved, for one of the chief functions of the somatic nerve's is to interpret pain, while those of the uterus are concerned more with nutrition and muscular tone. So that pain stimuli present in the nerves supplying the uterus are not interpreted definitely as coming from the uterus, but are referred to the area of distribution of the pudic, one of the functions of which IS to transmit pain sensation. GENERAL COXSIDERATIONS 709 size. The nerves increase in size but not in number. The gan- glia also increase in size ; naturally they will be somewhat stretched, and this stretching produces irritation, which is trans- mitted to the cord, and is reflexly felt as a pain or aching in the back or dowTi the thighs in the area of distribution of the cord zones connected with the uterus. The sensibility of the uterus, ovaries, and tubes to ordinary stimuli is very slight, if it is present nt all, so that, on exposure, during operation (cocain anesthesia), a normal ovary can be pinched w4th a clamp or a mouse-tooth forceps without the pa- tient's knowledge. The same can be done, in the majority of cases, with normal tubes (Sampson, Meyers, 152, p. 7i9). Deep pressure upon an ovary produces that peculiar sickening sensa- tion so familiar in the male when the testicles are squeezed. Some women are more sensitive to ovarian pressure than are others. Intrapelvic manipulation is usually less painful iii women past the menopause, and also less painful in those who have borne children. Most observers agree that the uterine, tubal, or ovarian peritoneum is not very sensitive to traction, to pressure, or to gauze rubbing against it, but that the parietal abdominal peritoneum is most sensitive to these same stimuli. The cervix uteri is insensitive to touch, but is very sensitive to crushing or dilatation. The endometrium is as a rule without pain sensation (Xovak), though when inflamed it may give rise to a sensation of weight and heaviness. In this condition intra- uterine points or areas of tenderness may develop (see under Uterus) . Diagnosis of Pelvic and Hysterical Pain. — Pelvic Pain. — If the patient complains of pain, and pelvic disease is suspected as a cause, inquiry should be made as to the periodicity of the pain, its exact location, its relationship to the menstrual period, and the history of past diseases. If such inquiry is made, it will be found that pain, if it is due to pelvic lesions, will have some or all of the following characteristice : (1) It is either constant, with periodic exacerbations corre- sponding to the menstrual period, or is present only at the time 710 PAIN IN THE FEMALE GENITALIA of menstruation; (2) it is felt in the lower abdomen and radiates to the back or lower limbs, or it is felt in the right or left iliac region; (3) it is associated, in quite a fair proportion of cases, with a tender point one to one and one-half inches below, and three-quarters of an inch internal to, the umbilicus (Morris's point). In regard to the anamnese, careful questioning of these patients will generally elicit the fact that at some time in the past they have suffered from parametritic inflammation. Yet great care must be exercised in judging of the value of subjec- tive symptoms, as given by the patient, for, at the present time, because of the prevalence of pelvic diseases, and the diffusion of knowledge concerning their symptoms, it frequently happens that a hysterical patient will simulate a uterine or ovarian disorder so closely that it is very difficult to make a diagnosis. However, in nearly all cases a fairly positive diagnosis can be made, for, as Eulenberg says (145, pp. 1274-1275) : "Spon- taneous recurring pains in the inner or outer genitalia (in the pelvis, coccyx, or abdominal wall), when they are the exclusive or predominating symptom, if they occur without positive organic findings, independently of the quality, intensity, persistency, and former quality of the pain, speak first against the acceptance of a genuine local disease, and eventually for a clear nervous cause, in the sense of neurasthenia or typical pain of psychical hysteria. "In any case spots, painful upon pressure, can only be re- garded as affections of genuine genital suffering if they can be referred back to a local change ; for instance, to enlargements of the ovaries, or to parametritis. Should the pain, present on pres- sure, remain ip. the same place, on the same side, and exist at certain periods (menstruation) organic lesions are indicated, while vacillation, irregularity, changes of the kind of pain occur- ring periodically, and resistance, point on the contrary to the neuropathic causes." Hysterical Pain. — When pain is present in the ovarian re- gion, hysteria should be considered as a cause ; the hysterical origin of the pain may be proven by finding pressure points on GENERAL CONSIDERATIONS 711 other parts of the body (Windscheid, 148, p. 484). Another point which aids in diagnosing hysterical pains is that they bear no relation to sensory nerve distribution, nor to segmental cord distribution (Dercum, 150, p. 849). Another point aiding in the diagnosis is that pain due to hysteria does not, as a rule, subside upon rest in bed, while pain due to inflammatory disease of the pelvic organs usually does. This is not invariably so, because many cases of hysteria and neurasthenia are greatly benefited by rest in bed, owing to the improvement in the general health which then ensues (Rothrock). In hysteria, also, there is, as a rule, diminution or absence of the conjunctival and pharyngeal reflexes (Windscheid). Hysteri- cal (or neurasthenic) pain is confined to the left side. In hys- DIAGNOSIS OF PELVIC FROM HYSTERICAL PAIN Symptoms Pelvic Disease Hysterical Pain Pain. Has definite location and remains constant in this location. It makes no dif- ference whether the pa- tient's attention is attracted elsewhere or not; pressure over the site of the pain wiU produce an exacerba- tion of it. Menstruation usually influences the pain, generally increasing it. Has no definite location, but flits from one place to another. Pain often is of a burning character. Fre- quently, when the patient's attention is attracted else- where, severe pressure can be made over the indicated site of the pain without initiating it if it is not pres- ent or without increasing it if it is present. Menstrua- tion usually has no influ- ence on the pain. Fever. May be present in acute disease. None. Leukocytes. May be increased in acute attacks. No increase. History. Generally of gonorrheal, tubercular, or puerperal in- fections, pelvic tumors, or of pelvic traumatism. No history of gonorrhea, etc., but one of neurosis. Reflexes. Conjunctival and pharyn- geal present. Conjunctival and pharyn- geal absent. Areas of hyperes- thesia. Absent. Present. 712 PAIN IN THE FEMALE GENITALIA teria (neurasthenia also) there seems to be a lessened resistance to pain production in lesions of the female genitalia. This causes them to react much more strongly than normal to the slightest irritation (Dercum, 347; Herman, 316); so that when the pelvic disease has produced a secondary neurasthenia or hysteric weakness the pain may, after removal of the cause which has originally produced it, persist and be renewed on the slightest stimulus arising from causes which, in a normal state, would not produce even a discomfort.^ As an aid in the diagnosis of these conditions a diagnostic chart is given on page 711. Varieties of Pain. — In some patients a long-continued lesion has produced so much disturbance in the nervous system that a permanent state of nerve weakness has occurred, and the jDatient suffers from the condition termed neurasthenia. She is now particularly unfortunate, for her years of suffering have so re- duced the resistance of the nervous system, and the pathways for pain have been so well defined, that irritations, even those of the least magnitude, are interpreted as painful. It should not be for- gotten, however, that the term ^'female complaint" is often used as a subterfuge for weak, irresolute, or lazy souls to indulge their innate propensities for idleness. So far we have been speaking of pain and painful areas, not specifying definitely their location, and therefore before we ad- vance further it will be well to consider more exactly the limits of these areas in which pelvic pain is felt. In doing so, it is again necessary to draw attention to the fact already stated that the j^elvic viscera, unlike most of the other abdominal viscera, have two sources of nerve supply: the sympathetic and the cerebrospinal. The cerebrospinal system, as is known, refers all its irritations to the peripheral distribu- tion of the particular nerves concerned, while the sympathetic carries the stimulus to its centers in the cord. Here the irrita- tion is communicated to adjacent centers of the cerebrospinal 1 According to Fritsch (348), pelvic pain persists in 33 per cent, of the cases after corrective operations. GENERAL CONSIDERATIONS 713 system, by which it is relayed to the brain, where it is perceived as coming from the peripheral distribution area of the nerves connected with these centers. Tims the pains due to cerebrospinal irritation are more apt to have an exact orientation than those due to irritation of the sympathetic system. This is exemplified in uterine muscle-contraction pain, where the localization is some- what exact and the pain is of considerable magnitude, because it is due to cerebrospinal involvement; while in endometritis, the l^ain, when present, is indefinitely placed in the lower abdomen, is referred to the back, to the hips, or to the lower limbs, and is of less intensity, being more of an aching than a pain, because it is of sympathetic origin. The sympathetic supply of the body of the uterus seems to be from the tenth, eleventh, and twelfth dorsal segment [first or first and second lumbar (Donald and Lickley)], while the lower uterine segment is supplied by the third and fourth lumbar, and some- times the first and second sacral segments [second, third, and fourth sacral (Donald and Lickley)]. In this connection it is always well to remember that the sacral segments do not by any means correspond to the sacral nerves. The sacral segments are concerned principally with the dilatation of the cervix, such as occurs in the first stages of labor, while the dorsal segments are concerned principally with the contraction of the uterus. In Fig. 168 the distribution areas of the different segments are de- fined. By an examination of this figure it is seen that the uterine corporeal pains are referred to the lower abdomen and back, while the cervical pains are referred to the sacral region, the back of the hip and thigh, and the lower and back part of the foot. The pains due to the ovary are reflected to the tenth dorsal visceral areas, and those from the Fallopian tubes into the elev- enth and twelfth dorsal and first lumbar visceral areas. In this respect a peculiar characteristic of the genital pain to be noted is that, irrespective of the location of the lesion, the pain is most common on the left side. ' IN'ovak (117, p. 480) states that Champneys, in a series of 714 PAIX IN THE FEMALE GENITALIA cases of uterine cancer, found the proportion between left-sided pain and right-sided pain to be as six is to one, and in these cases no greater tendency to involvement was present on the left than on the right. Herman, likewise, found that, in cases of retrodisplacements of the uterus, pain was three times as fre- quent on the left as on the right side, without regard to the fre- quency of the displacement on the same side. Herman ascribes Supply r lOtli D the body of j llth D the uterus ^ 12th D Fig. 168. — Area of Distribution of Cord Segments Involved in Uter- ine, Ovarian, and Tubal Diseases. The bodj'' of the uterus is supphcd by the 10th, 11th and 12th dorsal seg- ments; the cervix by the 3d and 4th lumbar and sometimes by the 1st and 2d sacral segments; the ovary by the 10th, and the Fallopian tube by the 11th and 12th. dorsal and the 1st lumbar segments. the greater frequency of pain on the left side to the fact that the left side is weaker and less resistant than the right. Accord- ing to Herman (144, p. 1,056), the greater frequency of pain on the left side has been fancifully explained as being due to a shortening of either the left tube or of the left ovarian ligament. It is also explained by Clark (350) as being due to tension of the tightly drawn mesentery over the brim of the pelvis. It may also in many cases be partially explained from the fact that on GENERAL CONSIDERATIONS 715 the left side (in hysterically inclined subjects) there is usually a hysterical zone in the region of the ovary (Charcot). Sympathetic pains, occurring in the occiput and breast, are very frequent in disease of the female genitalia. The presence of the breast pains cannot entirely be explained on the hypothesis that the stimuli are carried through the nervous system, although it is probable that the nerve supply of the breast has a more special connection with the genitalia than with other organs. The pain in the head, and particularly that in the breast, seem to be due to an active congestion of the meninges and of the breast respectively, so that, in pelvic disease, at the time when the pain appears in the breast, the mammary gland swells, becomes tender, and the pain is (frequently) of the dull, aching variety that indi- cates capsule tension. When the pain is felt in the head the meninges are j^robably likewise congested, and the headache is likely due to increased intraventricular tension. The cause of both these congestions may be a toxin or ferment either of uterine or of ovarian origin circulating in the blood. This substance has a selective action on the meninges and on the breast; the breast, because of the related sexual functions of the two ; and the meninges, because they seem to be particularly sensi- tive and reactive to deleterious circulating substances of any kind. As yet a substance of this nature has not been separated from the blood, nor has one been produced from the uterine or ovarian tissue, though the actuality of its existence seems to be strength- ened by the fact that during gestation, with all nerves divided, the mammary gland develops. The only way a stimulus could be carried to it is by the blood (Mott). A peculiarity of breast pains, that might seem to show that the uterus and the breasts are correlated through the nervous sys- tem, is that breast pain is most frequent on the side in which the diseased organ is located. If the causative factors were car- ried through the circulation, why should the breast on the dis- eased side be more frequently involved ? As yet no clear expla- nation has been offered. As a conclusion it may be stated that the female genitalia are 7ie PAIN IN THE FEMALE GENITALIA capable of producing local, referred, reflected, transferred an^* sympathetic pains. The transferred pains are found in some cases of salpingitis, in which the pain is felt on the side opposite to the one in which the lesion is located. Nearly all surgeon? have had experience of such eases. Character of Uterine Pains. — ^While a description of uterine pains may entail some slight repetition, yet, for the sake of clear- ness, we shall again very briefly consider them. x\s has beeis said, they may be classified as constant and intermittent. Th^ constant jDains are those due to a continuously acting cause, sucl? as is found in inflammations (endometritis, metritis, salpingitis- and oophoritis). Exacerbations frequently occur, producing in- termittent pain, and usually indicate uterine contractions. Con- stant pains, varying in intensity on change of position, are found where inflammation has been followed by the formation of adhe- sions. These adhesive formations are a potent cause of pain pro- duction during the functional acts of the parts involved. For instance, where the uterus is attached by adhesions to the bladder wall, urination, owing to a lessened capacity of the bladder, tha result of traction, etc., by the adhesions, becomes frequent and generally is joainful ; likewise adhesions to the rectum are the cause of pain during defecation, and in some cases pain is felt as soon as the fecal matter begins to accumulate in and distend the sigmoid. Position Assumed hy the Patient Suffering from Pelvic Vis- ceral Pain. — Some women who are afflicted with uterine or ad- nexal disease have no rest in any position; standing or walking, in motion or at rest, they are always subject to distress. Their pains, like an unwelcome heritage, are ever with them. On the other hand, there are others who have pain only when they as- sume certain positions or perform certain acts. Very familiar is the woman who is always complaining of her back. She has a constant, steady aching, that is made worse on bending and on flexion of the body. She will prove to be one who has a displaced or retroflexed uterus. Women who not only have pain on standing but on lying on one side will frequently be found to have an acute GENERAL CONSIDERATIONS 717 inflammatory state of the adnexa on that side. Some women, though, seem to have ease by lying on the affected side. Bending forward or backward is j^articularly painful in all pelvic disease. Especially in inflammatory states of the pelvic peritoneum are frequent repetitions of the same act very painful. On ascending stairs pain in the inguinal and lower abdom- inal region, coming on as the foot is being removed from the ground, generally indicates an involvement of the psoas muscle or its sheath in the inflammatory adnexal disease. Pain on ele- vating the arm indicates an increase of intraabdominal pressure and disturbed peritoneal relations. This is common in adhesive formations and in pelvic peritonitis. If the adhesions are to the small bowels intestinal peristalsis is painful. Pain of this sort comes on at irregular intervals and is of varying intensity. It is frequently accompanied by a gur- gling which indicates the reduction of a stenosis and the onward passage of the bowel contents, with an almost immediate relief from the pain. Relation of Pelvic Visceral Pain to Functional Acts. — In all acute and some chronic inflammations of the pelvic viscera, and in those cases of adhesive union between different viscera, pain is present on coitus. This pain may be severe during the entire act or may be present only at the end, and, in either case, may persist for some time after the act. When it is present during the entire act it is generally due to an acute inflammation, which has progressed beyond the uterus and has involved the adnexa. This pain persists, as a rule, for some time after the act. In chronic pelvic inflammation the pain may often persist through- out the next day. The site of the inflammation modifies the pain to a great .extent. Inflammation high in the body of the uterus generally does not cause as much pain as if the inflamma- tion were low down in the cervix. Of course, vaginitis or cys- titis will also cause pain, and should be considered. This pain is present on the entrance of the male part, while the pain of the inflammatory and adhesive states is present only during the act, and, in many cases of mild inflammatory states persists only 718 PAIN IN THE FEMALE GENITALIA during the time of the active movements. When it persists after the cessation of these movements it is a sign that some damage has been done to the female parts. If the patient has pus tubes, a pain persisting in the tubal area after the completion of the sexual act maj, in some cases, indicate a leakage from the tube, with a peritoneal irritation. Pain on entrance of the male organ into the vagina may indicate a bartholinitis, fissures, sometimes growths, or a tight introitus, either of spasmodic (vaginismus) or organic origin. A pain, or rather an aching and discomfort, only present at the time of and at the completion of the sexual act (orgasm) in- dicates an endometritis. Menstruation acts as an exciting cause to pain production in many cases of pelvic disease. When the pain comes on prior to menstruation it indicates an existing inflammation, very fre- quently of the tubes. Frequently, also, it is the best sign of a cirrhotic ovary. Pain during the early stages of the menstrua- tion indicates (generally) a stenosis of the cervix, while if pres- ent during the entire time it indicates an inflammation of the uterus or adnexa. Pain existing prior to and relieved by men- struation indicates a uterine congestion, a very probable cause of which is fibroid tumor. Relation of Pelvic Visceral Pain to Motion and Change of Position of the Patient. — In diseases of the genitalia all vibra- tory motion produces pain, which is especially well marked dur- ing violent movements, such as occur during horseback riding, jumping and running. A form of motion particularly productive of pain is that which occurs in sweeping, and in the lifting or moving of heavy objects. This pain probably depends for its production upon the in- crease of the intraabdominal pressure, due to contraction of the muscles of the abdominal walls. Certain functional acts, such as vomiting, also incite pain. The vomiting causes extremely marked variation in the intraabdominal pressure and visceral re- lationships, and this probably leads to the pain production. Certain ordinary acts of every-day life may also be produQ- GENERAL CONSIDERATIONS 719 tive of pain, for instance, a patient who has a unilateral pelvic inflammation finds it difiicnlt to sit down and cross the limb of the affected side over the other limb in a posture which I have called "lacing-the-shoe position" (q. v.). Pain during this act is due both to the direct pressure of the limb against the tender abdomen, and to the stretching of the psoas and the increase of the intraabdominal pressure. In all cases where inflammation is beginning to spread from the pelvic viscera to the adjacent tissue the patient voluntarily seeks quiet, and, because of the resultant pain, is not easily aroused from her lethargy. Tenderness due to pelvic lesions can be elicited either by ab- dominal or vaginal examination. The abdominal examination is divided into the superficial and the deep. The superficial examination is limited to defining the areas of hyperalgesia. The limits of these areas have been given under the heading. Reflected Pain (q. v.). The value of these diag- nostic phenomena in pelvic disease is that they frequently offer a "leader" as to where to search for the lesion causing ill-defined abdominal pain and discomfort. As no physician or surgeon relies absolutely ujDon one symptom in forming a diagnosis, so the phe- nomenon of hyperalgesia should not be taken as pathognomonic of any one disease, but rather should be used as an aid in confirming or contradicting the conclusions arrived at by other means. Tenderness produced on deep palpation is more reliable and helpful than that produced by superficial palpation. Where ten- derness is being sought for, the relationship of the pelvic viscera to the anterior abdominal wall should be borne in mind. The uterus lies deep in the abdominal cavity, and the tubes likewise are deeply placed. They are in intimate contact with the perito- neum. Any inflammation of these viscera quickly spreads to the surrounding tissue, and, because of the abundant lymphatic sup- ply, the area of involvement is much greater than is apparent. This is the reason that the tenderness is much more extensive in these inflammatory conditions than one would expect from the type of lesion. 720 PAIN IN THE FEMALE GENITALIA ._^ / /o'* A method of eliciting abdominal tenderness in tubal disease is to make pressure with the hand, with a slowly progressive, downward motion, in the iliac fossa, so as to pinch the tube and ovary between the hand and the pelvic wall. As soon as the ovary and the tube are caught the patient makes an outcry, and the lower segTiient of the rectus muscle becomes rigid. This sign cannot always be elicited, for in some cases rigidity of the rectus is so great that it is impossible to press the hand into the pelvic fossa. A method of making use of the ob- servations of Mackenzie, that "the muscular tissues" and of Lennan- der that "the subperitoneal tissues" are tender in visceral disease, is to place the hand palm downward on the upper part of the thigh, and tlien, with the fingers slightly flexed and depressed into the flesh, to draw the hand upward over the abdomen. As soon as the fingers pass above Poupart's ligament, and a drag is made upon the abdominal muscles and peritoneal tissues, the patient complains of pain. These tubal tenderness; u, uterine signs are only confirmative of other tenderness; u', accessory uter- _ ^ i j. 4. i , , ' ' '' svmptoms and are not to be con- ine tenderness. " ^ sidered of pathognomonic value. In this connection, the areas of tenderness, as found by Donald and Lickley (138, p. 434) in pelvic visceral disease, are of interest. They found that, by pinching the skin between the fingers, or by making slight pressure upon it, certain areas or points were more sensitive than others. Each of these areas seems to have a certain definite relationship to a visceral organ. The area connected with the ovary is slightly below the umbilicus, Fig. 169. — Points of Tender- ness AS Elicited by Donald AND Lickley (138) in Ova- rian, Tubal, and Uterine Diseases. ov, ovarian tenderness; ov', ac- cessory ovarian tenderness; T, GENERAL CONSIDERATIONS 721 and about two inelies to one side of the median line. It lies on the intersection of a line joining the umbilicus to the antei'ior superior spine, with a line lying on the outer border of the rectus. At this point the eleventh dorsal nerve pierces the sheath of the rectus and becomes superficial, so that, because of its exposed position, pressure may easily be exerted upon it. There is also found an associated area of tenderness on the lateral wall, at the point where the lateral cutaneous branch of the eleventh nerve becomes subcutaneous. The area associated with tubal disease is found at the intersection of the horizontal line joining the two anterior sjiincs with the outer margin of the rectus sheath. It corresponds to the point of emergence of the twelfth dorsal nerve. The uterine area is located over the inguinal ring.^ At the internal ring the ilioinguinal nerve enters the canal and becomes superficial. Other areas of tenderness associated with the uterus are: (1) immediately below Poupart's ligament, where pressure on the anterior crural is painful; (2) an area extending from the outer margin of the erector spina3 muscle to the gluteal re- gion, following the posterior divisions of the first three lumbar •nerves (this area generally is associated with disease of the body of the uterus) ; (3) in some cases also there is a tender area over the sacrum from the second sacral vertebra to the coc- cyx. This area extends laterally, and in extent corresponds to the posterior primary divisions of the mid-sacral nerves, and may be j^resent in diseases of the cervix uteri. The most responsive of all these areas to disease of their asso- 1 Regarding the cause of tenderness at the internal inguinal ring, two theories are given: (1) the mechanical, and (2) the reflex neurological. In regard to the former, the points apparently in its favor are the dragging nature of the pain, and its location at a point where the broad ligaments are inserted. This would be of considerable value if, in all cases in which the pain is present, a dragging on this section of the abdominal wall were made by the broad liga- ments, or if, in all cases in which dragging is found, pain were present. Many examples of each of these states without pain production at this point can be foi:nd, and their profusion rather negatives the value of this deduction. On the other hand, it has been found that electrolysis of the uterus will produce pain in this same area, without any general disturbance of relationship of the other organs. This would indicate that if, in all cases, the pain is not pro- duced reflcxly, at least in every ease it is capable of being so produced. 722 PAIN IN THE FEMALE GENITALIA ciated organs is the ovarian, while the nterine area is the least responsive. A bimanual vaginal examination should be made on every patient who complains of pelvic pain. Often the tube can be felt through the abdominal wall to be enlarged and tender ; even tender- ness of the ovary can sometimes be elicited. When pressure is made upon either of these, reflected or referred pain will be felt in the cutaneous areas associated with them. During the vaginal examination the fingers in the vagina should push the cervix from side to side. If the adnexa of one side are diseased, pain is complained of in that side. In case of adhesions pain is •produced when the position of the uterus is such that the adhe- sions are put on the stretch. Acute inflammatory conditions are painful either on pressure or on traction. The pain is felt on the side manipulated, and is produced either by pushing or by rotating the uterus toward the opposite side or by pressing it against the diseased tissues. Rotation of the uterus may be ac- complished by using the cervix as a fulcrum to make pressure in the direction opposite to that in which it is desired to have the uterus turn. Pain on drawing the cervix forward and downward may be due to a short, sensitive, uterosacral ligament (I^ovak), inflammation of the parametrium, or recent uterine adhesions. According to Garrigues (163) pain is produced at the side of the second sacral vertebra by pressure on the corresponding utero- sacral ligament. * Diagnosis of Pelvic Diseases. — Of value in the diagnosis of pelvic diseases are: (1) The history of the case, which should always be carefully reviewed. The manner of the onset of the present symptoms and their duration should be defined. It should also be deter- mined if they came on after a suspicious intercourse. Yet the absence of such a history should not be of too great influence in the forming of a diagnosis. For in many cases of pelvic disease, gonorrheal in origin, the patient has innocently acquired the coccus from an impure husband, and does not know of her affec- tion, so that a negative history is but of slight value in forming GENERAL CONSIDERATIONS 723 an opinion. In others puerperal sepsis is the cause of the trouble. What proportion of pelvic lesions come from other causes than the above is rather hard to decide, but the common opinion is that it is very small. The non-specific lesions causing pain are tumor, tuberculosis, etc. (2) After a history of the onset a good description should be obtained of (a) the character of the discharge, and (b) the type and character of the menstrual flow. In specific infection the vaginal discharge generally is thick and creamy, and if the disease has to any extent invaded the uterus is usually of a foul odor. A mixture of blood may indicate (unless it occurs at the men- strual time) an endometritis or extrauterine pregnancy. A slight whitish discharge before or after the menstrual period is of no diagnostic value, as it is a common occurrence in many normal women. The vaginal discharge should always be examined mi- croscopically in order, definitely, if possible, to identify the caus- ative germ. Because it is so common, and occurs in so many ways, it is very difficult to derive any useful information from menstrual disturbance ; but change in its character is of great significance in extrauterine pregnancy, cancer, fibroid, and pelvic inflammation. As predisposing factors to the production of pain in tubo- ovario-uterine disorders may be mentioned anemia, severe or pro- longed illness, depressing mental influences causing a lessened psychic resistance, and starvation. Before passing on to a more special consideration of the pain-phenomena in the special or- gans composing the pelvic viscera, it is well to consider in a nervous, high-strung woman the possibility of the presence of hysteria. In this condition many other criteria and indications of involvement are present — for instance, the eye phenomena and the areas of anesthesia and hyperesthesia present in other parts of the body — and even though a severe pain may be complained of over the region of the ovary (the so-called ovarian neuralgia), it is not associated with such severe local abdominal rigidity as are organic lesions of the ovaries, tubes, or uterus. After this brief survey of the principal causes for pelvic pain 724 PAIN IN THE FEMALE GENITALIA and the areas in which it is found, it is well, before a more de- tailed description is undertaken, to offer as a caution to those who consider only the symptoms and not the patient, Novak's warning. He says : "The gynecologist must learn to look on pain as the resultant of two factors, the lesion and the patient; and in order to arrive at an intelligent appreciation of the true significance of pelvic j^ain he must study both these factors with equal fidelity." UTERINE PAIN As a slight review of what has proceeded, let it be recalled that the uterus is supplied by two sets of nerves, the cerebrospinal and the sympathetic. The cerel)rospinal nerves are derived principally from the second, third, and fourth sacral nerves, and supply the lower segment of the uterus. It is owing to the stretching of these nerves in labor, and pressure upon them by cicatrices and the like, that pain is felt. Above the cervix the muscular tissue is su2:)plied by sympathetic nerves from the hypogastric plexus. The nerves forming this plexus are derived principally from the tenth, eleventh, twelfth dorsal, and first lumbar, the third and fourth sacral, and, at times, the first and second visceral sacral segments. There seems to be some relationshij) between the uterine and the nasal mucosa, for, according to Chrobak, there is "apparently a connection between the two organs, and pains of a genital type can be relieved or stopped by the application of coca in (5 to 10 per cent., a few drops on cotton) to the sej)tum or the lower tur- binate bone." He found that "labor was made less painful, and in one instance even painless." However, this might have been the result of suggestion. Yet it is a fact that smell and the genesic sensibility are connected in a variety of ways. Character of Uterine Pains. — Uterine pain has certain charac- teristics, namely, it is of irregiilar intensity; at times it may bo constant and remain so for some time ; or the constancy may be interrupted by a violent paroxysm, and the pain may then as- sume the type of a colic. In fact, it is this colicky, cramjD-like t?JI> •o II .9 b >> o «3-3 1 a o a o 3o ■3 > "a 3 2 (U "3 ♦^ a > a -u o i £ J^'S m C3 h o 03_^ S'o a J T) £"3 >> a a; C.S a O OS a o 5 < > O "3 a S at o . O 3 a o a 0) IS 0) in « si » ^" 5 - J3 _>> ^■■si J3 §1 ■"I'H 1 a "3^ c S-2 ss§ S a> a £> ga-S ^ 'C & 'Sou 3 V "S o'3 a O M Ph = a Q O « O a-2 ■z ZcS a o'3 i a " o S 2 ■o3g o 3 - I-. 2 o J3 ft o S c: 2 •-■g^ m" ^ & .2~ gg- a. o "o >> o ■2 a' ~.2 •3 =5 ~ o S £ o ^^ o =5 . _. fl — ej 6 > 2 1 >> a OS a S3 a" ID S ^ a 3 S § « >> a S > > a c3 *^ 3 a S IK — a £.2 o S ? 03 a. 03 o t. o >" a "^ 2 a os-;3 a"' §■3 3 1 M 4) ^. ^1 a .1 1 ■i>-a .r: o c, a) a > j3 '■ ■"* S'S 2 — o i OS (O ^ (73 4) X a & 1a J3 o o"? ■** 2 o tH t. M a a g . o c3 ™M -tf o o a l^sl a a a 2 03 Ml U) .ti o ^ ^ •3 s - o > _a P.3 oa 0. 3^ . ■« oo &1 p s t- a o » m ^ (~< X o aj ':i ja" ^ E^ 0) E^ *--X rt a b s Eh o a a • OS % o ^ o 3 S o 3J 0) a. s^ "o > ,a > 23 o C3 "S . II II a'-S o o -a o 3'm g a • a^ fl .0 o3 aj III ills 0<3 3 o. o — : 0) a N O — II 2 3 ft a u a o g ■B O a c3 a c3 a 'Si S >< CO '3 a «■ 3 C3 V S o a Ul a >. o V K PL, O PJ H Q H 725 726 PAIN IN THE FEMALE GENITALIA manifestation which makes uterine pain so characteristic. An- other characteristic is its intensity, for the uterine pain is one of the most intense that the human organism endures. Espe- cially is this true of labor pains. In most cases uterine disorder causes a pain in the back; in fact, a dragging pain in the back is said to be characteristic of uterine disorder. The pains due to disease of the uterus will not at this time be minutely con- sidered. Later the different pains and the factors producing each will be discussed. The disorders of the uterus causing pain are: (1) neuralgia, (2) displacement, (3) functional acts (as menstruation, preg- nancy, and childbirth), (4) inflammation (as endometritis, me- tritis, peri- and parametritis), and (5) new growths. Neuralgia. — JSTeuralgia of the uterus is often (as was said when the term was used in speaking of pains in other organs) but a cloak for ignorance. That neuralgia may occur in the uterus, the same as in other organs, cannot be doubted ; but, even so, the term is generally used by the attending physician to hide his lack of diagnostic skill. A diag^losis of neuralgia should be made only after a negative search for lesions of sufficient gravity to cause the pain. I^^euralgia is frequently a term wrongly used in speak- ing of the pain due to endometritis, etc. Displacement of the Uterus. — Displacement of the uterus, of itself, does not produce anj^ severe pain, though it is frequently the cause of the aching in the back, so common in this disorder. This aching is due to two factors: (a) the drag upon the liga- ments attaching the uterus to the pelvis, and (b) the congestion of the uterus from partial obstruction to the return blood flow in the broad ligaments. The displacement, of itself, produces a direct pain, localized in the tissues deep in the back. Unless con- gestion is excessive the pain, the result of displacement, disappears on replacing the uterus in the normal position. However, if the congestion is excessive the pain does not disappear so readily on the correction of the mechanical defect, because it takes time to eradicate the changes which have taken place in the structure of the uterus following a long-continued congestion, and which have UTERINE PAIN 727 been acting as causative factors of pain production. When con- gestion and structural changes occur, sensory disturbances in Head's zone also apj^ear, and persist until recovery has taken place. In some cases, where the uterosacral ligaments are par- ticularly sensitive, a slight drag or pull upon them by an en- larged uterus, or by the examiner, through traction made on the cervix, will produce a very severe pain. Character of the Displacement Pain. — Displacement produces more of an aching in the back than an actual pain. In some cases, where the displacement is excessive, as in complete pro- lapsus, traction may be made upon some of the nerves arising from the sacral plexus. When this happens pain occurs in the distribution area of these nerves (sacral plexus). In fact, under such circumstances, any of the nerves passing through the pelvis may be interfered with and pain be produced. The pain of dis- placement is made worse on walking, especially should the dis- placement have been transformed into a prolapsus. The pain in retrodisplacement is eased only by lying on the abdomen and is increased by lying on the back, while in prolapsus, ease comes on lying down in any position. On the other hand, all changes of position are painful if adhesions bind the uterus to adjacent struc- tures. Then the pain, instead of being entirely of uterine origin, is modified by that due to disturbances in other closely related organs. Antero-displacement is not as painful as retrodisplace- ment, possibly because the anterior displacement occurs in younger people in whom the pelvic structures have not been in- jured by childbirth, and in whom other associated changes are not so likely to be present. In retrodisplacement defecation is sometimes painful, while in displacements of the anterior type there are often both complaint of pain during defecation and a frequency of urination. In anterior displacements there may also be a sense of pressure or of aching behind the symphysis pubis. Displacements are among the common causes of dysmenor- rhea (Herman, Kelly). In displacement there often is an angu- lation of the cervix, so that, during the menstrual period, the 728 PAIN IN THE FEMALE GENITALIA blood and membranes are not so easily discharged, because of the narrowing of the canal, due to the angulation. As a conse- quence, the menstrual discharge from the uterus is hindered, and uterine colic results. Functional Disorders of the Uterus. — The principal functions of the uterus are menstruation, pregnancy, and childbirth. The first two should be j)ainless; but unfortunately, as a price of our higher civilization, the woman finds that frequently, instead of these being periods of well being and content, they are, because of the frightful pain and distress which she suffers, periods of dread and dismay. MENSTEUATIO^^. — Amoug savages, menstruation is generally without pain, and even among those of higher civilization it is fre- quent to find the menses coming on without distress. Yet, as civ- ilization advances, and our women mount the ladder of indolence and ease, pain and distress gradually become more and more pronounced, until, at the summit, in our latter-day civilization, woman is incapacitated for a greater part of her time by condi- tions which ordinarily should cause but slight, if any, incon- venience. Painful menstruation is termed dysmenorrhea. Holden ana- lyzed the histories of one thousand consecutive cases of abnormal pelvic conditions with reference to the occurrence of this symp- tom. As the result of his observations he presents the following conclusions : "Dysmenorrhea is present in 47 per cent, of all gynecologic hospital patients. In about 23 per cent, of the entire number it seems to be definitely caused by certain abnormal conditions of the pelvic organs. In 22 jier cent, of the entire number it is present in conjunction with such conditions, but is apparently not caused by them. The pathologic conditions which are most frequently seen as the causes of dysmenorrhea are: (1) retrodisplacements of the uterus, (2) pelvic inflammatory disease, and (3) myomata. These three conditions account for nearly 90 per cent, of all the dysmenorrhea which is caused by pathologic conditions of the pelvic organs. Retrodisplacement accounts for 41 per cent., pel- UTERINE PAIN 729 vie inflammatory disease for 37 per cent., and myomata for 11 per cent. Of nulliparons patients with retrodisplacements causing symptoms, 86 per cent, have dysmenorrhea. The frequency of this association leads to the conchision that the abnormal position causes the dysmenorrhea. In retrodisplacements occurring after child- birth it is much less common; 25 per cent, of multiparse with retrodisplacements have dysmenorrhea, which is apparently caused by the malposition. Of all the patients with pelvic inflammatory disease, 31 per cent, have dysmenorrhea, which is apparently caused by the condition. Of all the cases of myoma, 20 per cent. have dysmenorrhea apparently caused by the tumor." During the normal menstruation the uterine muscles undergo a slight contraction, but not of sufficient strength to be felt as such (Winter, Menge). The factors that would cause the normal con- traction to become abnormal, either in regard to the time or the strength of the contractions, are : some hindrance to the expulsion of the menstrual blood (as a contracted os uteri), an inflammatory thickening of the endometrium,^ or a faulty position of the uterus in which it is flexed and the cen-ical canal is angulated. Stenosis of the external os is not as frequent a cause of pain pro- duction as is stenosis of the internal os. Winter says that he has occasionally seen collections of blood behind the external os sufli- cient to cause ballooning of the cervix without causing the least pain. Dysmenorrhea, when due to cervical stenosis or angulation from whatever cause, is generally relieved by pregnancy. If the dysmenorrhea be entirely mechanical, or be due to some struc- tural defect (either a narrowing or contraction of the cervix, or an angulation of the same from a faulty position of the uterus), it is found that the menstrual pain dates from the period of the first menstruation or from the time of some operative interfer- ence. It is very characteristic, in that it begins only a very short time, a few hours, before the blood commences to flow, and con- 1 Theilhaber claims that 25 per cent, of all cases of dysmenorrhea are caused by a stenosis of the een-ix, either congenital or acquired. Theilhaber also claims that in hysteria a contraction of the circular muscular fibers of the cervix may occur, causing a stenosis and consequent pain. 730 PAIN IN THE FEMALE GENITALIA tinucs as long as the blood flow is active, and then ceases as abruptly as it came on. All other forms of dysmenorrhea gener- ally start a day or two previous to the flow, and are the result of the pelvic congestion incident to the flow. If anteflexion is suspected as the cause of the dysmenorrhea, to make the diag- nosis certain it is necessary that there should be present a freely movable, normally developed uterus, in permanent, rigid ante- flexion, in a person Avho is neither nervous nor hysterical (Winter) . In some cases congestion of the endometrium, incidental to the menstrual flow, may block up the cervical passage, and the expul- sion of the uterine contents is difficult. Spasmodic contraction of the cervix is a frequent cause of uterine pain. This spasmodic contraction, according to Herman, is due to the fact that the uterine center in the cord, or in the sympathetic system which regulates the movements of the genital canal, is imperfectly developed. The vagina, uterus, and Fallopian tubes are muscular organs like the intestine. During the sexual orgasm there is coordinated muscular action of these organs, the object being to help the ovum from the tube and the spermatozoa from the vagina into the uterus. In a normal, painless men- struation there is also a coordinated action, the body of the uterus contracting and the cervix dilating, so that the menstrual flow is expelled without pain or difficulty. In this neurotic variety of dysmenorrhea the natural dilatation, because of changes in the cord or sympathetic ganglia located in the cervix, is absent ; and as a consequence the .contractions of the uterine body are mor- bidly violent and painful. The only physical sign observed in these cases of dysmenorrhea is difficulty in dilating the cervix. Another cause of dysmenorrhea is hindrance to the separation of the decidual membrane. Owing to degeneration or disease the endometrium may be difficult to separate entirely. Parts of it, not being entirely free, lie loose in the uterine cavity, and may cause repeated and violent contractions of the uterus. Endome- tritis is one of the most common causes of this condition. Mem- hranous dysmenorrhea gives rise to large, free masses of mem- UTERINE PAIN 73JL branous tissue in the uterine cavitv, and it is the effort of the uterus to expel them which probably causes pain.^ Endometritis dolorosa is the name given to an endometritis in which severe pain is present ; but here again the pain is due to a compression of the uterine nerves, for as soon as a dilatation of the cervix is performed the pain vanishes (Sneguereff). Maldevelopment of the uterus acts as a cause of pain during menstruation. In these cases the uterine cavity is so small that during menstrual congestion the two walls become so swollen that they completely block up the opening and the blood and men- strual debris cannot be discharged. Winter accounts for this form of dysmenorrhea as the result of reflex contractions of the uterine musculature, the reflex in turn being the result of in- creased pressure in the uterine vessels; the increased pressure being due to the facts, that the vessels are too small to allow for the accumulation of the blood, and that the cavity of the uterus is too narrow to permit the necessary degree of swelling of the mucous membrane. Hyperesthesia of the muscles (uterine) and of the uterine mucous membrane may also be present. These may cause con- traction of the uterus during menstruation, when otherwise the menses would have been normal. Such is the case in those indi- viduals of a neurasthenic nature, in whom we so often find a marked dysmenorrhea. Very frequently this variety of dys- menorrhea is also found in those of reduced vitality. It may be that in some of these jDatients the receptive state of the nervcftis system is also in a peculiar irritative condition in which it responds to lighter stimuli than ordinarily would af- fect it. In cases of this character the pain is not relieved on lying down, as it is when the dysmenorrhea is of congestive origin. It generally begins with the flow and is of very short duration. The 1 Painful areas, present in one case, were (Sneguereff) the tuberosity pubis on each side, the inner surface of the thighs, the renal plexus on both sides, the solar plexus, the rectum ( ?) and the anterior superior spine. Perineal areas were the emerging point (1) of the ilioinguinal, (2) of the sup. int. cutan., and (3) of the pudic. w Pi o >H Q fa o t-H H fa fa CO s n P H A history of tubercular in- fection; other structures may be involved, though in many cases a history of tuberculosis in any form ia absent. 1 .2 -1.3 a 1 b" o S 6 « o 2 7- >, 03 U oj Presence of tubercle bacilli (?) in the discharge or in the uterine scrapings. The dis- charge may be cheesy in v character. 3 g c 'a 2 o >> Si > Generally absent, until the metrium and perimetrium are involved; then local- ized and referred pain is present. "^i^.S ^ g a; rn ^ «J U CO _o -Ho ^+5 3 " O^ liuil e " 3 « S3 O c 8 O s s o o 1 • Qi m 01 o c3 3 -^ t*! +3 3 ^ £; .s ^ ^ ii3c3° «bC^>. 3 (U Si fa «*- CO )— 1 ^ 1 -u 3 3 +j .2, aj'5* 3 c3 ^ (0 fe . .sag rt S fa > a W M « o • Z o O • S ^ (D (-* 33. S <« -a 6 3 o 83 3 o bC _S "C 3 ^3 -1.3 3 S . ^■^ 3 3 "^-^ .^ ° en , S fe g C3 S^ > bC<; c3 o 3 O) ai a >; a CO c3 aS 38 "^.^ (JJ-- III a5 to c" 9 -t-i,^ 3 a; CO ~ 3 lib •S rt 3 S -3 =3-3.t5'3 300 bC^ fa HH -kJ c3 CD 1 ^*-i 1 3 o aj o o fl Qj &-r3 Vh, OC fl jy (H ^•^•^^-^ 1-2 -is -3 > fa O 3 o 3 5 3 rt C 02 . i^ « S 0= l3bC|3 3 oj 3i2 g CO ■ d ■3 w >> 33 .2 g 00 w -0.^-2 a; b 0^ S £ « bc 3 citJ-- c ^ ^ a ^ I g^.2 .Sj3 3 fl +2 -|j -kJ '-^ § .« 3 ^ g s CD .1 1 bi) 3 3 1 aj s -a 1 ^ ^ ^ •i fa 732 < Q O H Q History of present preg- nancy. History of an endometritis present be- ,fore pregnancy began. Occurs in the early course of pregnancy and per- sists for three or four months. .a S a a o m C 3 |S a 03 i 02 >> 3t3 p O 03^5 3 03 03 Symptoms generally dis- appear in the latter half of pregnancy. Resembles labor pain. Abortion or miscarriage sometimes occurs. CO §1 .a 1 Is CQ O 3 O a a o 03 g a. 03 3 03 03 6 1 O o >> 03 > -1^ O 03 ^ • 3 bC 03 3 .a1 a§ *^ 00 ° 3 ^ o OQ to n S s o Ig i o3 o .2 '3 o a 03 03 -(.3 o . 3 6 03 ^ "3 3 S 1. ^§ 03 t3 1 a -1.3 o Membranous shreds, or even casts of the uterus; are thrown off during the last stage of the menstrual discharge. 3 o m •a o 6 Very severe, being espe- cially marked at the end of the menstrual period, at the time of the separation of the membranes. Neurotic Dysmenohuhea The pain may date from the first menstruation or it may come on after years of pain- less menses. After it once commences it is seldom re- lieved except by operative means or by pregnancy. Generally sudden. May follow after years of normal periods. -i a o a 3 ^-^ °^ ^^ e3 -3 ^ 3 w aj 03 P J2 03 3 o 1 3 03 a '3 03 rt r^ ;i.2 Occurs generally at the time of the menses, and is most severe. It also may occur at intermediate periods. DQ a o 03 -8 O 1 t3 a3 03 Q o a ■3 733 734 PAIN IN THE FEMALE GENITALIA individual spasm lasts about one minute and recurs with about the frequency of labor pains. This type often arises after years of painless menstruation. Polypoid growths inside the uterus may, by hanging down, obstruct the cervix, and thus, by a ball-valve action, be a cause of pain. Ovarian dysmenorrhea is a term used to define the pain pro- duced in the ovary from the congestion incidental to menstrua- tion. It occurs before the flow commences and ceases as soon as it becomes profuse. Possibly a fissured state of endometrium at the internal os may also excite such a spasm of the uterine musculature as is produced in the sphincter in anal fissure. A spasm of this type is increased by congestion of the tissues. It is given as a cause of pain by Keating and Coe. Winter, after a careful review of the subject, gives the fol- lowing very clear conclusions in regard to menstrual pain, namely, that it is necessary, in order that the natural process may run a painless course, that "nothing interfere with maturation and rup- ture of the follicles ; that the congestion in the uterine wall does not meet with resistance from infiltration of the tissues ; that the mucosa be capable of swelling and of taking up the extravasated blood ; that the size of the uterine cavity be sufficient to accommo- date the swollen mucous membrane; that the menstrual blood escape readily from the cervix, and that the congestion of the tubes and of the peritoneum take place in normal tissues. In addi- tion the nervous system must joossess a normal degree of irritabil- ity and the psychic function must be normal ; othierwise the slight alterations which take place in the nervous system during normal menstruation may be abnormally exaggerated" (Winter, Clark's translation) . Referred hyperalgesia in the uterine segments is very com- mon in all these conditions which produce uterine pain. Pain in the breasts is also a frequent accompaniment of menstruation. It generally precedes the menstrual discharge by a few days. Be- cause of this breast pain, breathing may be painful. UTERINE PAIN 735 In resume, it may be stated that menstrual pain may occur before, during, or after menstruation. When it occurs (1) be- fore menstruation, it is due to hindrance to the discharge of blood from the uterus because of (a) narrowing of the lumen of the cervix, the result of a stenosis which has taken place from a chronic inflammation of the endometrium, or from an angulation of the cervix from a flexion of the uterine body on the neck ; (b) blocking of the lumen of the cervix by a blood clot or by a piece of endometrium ; (c) obstruction to the menstrual discharge by a foreign body (as tumor) ; and (d) chronic inflammation of the ovary, which has caused a thickening of the tunica albuginea, so that the Graafian follicle, because of the thickness and tough- ness of this layer, has great difficulty in penetrating to the sur- face ; congestion results, and this stretches the peritoneal coat and causes pain; (2) during menstruation, it is generally due to chronic endometritis; and (3) after menstruation, it is due, as a rule, to inflammation of the adnexa. Intermenstrual pain is the name given to a pain which generally comes on about the middle of the mid-menstrual period. It usually lasts for two to four days, though it may persist till the next menstruation. Several theories have been advanced as to its causation. Among the most reasonable are : (1) That it is due to the retardation of the outward passage of the Graafian follicle toward the periphery, by some change in the ovarian stroma; the resultant congestion and tension pro- ducing pain. (2) That in cases of ovarian adhesions the pain is due to the traction made on these adhesions by recession of the ovary after each menstrual period. This recession necessarily reaches its climax about the middle of the intermenstrual period (Reed). (3) Circulatory changes in the ovary, causing ovarian conges- tion, may also produce intermenstrual pain (Sheill). The pain resulting from these factors may vary from a dull ache to one of great intensity. It is generally reflected to the ovarian region, on one or both sides, or it may be felt alternately on either side. "It comes on about the twelfth to the fourteenth 736 PAIN IN THE FEMALE GENITALIA day after cessation of the menses. It lasts for a day or two, is often accompanied by a discharge of clear fluid, and is followed by a period of rest or complete cessation of pain np to the onset of the next period" (Addison). Change of position does not influence the intensity or character of the pain. On examination, in many cases, no lesion can be found. i?rL &? 00 3«o SACRAL Y Fig. 170. — Areas of Hyperalgesia in a Woman Two Months Pregnant. They represent the 10th and 11th dorsal zones of Head. The maximum point of tenderness is in the 10th dorsal. The zones did not e:itend uninterruptedly around to back. Tenderness and hyperalgesia were present over the corresponding spines. These areas of hyperalgesia very likely are due to traction exerted on the ovary and tube of the left side by adhesions. Pregnancy. — In a normal woman pregnancy is entirely free of pain ; yet, it is common for the physician to be troubled by the complaints of his patients who are with child. The causes of pain during the gi-avid state are : (1) Pressure upon adjacent and associated organs, as the tubes, or ovaries; (2) traction on adjoining structures by adhe- sions; (3) the weight of the organ itself, which, even though nor- mal, may drag upon neighboring structures and produce discom- fort and distress; (4) in some cases, the projection of a fetal part UTERINE PAIN 737 into the uterine wall; (5) intestinal coils may drop beneath the uterus, causing a partial strangulation; (6) should the ovary be cirrhotic, the corpus luteum, when it begins to anlarge, is com- pressed by the nondistensible .connective tissue, and dull, aching pain in the ovarian zone results; (7) partial obstruction to the bowels may occur during pregnancy, owing to some of the intes- tinal coils being caught between the uterus and the surrounding parts; (8) obstruction to one or both ureters may occur from pressure by the uterus, and thus hydronephrosis, with its conse- quent pain, may result. The case given below illustrates the production of pain due to a partial obstruction of the bowels. It might, also, be taken as an example of pains produced by ovarian and uterine conges- tion, the pains early in pregnancy being due to the congestion, the colicky attacks, later in the pregnancy, being the result of intes- tinal colic. The early j)ains of which the patient complained began about the second week of pregnancy and continued inter- mittently. They were colicky in type and were located in the lower abdomen. The individual attack was produced by the patient's moving, especially by her turning on the right side. During the attack she was doubled up, with the knees flexed, and the abdo- men was tense and rigid. The hands were clinched and were pressed tightly into the suprapubic region. The face was drawn and the eyes closed. The individual attacks lasted about three minutes. These colics appeared at irregular intervals, ranging from a few days to one week; sometimes they appeared more frequently, several in a day. After being present for six weeks, they disap- peared and the patient then had neither pain nor colic. A vaginal examination disclosed a retroflected, enlarged uterus, about two months pregnant. The attacks ceased when the uterus rose above the pelvic brim. It is just possible that in this patient a part of the intestine had been caught under the displaced uterus, and that its lumen was constricted, the severe colic of which, at times, the patient 738 PAIN IN THE FEMALE GENITALIA complained being due to the effort of the intestine to force its contents beyond the constricted portion. Childbirth. — Like menstruation, childbirth naturally should be a painless j^rocess. It is only as culture advances Fig. 171. — Phenomena Accompanying Tubal Disorders. The uterus was at this time above the pelvic brim and the ovary was free of its compression, yet the tube in the meantime evidently has become injured and caused the above phenomena. Hyperalgesia was absent. A few weeks after the above phenomena was defined, all pain and dis- comfort ceased, and the patient had a normal delivery. A — Area of local tenderness, also area of pain to deep pressure. Superficial pressure is not painful, neither is muscular pressure. B — Area of maximum tenderness to deep pressure. C — Area of pain to deep pressure. D — ^Area of maximum tenderness. that the labor becomes painful, for in women of primitive races pain is absent. Savages of a low degree of civilization are gen- erally but little troubled by parturiency. The reason is that, although among primitive people the contractions of the uterus are as severe during childbirth as they are among civilized races, yet, because of the easy dilatation of the cervix,^ they do not 1 Why this should be is as yet unexplained. UTERINE PAIN 739 suffer pain. Among observers it is generally agreed that pain of uterine contraction is not due to the contraction of the muscle itself, but is the result of the restraint of this functional activity by cervical obstruction. This cervical obstruction is not so promi- nent among primitive people ; therefore they have less pain. When dilatation of the cervical segment occurs easily, pain is absent. At the present time, though rare, pain may be entirely absent during labor. Allen explains this absence of pain as being due to the relaxation of the parts by nature, while Young claims that sometimes at the acme of labor there is a physiological anes- thesia. A peculiarity that has been noted of the pains occurring during labor is that, instead of being in the normal locations, they may, as in a case seon by the author, be radiated from the thigh to the knee. In this case the pains were excruciating and occurred synchronously with the uterine contraction, as Avas verified by ab- dominal palpation. In this respect the words of Granville, whose remarks hold true to-day, may be quoted. He says: "Sensations of pain experienced by the parturient woman are not invariably synchronous with what, for want of a better name, we term the pains of labor; and from this and other premises, for example, the circumstance that they are commonly referred to regions more or less remote from the contracting uterus, or the dilating external passages, in which the real seat of pain might have been supposed to be located, I deducted that the pain attend- ant on labor is neuralgic in character." Labor pains, when present, are as a rule first felt as a drag- ging or aching in the back, low down in the lower lumbar region. In some there is present a sensation as though the back were breaking. At this time (the first stage of labor) the pain corre- sponds to the early stages of cervical dilatation. Later, when the uterus commences to contract and the cervix begins actively to dilate, pain is felt over the sacrum and coccyx in the second, third, and fourth sacral areas, and sometimes in the first and second sacral areas (Head). When the cervix has dilated, and the contractions are forcing the head through the pelvis, the re- 740 PAIN IN THE FEMALE GENITALIA ferred pains are felt in the tenth, eleventh, and twelfth dorsal and first lumbar areas. These are the areas in which pain is felt post partum, when the uterus is forcing out of its cavitj the residual clots. After labor and during the puerperium, if subinvolution A— -/- Fig. 172. — Areas of Referred Pain in a Case of Labor. (Head.) a — Dilatation in the second stage of labor. The pain is in the 11th dorsal segment and is due to contraction of the uterus. B — Hyperalgesia is present in the 10th, 11th, 12th dorsal, 1st lumbar and 3d sacral, posteriorly present after the effort of the uterus to expel post-partum clots. should occur, a feeling of weight and of dragging is felt in the pelvis. Inflammation of the Uterus. — Inflammation may occur in the lining structure (endometrium, endometritis), the contracting por« tion (metrium, metritis), and the inclosing structures (perito- neum, broad ligaments, peri- and parametritis). UTERINE PAIN 741 Endometritis. — ^A pronounced inflammation of the endo- metrium can hardly take place without involving the next adjacent structure (metrium), so that the pain due to a severe endometritis partakes more or less of the character of the pain due to a metritis, and if the inflammation is severe and involves the peritoneum, the pain has also the characteristics of that due to peritonitis. Ordinarily, the endometrium has no pain nor touch sensation, but when inflamed it becomes very sensitive. This is of great diag- nostic value, and tenderness (endometrial) should be searched for in endometric inflammatory states. This tenderness may be dem- onstrated by means of a sound (Winter). The sound must not be too large, and should be carefully in- troduced through a previously dilated cervix, and search should be made for the sensitive spots. When the sound touches such a spot the pain may be so severe that the woman "cries out, shrinks from the sound, or faints." Should pain be severe only on the introduction of the sound, and on moving it with sufficient force to disturb the relations of the uterus to the surrounding tissues, and not present on gentle manipulation, peri- or parametritic inflammation should be diagnosed. That the endometrium has pain sensation in a normal case can hardly be admitted (Roth- rock), though in the presence of inflammation, the adjacent layer may be so involved by the inflammatory process that it becomes irritable and responds to any irritation with a sensation of pain. It is noticeable that the pain sensation in endometritis of ordi- nary severity is never localized to the area of its production, but is always referred; but should the inflammation be severe, and perimetritis result, and the peritoneum become involved, espe- cially if the inflammation occurs near the cervix in the area sup- plied by the spinal nerves the pain is localized to the area of its production. Endometritis also causes pain, having somewhat the charac- teristics of labor pain; this pain is caused by the same factors that produce labor pains, namely, the contraction of the uterine muscle, excessive in the endeavor to force foreig-n material from the cavity of the uterus. The pain is most severe at the time of 742 PAIN IN THE FEMALE GENITALIA the menses, though it does not necessarily appear at this time, but may come on at any time that the secretions collect to such an extent that, in the presence of a stenosed cervix, their expul- sion requires forcible uterine contractions which are very painful. The pain of endometritis is worse on standing than on lying down. Tenderness on palpation is not present unless the metrium and the surrounding tissues are involved. When this occurs, abdominal and bimanual palpation are very painful. If peritoni- tis has set in, pressure in the pouch of Douglas produces severe pain. Likewise, rectal palpation is very painful. Later, as a result of these inflammatory states, adhesions form and pain results from their drag and pull. The areas of reference of these pains have been described. Cervicitis. — Erosions of the cervix cause pain either through the sympathetic or the cerebrospinal systems. When the sympa- thetic is involved, the pain is referred to the area of distribution of the second or third sacral segments, but when the cerebrospinal is involved the pain is referred generally through the branches of the pudic to the perineum, or to the bladder. When the lat- ter reference occurs, there is painful and frequent urination. The involvement of adjacent nerves is probably the result of a lymphangitis which has spread from the erosions into the peri- uterine fascia. Diagnosis of Endometritis. — The following, which are gen- erally present, may aid in the diagnosis of endometritis : (1) Hemorrhage; eliminate carcinoma, myomata, and tubal inflammations, all internal disorders producing it, or local circu- latory derangements, such as extrauterine pregTiancy, obstruction to the return flow by tumors, etc., and it is safe to say, in the ab- sence of menstruation, that it is due to endometritis. (2) The pain of endometritis is somewhat characteristic in that it is much worse at the time of menstruation. (3) Discharge of inflammatory products and endometrial shreds from the uterus. The variety of endometritis is decided by the history, the onset, the discharge, and the course. Ulceration of the cervix, unless it is deep and has produced a UTERINE PAIN 743 pelvic lymphangitis, causes no local pain, but a reflected pain is felt in the region over the sacrum and the coccyx and is fre- quently localized to a spot immediately dorsal to the anus. This spot is also very tender to the touch. Metritis. — In inflammation of the muscular layer of the uterus pain may be due to the contraction of the uterine muscles, or to the irritation of the nerve terminals by the toxic products of the inflammatory process. It may also be due to the pressure exerted upon the terminal nerve filaments by the inflammatory products. These pains are referred to the zone areas associated with the uterus (see Fig. 168). Another cause of pain production is the spread of the inflammation to the peritoneum with involve- ment of the parietal layer. These causes are active only in the acute cases, for as a rule chronic metritis is without pain (Theil- haber). New Growths of the Uterus. — New growths are either benign or malignant. Benign growths are not painful unless they block the cervical canal ; when, during contraction of the musculature, pain of the type of a labor pain is felt. This pain persists in rhyth- mical periods until the mass has been expelled or until the canal has become free. The pain, naturally, would be greater at the time of the menstrual periods. Growths may also press upon ad- jacent structures and interfere with their function and so cause pain. They may also press upon the lumbar and sacral nerves and cause pain which is referred to the peripheral distribution of these nerves in the back and legs (Donald and Lickley). Pain due to pressure from growths, as a rule, is constant. Malignant growths toward the end are always painful, but early in their course are usually free from pain. Pain occurs only when the growth makes pressure upon the surrounding struc- tures, or interferes with the emptying of the uterus, or when the tumor cells invade the nerve trunks. Kundrat has shown, in the case of carcinoma, that the nerve trunks become infiltrated with cancer cells. In other cases pain may be due to the absorption of toxins or to the extension of the inflammatory growths (Roth- rock). In all these conditions, when the growth is in the fundus 744 PAIN IN THE FEMALE GENITALIA or deep in the cervix, referred pain in the skin area, associated with the particular part of the genitalia involved, is present. Should the cervical canal become obstructed, typical uterine colic pain appears. Pain seems, when present, to be more often felt on the left side (Champney). Fibroids of the uterus are fairly common. They announce their presence by two varieties of pain : ( 1 ) a periodic pain which appears before each menstrual period and is relieved by menstrua- tion, and (2) an intermittent pain, which, in the case of intra- uterine fibroids, accompanies the menstrual flow. It may also ap- . pear at other times. Some fibroids have also been known to extend into the pelvis, and, by pressing on the lumbar and sacral plexis, to give rise to pain in the distribution areas of the involved nerves. The great sciatic is most frequently affected, and pain in its dis- tribution area is common (Wilson, 361). In cancer of the uterus, out of sixty-seven cases pain was the first symptom to appear in twelve (Craig) ; leucorrhea, in forty- five, and hemorrhage, in twenty-two. FALLOPIAN TUBES Pain due to disease of the Fallopian tubes may result from (a) distention of the tubes; (b) inflammation of the tubes; (c) adhesion of the tubes to neighboring structures. Tubal Conditions Causing Pain. — All who practise medicine, and particularly surgeons, are familiar with hydrosalpinx, a con- dition in which the Fallopian tubes contain a considerable amount of clear serum. In these cases the uterine and the fimbriated extremities of the tubes are blocked, so that it is impossible for the fluid to be discharged. Pain may follow this stagnation, though the swelling in many cases reaches a considerable size before its presence becomes intolerable ; in fact, it may never cause pain. Yet, because of the pressure exerted upon adjacent structures, or because of the active inflammation which is pres- ent, pain is frequently a prominent symptom. If the pain l>e due to dragging or to pressure on adjacent structures, it may be FALLOPIAN TUBES 745 eased by the patient's assuming a counter-posture. If it be due to inflammation, the increase in j3ulse rate and elevation of tem- perature will help to define the lesion. When the tube is inflamed, the resulting pain is either reflected (Head zone, see figaire) or is localized to the area in which it is produced. In the latter in- stance the pain is felt in the lower iliac region, and is due to the inflammation, communicated to the parietal peritoneum from the diseased tube. It is of a burning, stabbing character, and may be very severe. If the pain is the result of an acute hyperemia, it is of a throb- bing character, while that due to chronic inflammation is of a dull, aching type. All inflamed sensitive tissues are tender to pressure ; therefore, pressure on the tubes will also be painful. This pres- sure on the tubes may be exerted by two methods. The first is the bimanual, by which pressure is made between one hand placed over the abdomen and the index or the first two fingers of the second hand inserted into the vagina. With the fingers in the vagina, the uterus can be rocked to either side. If on this mo- tion pain is produced it may be surmised that inflammation is present. When the uterus is thrown to the side away from the inflamed tube, pain is the result of the traction and stretching which ensue, while if it is thrown against the inflamed tube, pain results from the pressure. The pressure of the uterus against the inflamed tube is much more painful than is the trac- tion away from it. Should chronic salpingitis be present, pain may be produced by grasping the tube between the examining fingers, thus making pressure directly upon it. Sometimes, in pyosalpinx, if the ex- amination has been rough, some of the pus may be pressed out of the end of the tube, and a localized peritonitis results. This is indicated at the time by a severe pain, persisting after the examination. It may be accompanied by an elevation of tem- perature and a rise in the pulse rate. Spontaneous rupture of a tube through its fimbriated extremity is very rare. In tubal inflammation all functional acts which in any way cause a changed relationship between the tubes and the surround- 746 PAIN IN THE FEMALE GENITALIA ing functioning structures are very painful. In many, micturi- tion and defecation are productive of much pain ; indeed, they may become so painful that the patients voluntarily inhibit them- selves from performing the acts. Constipation and retention of urine necessarily result. Micturition is not so painful when the inflammation is confined to the tube, but becomes extremely so when the bladder itself is involved in the inflammatory process. These disturbances produce, in addition to those already present, their own particular form of pain. Sometimes tubal inflammation causes uterine colic (Winter and Clark). In such cases exacerbations of pain, occurring gen- erally prior to the periods, are frequent. Should pain be present in the ovarian, tubal, and uterine areas at the same time, it in- dicates an involvement of all these associated structures. In a case of gonorrheal salpingitis, Saenger (362) thought the pain was due to the excitation of peristalsis by the inflammation present. As a result of tubal inflammation, adhesions are formed and resist subsequent distentions of the tube, and are accountable for a large share of the resulting pain, particularly so if the disten- tion is accompanied by certain functional acts that in the ordinary course of events would be painless. However, tubal swelling, alone, without the presence of adhesions, may be painful. How large it may become before it is painful depends particularly upon the local conditions. A tube in a free and clear pelvis may reach a much greater size without discomfort than if it were in a pelvis filled with pelvic exudate and bound with adhesions. In some the tube may reach the size of an orange without causing great discomfort, while in others a very small swelling will produce the utmost distress. Extrauterine Pregnancy. — Extrauterine pregnancy (tubal or tuboovarian) may cause no pain unless a rupture or a partial rup- ture occurs, and bleeding into the peritoneal cavity takes place. This complication may follow a vaginal examination, or it may be the result of sudden motion or of forcible bending or flexion of the body. It is indicated by severe and agonizing pain, generally in ■ DIFFERENTIAL DIAGNOSIS OF EXTRAUTERINE PREGNANCY EXTRAUTERINR Salpingitis Appendicitis Peritonitis, Perforative Abortion Pain. Comes on generally after exer- tion, and is sudden in onset. The pain is most intense and is local- ized in the lower abdomen. In some cases a pain is also felt in the shoulder of the same side. Pain may be gradual in onset, though in some cases it is very acute. Begins in the lower part of abdomen. In acute cases the pain is sudden in onset and is local- ' ized in the tubal areas. In general- ized peritonitis pain is absent. Generally sudden in onset. At first is in the midline. Later it passes over to the right iliac fossa. Sudden in onset. Continu- ous. Referred to lower ab- domen. Pf.',^..r^embles that of childbirth. Comes on at mtervals, and is associated with uterine hemorrhage. Vomiting. Frequent and synclironous with the pain. Vomiting is a late symptom. Vomiting is an early symptom. Vomiting is an early symp- tom. No vomiting as a rule. Pulse. At first, because of shock, may not be gi-eatly increased in rapid- ity. After the primary shock, the rapidity is not very great until the amount of blood lost becomes Generallv rapid in acute lesions. In chronic lesions generally no change. Generally very rapid in acute Generally very rapid. Typ- ically small and thready. Pulse may be slightly in- crea.sed. In some cases, owing to fright and exces- sive loss of blood, it may be very rapid. Tumor. Very sensitive and tender and lies to one side of the uterus. Is con- stantly increasing in size. After rupture, when a hematocele has formed, the tumor mass of the uterus rapidly increases in eize, and is soft and boggy. Painful swelhng to one side of the uterus. Generally the uterus is fixed and is not freely movable. Tumor is often bilateral. Tumor in acute appendicitis can rarely be defined because of the excessive tenderness and rigidity of the abdominal muscles. Per- cussion sometimes elicits tender- ness when palpation fails to do so. If an abscess has formed, it can be felt by vaginal examination. Tumor absent. Tumor mass is absent. History. Of pregnancy, with enlargement of the uterus which is not in propor- tion to the stage of the pregnancy. History of recent childbirth or of a vaginal infection. Often no accountable cause is present. History of a previous attack may be present. History of appendiceal in- flammation. Intestinal in- flammation; typhoid, tu- bercular. History of pregnancy. Temperature. No clevatiun. GcruTally normal. Rise of temperature. Generally sudden, progressive rise. At first, as a rule, is not so high. Shock with a low temperature may at first be present. Normal. Uterus. Enlarged. Not enlarged. Not enlarged. Not enlarged. Enlarged. Blood. Hemoglobin low and decreasing. Red and white cells both reduced. Hemoglobin high; whites in- creased ; reds normal. Leukocytosis. Hemoglobin and red cells normal. Leukocytosis. Hemoglobin and red' cells normal. In cases of great loss of blood hemoglobin, reds and whites may be all decreased. In other cases no marked change. Abdomen. Fluid, if the hemorrhage has been very great, may be elicited on pal- pation and percussion. Puncture of the posterior vaginal vault with an aspirating needle frequently will at once reveal condition. A mass is present in pelvis. Rigid- ity of abdominal muscles may be present. No change in intestinal peristalsis. No ,fluid, but a mass connected with the uterus may be felt in the pelvis. Rigidity of the lowest se^ent of the rectus. No change in intestinal peristalsis. No fluid present. Mass in right iliac region may be felt when abscess has formed. No change in peristalsis. LocaUzed rigidity over lower segment of rectus. Free fluid may or may not be present. Mass absent. Peristalsis diminished. Fluid absent. Mass (en- larged uterus) can often be demonstrated. No abdom- inal rigidity. Peristalsis normal. OVARY 747 the iliac region of the side involved, though it may be spread over the entire lower abdomen. In same cases the pain is re- ferred to the shoulder. In these cases it is possible that the blood may extend as high as the diaphragm and so irritate it; this irritation, in turn, is transmitted through the phrenic to the supraacromial nerve, and so causes pain to be referred to the shoulder. It is rather surprising to note the small quantity of blood which ■produces such a severe sensory reaction. In many cases the pres- ence of an ounce or two of free blood in the peritoneal cavity will cause the most severe distress. The pain probably represents the prostration of the perito- neum to the traumatism of the hemorrhage. In hemorrhage pro- duced by the slipping of a ligature from the stump, following an ovariotomy, no pain is present, probably for the reason that the peritoneum, having already been subject to the shock and trauma- tism of an abdominal operation, is not capable of again responding when the hemorrhage occurs (Richardson). Ruptured tubal pregnancy may be confused with (Crossen) : (1) hemorrhage from the ovary, (2) tuboovarian hemorrhage, (3) fulminating pelvic edema, (-i) gonorrheal salpingitis, (5) miscar- riage, occurring in a patient who has an ovarian tumor, (6) preg- nancy with hydatidiform mole, (7) rupture of a pus tube, (8) ap- pendicitis, (9) strangulation of internal hernia, and (10) perfora- tive peritonitis. In extrauterine pregnancy intense, lancinating pain in the lower part of the rectum is at times complained of. The cause of this pain may be adhesion between the gestation sac and the rectum (Boldt). OVARY "No pain is caused during pelvic examination by taking a nor- mal ovary between the fingers and thus making pressure upon it, but a peculiar sickening sensation is experienced, somewhat of the same character as is felt by the male when his testicle is s(jueezed, 748 PAIN IN THE FEMALE GENITALIA Local Point of Pain. — Head gives the area of cutaneous hyper- algesia for ovarian disorders as that of the tenth dorsal segment (see Fig. 173) and he mentions two points of maximum tender- ness, one in the small of the hack over one or more lumbar verte- brae, and the other at a point a little below and external to the um- bilicus on the same side as the ovary which is at fault. It seems very odd that Morris should have called attention to this point during the past few years, as a sign of oophoritis or of disease of the appendages. He claims that in disease of the ovaries or ap- pendages there is a spot tender to pressure, about one and one- half inches down from the umbilicus and one inch external to the midline of the abdomen. In appendicitis there is pain on pressure at this point, but it is present only on the right side, while in ovarian or tubal disease the pain is present on both sides. Pain from the ovary has also been known to be reflected to distant points. In one case it was present in the shoulder, and ran do^vn the left arm. Causes of Pain. — The causes of ovarian pain are: (1) pressure from an increased cell production, (2) structural changes in the nerves supplying the ovary, (3) functional changes in the nerves by which their sensibility is greatly increased (McEvitt).^ Characteristics of Ovarian Pain. — Cuthbert Lockyear (307, p. 1061) gives the following characteristics of ovarian pain: (1) It is referred. (2) It is associated with superficial or surface tenderness. 1 Herman (144) says that the point that is commonly pressed upon in eliciting ovarian tenderness is about two inches internal to the anterior su- perior spine. That pressure over this area makes pressure on the ovary is very doubtful, for the relationship between the abdominal wall and the ovary is con- stantly changing by every variation of intraabdominal pressure, and by every change of position of the intraabdominal organs, so that, because of this mobility, it would be impossible to compress the ovary even by pressure on the abdominal wall, applied directly over the ovary. The only effect would be to cause a slight change in its position. Such an area of tenderness is also found in hysterical men. From such data we may conclude that the pain is not due directly to the ovary, but to related conditions such as irritation of the peritoneum from inflammation spreading from other organs, or from stretching due to traction made upon the peritoneum by ligaments and adhesions joining it to abdominal organs. OVARY 749 (3) It tends to become generalized or diffused. (4) It follows the lines of spinal segmentation and not of peripheral nerves. (5) It is associated with exaggerated superficial reflexes. (6) It is closely connected with the neurasthenic state. Ovarian disorders mav cause pain in distant regions, such as headache, which is frequent. It is most common in the frontal region and is worse at the menstrual period. The diseases of the ovarj^ causing pain are : neuralgia, dis- placement, inflammation, abscess, and new growths. Neuralgia of the ovary is possible, but generally, when ovarian pain is present, it is due to structural changes in the ovary, such as occur in congestion and inflammation. Displacement of the ovary, or prolapsus, generally produces pain which is felt in the ovarian reference areas. When displace- ment occurs, vaginal examination will show the ovary to be in a false position. If adhesions between the ovary and adjacent or- gans have formed, the traction upon the adhering organ will cause pain, which, as a rule, is referred to the pain area of the organ adhering. Hernia of the ovary is generally associated with hernia of other organs, and is not especially painful. The presence of an ovary in a hernial sac may be surmised from the peculiar sickening sensation which is produced when pressure is made upon the sac. Hyperemia of the Ovary. — Immediately preceding menstrua- tion, all of the female genital organs are engorged with blood; if they are normal, this engorgement produces no disturbance, ex- cept a slight physical discomfort ; but, should a hypertrophy or a hyperplasia of the connective tissue have taken place, pain results. This pain is present for one or two days preceding menstruation. It is due to the constriction and pressure upon the terminal nerve filaments of the ovarian stroma exerted by the congested tissues. After the blood flow is well established, the pain quickly disap- pears. The congestion may be so intense that hemorrhage into the ovarian stroma occurs. This is productive of very intense and throbbing pain in the region of the ovary or in the area to 750 PAIN IN THE FEMALE GENITALIA which ovarian pain is referred. It is characteristic of this dis- order that it progressively becomes worse, and removal of the ovary is the only hope of relief. In addition to the passive form of hyperemia, pain also may be due to the active variety. One of these forms of hyperemia is due to bacterial invasion. Here an active inflammation has taken place, and the pain which, in passive congestion, was present only preceding menstruation is now more or less continuous, and is markedly increased during the menses. As may happen during any intraperitoneal visceral disease, the inflammation may spread beyond the organ of its origin and infect the adjacent organs, especially the peritoneum. Such a spreading may also occur in the ovarian inflammation. The referred ovarian pain, as well as the mild local tenderness, is now much increased by the symp- toms of the peritonitis arising around the ovary. The most prominent of these symptoms is excessive tenderness in the lower iliac region. The patient, who previously may not have been compelled to take to her bed, now gradually avails herself of such an opportunity. She is inclined to lie flat on her back and to draw up the limb on the affected side; or, if both sides are affected, to draw up both limbs. At the same time the lower segment of the rectus muscle on the diseased side becomes quite rigid. Should the inflammation spread further, all her symp- toms are aggi'avated. She now lies slightly inclined to the side involved, with the limbs drawn up. Breathing is restricted and becomes entirely costal. All motion is abolished and the patient is content to stay in bed, quiet and inactive. Such states are the forerunners of an invalidism that may become chronic, and per- sist, even after the original cause has been removed. When the acute attack subsides, and the lesion assumes a chronic form, the woman, although she can go about and do her work to a moderate degree, is subject to sudden recurring attacks of inflammation; perhaps in the midst of festivities, or at the time of greatest need, she is compelled to take to her bed until the acute attack again subsides. In any case, she is a poor unfortunate creature, whose life, unless she is relieved by surgical measures, becomes OVARY 751 an endless series of periods of ease, alternating with those of the most intense distress. The pathology clearly shows why this lesion is so painful. An ovary, the seat of chronic inflammation, generally is either sclerotic or cystic, and has a thickened tunica. An examination will disclose that nearly all of the normal stroma has been re- placed by connective tissue, so that at the time of menstrual or other engorgement there is no room for expansion, and the sensi- tive terminal nerve filaments are caught between the swollen masses of tissues and are subjected to a severe pressure. This causes pain. The greater the engorgement the more severe the pain. Should the inflammatory engorgement continue, and con- nective tissue form, the contraction of this tissue on the sensitive terminal nerve filaments produces the pain. As this pressure is continuous, the pain and distress become constant. Jessett (300, p. 1059) thinks that, in cases in which "the capsule of the ovary is found to be thickened and corrugated with fibrous tissue dip- ping down into the ovarian stroma, and in which a single cyst or multiple cysts are found incorporated, it is the binding down of these by the dense capsule, which is the cause of pain." Her- man, however, thinks that sclerocystic disease of the ovary is generally free from pain unless it is associated with peritonitis. Following inflammation, adhesions to other organs may form. These adhesions are a common cause of pain production.^ Abscess of the Ovary. — If the pain of an acute inflammation of the ovary does not subside within a reasonable time, an ab- scess formation should always be considered. When this occurs, the pain becomes greater instead of less, and a gradual but sure increase in the local tenderness is noticed. At the same time, a mass connected with the uterus and slightly movable makes its 1 Heywood Smith (305, pp. 1060-1061) says that ovarian disease is painful in three stages: (1) "In stage of congestion through tension of the blood vessels. (2) "Thickening of the stroma. (3) "Indrawing or contraction of the fibrous stroma. "In all these conditions, the tension of the blood pressure at the men- strual molimen is the cause of pain," 752 PAIN IN THE FEMALE GENITALIA appearance in the lower iliac region. At once the question is pre- sented : Is this mass the ovary or is it an inflammation of the tube with a local collection of pns ? To answer rightly, it is necessary to call into requisition the most acute diagnostic skill. A diag- nosis, it is true, may be easy if one is able to connect the inflam- matory mass with the uterus, such as is possible if the abscess is tubal, or to the ovary, if the abscess is ovarian. Some slight aid in diagnosis of the exact location of the ab- scess is furnished by the different areas of referred pain; but generally it may be stated that only the diagnostic skill of the examiner, combined with a clear and almost instinctive method of deductive reasoning, will enable him to arrive at a correct conclusion. After all, practically it makes very little material difference whether the abscess is of the ovary or of the tube. Inflammation of the ovary, with abscess formation, demands iden- tical treatment with inflammation and abscess formation of the tube. Both produce localized pelvic peritonitis and pus forma- tion, the symj)toms of which have been described. Adhesions of the ovary frequently follow inflammation. When they form, the resulting pain is related to the functional acts of the adhering organ ; for instance, micturition causes pain when the bladder is adherent (this is rare) and defecation is painful when the rectum is affected. In all cases, an ovary which is sur- rounded by adhesions, as a rule, has been so badly diseased that functional acts of its own, such as ovulation or the congestion incidental to sexual connection, will cause pain. Tuberculosis. — A tuberculous ovary is, as a rule, not very sensi- tive. A characteristic of it is that it is closely approximated to the uterus and seems glued to it (Reed, Martin). Enlarged Uterus.- — Pressure on the ovary by an enlarged uterus may, in some rare instances, cause pain. In some cases the pressure hinders the return blood flow from the ovary, and the pain is the result of the consequent congestion. Relationship of Ovaries and Parotids. ^ — Swelling of the ovary, and pain in the ovarian region, are common in parotitis. Like- wise, in cases of swelling and inflammation of the ovary, pain OVARY 753 and swelling may, in some cases, be present in the parotids. It hardly seems possible that the association of these two organs can be through nerve paths, for they are so widely separated from each other and each derives its nerve supply from unrelated nerves. It seems more than likely that the exciting cause is a ferment, elaborated either by the ovary, or the parotid, the fer- ment of the one producing activity in the other. Tumors of the ovary include cysts and new growths, carci- noma, and sarcoma. Cysts of the Ovary. ^ — Cystic disease of the ovary, unless peri- toneal or pressure symptoms have developed, is without pain (Herman, Gallaban). In a study of eight large ovarian cysts Sampson found that the walls of all were. insensitive to touch and pain, the insensibility to pain being tested by cutting, pinching and clamping. However, traction on the pedicles of cysts causes pain, which becomes greater as the traction is increased. The pain is usually felt at or about the pelvic brim, but if the traction is increased it becomes more diffuse, and is then generally felt over the entire side of the abdomen or in the back. In some instances it may be so diffuse that the patient is unable to localize it. Also, if the pain be severe, nausea may occur. Immediate relief of both pain and nausea follows removal of the traction. Clamping or pinching of the pedicle gives contradictory re- sults. In some cases it seems to cause pain, even when great care is exercised to avoid all traction on the cyst or on any part of the parietal peritoneum. In other cases the pedicle is relatively insensitive to clamping, cutting, and ligating, if these are ac- complished without traction. The pain from pulling or twisting of the pedicle seems to originate from the traction on the parietal peritoneum and the retroperitoneal tissues of the side and back. The pain varies according to the force of the traction, and is felt in the back or side. If it is very severe, the patient may be unable to locate it. When the traction is slight, headache, accompanied by indefinite abdominal and pelvic pains, may result. As stated above, twisting of the pedicle almost invariably 754 PAIN IN THE FEMALE GENITALIA causes severe pain. This is in accord with clinical experience. The pain may be localized in the side or in the back, or may be very diffuse, and is frequently accompanied by nausea. There may be many mild attacks of pain, due to slight twisting of the pedicle, which is quickly relieved by a shifting of the posi- tion of the cyst with a consequent relief of pain. A sign very characteristic of twist of the pedicle is that the pain is very much increased when the patient turns from one side to the other. This is due to the rolling over and dragging on the twisted pedicle, by the tumor (Donald and Hickley). Should the twist persist, stran- gulation may result, and another source of pain may arise in the escape of the fluid from the engorged cyst. However, pain Avill not immediately be felt unless the contents of the cyst are such that they irritate the parietal peritoneum, though they may be such that a non-infectious irritative peritonitis may ensue, and pain may arise from this source. Pain may also be associated with acute swelling and sudden enlargement of the cyst, such as occur at the time of great pelvic engorgement, as, for instance, during menstruation or at the time of sexual connection. In some cases the sac ruptures, and blood is thrown into the peritoneal cavity. Symptomatically, it now closely resembles ruptured extrauterine pregnancy, from which it is hard to diagnose (Winter, Sampson). Adhesions between the cyst and other structures will not cause pain unless the adhesions unite the cyst to sensitive structures (parietal peritoneum), and conditions arise which cause traction on the same. The presence of abdominal or pelvic pain in patients with ovarian cysts usually indicates either secondary changes in the cysts, involving some sensitive nearby structure, or the presence of some other condition, independent of the cyst, which may cause pain. Previous symptoms may aid in the diagnosis. Therefore, the principal causes of pain arising from ovarian cysts are traction or twisting of the pedicles and the traction on the parietal peritoneum by adhesions (Sampson). New growths of the ovary as a rule are not painful. Out of THE VAGINA 755 an enormous experience Mr. Doran could only find sixteen which were painful and of those two were due to adhesions. New growths are divided into two classes: (1) benign and (2) malig- nant. The benign growths are painful when they interfere with the ovarian functions or when they reach such a size that they stretch the anterior abdominal wall (Donald and Lickley, p. 430). Likewise, in the earlier stages, from the same cause, the malignant growths are painful; while in the later stages pain is also caused by infiltration of the nerve fibers by the tumor cells, or by the action of the toxins of the malignant process upon the incorporated terminal sensory filaments. In some cases torsion of the pedicle of the ovarian tumor occurs and pain is severe. It is due both to congestion and enlargement of the ovary from the obstruction to the blood flow, and to the injury to the nerves in the pedicle. In every case it must not be forgotten that malig- nant growths may be present and not cause the least pain (Brothers). THE VAGINA Nerve Supply. — Pain is a common indication of vaginal dis- orders ; yet, because of the easily accessible location of the vagina, other and better methods of diagnosis than pain syndromes are available. The vagina is supplied by sympathetic and cerebro- spinal nerves. The sympathetic fibers are derived from the in- ferior hypogastric, while the cerebrospinal are derived from the third and fourth sacral nerves. The reference pain seems to be in the fourth sacral area. The sympathetic fibers are supplied to the upper end of the vagina, which is comparatively insensitive, while the lower portion, which is quite sensitive to irritation of every description, is' supplied by the cerebrospinal, through the pudic, which is derived from the third and fourth sacral. Affections Causing Pain.- — Pain produced by palpation of the vagina should always lead to inspection, as it may be due to col- poritis. This is indicated by the reddened and inflamed appear- ance of the mucous membrane. A profuse discharge is also pres- 756 PAIN IN THE FEMALE GENITALIA ent- In inflammation the joain is of a burning type. Tenderness of the vaginal wall and the pelvic floor is marked. Hemorrhage into the soft parts surrounding the vagina is, as a rule, j)ainful. Even during the pains of labor, as Reed says, the patient's attention is immediately attracted, when this compli- cation occurs, by the increased pains which are then produced. On the contrary, chronic edema or hemorrhagic infiltration of the vagina or vulva is entirely free of pain. A small nodule on the vagina may be a neuroma or a poly- poid growth of the urinary meatus. Both are very painful. Tu- herculous disease of the vidua is at first not painful, but later it may cause considerable pain. Cancer of the vulva is nearly al- ways very painful. Fortunately, the disease is very rare. Cysts of the vidva, unless inflamed, cause no pain. Cancer of the vagina, is generally free from pain until late in the disease. Pain on urination and on coitus generally means an inflamma- tion of the lower genital tract or a cystitis. This inflammation is frequently gonorrheal, but may be the result of trauma. Every case of pain in the lower genital tract, associated with a copious discharge, should be examined for gonorrhea. If the affection is gonorrheal, as a rule, the vulvovaginal gland (Bartholin's) is in- volved. The onset of this complication is indicated by sudden acute pain localized to the region of the gland. Examination dis- closes the enlarged and inflamed gland. A marked pain on urination may indicate a vaginal (anterior wall) tuberculosis. A slight fissure at the urethrovaginal juncture is also a cause of severe pain. Sexual Connection. — When pain is present during sexual con- nection, the female is the one who most frequently complains, except possibly in some cases of disproportion of the parts, when both the male and the female are pained, though the female suf- fers much more than does the male. Especially is this so in the period following the first intercourse. To the female, the first intercourse is almost invariably painful, and at this time the male should exercise the greatest moderation. After a short time, this pain during intercourse wears away, unless the partners are ill- m « H P m Patients are extremely neurasthenic and nervous; generally occurs in those who work very hard or who are subject to many worries. a3 > 0) 8 tc Ct OJ a With the stopping of the menses though a feeling of discomfort may persist for some time. 13 a 3 05 O Essentially chronic. It im- proves on improvement in the patient's general condi- tion. 73 05 _3 "S Or" P i to 03 3 03 W -tJ , 313 11 ^<1 O Hi h^? 2 s s3 § 05 > a 2 CO OJ S -^-^ O 3 a °^ 2? 3 p,j3 . O «J2 "^ g « rf l^l^oj^bc a 8 il ^ a o <1 "S g 3 05 II 05 ^a g"^ c3 ■3 '■+3 3 cc w 73 .C (3 2 o g1^2 a bC 3 oj o o ts 2 a) ^§ ^^ to 3 4J o a 6 m 3 -o ;.< O. m a o o 1 c3 05 "> 05 .22 § bC I— 1 02 1 05 73 ^t "A ^ 3 a 05 -C 05 0-.3 2 05 3 05 P 'o'o S 22 •2 S +j a ^ g° ^^ & i3S 05 05 -^ JS J3 H H Hi l-H OJ 5 fl ^ OJ O ^ += a; ts .S 3 "^ a a^ <2fi§sl 2 a; > CO s > O +^ 3 O ft 1 >i a> o 02 53 2 a to 05 a o 05 o '^'^ 3 " l§ ^§ CO 05 "Ct > •a fe ->° 03 ^ C3 bJD^ i3 "05 to 03 >.a l-H 03 05 5 03 3 03 05 g c 2 3 2"^ § ^g a 2^3 3 o- 05 3 05^ to o3 05 05 _s "E 05 P 05 1 "05 % 3 3 =^ a 73 GO tn & 3 1^ -3 +J C» 3 1 CO CO § a 3 o 1 0) a 73 O 05 ,3 o 03 s _3 05 t3 3 03 05 £ . 3 3 3 05 3* '+3 3 a c3 !>< 757 75S PAIN IN THE FEMALE GENITALIA mated ; then the aversion of the female to the male may hinder the development of the normal libido so that the vagina instead of being moist and well lubricated during intercourse will be dry and rough. Under these circumstances the friction which ordinarily is productive of so much pleasure, inversely is productive of as much distress. This is only a temporary impediment, however, and, under propitious circumstances, entirely disappears. It is only when it persists longer than a reasonable length of time, for instance, a few months after the first intercourse, that it should become a subject of medical inquiry. How much the future happiness of the husband and wife may depend on the cure of this abnormality can be judged when it is borne in mind that no true conjugal bliss can be experienced so long as natural and pleasurable intercourse is denied. Many men spoil their entire married life by reason of stupidity and lack of ordinary common sense in the act of coitus. ISTo two women are entirely alike and each should be treated differently and be made the subject of careful medical study if difficulties due to painful intercourse arise during married life. In the majority of cases the female patient generally is the first to complain and to seek medical advice, because, as a rule, she is the one who suffers most. She should be closely questioned as to the time of the pain, as to whether it occurs before, during, or after intercourse, and she should also be asked to define the positions in which intercourse is most painful. Pain at the beginning of intercourse generally indicates a lack of lubrication of the vaginal canal, and this, since it is functional, is generally due to an absence of sexual desire on the part of the female, or a fear of the results of a coitus even though the desire be present. These women are the ones who are unable to experi- ence more than a single coitus a night without suffering greatly for it. They generally complain of a burning pain during the early stages of the act, which disappears under the excitement of the libido to reappear in many cases after the conclusion of the act. Generally, the pain disappears almost entirely in a very short time, but often may persist to such a degi'ee that the female will THE VAGINA 759 not again, for some time, permit the approach of the male. Should pain occur during the act, it indicates some abnormality or patho- logical condition of the female parts ; inflammation or ulceration of vaginal mucosa. Inspection will reveal this. It also may indi- cate pus tubes, oophoritis, or appendicitis. In these cases pain is present during the whole of the act and remains for some time after. It is also present on particularly forcible and violent movements, which the woman is very averse to making. When pain occurs at the end of the act, after the orgasm has taken place, it indicates some trouble with the uterine glands. Such a period of j)ain is very unusual. Perimetric adhesions also cause pain, which is more marked toward the end of the act. In some women, by whom pain is complained of in the vagina during the sexual act, digital examination reveals only a painful spot at some point in the vagina. No pathological lesion can bo found. The pain of the male arising during sexual intercourse is slightly diiferent in its manner of production from that of the female. The periods of pain likewise may be divided into: (1) the pain j)rior to connection; (2) the pain during connection, and (3) the pain following connection. Pain before connection is due to some pathological lesion in- hibiting erection of the penis, the most common being inflamma- tion of the urethra (frequently gonorrheal). Pain during connection is due to herpes of the glands, ulcera- tion of the glans penis, fissure at the meatus, inflammation of the glans or foreskin,' adherent prepuce, or an inflamed frenum. Pain at the time of the orgasm and persisting for some time afterward is due to prostatitis or posterior urethritis. In any case, when pain during intercourse is complained of, all possible lesions in both the male and the female should be thoroughly in- vestigated before forming a decision. CHAPTEK XXXIII PAIN IN THE CHEST When a patient has a pain in the chest, the idea first sug- gested to himself, as well as to most physicians, is that he is suf- fering from some lesion of the heart or of the lungs — of the heart, if the pain is in the left half of the thorax; of the lungs, should the pain be in any other part of the chest. While in many cases this is true, in many others it is not ; and, unfortunately for the careless physician, the exceptions far outnumber the rule. Pains in the chest are the result of many causes. In the first place, they may be due to injuries or disease located in any one of the structures composing the chest walls; or they may be felt in the walls and be produced elsewhere, as is seen in referred, reflected, and transferred pains. THE THORACIC WALLS The structures composing the thoracic wall are: (1) the skin, (2) muscle, fascia, and nerves, (3) bone, and (4) pleura and sub- pleural tissues. THE SKIN The skin of the thorax is painful in all those lesions which cause epidermic pain, such as neuralgia, hysteria, inflammation, hyperesthesia and hyperalgesia from reflex causes. Neuralgia. — Neuralgia produces a very tender skin, so that the slightest touch is painful. It is a frequent accompaniment of influenza or some of the acute infectious diseases. When found, inquiries should be made in regard to the presence of any recent illness. A characteristic of neuralgic pain is that it moves around freely from place to place, and does not stay very long in any one location. It is also present in other parts of the body, and 760 THE THORACIC WALLS 761 the subjacent muscnlar tissues are, as a rule, very sensitive to pinching or squeezing. Hysteria. — In hysteria the skin is tender only in certain areas. These areas in the same person are constant in location, and generally are produced only by certain types of irritants. In some these areas may be sensitive to pinching and entirely insensitive to Fig. 173. — Areas of Cutaneous Distribution op the Thoracic Seg- ments. (Head, Brain, Vol. XVI, p. 130.) The 1st, 2d and 3d thoracic areas are the ones mostly affected in cardiac disease. The 4th thoracic is the one especially involved in lung disease. pin-point pressure; while in others these sense perceptions may be reversed. Inflammation. — Inflammation of the skin of the thorax is un- common, except when local irritation, particularly in the form of a mustard plaster, etc., has been applied. Hyperesthesia and Hyperalgesia. — Hyperesthesia and hyper- algesia are the result of nerve irritation, either in adjacent or in distant areas. The adjacent causes may be inflammation of any of the sublying organs, such as osteomyelitis of the ribs, myositis of the chest muscles, or a communicated inflammation from the pleura. In all cases where pain is complained of in the chest these conditions should be carefully sought. Symptoms leading to the diagnosis of inflammation are swelling, local edema and 762 PAIN IN THE CHEST restriction of the respiratory movement on the affected side. In addition to local causes, hyperalgesia may also be produced reflexly by lesions of the heart and lungs. The segmental areas of these hjperalgesic zones are given, according to Head, in Fig. 173. MUSCLE^ FASCIA AND NERVES Muscle Pain — If there are no definite zone areas of hyper- algesia and hyperesthesia and the areas of sensitiveness corre- spond fairly well to the limitations of the different chest muscles, myositis is very likely present. When it is, pain is produced by grasping the muscle between the fingers and pinching it, or else by trying to raise it from its bed. If the muscle is hypersensi- tive, pain results. Also, pain is produced on breathing by move- ment of the affected muscle, while rest gives relief. If the inter- costal muscles are affected, sudden pressure in the intercostal spaces causes pain, and breathing is inhibited on the affected side. If myositis be present light pressure applied to the muscle is grateful, and severe pressure is painful. Also the pain does not radiate. In neuralgia, on the contrary, pressure of all kinds is most painful and radiation is usual. Fascial Pain. — Musser speaks of a chronic inflammation of the fibrous attachments of the muscles as being one of the causes of chest pain. This pain is increased by motion, and persists for long periods. NEEVE AND MUSCLE PAIN Nerve Pain. — If pain is present in the intercostal spaces, either the nerve or the muscle is involved. The nerve may be affected either with neuritis or neuralgia. Neuritis. — When the pain is due to neuritis, it is referred along the interspaces and the breathing is very much restricted. The pain is also produced by pressure made in the interspace about two inches from the vertebra, and when so produced runs out anteriorly over the distribution area of the intercostal nerves. A good way to determine the presence of nerve inflammation is to run the finger round from the back to the front, in the inter- THE THORACIC WALLS 763 costal space, making, at the same time, considerable pressure. If neuritis is present, the pain is severe. A somewhat similar condition is the nerve pain due to herpes zoster. In this pain is very severe over an intercostal nerve. Tenderness, also, is excessive. In a day or two small vesicles C, Intercostal nerve XII D, M. transv. abdom. E, Iliohypogas- tric nerve F, Lateral branch inter- costal nerve XII G, Ramus cu- taneous later- al, iliohypo- gastric nerve H, 1 1 i o-i n g u i- nalis nerve Fig. 174. — Points At Which The Inter- costal Nerves Become Superficial. Especially the 11th and 12th over the iliac region, which is the location of the referred pain in pneumonia and dia- phragmatic pleurisy of the right side. (Splateholz, Leipzig, 1909, vol. 3, 740.) I, Sheath rect. abdom. J, Umbilicus K, M . rect. abdom. L, M. obliqu. int. abdom. M, Rami cuta- nei ant. inter- costal nerve XII N, A n nul us inguinalis O, Funiculus spermaticus make their appearance over the site of the pain. Herpes then be- comes apparent. Neuralgia. — True intercostal neuralgia, like all neuralgias, may arise without any obvious cause. The fifth to the ninth thoracic nerves are the ones generally involved. The pain, owing to the anatomical relation of the parts, is worse on breathing, or on any movement of the chest wherein stretching of the nerve (pressure irritation) may occur. This pain must not be mistaken for pleurisy. The absence of the pleural friction rub is evidence of value against its pleural origin. The reason for this confusion is clear when it is stated that the thoracic nerves divide into two branches, the external and the internal. The internal supply the 764 PAIN IN THE CHEST pleura, and the external supply the anterior body wall, so that, should the pleural branches be affected, the stimulus may be trans- ferred to the external branch and neuralgic-pleural pain may re- sult. On the other hand, when the first two dorsal nerves are affected, the pain may run down the inner side of the arm through the intercostal-humeral nerve. Intercostal neuralgia may arise from thickening of the spinal meninges, specific or tubercu- lous meningitis, or from new growths, osseous or otherwise. It may also arise from intravertebral pressure, diabetes, or other general conditions causing neuralgia. An intercostal neuralgia may be the early sign of a tabes or of a spinal cord tumor. BONE PAIN Bone Disease. — Bone diseases (osteomyelitis) produce pain, soreness, and redness over the area under which lies the necrosing bone tissue. In these cases the location of the swelling and the signs of inflammation render a diagnosis easy. Elevation of tem- perature and an increase in the pulse rate also aid in the diag- nosis. Fractures. — Where a rib is fractured, the pain, on breathing, is very severe. Generally, the inspiratory act commences all right, but, because of pain, is brought to a sudden stop. On palpation, crepitus and abnormal mobility of the rib can be felt. A diagnos- tic sign of value is pain over the location of the fracture when pressure is made between two hands, one placed on the anterior chest wall and the other on the back. PiiEUKAL Pain See p. 769. REFERRED AND REFLECTED PAINS OF THE THORACIC WALLS Referred and reflected hyperalgesia have been mentioned as causes of chest j^ain. These are generally accompanied by subjec- tive pain. There may also be a subjective pain without hyper- algesia. This pain is referred from distant lesions, such, for in- stance, as pain in the shoulder, in diseases of the gall bladder, REFERRED AND REFLECTED PAINS 765 or posterior thoracic pain in lesions of the stomach. Both of these are transferred pains, the same as the pain which is present in the chest wall over the cardiac area in some cases of heart disease. All these pains depend for their production upon the transference of stimuli from the sympathetic, through the cells in the cord, to the nerves supplying the body wall. In some cases, this reflection A, Tenderness in aortitis B, Liver disease Gall-bladder disease Extra-uterine pregnancy ruptured C, Pain in inter- costal spaces: 1, Intercostal neuralgia 2, Referred pain (spinal caries) 3, Intercostal myalgia D, Tenderness due to trac- tion from coughing E, Gall-bladder disease F, Tenderness in liver dis- ease Fig. 175. — Location of Tenderness in Various Diseases of the Chest AND Abdomen. G, Cardiac dis- orders H, Subacro- mial bursal inflammation I, Tenderness in angina pec- toris J, Bronchitis Necrosis of the sternum Mediastinitis or medias- tinal sarcoma Aneurysm Hyperchlor- hydria K, Gastric ulcer L, Disease of the spleen M, Disease of the cecum passes entirely across the cord, and the pain is felt on the side opposite to that of the lesion. It also may be transferred to a higher or lower level of the cord and be felt at a higher or lower level of the body. These transferred pains, when present in the chest, often cause mistakes in diagnosis, since they are likely to cause confu- sion as to which is the side of the lesion. They may also attract attention from a distant causative pathology, as is sometimes seen 766 PAIN IN THE CHEST in appendicitis, when pneumonia or pleurisy is diagnosed witli an entire disregard of the appendiceal condition. However, the diagnosis is not always wrong, for in some cases there may be local conditions (congestion, etc.) in the lungs to account for the chest pain associated with appendicitis, as is emphasized by J. B. Roberts (^76). In other cases the pain may be felt in the ap- pendix area when the lesion is in the lung. This pain may be due to irritation from a diaphragmatic pleurisy associated with the pneumonia, the stimulus being carried through the eleventh and twelftli intercostal nerves. The j^ain, as is usual, would then be felt at the point where the eleventh and twelfth nerves become superficial, that is, in the right lower quadrant of the abdomen. Transferred and reflected pains, in distention of the stomach and colon, are found on the lateral surface of the chest, follow- ing ihe points of attachment of the diaphragm. These pains occur in the two conditions in which the greatest traction on the dia- phragm is present, namely: (1) In states of gi'eat cardiac and respiratory activity. The heart and lungs, which in a normal person, under abnormal con- ditionfe of exertion, would be incited to great effort, would, in a patient who is emphysematous, be incited to much greater effort, owing to the difficult circulation of blood through the lungs. This relatively greater increase of cardiac and respiratory activity would produce much greater than normal traction on the dia- phragm, and this, in turn, would be communicated to the chest wall at the points of diaphragmatic attachment. Thus it is that after violent exercise pain is so frequently produced at these points of attachment. (2) In enlargement and dilatation of the stomach it is also common to find pain or a sense of traction along the line of attach- ment of ihe diaphragm to the chest walL This pain is the result of the diaphragmatic pull. Distention of the stomach and intestine frequently causes such a sudden and severe pain in the cardiac region that it is confused with angina pectoris; but a hurried examination of the epigas- trium will disclose the enlarged and tympanic stomach and quickly REFERRED AND REFLECTED PAINS 767 clarify the diagnosis. The distended large intestine, also, at times produces the same symptoms. Symptomatic of the latter condi- tion is a painful spot on the left side of the chest at the margin of the ribs (in men at a point opposite the suspender button). In women the presence of this pain frequently causes them to loosen the corsets (Reynier, 231). According to Brown (Osier's "System"), pain over the front of the chest is, as a rule, a referred pain from a diseased lung, though it may also be due to an acute pleurisy or to the traction of pleural adhesions. According to the same author, pain over the lower part of the thorax may be due to pleurisy, while, if it is over the interscapular region it is, as a rule, referred, and is the result either of a pleurisy or of jiressure on the intercostal ner\'es from enlarged mediastinal glands. Pain radiating around the chest wall is also present in herpes zoster and tabes dorsalis, as well as in vertebral caries, if the intercostal nerves are involved. Mediastinal glandular involve- ment at times produces a pain in front of the chest, beneath the sternum, and at other times in the back, underneath the vertebrae. Should pain be present in the back between the scapulse, the fol- lowing should be sought : vertebral disease, limg disease, particu- larly tuberculosis (here the pain is more of an aching), aortic dis- ease (aneurysm), j^leural disease (pleuritic adhesions), splenic and gastric lesions (inflammation and over-distention). Should pain be present at the angle of the scapula on the right side, it indicates liver involvement; if at the angle of the scapula on the left side, it indicates splenic involvement. Localization of Pain on the Chest Wall. — Pain on the lateral wall of the thorax may be due to pleurisy, intercostal neuralgia, or pleurodynia. Upon the upper surface of the thorax, in the region of the shoulder, pain may be due to pericarditis (left shoulder) (McKenzie), peritonitis, pleurisy, hepatic abscess (right shoulder), or colic. According to Monro (32), Schmidt, and others, the pain referred to this area is propagated through the phrenic nerve to the fourth cervical (sometimes, also, to the fourth and fifth), and thence through the external supraclavicular z o s a 1. There is no pain except when the pleura is in- volved. a >. m H a 1. Rilles crepitant. 2. Elevation of temper- ature, pulse and respira- tion increased. 3. Sputuni, rusty colored. 4. Consoliiiation, dulncss on pprcu.ssion. 5. Vocal resonance increas- ed. 6. Cough. a> 3 ^ a ^ a <8 C3 53=1=J3 O 5--== c.Sft-2^ go- 's &5-2^^.S«-^S= £ c C3.2 Cg^ g--g og.sg-s.g5.=.s^S .a 1 a lU a J a> a M g £"0 Ja .1 if -1 r- m 1 Pi 111 1 c £ ° S -3 ° " Si .2 2 3 .J= a %—, c c s K 3 . •3 a a -nSfesoM (!,:»§ P= 3 >S^-C .2 gfec^"- ■- a- g :s 1 2i^= 1 ««='§■& 2 c 2 S&S S 3 .^-s^-.S '^ E « 2 ^'rt -Sf g.2g a- 0-2^2 •sgipo m c Cjr a ^ « ^- ^ c « g aa H ttc^ ca •a S a u < z >< a o p a "^ 1.2 2 1:%^ .2 1 gi "5 2 3 .c « S.3 c £ 3 a 1 • 1 I 3 "3 1 I no S >< d ■3 1 i a 80 1 f 768 PAINS WITHIN THE THORAX 769 nerve (derived from the third and fourth cervical nerves) to the integument over the shoulder tip. Pains above the shoulder are due to involvement of the supra- acromial nerves, branches of the fourth cervical. Deep-seated pains, referred to the parts over the shoulder joint, and in the deltoid, lie in the distribution area of the circumflex nerve, which originates from the fourth, fifth, and sixth cervical nerves. When the pains are behind the shoulder and over the deltoid, thej are also due to involvement of the circumflex, and at the point where the nerve becomes superficial a painful spot is present (Dana, 123b). Tenderness is present over the eleventh and twelfth dorsal and the first and second lumbar vertebral spines in gastric lesions. (For other points of tenderness in gastric lesions, see under Stomach.) PAINS WITHIN THE THORAX Inside the thorax are the following, all of which have the power, directly or indirectly, of causing pain: (1) the pleura, (2) the heart, (3) the lungs, (4) the mediastinal glands, (5) the esoph- agus, and (6) the nerves and vessels passing through the thorax. In diseases of the heart and lungs hyj)eralgesia may be present in the area of the first six dorsal visceral segments. Sometimes it is felt as high as the seventh or eighth cervical or as low as the seventh or eighth dorsal (Head). Generally, though, in the case of the heart, the hyperalgesia is limited to the upper four dorsal, while that of the lungs is comprised within the upper six dorsal. The areas of distribution of these segments are illustrated in Fig. 173. THE PLEUEA Innervation. — The parietal pleura is iimer\''ated by the inter- costal, sympathetic, and vagus nerves. The visceral pleura is innervated by the vagus and sympathetic. The pericardial pleura sends its sensory stimuli through the vagus and possibly through the phrenic. The diaphragmatic pleura sends impulses over 770 PAIN IN THE CHEST the phrenic and also in jiart through the last six intercostal nerves. In iileurisj pain is a symptom of gTeat diagnostic value, be- cause it is almost invariably present.^ The method of its pro- duction and its areas of distribution have been discussed in the preceding j^ages. In some cases the cutaneous liy23eralgesia may be on the opposite side of the body to the one aifected ; but the deep tenderness is always on the affected side, and this is a point to be remembered, for it may be most useful in a differential diag- nosis. Percussion is a good method of defining this deep tender- ness. On palpating or percussing those cases of pleurisy in which pain is complained of over the abdomen as far as the umbilicus, it is noticed that tenderness is not present on percussion and pal- pation beyond the costal margins, and this is a sign of the utmost value in the making of a diagnosis. When tenderness to deep pressure or percussion is present, it is a fair indication that the diseased process lies in the percussed area. The mere fact that an area painful to palpation or percussion is present does not necessarily prove a pleural involvement, for these pain areas may be due to other causes than a pleurisy ; like- wise their absence is of no negative value, for a pleurisy may be present and run a painless course. A method of arriving at a diagnostic conclusion as to whether the pain felt in the chest wall is or is not due to pleural involvement is to inhibit the respira- tions on the affected side, as by strapping. This will at once stop the pain, if it be due to a pleurisy. On the right side, if the pain is the result of perihepatitis, strapping will aggravate it. In dia- phragmatic pleurisy respiration is painful, but not nearly so much so as it is in pleurisy of the lateral wall. In many cases of diaphragmatic pleurisy the pain is referred to the chest and abdominal wall, in the distribution area of the tenth, eleventh, and twelfth thoracic nerves. The pleura also is probably connected with the seventh, eighth, 1 According to Dr. Lord, 89.70 per cent, of all cases of serofibrinous pleurisy give rise to pain at least sometime in their course. PAINS WITHIN THE THORAX 771 and ninth visceral dorsal segments, so that the pain, when reflected, is felt in these segmental zones, most commonly on the right side (Head. See Fig. 173). This corresponds closely with the state- ments of Huss (102), who says that, in pleuritis, irrespective of the area in which the disease is present, the pain occurs princi- pally in the region of the mammillary line, between the fifth and eighth ribs. When the inflammation lies in the outer and lower half of the pleura, the pain may be felt in the region of the hypochoudrium, in the region of the quadratus lumborum, and in the epigastrium (though infrequent). In all cases in which the parietal pleura is involved (and it is involved in nearly all pleuritic processes of whatever origin) pain due to irritation of the intercostal nerves is also felt, and is localized to the diseased area. If the pleurisy should extend and involve the mediastinum there is then produced a mediastino- pericardio-pleuritis. This causes severe pain on breathing. Per- cussion over the sternum is painful, and pressure in the intercostal spaces on either side of the sternum causes pain. Reflected and referred pains are absent ; only the direct pain is present. Character of the Pain in Pleurisy. — The pain of pleurisy may be slight or severe, depending upon the type and the location of the pleuritic involvement. If the visceral pleura is involved, it is not as severe as though the parietal pleura were afi^ected. Like- wise involvement of the diaphragmatic pleura, in the absence of deep inspiration, may produce no very severe pain. In all cases pleural pain of whatever origin is generally provoked on deep in- spiration, coughing, yawning, singing, and laughing. As a rule it is localized in the areas of maximum tenderness of the seventh and eighth dorsal segments (q. v.). If the intercostal nerves be- come affected and intercostal neuritis results, the pain is referred to the anterior area of distribution of these nerves. Should the pain suddenly cease, it is frequently an indication of a beginning hydrothorax. In those cases in which the subjective pain is on the opposite side to the one involved Gerhart thought that the transference 772 PAIN IN THE CHEST might be due to a comnmnication in the anterior mediastinum, be- tween the two sets of intercostal nerves. In this regard, Huss speaks (102, p. 245) of a case in which such a connection was found between the fourth and the middle part of the third nerve on the right side and the corresponding nerve on the left side. CHAPTEK XXX17 HEART DISEASE GENERAL CONSIDERATIONS It has frequently been said that cardiac disease does not cause I^ain. Even well-known clinicians have claimed that the heart (of itself) does not give rise to painful sensations. Thej attribute all the pains which may be present in the chest, over the area of the heart, as not being due to disease of the heart itself, but as the result of other changes, such as rheumatism of the pectoral or intercostal muscles, or intercostal neuralgia. Yet it is not always wise for the clinician summarily to dismiss a pain in the chest and rate it as being due to any one of these conditions, especially so in those who are weak and debilitated from over- work or disease. In the former class of patients the pain, though slight, may be the first indication of a cardiac exhaustion. Early and efficient remedies directed against this exhaustion may pro- long the patient's life for years, while neglect of the warning signs may pave the way for his early death. Every case of pain or discomfort, in the areas usually associated with cardiac disease, should lead the physician to question closely his patient as to age, habits, manner of work, and past diseases, and then to make a thorough examination of the entire body, with special attention to the chest. The physician should also bear in mind that the heart may be gTeatly diseased and yet give no apparent sig-n of its dis- tress, excepting in cases of referred visceral hyperalgesias. Should these hyperalgesias be present, they of themselves, even though no other signs of heart disease are apparent, are of sufficient value to merit a diagnosis of cardiac involvement. The absence of hv- peralgesic zones does not carry weight against, as their presence carries weight for, the existence of cardiac disease. 773 774 HEART DISEASE It was in 1873 that Loomis first called attention to the asso- ciation of heart lesions with referred pains. For instance, in an article published in that year, he says that "disturbances of the cardiac plexus, by reflex irritation, produce pain in the arm, in the top of the shoulder, and the base of the neck." However, it was not until Head and McKeuzie published their articles on referred and reflected pain that a clear conception of this rela- tionship of the pain to the cardiac disease was reached. Nerve Supply of the Heart. — The cutaneous hyperalgesia, in a case of heart disease, lies in the cutaneous tissues which extend from the eighth cervical to the fourth dorsal segments, as illus- trated in Fig. 176. In this illustration, it should be noticed that the eighth cervical and the first and second dorsal zones are shown as extending down the arm. This downward extension explains why, in some cases, the pain of cardiac disease runs down the inner side of the arm, frequently as far as the little finger. The reason for this downward extension is that, in early embryonic life, the spinal nerves are distributed around the entire body ; but as the body develops, and the arms and limbs are projected from its surface, the nerves are dragged out with them, and are carried by developing tissues farther and farther away from their point of origin, until we find them in irregular though always concentri- cally arranged zones, as in man. Ross explains how, in some cases, the areas supplied by the dorsal segments are not continu- ous from the chest to the arms, but are broken by intervening areas ; for instance, the third dorsal is broken, the gap between the two portions being made by the ingrowing second dorsal. The different segments of skin grow with various degrees of rapidity, so that in some cases the different skin segments become sepa- rated from each other. Diagnosis by Means of Location of Referred Pain ^^The man- ner of distribution of the cord zones explains how the pain of cardiac diseases may be distributed down the inner side of the arm, and at the same time over the left upper half of the chest. It also explains why, in some cases of cardiac lesions, the breasts are very sensitive. Hyperalgesia due to cardiac disease may first GENERAL CONSIDERATIONS 775 appear only after some severe and debilitating disease, such as pneumonia, which so sensitizes the already reduced tissues that the slightest stimulus will give rise to pain (in the cardiac areas). At the same time the hyperalgesic areas of the debilitating disease will be present. For example, if the heart is affected (without pain) and the patient catches pneumonia, then the previously non-painful heart becomes very painful, and cutaneous areas of hyperalgesia appear. These heart areas may persist for a long time after the pneumonic areas have disappeared, and vice Local tenderness Area of hyperalgesia Points of local ten- derness (Hoover) . Tenderness aortitis (Hoover) Area of hyperal- gesia in heart disease Fig. 176. — Location of Hyperalgesic Zones and the Areas of Pain IN Cardiac and Aortic Lesions. In some cases there is a crossed reference and the pain is referred to an analogous area on the opposite (right) side. versa. In cardiac disease certain muscles, such as the pectorales, the intercostals, the trapezius, and the sternomastoid, may be very sensitive to pinching and squeezing. That the pain felt in heart disease is not local but referred pain is set forth in the following arguments: (1) The heart is in contact w^ith the chest wall in only a small part of its anterior surface, and the pain and tenderness associated with the cardiac disease cover an area several times this extent. (2) If the pain were present in the heart itself, movements of the heart, such as expansion or contraction, would produce a varia- tion in the pain and tenderness. Such is not the case. The same arguments apply to the origin of pain in lesions of the lungs. "76 HEART DISEASE Another point of interest, as well as of value, in diagnosis of heart lesions is that in the first attack of an inflammatory affec- tion of the heart, say, in endocarditis, the hyperalgesia zones ara very prominent, increasing and receding with each exacerbation or recession of the disease. After the first attack, when the process becomes chronic, as in chronic valvular disease, the re- ferred zones of hyperalgesia arc, as a rule, absent. However, if 'V Area of hyperalgesia « The area of h>'per- algesia down the arm was not wider thanj^ inch, and began abruptly below the shoulder, and ended abruptly before it reached the elbow Fig. 177. — An Area of Hyperalgesia Corresponding to Portions op THE 2d, 3d and 4th Dorsal Zones. The 2d dorsal is almost absent. The area corresponding to a portion of the 4th dorsal is more than ordinarily prominent. In this case also there was no tenderness to blunt pressure, even in the area which was hyper- algesia to pin-point pressure. The case was a mitral regurgitation re- covering from an acute attack. at this time an acute attack of endocarditis should ensue, the hyperalgesic areas may or may not appear. The reason that they do not reappear is not clear, but it probably is the result of tli3 destruction, in the first attack, of the sensory terminal nerve fila- ments in the endocardium, so that, during the second and subse- quent attacks, they cannot respond to the irritating stimuli. This is well illustrated in the case of Lillian IT., a school girl affected with chorea. While under observation a mitral regurgitation de- veloped, and at its height gave rise to the hyperalgesic areas shown in Fig. 177. As improvement occurred the zones gradually became less ex- GENERAL CONSIDERATIONS 777 tensive, first disappearing in the arm, then over the chest, until only a small area over the heart remained (See Fig. 177). This was the area of the third dorsal segment (the segment most fre- quently associated with lesions of the left auriculo-ventricular opening). In cases of mitral disease I have found it present even when the other segmental areas were absent. Another fact worthy of attention is that disease of the aorta seems to be associated espe- cially with the first dorsal segment. In all cases it will be ob- served that the segmental areas are not as clearly defined as they Cutaneous hyperal- gesia in cardiac disease Fig. 178. — Areas of Cutaneous and Deeper Hyperalgesia in a Case OF Acute Dilatation of the Heart, Accompanied by Acute Dis- tention OF the Liver. are in the figures in which the distribution areas of the visceral segments are shown. (See Figs. 2 4 to 26.) This is probably due to the fact that hyperalgesia in cardiac disease is felt best in the center of the area which is most frequently associated with the heart ; and that the intensity of the sensation gradually fades into the adjacent areas. In many cases the cardiac hyperalgesia does not exactly coincide with the area of the cord zones, but may overlap them or be confined only to certain portions of the zones, which are most likely the zones of maximum tenderness of Head, 778 HEART DISEASE In some cases of heart disease there niaj also be present an area of hyperalgesia on the arm in the second dorsal segment and another over the heart in the fourth dorsal segment, as in Fig. 177, wherein the hyperalgesia was present on the chest, and also in a long narrow strip on the anterior surface of the arm. In this case the area of hyperalgesia most likely represented a dis- appearing zone of hyperalgesia. It is in cases of this kind that hyperalgesic zones are overlooked. The hyperalgesia may sometimes extend into the right side or Fig. 179. — Hyperalgesic Area in a Case in Which the Myocardium is Probably in a State of Intoxication. The heart rhythm is slightly irregular; at times the first sound is redupli- cated, or, rather, instead of the normal first sound, there is a double first, with an absence of the second. The right side of the heart is also involved, a tricuspid regurgitant murmur being present. up into the neck, as in the case of a negress (Fig. 179), who, after recovering from pneumonia, developed a delirium cordis with variable pulse and a slight tricuspid regurgitation. Since the right side of the heart and the great veins bear the greatest part of the stress of a tricuspid regurgitation in lesions of this char- acter, the higher cardiac areas (the first and second dorsal) are most frequently affected, and can be taken as indicators of this condition. In this connection it is well to remember that the right ventricle of the heart, when diseased, is not so apt to pro- duce pain as is the left ventricle ; so that i^ain is not as prominent a diagnostic symptom of right heart involvement as it is of in- GENERAL CONSIDERATIONS 779 volvement of the left. In fact, the only symptoms complained of in disease of the right side of the heart may be a feeling of weight or pressure over the cardia, and a tendency to take strong, deep inspirations. In some cases the anatomical structure of the — — Area of sympathetic paiu (from chest) Areas painful to the touch. On making pres- sure at times over these spots a very severe pain was produced on the forehead in the left frontal region Fig. 180. — Areas of Pain in a Case of Mitral and Aortic Regurgita- tion. During the last few days previous to the time at which the outline was made, the heart had been acting very badly, and only the night pre- vious to the outlining of the pain areas the patient had an attack re- sembling angina pectoris. At these times she also had pains referred to the labia on both sides with painful urination and retention of the urine. Examination of the urine and the urinary organs showed nothing abnormal. heart may be greatly deranged without causing any marked symp- toms, as in one case, in which a column of fat one inch in diam- eter extended through the wall of the ventricle, and the only symptoms complained of were a slight shortness of breath and a feeling of weight in the pericardium. But, as a general rule, it 780 HEART DISEASE DIFFERENTIATION BETWEEN ACUTE ENDOCARDITIS AND CHRONIC AND RECURRING ENDOCARDITIS Acute Chronic Fever. Present. Absent. Hypertrophy (Heart). Absent. Present. Murmurs. Changeable i n character — gradual increase in intensity, as the diseased process ad- vances new murmurs may make their appearance. Constant in character — presystolic murmur at apex and aortic murmurs are in favor of chronic endocarditis. Secondary phenomena. Blood. Emboli are carried to several organs and give rise to hem- orrhagic infarcts in the 1. Brain. Hemiplegia. Aphasia. 2. Kidney. Bloody urine. Pain in the renal region. 3. Spleen. Pain. Swelling. 4. Lungs Hemoptysis. Circumscribed dulness, generally at the base of the lung. Dyspnea. These are generally ushered in by a chill; also sympa- thetic vomiting sometimes occurs. Culture generally shows bac- terial growth. Secondary phenomena are due to changes in the valve segments, etc., and manifest themselves as passive congestions (lungs, liver, etc.) No bacterial growth on culture. may be stated that acute inflammatory lesions of any part of tlie heart will produce reflex hyperalgesia in one or all of the cardiac zones of hyperalgesia. This hyperalgesia is of considerable value as a prognostic sign in acute endocarditis. Its disappearance indicates the recession of the lesion and the return of the parts to the normal. However, it must be borne in mind that the absence of hyperalgesia does GENERAL CONSIDERATIONS 781 not positively indicate an absence of pathology in the heart, for the pathology may be of such a character that it may not produce any cutaneous hyperalgesia. Cardiac pain may also in some cases be referred to distant areas, as in one case 'where it was referred to the head in the distribution area of the fifth nerve, being especially severe in the area of distribution of the supraorbital branch (See Fig. 180). Dilatation of the heart is always painful, and causes hyperal- gesia in the second, third, and fourth dorsal, and in the cervical regions, especially on the left side. The zones over the liver, the seventh, eighth, and ninth dorsal, are also painful (see Liver). This is due to the congestion of the liver which is always asso- ciated with a failing heart. Fig. 178 illustrates the point exactly. The diagnosis between heart disease and intercostal neuralgia is sometimes difficult, but is made easier if the physician remem- bers that in intercostal neuralgia the pain is along the course of the intercostal nerves, while in cardiac disease it has no such distribution. The differential diagnosis is as follows : ? Cardiac Disease. Intercostal Neuralgia. Pain is in the cardiac zone Xo pain in the cardiac areas. areas. Movement of thorax is not espe- Movement (respiratory, etc.) cially painful. of thorax is painful. Pain does not radiate around Pain may radiate round the the chest, and the inter- chest and is present on costal spaces are not ten- pressure in intercostal der. spaces. Pain, when present, is more or Pain is intermittent. less constant. Pressure on area of tenderness Areas of tenderness are pres- will not produce a pain ent, pressure on which will radiating around the chest. produce a pain radiating around the ch^st, 782 HEART DISEASE Intracardiac Lesions as Causes of Pain. — The raising) of the intraventricul ar ienston often causes cardiac pains. They gener- ally occur after pronounced exertion, and are rather common in patients with arteriosclerosis who have a leaking aortic valve. A peculiarity worth noting is that, as soon as a mitral regurgitant murmur develops, and an outlet is provided for the increased intra- ventricular tension consequent to extra muscular effort, the pain disappears. Mitral regurgitation often causes a pain referred to the left shoulder and down the arm. Palpitation is a frequent accompaniment. The cause of this pain may be that early in, and, in fact, during the entire course, of the disease, the intra- ventricular pressure in the right ventricle is increased, the ten- sion is raised, and as a result pain arises from the greater work thrown upon the heart. (This may occur only in stages of acute loss of compensation.) Degeneration of the cardiac ganglia is given as cause of cardiac pain by W. H. Thompson, who speaks of cases wherein severe pain was felt in the cardiac region, with all the signs of angina; and yet, when death supervened during an attack, no apparent patho- logical abnormalities could be found. He suggested that a degen- eration of the cardiac ganglia would probably account for the condition. (Degeneration of these ganglion could have been proved by careful microscopic examination.) In some cases it is difficult to differentiate the pains of gastric origin from those due to cardiac disease. The following differential diagnosis after Smith may be useful : Pains of Gastric Origin. Pains of Cardiac Origin. Appear after food, and appar- Appear quite irrespective of ently are the direct result whether food is taken or of its ingestion. not. Accompanied by feeling of ful- No such feeling of fulness; not ness in stomach; often re- relieved by eructation of lieved momentarily by wind. belching. ANGINA PECTORIS 783 Pains of Gastric Origin. Pains of Cardiac Origin. JSTot increased by active move- Increased by active movements, ments, such as walking. which, owing to the sever- ity of the pain, may even be impossible. Heart sonnds normal in rhythm As a rule, some cardiac bruit is and character. present, or at least some alteration in rhythm and volume of pulse. Because it is the most characteristic of the painful diseases of the heart, angina pectoris will next be separately considered. ANGINA PECTORIS Etiology. — Angina pectoris, which is the most painful as well as the most distressing lesion of the heart, is said to be due to the following : (1) Anemia of the heart muscle, which in turn is the result of the narrowing of the coronary arteries. This narrowing may occur at their place of origin at the aortic valves ; for instance, aortitis, with consequent sclerosis of the aortic valve, may occur, and lead to a partial closing of the coronary opening. The result- ing pain is due to factors acting similarly to those which cause the pain in intermittent claudication. Any condition causing anemia of the cardiac muscle, such as exhaustion, bad health, non-assimilation, etc., in a person previously disposed, will fre- quently bring on this pain. (2) Irritation of nerves in the heart wall. These nerves are of the sympathetic variety, and consequently do not carry direct pain stimuli, but only irritating ones, which are carried to the cord and from thence are referred to the periphery as pain. (3) Exhaustion of the heart muscle from overwork causes pain. This pain is due to the same causes as the pain produced in the affected muscles after excessive muscular fatigue (Mac- kenzie). 784 HEART DISEASE (4) In addition to the above causes of cardiac pain, Mac- kenzie also claims that angina pectoris is due to a loss of con- tractability of the cardiac muscle fibers. (5) However, the direct exciting cause in angina pectoris seems to be (a) psychic, the result of emotion, such as anger or extreme jov; or (b) physical overstrain, such as accompanies the lifting of excessive weights, running long distances, or the per- forming of long-continued exercises. Bramwell (890) and Osier (892) "seem to be somewhat in- clined to the view that it is the physical strain which is the cause of the pain in angina pectoris, because it necessitates extra work by the ventricle, and, as a consequence, irritation of the cardiac nerves. (6) Angina pectoris may also be due to a raising of the intra- ventricular tension in a weakened heart. The most frequent or- ganic lesion of the heart producing angina pectoris is aortic re- gurgitation and stenosis, without an accompanying mitral lesion. When the intraventricular pressure is relieved by a mitral regur- gitation the blood is thrown back on the lungs, and the pain ceases. Pseudoanginal pain also occurs, and is frequently due to stomach disorders. The cord centers for the stomach are near the same level as the cord centers for the heart, consequently the re- flected pain and cutaneous hyperalgesia for both occur in the same area, and one is apt to be mistaken for the other (Curtin, 891). It seems that cardiac angina is often brought on by overeating, or by the eating of unsuitable or indigestible food, or food that is very apt to ferment, and thus cause dilatation of the stomach, which would press up against and inhibit the work of the heart. Character of the Pain in Angina Pectoris. — In some the sen- sation may not reach the dignity of a pain, but is felt as a creep- ing or a formication under the skin, or, in other cases, as a tingling, or coldness of the skin surface. When it does approach the magnitude of a pain it becomes very severe ; so much so that the suffering individual thinks his life is about to terminate. A ANGINA PECTORIS 785 definite characteristic of the pain of angina pectoris is that it almost always follows exertions, mental or physical. Location of the Pain. — The pain may be felt directly over the heart ; in the arms ; in the chest as a girdle sensation ; in the neck; in the gums and throat, or in the right side. Monro (32) Fig. 181. — Area of Sensory Disturbances in a Case of Angina Pectoris. A, analgesia with anesthesia; B, analgesia without anesthesia; C, hyper- esthesia. (From G. A. Gibson, 250.) mentions a case in which there was pain in the left eyebrow and in the right upper limb. This pain was accompanied by an in- tense desire to urinate. Osier mentions a case in which the pain was in the testicle. In some cases a pain equal in intensity to that usually felt over the heart is present in the arm and is entirely absent over 786 HEART DISEASE the heart. It may start in the little finger or in the forearm, and gi-adually progress up the arm until it passes over the chest to the cardiac area, where it may remain. In other cases the pain may be felt in the chest in the cardiac area (third dorsal zone), and in the forearm in the first dorsal area, the remainder of the arm being entirely free of pain. In other cases the reverse is ACCES^RY PORTION \- UPPER GANGLION OF VAGUS FILAMENT UN(TlN(b SPINAL ACCeSSORY TO OANGHON OF VAGUS. •JUGULAR FOR. A MAN •SPINAL PORTION ORIGIN BY SEVERAL FILAMENTS FR,OMTHE LATERAL TRACTS OF THE CORD •-•CER.VJCAL PLEXUS Fig. 182. — Communication between Spinal Accessory and \'agus. The tender spot at the point of emergence of the spinal accessory from the sternomastoid (in cardiac disease) is probably due to the close asso- ciation between the accessory and the upper ganglion of the vagus. true, the pain being present in the cardiac area on the chest and absent elsewhere. In nearly all these cases there is a peculiar constricting sensation around the chest, as though the body were wound with a rope drawn so tightly that breathing was inhibited. The cause of this sensation is the spasmodic contraction of the in- tercostals, such contraction being explained by the hypothesis of a visceromotor reflex. In cardiac disease pain may also be felt in the trapezius and the sternomastoid, and in the skin overlyin-^; these muscles. This pain can be accounted for by the close rela- ANGINA PECTORIS 787 tionship of the vagal centers in the medulla to the centers of the sensory nerves supplying the trapezius and sternomastoid muscles, so that an irritation of the vagal centers will produce an irritation of the sensory centers supplying the trapezius and sternomastoid and overlying skin, and, as a consequence, pain will be perceived in this area (Mackenzie). In still other cases pain has been felt in the gums and throat. It may even be located on the right side of the body, and may appear on the left side only late in the disease, or not at all. According to Hoover, the pain in the neck is in the distribution area of the third cervical segment. Spinal accessory nerve ■— rPoint of tenderness in patient suffering -s f r o m cardiovascular disease with anginal ^attacks Fig. 183. — Emergence of the Spinal Accessory from under tee Sterno- mastoid. This is the point where local tenderness is frequently present in cardiac disease. Local Tenderness. — In angina pectoris local tenderness is pres- ent at a point on the border of the sternomastoid, where the spinal accessory becomes superficial, and is also present over the second and third ribs, about one inch external to the left sternal line (Hoover). Associated Symptoms. — The symptoms associated with angina pectoris are: increase in the flow of the urine and saliva, an increased arterial pressure, shock (indicated by pallor, etc.), dila- tation of the pupils, and absolute inability to undergo any physical or mental work during the time of the attack. The feeling of approaching death is frequent. . The termination of the attack may be announced by the expulsion of the air which has been 788 HEART DISEASE drawn unconsciously into the stomach during the attack (Mac- kenzie). Myocarditis is generally free of pain, though exertion is fre- quently followed by pain and dyspnea. %Ly. \ Fig. 184. — Conducting Paths for Impulses from the Heart. The figure shows the relationship existing between the heart, the pupillary reactions, and the radiation into the arm. DP, the pupil dilating cen- ter in the base of the brain; DP, radiating fibers of the iris; MM, muscle of Miiller; LP, non-striped portion of the levator palpebrse; S, indicates the method of radiation into the arm. (Copied) DISEASE OF THE PERICARDIUM In disease of the pericardium pain may be entirely absent. When present it is located in one of the areas of reflected cardiac pain. A characteristic of pericardial disease, not so frequently present in heart muscle or endocardial involvement, is that tender- ness is marked over the cardiac area, especially so should a medi- astino-pericarditis be present. In this condition, where the in- DISEASE OF THE PERICARDIUM 789 flammation lies so close to the chest wall, pain and tenderness are present over the third rib on the left side, and extend about one to two inches from the left sternal border. This is also the area which Hoover gives for tenderness in angina pectoris, and which Head gives for the maximal tenderness in the third dorsal zone (anterior). This accord is wonderful when it is considered that the location of these areas has been worked out from different premises, Head's area being considered as the result of a stimulus acting reflexly through the cord, while Hoover's areas are re- garded as the places where the local tenderness is most marked. The tenderness of the skin and subjacent tissues in pericarditis extends for a considerable distance lateral to the right sternal margin. The pericardium of itself is insensitive to all ordinary stimuli, as Richeraud has claimed and as many others have found (during operations). CHAPTER XXXV THE EESPIKATOEY OEGANS THE LUNGS GENERAL Etiology of Lung Pain. — Pain in the segmental areas asso- ciated with the lungs may be the earliest indication of a pul- monary involvement, though in many cases there may be no actual pain manifestation, but only a feeling of discomfort in the chest wall. It seems that pain is not as common in lung disease, with the exception of pneumonia, as it is in disease of the heart. When it is present many causes are assigned, the principal one being an inflammation of the pleura. That this is a very important factor in the production of lung pain can hardly be doubted, in view of the almost universal association of a pleurisy in those lung dis- eases in which pain is a prominent symptom. Yet the visceral pleura of itself has very little sensation, as can be demonstrated during the removal of a pleural exudate, when, should the pleura come in contact with the tip of the cannula, no pain results. Mac- kenzie says that in several cases he has made careful dissections of the intercostal nerves, following them to their terminations, and that in no case could he find "a single filament going to the pleura." He suggests that the referred pain of basal pleurisy may be due to the invasion of the diaphragm by the inflammation. Distribution of Referred Pain.^ — If such is the cause, the pain of pleural disease must be produced in the parietal subjacent pleural tissue, and be carried through some of the branches of the intercostal nerves, which, though not directly connected with the pleura, are found ramifying in the subpleural connective tissue (Johnston, 538). If this were so we should expect to find pleural 790 THE LUNGS 791 pain referred to the points of maximum tenderness of the inter- costal nerves ; that is, to the points where the nerves become super- ficial. !Now, if v^e examine a case of pleurisy, with pain produc- tion, we find that this is true, the pain due to pleural lesions be- ing most often felt in the anterior axillary line, which corre- sponds fairly well with the line of the points of emergence (areas A. N. cut. brach. med. B, N. inter- costo-brach. A C, N. thoracalis longua B D, Ramus cut. lat. (pect.) intercostalis C D E, Post, ramus of the ramus of the cut. lat. E F F, LatissimuB dorse G G, Ramus cut. lat. (pect.) N. intercost. VII H H, N. intercost. IX I, N. intercost. XI I J, N. intercost. XII J K, L, N. ilio- hypogastric. K L M, Ramus cut. ant. (pect.) N. intercost, I N, M. pecto- ralis major O, Ramus mam. med. P, M. serratus ant. Q, Ramus cut. ant. (pect.) N. intercost. VII R, M. rect. ab- dom. S, Linea alba T, Rami cut. ant. (abdom.) N. intercost. IX U, Umbilicus V, Appendix area Fig. 185. — Points of Emergence op the Dorsal Nerves (Anterior). These points are, as a rule, the places where pain is complained of when the thoracic nerves are irritated. Generally, tenderness is also present in the skin immediately 'over these areas. (Spalteholz, Leipzig, 1909, vol 3.) of greatest tenderness) of the intercostal nerves. Sowever, be- cause of the close relationship of the parietal and visceral pleura it is almost impossible for one to be diseased without the other being affected, so that we always find both taking part in the inflammatory process. When the parietal pleura is inflamed it is very easy for the inflammatory process to spread and involve the intercostal nerves, and thus cause an intercostal neuritis. Should this occur, tender- ness is present in the intercostai spaces, is most marked at the 792 THE RESPIRATORY ORGANS anterior axillary line, and extends out onto the anterior wall of the chest. Pain is also felt in this area, but lies more toward the sternal margin. When the lower part of the pleura is involved resjjiration becomes very painful. This is due to the constant friction of the parts, and the slight pressure and traction made upon the supersensitive intercostal nerves during each respiratory act. Pain due to inflammation of the visceral pleura is not direct, but is referred, through the sympathetic nervous system, to the cord, and thence back to the chest wall through the spinal nerves. This reference pain is located in one or more sharply defined areas, the so-called Head zones. The zones in relation with the lungs or pleura are those of the first seven dorsal segments of the cord. The maximum points of tenderness of these zones are the places where the patient fre- quently feels the most severe subjective pain. That all these zones are involved to an equal degree in disease of the lung or pleura cannot be held. Indeed, it seems more than likely that the only zone almost constantly involved, either in visceral pleural disease or in disease of the lung itself, is the fourth dorsal, which has its area of maximum tenderness slightly above and external to the nipple, the point where the patient complains of the greatest pain. How true it is that the physician often sees cases which begin with a chill, followed shortly by a rise of tem- jjerature and an increase of pulse rate, and which, with the excep- tion of a cough, have no sign of lung involvement, except the pain in the chest above and external to the nipple ! And yet after two or three days typical signs of pneumonia appear. To those who are not aware of the relationship of pain and pulmonary disease it is surprising to find that the area of greatest pain does not always correspond with the location of the lesion; yet, from our previous knowledge, it is easy to explain this apparently erratic reference. If, on careful examination, no pleural friction rub or other sign of pleurisy at the place where the pain is felt can be found, how, otherwise, in the absence of other symptoms, can this chief THE LUNGS 793 pain be accounted for, except under the hypothesis that through the sympathetic stimuli are carried to the cord, and are thence referred back to the body walls through the somatic nerves and are there perceived as pain ? A serous pleurisy of considerable magnitude may exist with- out giving rise to the slightest pain. This has been exemplified in many cases. They were all the result of chronic disorders, ,''V\ Fig. 186. — Areas ofHyperalgesiain a Case of Diaphragmatic Pleurisy. and were associated with a backward stasis from a failing heart. In acute pleurisy pain is always a prominent symptom. In inflammation of the pleura, over the diaphragm and adja- cent to the mediastinum, the phrenic nerve may become irritated. When this occurs the irritation is conveyed to its center ; and since, according to Van Gehuchten, the phrenic conveys sensory fibers, the stimulation may be felt as coming from its peripheral distri- bution in the diaphragmatic, pericardiac, and costal pleura. If the diaphragm alone is involved in the pleurisy the pain is conveyed through the tenth, eleventh, and twelfth thoracic nerves, and is referred to their area of distribution in the lower abdom- inal wall. 79i DISEASES OF THORACIC ORGANS CAUSING PAIN 795 Of these the tenth is the nerve most frequently involved. The pain is of a characteristic dull, aching type. It may he stated as an aphorism that as a rule only acute diseases of the lung and pleura produce pain, and that chronic diseases are painless. DISEASES OF THORACIC ORGANS CAUSING PAIN The acute diseases most commonly producing thoracic pain are : lesions of the j)leura, as acute inflammation, empyema, adhesions (diaphragmatic, costal), and diseases of the lungs, which are: acute bronchitis, pneumonia, and tuberculosis. Pain, as a rule, is not a prominent symptom in the following chronic diseases: chronic bronchitis, bronchiectasis, asthma, emphysema, chronic tuberculosis, chronic pleurisy, hydrothorax, and new growths, either of the lung or of the pleura. Acute bronchitis, localized exactly in the bronchi, causes pain, which is referred to the same somatic areas as is the pain of parenchymatous pulmonary disease.^ But since all cases of bron- chitis involve the trachea to a greater or less degree, the pain is felt also in the area of distribution of the nerves supplying this organ. These nerves are the pneumogastric with its recurrent branches and the sympathetic. It is evidently the referred sensa- tion from the trachea through the sympathetic to the skin of the neck and the uj^per part of the chest that is the cause of the ach- ing and soreness in these regions, complained of so much in tracheitis and bronchitis. A pnin in the lower part of the thorax, or in the upper part of the epigastrium, is also present at times in bronchitis. This pain is the result of the traction and pull on the ribs and costal cartilages made by the abdominal muscles and the diaphragm in the act of coughing. It is present only in severer forms of bronchitis, which are accompanied by consider- able coughing. As bronchitis is often but a localization of a gen- eralized infection, pains due to this infection may at the same time be present in other parts of the body. These pains are due to the general toxemia, and are not caused by the bronchitis, ' Head gives the second dorsal visceral segment as related to bronchial disease. O to a O flfD '3 .n 0, a a o B O « > Wffi '^ -g-i V oSil 03 i=! a o o m ^- o i J2 a " a) J; t- J=.9 3 2 Q 3 3-s oj 3 " £ S .^5 s n oj a> r_; 3 X O !3 t t <1 o a-" T3 ^ <1 Q ,^2 ^ < t-H '^ ?^ <; aj T) ^-< C: O; 2 5^ ^TJ 3 o s^ cj o as tC C/J 'z Lj ni <1^ o (^ 3i ^ +J H W -^ f^ a 2 CO +f TO Q K O 2 S fo W '^ m dJ ^ Eh a o >* M W O 55 2 O m .5 .is o ^ ^ ^ S 5 o m ^ d 5Q 1 00+3 rs -s^ _ CO J2 -^ £ O ^<§ •S.s:S a I— I ^ ^ 2 a w a 706 DISEASES OF THORACIC ORGANS CAUSING PAIN 797 which, in the general involvement, is but a factor. Chronic bronchitis is without pain-phenomena. When pain is present it is due either to a myalgia or an intercostal neuralgia. Pneumonia. — Pneumonia practically always is productive of pain. Even the so-called central pneumonia causes pain. The pain of pneumonia varies. In some cases it is an aching and a dragging felt in the fourth dorsal visceral zone, while in others it extends up into the first, second, and third dorsal zones. It may also, according to Head, be found in the fifth, sixth, and seventh dorsal zones. Owing to the co-association of these lower cord zones with the lungs, the liver, and the stomach, lesions of the lungs frequently give rise to hepatic and gastric symptoms, and cause some confusion as to which of these organs is involved. In involvement of these zones the pain is frequently felt in the epi- gastrium or low down on the same side of the chest as the lesion. There are also present in these zones maximal points of tender- ness, in which pain is felt subjectively by the patient, and in which the skin is exquisitely tender to the touch. It is in these areas of maximum tenderness that pain is often referred in pneu- monia. In central pneumonia these areas of pain may be the only indications (in the early stages) of the pneumonic involvement. Other forms of pneumonia are generally associated with a pleu- risy, and the pleurisy generally monopolizes the pain syndrome to such an extent that the pain of the pneumonia proper is over- looked. When pleurisy is present tenderness may be marked over the diseased area, so that, therefore, the associated pleuris}' in pneumonia may give rise to pain felt either locally or referred to the abdomen (iliac region). This latter has been mistaken for appendicitis pain. This probably occurs only when the diaphragm is involved in the inflammatory process, in which case the twelfth intercostal nerve is irritated, and the stimulus is perceived as coming from its terminal filaments, which are distributed over the area usually associated with appendix disease. A reference of this kind frequently takes place in children, and when associ- ated with abdominal rigidity, chills, elevation of temperature, and a rapid pulse is apt to lead to the diagnosis of appendicitis. This 798 THE RESPIRATORY ORGANS is all the more likely when, as in many cases^, the signs of the pneumonia do not ajopear until tweuty-fonr to forty-eight hours after the onset of the disease. Janeway, Osier, Frantzel, Cozolina (492), Barnard, Hampe- lin, Brewer, Richardson (491), Massalong (490), Lovett (494), Ginnon (493), Comby and Zielenski (495), all report cases of this character. Yet a mistake of this kind is almost inexcusable, for in nearly all of these cases, upon a thorough examination, signs of dis- ease may be found in the thorax. In pneumonia, also, the rusty sputum, expiratory grunt, cough, rapid respiration which is out of all proportion to the pulse (respiration may be forty to sixty and the pulse only a hundred to a hundred and ten), and sudden, high elevation of temperature clearly point to the correct diagnosis. Another diagnostic sign of value is, that, in those cases in which the lung is diseased, there is noticed a slight reduction in the rigid- ity of the abdominal wall at the beginning of inspiration. This is not present in cases of abdominal inflammatory disease. The abdominal wall in pneumonia also is sensitive to superficial pres- sure and insensitive to deep pressure. Rings are absent from around the eyes, and a flushing of the cheek on the affected side is generally seen. In reference to the confusion of these two diseases, Rodman, in a discussion on referred pain before the Pennsylvania State Society, said that everyone, perhaps, has made mistakes in diag- nosing pneumonia as appendicitis. He spoke of one case, a man with an acute pneumonia, in whom pain in the abdomen was the most prominent symptom. He was asked to see the case as one of appendicitis, and concurred in the diagnosis. He was also impressed with the fact that the man had a beginning pneumonia, and declined to operate, believing that the patient's chances would be best subserved by carrying him through the pneumonia and operating for the appendicitis afterward. Another physician who was called in did not concur in this opinion, especially as the abdominal symptoms increased in severity, and as the pain was very severe and did not yield to a large hypodermic injection of DISEASES OF THORACIC ORGANS CAUSING PAIN 799 mor23hin. An operation was performed, and the appendix was found to be practically normal. A case of referred pain in pneumonia was reported to me by McFarland. It was of a child, four years of age, in whom the pain was over McBurney's jDoint Signs of consolidation were present at the base of the posterior jDart of the right lung. In anothei* patient, suffering from bronchopneumonia, the pain complained of was half way between the xiphoid cartilage and the umbilicus. In these cases of referred pains the diagnosis is all the more difScult should the pneumonic lesion be centric, though from the absence of local abdominal tenderness and the freedom from vomiting, etc., with the presence of rapid respiration, increased pulse rate, and coughing, the lungs should be considered as at fault, and a most searching examination made. One differentiating characteristic between abdominal disease and pneumonia with referred abdominal pain is that, in the pneu- monia, the skin over the painful area is very hypersensitive, but deep pressure can be made over it without causing much pain; while in appendicitis both superficial and deep pressure are very painful. Another characteristic of pneumonia is that the ab- dominal pain disappears as the pulmonary signs become more pronounced (Hood, Lancet, 1905). The pain of pneumonia may also be felt in the neck and shoul- ders. In some cases it may be transferred entirely and be felt on the side of the chest opposite to that of the lesion. Such a trans- ference is very common in infants. In infancy, pain is of doubt- ful value in making a diagnosis, because of its irregular location and frequently late appearance, for in many cases it does not appear until from three to five days after the onset of the disease. In some patients the pain present during pneumonia persists for long periods, after all the physical signs of the disease have disappeared. This continuance in the majority of cases is due to fibrous changes in the lung, or to adhesions. In a case of Anders, pain in the cardiac region, persisting for four months after the 800 THE RESPIRATORY ORGANS crisis, was shown, by tlie Roiitgen rays, to be due to a fibrous band stretching between the diaphragmatic pleura and the pericardiac sac. Tuberculosis.— In the early stages of tuberculosis, during ul- cer formation, pain is not so likely to be present as during the later stages, after an abscess has formed. At this later date, also, a pleuritis is more likely to be present, especially so if the tuber- cular lesion is in the apex. It is for this reason that pain in the supra- and infraclavicular regions is so often an early sign of pulmonary tuberculosis. During the second stage of tuberculosis the whole half of the chest on the affected side has a tired, aching feeling, not increased on deep breathing. It is during this stage, also, that pain is often a prodrome of hemoptysis. The reason for this may be that, prior to the hemorrhage, the lung, as the re- sult of increased arterial tension, is in a state of congestion, and this gives rise to pain. After the hemorrhage the congestion is relieved and the pain disappears. Coughing, likewise, possibly for the same reason, frequently increases the pain. The pain most commonly associated with coughing is localized to the area of insertion of the recti muscles into the costal borders. In some cases of pleurisy the inflammation spreads to the intercostal nerves and a neuritis develops; the pain is now felt over the lateral and anterior parts of the chest. The branches joining the nerves of the arm to the second and third intercostal nerves may also become involved, and then the pain runs do"\\Ti the inner side of the arm, in the area of distribution of the nervi intercosto- brachiales (intercostohumeral nerves). Character of the Pain in Pulmonary Tuberculosis. — In some cases there may be only a sense of discomfort or a feeling of dis- tress in the chest, while in others actual pain may be present. In many there is a sensation as though the pain extended all the way through to the back. It may be constant or fleeting. Tenderness is a marked feature of early pulmonary tubercu- losis; and, according to Francke, appears before many of the other symptoms. Tenderness is elicited by percussion, and is most marked in the apex. It is probably due to involvement of the sub- DISEASES OF THORACIC ORGANS CAUSING PAIN 801 jacent pleura. This percussion pain Francke found present in about 77.9 per cent, of all eases of pulmonary tuberculosis. When search for this percussion is to be made high up over the back, the anterior fibers of the trapezius are displaced to one side, by Pain and tender- ness in pulmo- nary tuberculosis J Pain felt here on percussion over the lungs Area of maximum tenderness in heart disease Fig. 191. — Some op the Areas of Pain and Tenderness in Cardiac AND Pulmonary Disease. having the patient bend forward and fold his arms, so that the percussion blows may be made as directly as possible over the chest. x^ccording to Klebs, in pulmonary tuberculosis tenderness is very common above the clavicles, anteriorly and posteriorly, and between the scapula posteriorly. A pain above the shoulder is 802 THE RESPIRATORY ORGANS felt with each cough, and pain on every movement of the arm may be present and is often mistaken for rheumatism. Other causes of thoracic pain in pulmonary tuberculosis may be myositis, nervous erethism, pulmonary congestion, pressure from enlarged glands, localized fatigue of the muscles used in respiration or in coughing, contraction of old cavities, traction by adhesions to j)leura or to the heart, pneumothorax, tuberculosis of the ribs, and referred pain. The intercostal muscles may also become involved in the in- flammatory process, and intercostal myositis may] develop. The muscles are now extremely painful to touch or to movement, and, owing to the jiain, resjiiration is restricted. If a pleurisy has ensued during the lung involvement, and ad- hesions have formed between the pleura and the pericardia, pain results. This may be felt both during respiratory movements and cardiac contractions ; in fact, it is pathognomonic of this variety of pain that it has an alternating character, due to the variation of pressure from the changed relationship of the heart to the sur- rounding tissues. Pressure over the places where traction is made upon the chest wall by the adherent pericardium and pleura is painful. When during tuberculosis a pneumothorax results, a sudden, agonizing pain is felt. This may be so severe that it resists all medication, even morphin. It is said by Clement that pronounced neuralgia, marking the onset of tuberculosis, is a very grave prognostic symptom. L. Brown claims that a stubborn pain, when coincident with a poor general condition, chills, and fever, is fre- quently an indication of a deep focus which is extending toward the periphery of the lung. THE MEDIASTINUM The mediastinal diseases causing pain arc aneurysm, medias- tinal inflammation, abscess, and enlargement of the mediastinal glands. The pain comjDlained of is both local and reforrtd. The local pain is due to the pressure of the gi-owths on the surrounding THE MEDIASTINUM 803 structures, which, in turn, causes pressure on the anterior chest wall and jDain production. The referred pain is due to involve- ment of the nerves in the diseased process. Pain is common in the epigastrium, and may be j^resent in the early stages. Pain may also be present in the back. In one case of mediastinal sar- coma it was present on each side of the chest over the scaj)uliae. In some cases of mediastinal tumors, especially in those of a ma- lig-nant nature, the pain is due to an intercostal neuralgia, the result of infiltration of the intercostal nerves by the tumor cells. Aneurysm of the arch of the aorta, or of the thoracic aorta, ca-uses but few painful symptoms except those due to pressure. When the aneurysm extends and lies just beneath the sternum, and begins to push its way through, causing necrosis of the bone, a boring, gnawing pain is felt. At this time marked tenderness over the diseased area is present. The esophageal pains have been described under the esophagus (q. v.). BIBLIOGRAPHY Abbe, E. 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BIBLIOGRAPHY 867 WuxDT^ H. (458, 535). "Grundziige der physiologischen Psycholo- gie." 5te Auflage, ii, 1; -ite Auflage, i, 111-112; 3te Auflage, i. 115-116, 290, 508-509. (508). "Lehrbuch der Physiologie des Mensclien," 503, 1074. WtJRTZEX. '"Eeferred Pain in Forty-four per Cent, of Three Hun- dred and Seventy-six Cases of Tuberculosis of the Lungs." Zeit- schrift fiir Tuberkulose, 1906, viii, 290. WuTZEE^ C. W. "Ueber ortliche Anwendung von betiiubenden Mitteln zur Schmerzstillung."' Rheinisehe Monatshefte f. prakt. Aerzte, Koln, 1851, V, 159-162. Xenophox's Anabasis (340). "Wound of Abdomen." See Index under JSTikarchos. Yates^ H. W. "Abdominal Pain, Its Clinical Significance." Jour. Mich. Med. Soc, Detroit, 1908, vii, 237-243. Yawger (772). J. A. M. A., 1, No. 17, 1310. Y^'eeo^ J. B. "Why Is Pain a Mystery ?" Contemp. Review, London, 1879, XXXV, 630-647. Young (908). British Med. Jour., Apr. 14, 1906. Y^ouNG, Hugh (733). Osier's "System of Medicine," iv, 331. Ziehen. "Krankheiten des Gehirns," in Ebstein-Schwalbe's ''Hand- buch der praktischen Medizin." Stuttgart, 1905. (462). "Leitfaden der physiologischen Psychologic." Jena, 1911, 5te Auflage, 53 (Gustave Fischer). Zielinski, C. (495). "Pneumonie simulant I'appendicites." Archiv. de med. des enfants, Dec, 1902, 741. ZiEMSSEN, 0. "Heilung der Ischias." Ztschr. f. Phys. u. diet. Therapeutics, Leipzig, 1907-08, xi, 678-681. INDEX Abdomen, divisions of, for localiza- tion purposes, 395, 396 lesions of, causing epigastric pain, 396, 397, 398 localizing center for pain, 307 muscular inflammation of wall of, 361 shoulder pains in lesions of, 392 use of, in estimating susceptibil- ity of patient, 124 zones of, 395, 396 Abdominal adhesions, causes of, 368, 369 groups of, 369 Abdominal incisions, 415 Abdominal inflammation, thoracic breathing in, 127 Abdominal pain, absence of, in lesions of abdomen, 416 areas of tenderness with, 394 associated with arteriosclerotic condition of arteries, 121 causes of, 307 characteristics of intestinal lesions causing, 469 classification of, 360 concentric palpation in, 394 conditions associated with, 413 diagnosis of, 390 differential diagnosis of, 414 table of, 376, 412 distinguished from hysterical pain, 414 due to biliary disease, 401 due to contraction and dilatation, 390 due to diaphragmatic traction, 307 Abdominal pain, due to extrav- asations of septic material, 400 due to functional processes, 400 due to incisions, 415 due to intestines, 401 due to irritation of the sympa- thetic fibers, 399 due to new growths, 362 due to pancreatic disease, 401 due to passive dilatation, 390 due to perforation in typhoid, 402 due to shock, 400 due to the stomach, 401 due to traction on the mesentery, 390 effect of, on diaphragm, 394 epigastric, 396 examination for, 394 forms of, 408 functional, 409 gastralgia, 409 hysterical, 360 in bowels, 372 in cysts, 399 in hernia, 371 indicanuria with, 414 intestinal lesions suggested by, 470 lesions causing, 408, 409 localization of, 394 organ producing, 395 muscular layer of wall as seat of (McKenzie), 360 myalgia, 362 nature of, 390 neuralgia, 361, 409 neuritis of intercostal nerves, 362 869 870 INDEX Abdominal pain, objective, 360 of the peritoneum, 362 of pneumonia, 392 organs causing, 408 points of reference of, 391 polyuria with, 414 post-operative, 415 posture in diagnosis of, 406 presence of, in neurasthenics, 409, 410 pressure in, 406, 407 referred, 307, 391, 392 to extra-abdominal regions, 416 reflected, 391, 392 regional, 393 relationship of, to defecation, 401 to ingestion of food, 400, 401 to menstruation, 401 rigidity of muscles with, 413 skin as seat of, 360 spasm of muscles with, 413 subjective, 360 sympathetic, 393 tenderness, maximum points of, 393 toxemia with, 414 transferred, 392 transmission of, in the peri- toneum (Lennander), 363 visceromuscular reflex with (Mac- kenzie), 413 Abdominal protective position, 126 Abdominal tenderness, 403 causes of, 404 indications of, 404 in tubal disease, 720 means of determining : percussion, 404 palpation, 405 Abdominal visceral disease, pain perception in, 377 Abscess, "closed" extradural, 338 extradural. See Extradural ab- scess. gas, 338 Abscess, hepatic, 553 in areola, from fissured nipple, 258 ischiorectal, 509 of the brain. See Brain abscess, of the hip joint, intraarticular, 244 of mastoid process, 336 of the ovary, 751 of the spleen, 601 "open" extradural, 338 perianal, 512 perisinus, 338 peritonsillar, 340, 351 retrophaiyngeal, 352 Adenoid vegetation of nose, 343 Adenolij^omatosis, symmetiical, 224 Adhesions, abdominal, causes of, 368, 369 groups of, 369 after intussusception, 498 appendieial, 519 epigastric pains from, 398 from tubal inflammation, 746 gastric, 369 hepatic, 553 intestinal, 370 distention due to, 492 of the bladder, 684 of the gall bladder, 563 of the omentum, 368 of the ovary, 752, 754 pelvic, 370 point of tenderness in, 405 perigastric, 459 perihepatitis causing, 560 peritoneal, 371 increased pain by tension, 368 nature of pain from, 367, 368 visceral, absence of pain in, 368 Adiposa dolorosa, associated condi- tions of, 225 differentiated, from other forms of adiposity, 224 from sciatica, 168, 169 fatty areas of, 224 INDEX 871 A d i p o s a dolorosa, hypophyseal symptoms, 225 pain as a feature of, 224 Adiposis cerebralis (of Frohlich), 224 Adiposity, forais of, 224 tuberosa (of Anders), 224 Aditus laryngis, tuberculous affec- tions of, 354 Adrenals, hemorrhage as cause of pain in, 259 Akinesia algera, 219 Alcohol, neuralgia due to, 142 Algometers, 68 in measuring pain, 130, 131 Alimentary tract, pains of, 418 referred pains in, 425 Alkalies, uses of, 119 Amblyopia, concentric contraction of %asual field from, 135 Amputated limb, imagined sensa- tions in, 104 projection pain in, 103 visualisation of, 103 Anal fissure, 510 acute pains of, 511 description of pain in, 511 reflex pains of, 512 Anemia, back pains due to, 304 chronic, of the brain, 181 pernicious. See Pernicious anemia. Analgesia, 61, 62, 63 area of distribution in a hysteri- cal subject, 78 central, 61 endogenous, 61 exogenous, 61, 63 extiinsic, 63 peripheral, 61 toxic, 62 tabes producing, 66 voluntaiy, 62, 63 Anemic headaches, 272 Anesthesia, 61, 63 by freezing, QQ Anesthesia, by interference with pain perception areas, 64 by ischemia, 66 by pressure, 64 cord tumor accompanied by, 65 dissociation of pain and touch under incomplete, 34 electric current causing, 65 lesions within nerves producing, 66 of hysteria, 76, 77 of leg, by skull fracture, 64 paresis causing, 65 pei'ipheral causes of, 65 pressure in nerve sheath produc- ing, 66 on a nerve trunk producing, 66 reflex protective action in, 122 severance of nerve pathways pro- ducing, 65 severance of posterior roots pro- ducing, QG syringomj'elia causing, 66 transverse myelitis causing, 66 Anesthesia dolorosa, 66 in neuralgia, 144 Aneuiysm, importance of pain as a symptom in, 255 neuralgia from, 142 of arch of aorta, 803 of the arteries, 254 of the brain arteries, 187 pressure indicating, 127 Angina pectoris, associated symp- toms of, 787 character of pain in, 784 distingaiished from gastric ulcer, 451 etiology of, 783 local tenderness in, 787 location of pain in, 785 similarity of, to aortitis, 250 sjTnpathetic pain due to, 103 Animals, sensation in the lower forms of, 1, 2, 3, 4 Anus, pain in, 509 872 INDEX Anus, pain in disease of, from def- ecation, 117 Aorta, arteriosclerosis of, 251 inflannnatiou of, 250 Aortitis, description of pain of, 250 time of onset of, 251 Aphasia, from tumors of the fron- tal lobe, 184 Appearance of patient as means of measuring intensity of pain, 120, 125 Appendicial disease, ingestion of food in, 116 pain from defecation in, 118 transfen-ed pain in, 107 Appendicial inflammation, aben-ant pains with, 527 Appendicial pain, distant, 519 due to adhesions, 519 due to inflammation, 517 due to obstruction, 517 left-sided, 527 local, 516, 517 referred, 516, 519 reflex, 517, 521 transferred, 516, 520 varieties of, 516 Appendicitis, colon involvement with, 527 constipation with, 535 differential diagnosis of, 537, 538, 539 increase in sensibility to pressure in, 536 induction of pain by peristalsis, 537 interference with, motion in, 535 jarring pain from, 536 nocturnal pains of, 111 pain from motion in, 117 pain induced by peristalsis in, 537 pain production in. symptoms as- sociated with, 535 posture assumed in, 536 pressure on the abdomen in, 536 Appendicitis, rigidity of the right rectus with, 535 sympathetic pains with, 527 symptoms associated with pain production in, 535 tenderness in, absence of, as a symptom, 531 as a symptom, 529, 530 locations of, 533 points of, 534 varieties of, 532 Appendix, adhesions of, 519 description of, 514 diffuse pain in, 515 epigastric pain from lesions of, 397 hyperalgesia in, area of, 527 indications of, 525 hyperesthesia in, pointing to in- flammation of, 524 inflammation of, 517 without symptoms, 516 obstruction in, causes of, 517 pain in, 514 vermiform, diseases of, 529 Apraxia, 1S5 Areas, cutaneous, relating to spinal cord segments, 56 indefinite, of pain, 48 of distribution, of hysterical pain, 78, 79 of lumbar segments, diagram of, 57 of nerves from lumbar plexus, 52 of nerves from sacral plexus, 53 of sacral and lumbar segments, diagram of, 57 of sensoi-y fibers, 51 of sensory fibers in posterior root, 51, 54 of hyperalgesia, 69, 70 of maximum tenderness and cord zones, 59 of pain perception, interference with, 64 INDEX 873 Areas of peripheral sensory fibers, 50, 51 of sensory nerves, 47, 48 of tenderness, 72 surface, relating to visceral dis- ease, 4, 5 Arsenic, neuralgia due to, 142 terminal anesthesia by, 67 Arterial congestion, 273 Arterial pressure, increase of, caus- ing headache, 272 Arterial system, functional activity of, causing pain, 249 Arteries, aneurysm of the, 254 diseases of, causing pain, 249 Arteries, inflammation of, 250 mesenteric, embolism of, 253, 254 thrombosis of, 253, 254 thrombosis or obliteration of, 248 Arthralgia. See Joint pains. Arthritis, gonorrheal, 238 symptoms of, 235 Arthrotomy, in intra-articular hip joint abscess, 245 Ascending path of sensory fibers^ 45 Aspect theoi-y of pleasure and pain, 18 Associated pains, 90 crossing of fibers in, 92 diffusion of stimuli in, 92 examples of, 92 hypochondriasis not manifested by, 93 hysteria not manifested by, 93 in neuralgia, 146 physiological relationship between areas of, 94 relation between irritated and sympathetic points, 93, 94 Asthenopic disorders, 330 Astigmatism, 330 Atrophy, of liver, acute yellow, 561 of muscles, in neuralgia, 146 resulting from pain, 135 Auditory canal, external, pain in, 333 Autonomic sympathetic nervous system, 12 Autosuggestion, 116 Autosuggestive sensations, 75 Autotoxic substances causing neu- ralgia, 141 B Bacillus pyocyaneus, 333 Back, localizing center for pain in, 296 Back pains, due to heart and aorta affections, 301 due to hystei'ia, 304 due to intestines, 302 due to kidneys, 302 due to liver and gall bladder, 302 due to lung affections, 300 due to menstruation, 303 due to pregnancy, 303 due to spinal cord lesions, 207 due to static foot errors, 304 due to stomach affections, 301 due to uterine disorders, 726 due to visceral lesions, 208 in anemia, 304 indications from, in different re- gions, 312, 313, 314, 315 muscular, 296 in myalgia, 297 of chlorosis, 304 over the coccyx, 300 refeiTed, 300 from genito-urinary organs, 304 from ovary, 303 from pancreas, 303 from spleen, 303 from uterus, 303, 304 rheumatic, 296 vertebral, 299 Bacteria, productive of muscular pain, 218 Belladonna, terminal anesthesia by, 67 874 INDEX Bile duet, twist of, from liver dis- placement, 559 Biliary cirrhosis, 554 Biliary colic, ingestion of food and drink, effect of, case cited, 574, 575 Biliary passages, cancer of, 577 Bladder, adhesions encompassing, 684 anatomy of, 672 cord zones in relation with, 674 diseases of, causing pain, 676 distention of, 684 foreign bodies in, 691 general considerations of, 672 inflammation of. See Cystitis. nerve supply to, 672 rupture of, 685. tuberculosis of, 690 tumors of, 689 Bladder disease, associated symp- toms of, 682 differential diagnosis of, 683 tenderness in, 681 Bladder lesions, differential diag- nosis of, 686 Bladder pains, causes of, 676 character of, 678 cold air, effect of, on, 681 diseases causing, 683 drugs, effect of, on, 681 food and drink, in relation to, 681 location of, 678 position of patient in, 680 production of factors influencing, 681 reference areas of, 675 reflected, 679 time of attacks of, 680 urinai-y, relation to motion of, 681 Bladder tuberculosis, associated symptoms of, 691 causes of pain in, 690 character of pain in, 690 location of pain in, 691 Bladder tuberculosis, production of pain in, factors influencing, 691 time of pain in, 691 Blood, changes in, causing pain, 247 decreased alkalinity of, causative factor of pain, 28 diminution of supply of, causing pain, 248 diseases of, 248, 249 increased supply of, causing pain, 247 Raynaud's disease of, 248 Blood pressure, elevation of, in labor, 121 in measuring intensity of pain, 120 hyperemia consequent upon varia- tions in, 62 increase of, 251 sudden alterations of, causing pain, 26 Blood supply, determining suscepti- bility of an organ to pain, 113 Blushing, 124 Bones, cause of pain from motion of, 117 changes in structure of, 231 freedom from pain in, 113 lesions of, differentiated from in- durative headache, 267 from those of the overlying structure, 226 Bone pains, character of, 228 continuous, 227 diagnostic value of diurnal varia- tion in, 228 differential diagnosis of, from bursitis, 233 from hysteria, 234 from neurotic ostalgias, 233 general considerations of, 226 generalized, 232 in carcinoma, 233 in chloroma, 233 INDEX 875 Bone pains, in hematopoietic system lesions, 233 in leontiasis ossea, 233 in lymphadenoma ossium, 233 in myeloma, 233 in osteitis deformans, 233 in sarcoma, 233 in spurs, 233 localized, 228 in contusions, 230 in fracture, 229, 230 in new growths, 230 in periosteal lesions, 229 in traumatism, 229 pressure, intermittent, 227 septic involvement in, 231 spontaneous, intermittent, 227 syphilitic, dull aching chai-aeter of, 228 nocturnal aggravation of, 228 tuberculous nocturnal aggravation of, 228 types of, 227 Bony pi'ocesses, neuralgia from, 142 Bowel, colic of, gas with, 486 distention of, 491 inflammation of, 484 involvement of adjacent struc- tures in, 486 peristalsis with, 486 symptoms of, 486 tenderness with, 486 obstruction of, absence of pain in, 495 causes of, 492, 495 pain of, areas of tenderness in, 372 distinguished from hernia, 372 due to distention by gas, 373 Brachial neuralgia, 147, 150 associated symptoms, 161 bilateral pain in, 155 brachial plexus as seat of, 150, 151 character of pain of, 159 Brachial neuralgia, differential diag- nosis of, 155, 158 table of, 162, 163 distribution areas of, 151, 152, 153 localization of, 158 location of pain in, 159, 160 tenderness in, 161 unilateral pain in, 155 Brachial plexus, area of distribution of, nerves derived from, 152 description of, 150, 151 distribution areas of cords com- posing, 155 of cutaneous nerves of upper limbs, 154 neuralgia from lesions in, 150, 151 Brachialgia, brachial neuralgia, 159 Brain, abscess of, as cause of head- ache, 271 ditferential diagnosis of, 195, 196 headache and other symptoms of, 181, 182, 190, 191 origin of, 181 aneurysm of arteries of, 187 hemorrhages, differential diag- nosis of, 196 pain in legs as forerunner of, 305 hypei'emia of, 181 metabolism, disturbance of, in hysteria, 77 pain in diseases of, 140 parasites of, 187 syphilis of, 188 substance, diseases of, unaccom- panied by headaches, 178 headaches originating in, 176, 177, 178, 179 syphilis of, differential diagnosis of, 196 tumor of, causing headache by in- tracranial pressure, 270 diagnostic symptoms of, 270 876 INDEX Brain, differential diagnosis of, 195, 197 headache and other symptoms of, 182, 190, 191 tumors of the base of, 186 Break-bone fever, backache -with, 298 Breast, carcinoma of, 259 diseases of, table of, 260 pains, correlation through nervous system with uterus of, 715 pains in, 258 Bright's disease, ulceration accom- panying, 509 Bronchitis, acute, 795 Burns, ulcers following, 489 Bursitis, distinguished from bone pains, 233 Calculus, progress of descent of, 610 Calculus pain, character of, 658 etiology of, 655 location of, 659 Cancer, of the biliary passages, 577 of the pancreas, 491 of the stomach, 452, 453, 454, 455 of the uterus, 744 of the vulva, 756 Carbolic acid, terminal anesthesia by, 67 Carcinoma, effect of ingestion of food in, 116 of the bones, 233 of the breast, 259 of the gall bladder, 57 of the larynx, 358 of the rectum, 507 of the stomach, 455 Cardiac disease, differential diag- nosis between intercostal neu- ralgia and, 781 Cardiac pain, degeneration of car- diac gangUa as cause of, 782 Cardiac pain, mitral regurgitation as cause of, 782 raising of intraventricular ten- sion as cause of, 782 origin of, cardiac, 782 gastric, 782 Cardiospasm, 436 cause of pain in, 437, 438 character of pain in, 438 contraction in, 437, 438 tension pains of, 437 Caries of the vertebral canal, 210, 211 differential diagnosis of, from neurasthenia and hysteria, 210 Catarrh, of middle ear, 339 Catarrhal ulceration of the intes- tines, 489 Cartilage, lack of pain in, 113 Caudal lesions, 209 Cell areas, superimposition of, for motion and sensation, 10 Centers of memory, for pain, 24, 25 Centers of motion, 173 of perception, for pleasure and pain, 21, 22, 23 of sensation, 173 of the senses, 173 Central ganglion, tumors of, 185 Central nervous system, 172 anatomy of, 173 back pains connected with, 208 courses of fibers of, 174 diseases of, 179 origin of headache, 175 thalamic pains of, 198 tumors of, 183 Ceptors, noci-, 29 nocuous. See Noci. Cerebellar abscess, 339 Cerebellar ataxia, sj^nptoms of, 185 Cerebellum, as a sensory organ, 11, 12 tumors of, 185 INDEX 877 Cerebral arteriosclerosis, headache as symptom of, 274 Cerebral congestion, as cause of headache, 272 brain fluid increased by, 272 due to increased arterial pres- sure, 272 predisposing factors to, 273 Cerebral hemorrhage, differential diagnosis of, 198 Cerebral tumor, as a cause of head- ache, 269 Cerebrospinal fibers, of the abdom- inal viscera, 378 Cerebrospinal fluid, increase of, causing headache, 276 Cerebrospinal system, development of, 32 Cervical lesions, 209 Cervical stenosis, dysmenorrhea from, 729 Cervicitis, 742 Cervix, spasmodic contraction of, 730 ulceration of, 743 Cervix uteri, sensibility of, 709 Cheeks, pain in, 418 Chemical action, as stimulus of sen- sation, 5, 6 Chemical changes, pain due to, 27 Chemical irritations, parenchyma- tous pains from, 88 Chemotropism, 1 Chest, localizing center for pain, 310 pain in. See Chest pain, thoracic walls of, 760 Chest pain, causes of, 310, 760, 767 diagnostic points on, 768 from diseased lung, 767 from stomach distention, 766 Chest wall, localization of pain in, 767 Childbirth, normal, 738 Chloral, effect on blood pressure ele- vation, 120 Chloroma, 233 Chlorosis, back pains of, 304 symptoms of, 181 Choked disc. See Papilledema. Cholangitis, 572 catarrhal, 577 suppurative, 577 Cholecystitis, 569 accompanying gallstone, 576 distinguished from gastric ulcer, 450 Choroid, pain in, 328 Cicatrices, neuralgia from, 142 Ciliary body, pain in, 325, 326 Ciona intestinalis, 2 Circulation, affection of, by pain, 134 Circulatory system : arteries, 249 blood supply, 247 veins, 255 Circumflex neuralgia, 147, 164 causes of, 164 distinguished from rheumatism of shoulder joint, 164 Cirrhosis, biliary, 554 of the liver, 552, 554, 556 chronic atrophic, 561 Claudication, intermittent, 251 Clavicular pains, 310 in extrauterine pregnancy, 392 Cocain, effects of, 119 terminal anesthesia by, 67 use of, 106 Coitus, pain in, 717, 756 Cold, causing pain, 28 neuralgic pain from exposure to, 142 physical factor of pain, 118 "Colds," productive of muscular pain, 218 Colic, 436 associated with uremia, 484 causes of, 223, 481 constant pain in, 483 due to contraction, 223 due to overdistention, 223 878 INDEX Colic, due to pressure, 223 due to tension, 223 due to traction, 223 hypotheses of cause of, 482 intensity of, 483 intermittent pain in, 483 intestinal, differential diagnosis of, 484, 485 due to plumbism, 484 without bowel lesion, 484 location of pain in, 482 morphin in, 125 muscular movement in, 125, 126 nocturnal pains of, 111 onset of, 482 pain of, 388 posture in, 126 pressure in, 126 type of pain in, 483 variations of, 222 Colitis, chronic, 502 mucous, 503 ulcerative, 501 Colon, displacement of, 503 distention of, 504 infective states of, 501 inflammation of, 501 spasm of, 502 tumor formation due to displace- ment of, 505 Colon spasm, description of, 479 Colonic disease, effect of ingestion of food in, 116 Colonic involvement, in intestinal pain, 500 Concentric palpation, 394 Conducting apparatus for pain, 29 Conducting fibers, pressure on, 29 Congestion, arterial, 273 causing affections of nerve trunks, 140 cerebral, as cause of headache, 272 Conjunctiva, discomfort from tear secretions in irritations of, 324 foreign bodies in, 324 Conjunctiva, pain in, 322 Conjunctivitis, severity of pain in, 323 stretching of the lid in, 324 Consciousness, 4 classes of, 5 loss of, in anesthesia, 63 from emotion, 133 from pain, 132 modifying pain production, 115 objective, 5 obtunded, 63 senses in relation to, 5 subjective, 5 Constipation, colicky pains due to, 509 neuralgic pain due to, 509 Contact, dependence of sensation on, 6 Contraction, of a hollow organ, 25 Contrary innervation, law of (Melt- zer), 388 Contusions of bcnes, 230 Conveying channels for sensations, 35 deep, 37, 38 epicritic, 37, 38 protopathic, 37, 38 superficial, 37 Cofivolutions, of sensory area, 10 Copper, as cause of neuralgia, 142 Cord, pain in diseases of, 140 Cord tumors, 95 causing anesthesia, 65 Cord zones, areas of maximum ten demess of, diagram of, 59 diagram of, 55 Cornea, erosions of, 324 foreign bodies in, 324 pain in, 322 perforation of, 325 sensibility to light in lesions of, 323 tear secretions from irritation of, 324 INDEX • 879 Corneal herpes, 325 Corneal toxemia, 325 Corneal ulcers, 325 Corpora quadrigemina, tumors of, 185 Corpus callosum, tumors of, 184 Cortex, absence of central objective pain in, 82 differential diagnosis between dis- eases of the thalamus and, 203, 204, 205, 206 interrelations between the thala- mus and, 200 Cortical lesions, unproductive of pain, 82 Cortical tissues, pain receptors lack- ing in, 82 • Cowper's glands, inflammation of, 703 Cutaneous areas, relating to spinal cord segments, diagram of, 56 Cutaneous distribution of nerves, diagram of, 56' Cutaneous hyperalgesia, relating to areas of visceral disease, 54 Cutaneous sensorj' nerve supply, diagram of, 49 Cystalgia, 683 Cystic disease, of the kidney, 645 of the pancreas, 491 Cysticercus cerebri, 187 Cystitis, 685 associated symptoms of, 689 attacks of pain in, factors in- fluencing, 688 character of pain of, 685 location of pain of, 687 referred pain of, 687 tenderness in, 688 Cysts, abdominal, 399 of the breast, 259 of the liver, 555 of the spleen, 602 ovarian, 399, 753 D Defecation, physical factor of pain in, 117 Deflected pain. See Reflected, 104. Delayed pains, 34, 111 Delirium tremens, differential diag- nosis of, 197 Deranged metabolism, causing neu- ralgia, 141 in influenza, 141 in senility, 141 Deterioration, physical, causes of. 134 Diagnosis, care in, 410 errors in, 410, 411, 413 intensity of pain a factor in, 114, 120 manual reproduction of pain in an organ in forming a, 132 sensory examination in forming a, 132 Diaphragm, crippling of, from ab- dominal pains, 394 pull on, from liver displacement, 558 Diarrhea, with intestinal pain, 475 Digestion, physical factor of pain in, 116 Dilatation of pupils, by pain, 73 causes of, 125 drugs causing, 125 means of measuring pain inten- sity, 120, 125 Dilatation of the stomach, acute, 439 from pyloric spasm, 438 Diphtheria, pains of, 352 Displaced kidney. See Movable kidney. Displacement, of the ovary, 749 of uterus, 726 Dissociation of pain and touch, 32, 33, 34 Distention, in intussusception, 498 of the bladder, 684 of the bowel, 491 880 INDEX Distention, of the liver, 551 Distribution areas, of nerves from lumbar plexus, 52 of nerves from sacral plexus, 53 of peripheral sensory fibers, 50, 51 of sacral and lumbar segments, diagram of, 57 of sensory fibers, 51, 54 Diurnal pains, 110 Diversion of attention modifying pain production, 116 Dorsal lesions, 209 Dorsal nerves, diagram of, 54 Dreams, subjective pain in, 75 Dream state, pain perception in, 31 Duct disease, effect of ingestion of food in, 116 Ducts, genital, 699 Duodenal ulcers, 489, 490 distinguished from pyloric, 450 ingestion of food in, 116 pain of, 388 Drugs, analgesia produced by, 63 pain production modified by, 119 predisposition to neuralgia by use of, 143 Dysenteric proctitis, 507 Dysmenorrhea, causes of, 729 differential diagnosis of, 757 membranous, 730 ovarian, 734 prevalence of, 728 Dysphagia, in pharyngeal affec- tions, 353, 354 in tuberculous laryngeal ulcers, 358 Dyspnea, in the alimentary tract, 425 E Ear, acute otitis media of, 335 external, 332 foreign bodies in the external auditory canal of, 334 frost bite of, 333 Ear, furunculosis of, 333 herpes of drum of, 335 labyrinth diseases of, 340 middle ear, catarrh of, 339 chronic discharge from, 336 complications of disease of, 337 disease of, 335 position assumed in lesions of, 334 pus in, 337, 338 suppuration of, 337 myringitis bullosa, 335 othematoma of, 332 otitis externa diffusa, 334 otosclerosis, 339 pain in diseases of, 332 in drum membrane of, 335 in external auditoiy canal of, 333 severity of, 332 perichondritis of, 332 reference areas for pain of, 335 referred pains of, 340 tumors of, 333 Ectopic pregnancy, epigastric pains from, 397 Eczema introitus, pain caused by, 342 Edema, presence of, in kidney area, 618 Electric current, anesthesia by, 65 Electrical reactions causing pain, 28 Electricity, faradic current of, 118 measuring pain by, 130 physical factor of pain in, 118 static spark of, 118 Embolism, 198 differential diagnosis of, 196 of mesenteric arteries, 253, 254 Emotion, 14 fatigue resulting from, 76 loss of consciousness from, 133 Emotional pains, 76 Emotional shock, inducing hysteri- cal pain, 79 INDEX 881 Emotions, modifying pain produc- tion, 115 phenomena accompanying, 132, 133 physical results of, 30 Empyema, acute, diagnosis of, 348 diseases in body related to, 344 headaches arising in, 343 treatment of, 348, 349 Encephalitis, from electric current, 65 Encephalitis haemorrhagica, differ- ential diagnosis of, 196 Endarteritis obliterans. See Inter- mittent claudication, 248. Endocarditis, differentiation between acute and chronic and re- curring, 780 Endogenous analgesia, 61 Endometritis, 730 character of pain in, 741 diagnosis of, 742 dolorosa, 731 involvement of adjacent structures in, 741 tenderness, demonstrated by a sound, 741 Endometrium, fissured state of, 734 sensibility of, 709 Endonasal operation for neuralgia, 350 Endonasal therapy, uses of, 342 Endurance, complaints of patients compared with, 120, 123, 124 Enlarged uterus, neuralgia from, 142 Enteralgia, 476 mistaken diagnoses of, 476 Enteroptosis, effect of constipation in, 118 Enterospasm, 478 causes of, 480 mistaken diagnosis of, for peri- tonitis, 480 primary pain of, 478 secondary pain of, 479 Enterospasm, tenderness associated with, 483 Eosinophilia, differentiated from acute polymyositis, 221 Epicritic fibers, 37, 38 Epieritic system, 37, 39, 47 of Head, 12 EpididjTuis, pain in, 699 Epigastric hernia, 375 distinguished from gastric ulcer, 450 Epigastric pains, character of, 398 lesions causing, 396, 397, 398 organs causing, 397, 398 suspected lesions in diagnosis of, 398 Epigastrium, lesions causing pain in, 396, 397, 398 organs causing pain in, 397 Epiphyseal disease (Marburg, Jel- liffe), 224 Equilibrium, loss of, from pain, 134 Erythromelalgia, 252, 253 Esophagus, effect of ingestion of food in disease of, 116 hyperesthesia of, 424 localization of pain in, 425 obstructions of, 425 pain in, 424 paresthesia of, 424 Esthesiometers, 68 Ether, effects of, 119 Evolution, factor in relation of pain to other sensations, 31, 32 Exogenous analgesia, 61, 63 Exposure to cold, neuralgic pain from, 142 External ear, trauma of, 332 External senses in the fetus, 12 Extracranial head pains, 265 Extradural abscess, differential diagnosis of, 195 Extrahepatic disorders, 557 Extraneural causes of neuralgia, 142 Extraparenchymatous jDain, 557 882 INDEX Extrauterine pregnancy, differential diagnosis of, 747 pain in, 746 Extrinsic analgesia, 63 Extrinsic factors modifying pain production, 116, 118 Extroeeptor sense organs, 12 Eye, action of stimuli on retina of, 316 asthenopic disorders of, 330 astigmatism of, 330 consciousness of normal retinal stimuli of, 316 diurnal pain of, 110 fifth nerve the seat of sensation in, 317 intensity of pain in, 316 lacrimation, 317 normal retinal stimuli to, 316 painful stimuli to, 316 pain ill, diagnosis based on locali- zation of, 318 duration of, 317 etiology of, 317 ill the choroid, 328 in the ciliary body, 325 in the conjunctiva and cornea, 322 in the iris, 325 in the lids, 318 in the optic nerve, 328 in the retina, 328 in sclerotic coat, 327 in surroundings, 322 localization of, 318 quality of, 316, 317 phthisis of, 328 reflex phenomena connected with, 318 sensations of, disagreeable and painful, 316 significance of pam in diseases of, 316, 318 tender pressure points of, 322 topography of, 317 trigeminus irritation of, 317 Eye, various painful disturbances of (Bielschowsky), 331 Eyelids, as source of pain, 318 diagnostic value of pain localiza- tion in, 319 herpes zoster of, 319, 320 inflammation of, 318 neuralgia of, 320 Eye muscle, rheumatism of, 328 "Eye-strain," 331 F Facial expression indicating pain, 127 Eacies, Hippocratic, 127 of peritonitis, 127 simulation of, 128 Factoi-s modifying pain production, 115 Fallopian tubes, acut€ hyperemia of, 745 inflammation of. See Tubal in- flammation, nerve supply to, 707 pain due to disease of, 744 tubal conditions causing pain in, 744 Fatty tissues, adiposa dolorosa, 224 pain in, 224 Fear, vasomotor collapse from, 133 Febrile herpes, of the cornea, 320 of the phaiynx, 352 "Female complaint," 712 Femoral hernia, 375 Fetus, external senses in, 12 Fibere, motor, 174 sensoi-y conducting, 174 Fibroids, of the uterus, 744 Fissure, of the lips, 418 of the nipple, 259 of the tongue, 421 Fitz's rule in pancreatitis, 488 Flat-foot, radiated pain of, to knee, 305 INDEX 883 Flat-foot disease, neuralgia (Mor- ton's) in, 169 Focal symptoms of the motor re- gion, 183 Folliculitis, pain caused by, 342 Foreign bodies, in the ear, 334 neuralgia from, 142 sensation of, in phaiynx mth carcinoma of base of tongue, 355 Fracture, 229 elicitation of pain in, 230 of the thorax, 764 Freezing, anesthesia by, 66 Frontal lobe, tumors of, 184 Functional pains, abdominal, 409 Furunculosis, causes of, 333 manifestations of, 334 G Gall-bladder, adhesions of, 563 back pains refen'ed from, 302 colic of, 562, 568 carcinoma of, 571 defecation in disease of, 118 infection of, 563 inflammation of, 563 ingestion of food in disease of, 116 location of pain and tenderness in disease of, 72 new growths of, 571 non-malignant growths of, 572 overdistention of, 562 sarcoma of, 571 Gall-bladder colic, causes of, 548 distinguished from gall-duct, 578 hysteria distinguished from, 572 Gall - bladder disease, associated pains of, 566 etiology of, 562 Gall-bladder pain, diagnosis of, 563 differential diagnosis of, 564, 567 diseases causing, 568 Gall-bladder pain, ingestion of food causing, 546 radiation of, 566 refeiTed, 567 reflex tenderness with, 567 tenderness in, 563 Gall-bladder and ducts, epigastric pains from lesions of, 397 Gall-duct colic, associated symptoms of, 576 Gall-duct pain, character of, 573 classiflcation of, 573 etiology of, 572 location of, 573 paroxysms of, 573 Gall-ducts, obstruction in, 572 Gall-stone colic, 575 differential diagnosis of, 577, 579 Gall-stone pain, 549 Gall-stones, 568 cholecystitis accompanying, 576 nocturnal pains of, 111 pei-sistence of pain after removal of, 142 Galvanic current, effect of, in neu- ralgia, 145 Gangrene of the viscera, 417 Gas abscess, 338 Gasserian ganglion, neuralgia from lesions in, 148, 149 Gastralgia, 431 abdominal pains of, 409 description of, 432 nervous, distinguished from ulcer and cancer, 452, 453, 454, 455 Gastric adhesions, diagnosis of, by pressure, 369 Gastric area, reflexes felt as pain in, 433 Gastric carcinoma, causes of pain in, 457 infection in, effect of, 456 local disease with, 458 location of, 456 lymphangitis with, 458 884 INDEX Gastric carcinoma, posture of pa- tient in production of pain in, 456 symptoms of, 455 Gastric erosions, 442 Gastric mucosa, excess of acids on, effect of, 435 Gastric pains, appearance of, 430 associated symptoms of, 431 character of, 429 confused diagnoses of, due to re- flexes, 434 distinction between gastric and nervous origin of, 433 duration of, 430 ingestion of food in, 430 previous attacks of, 431 referred pains compared with, 461 reflex origin of, difficulty in dis- tinguishing, 434 resistance of nervous systems to, 433 severity of, as a symptom, 429 Gastric ulcer, absence of pain in, 443 cause of pain of, 443 character of, 444 conditions accompanjdng and as- sociated with, 448, 449 diagnosis of, 449 diagnostic symptoms of, 458 diet producing or increasing pain of, 447 distinguishing characteristics of, 444 due to metastasis, 458 histoiy of, 448 ingestion of food in, 116 lesions mistaken for, 450, 451 location of pain and tenderness in, 72 pain after cure of, 142 pain of, 388 pathology of, 442 position in, change of, 447, 448 Gastric ulcer, relative position of pain to site of, 442 tenderness elicited on palpation in, 445 tenderness of, 445 time of onset of, 444 Gastritis, acute, 440 character of, 441 subjective pain of, 440 chronic, 442 Gastro-intestinal tract, pains of, diurnal, 110 Gastromyalgia, 431, 432 predisposing causes of, diseases acting as, 433 symptoms of, 432 Gastroptosis, 431 Generalized pains, 93 Geniculate ganglion, 141 Genital organs, female, pain in, 706 sensibility to ordinary stimuli, 709 male, pains in, 698 Genital pain, sympathetic, in breast and occiput, 715 in head, 715 tendency to, on left side, 713, 714 Genitalia, female, anatomy of, 706 differential diagnoses of, 725 nerve supply to, 705, 706, 712 Genito-urinary organs, back pains referred from, 304 Gestures indicating pain, 128 Girdle pains, 95 Glands, general, 257 mammary, 257 mesenteric, 261 thymus, 261 thyroid, 261 Glandular oi'gans, parenchymatous, pain in, 87 Glandular stnictures, 257 Glandular tissues, 257 Glans penis, pain in, 704 pain in, from prostate congestion and inflammation, 701 INDEX 885 Glaucoma, acute, 329 primary and secondary, 327 source of pain in, 318 system of secondaiy, 325, 326 Globes, sunken, 329 Glossitis, 422 Glossodj'nia, classification of, 422 Gonococcus infection of shoulder joint, 304 Gonorrheal arthritis, 238 Goi^t, nocturnal pain of, 110 Gouty hip joint, distinguished from sciatica, 245 Gray matter cells, nerve fibei-s aris- ing in, 42 Groin, incidents of pain in, from above and below, 96 Growing joints, symptoms of, 241 Growing-out pains of children, 229 Gummata of the rectum, 507 Gummatous masses, similarity of, to tumors, 212 H Habit headache, 289 "Habit pains," 80, 142 Hair, efi'ect on, of neuralgia, 146 excessive weight of, as cause of headache, 265 lack of pain in, 113 Happiness, phenomena resulting from, 133 Head, hj^peralgesic zones of, 290 localizing center for pain, 262 overwork on, effect of, 265 pain areas in, table of, 263 referred pains in, 264 sense of pain in, 264 sense of pressure in, 264 Headache, absence of, in diseases of the brain substance, 178 associated with, aneurysm of the brain arteries, 187 brain abscess, 181, 190, 191 brain tumor, 182, 190, 191 Headache, associated with, chlorosis, 181 chronic anemia of the brain, 181 diseases in general, 177 h^'droeephalus internus, 187 hyperemia of the brain, 181 hysteria, 188, 190 leptomeningitis purulenta, 180, 190, 191 leukemia, 181 neurasthenia, 189, 190 pachymeningitis interna hsemor- rhagiea, 179, 180 parasites of the brain, 187 pernicious anemia, 181 syphilis of the brain, 188, 190 tubei'culous meningitis, 180 tmnors, 183, 184, 185, 186 diagnosis of, 265 constancy of intennittent (peri- odic), 286 in brain and meningeal disease, 190 of recent origin : infectious disease, 281 intracranial lesions, 282 toxemia, 282 traimiatism, 282 of remote origin : alimentary tract, 284 anemia, 285 brain tumors and abscesses, 284 cerebral arteiitis, 285 ears, 284 eyes, 282 kidney lesions, 284 nose, 283 psychical strain, 285 sinus disease (accessory nasal), 284 diagnostic value of, as a symp- tom, 177, 178 differential diagnosis of, in brain and meningeal disease, 195 886 INDEX Headache, due to brain substance affections, 176 due to diseases of the brain and meninges, 192 due to empyema of the sinuses, 343, 344 due to hypertrophy of middle tur- binate of nose, 349 due to irritation of organs of spe- cial sense, 277 due to nasal stenosis, 342 due to nasal tumors, 347 due to obstructed sinuses, 345 due to sphenopalatine diseases, 345 due to visceral disease, 176 external influences of, in diseases of the brain and meninges, 193, 194 frontal, 192 hemicranic, 189, 190, 191 indurative, 265 intensity of pain of, in diseases of the brain and meninges, 190 localization of pain of, in dis- eases of the brain and men- inges, 192 lymphatic, 290 origin of, 175, 176 postures assumed by patients suf- fering from, 290 tension of pain of, in diseases of brain and meninges, 192 therapy for, 194 toxemic, 271 miilateral, 192 Head pain, causes of, 265 due to the alimentary tract, 284 due to anemia, 272, 285 due to brain tumors and abscesses, 270, 271, 284 due to cerebral arteritis, 285 due to cerebral congestion, 272 due to cerebrosjDinal fluid in- crease, 276 due to the ears, 284 Head pain, due to the eyes, 283 due to hyper blood-tension, 273, 274 due to increased venous j^ressure, 274 due to induration of muscles, 265 due to kidney lesions, 284 due to meningitis, acute, 271 due to metabolism, 268 due to muscle lesions, 265 due to nasal conditions, 283 due to nerve involvement, 268 due to neuralgia, 268, 278 due to neuritis, 268 due to jDachymeningitis, 271 due to psychical strain, 285 due to sinus (accessory nasal) disease, 284 due to skin lesions, 265 due to toxic irritation of the cerebral cortex, 279 headache, 265 meningeal changes as a cause of, functional, 269 organic, 271 origin of, extracranial, 265 intracranial, 269 projected, 268 referred, 269 referred from the viscera, 290, 291, 292, 293, 294, 295 reflex, 269, 277 rheumatic, 279, 280 toxemic, 271 Hearing, protective reflex action of, 123 Heari, back pains due to affections of, 301 dilatation of, 781 nerve supply to, 774 Heartburn, 435 Heart disease, diagnosis of, by means of location of i-eferred pain, 774 general considerations of, 773 INDEX 887 Heart disease, hyperalgesia, impor- tance of, as a symptom, 780 hyperalgesic zones in, location of, 777, 778 prominence of, 776 pain in, 775 refeiTed pain in, 775 Heart pain, intracardiac lesions as causes of, 782 Heat, physical factor of pain, 28, 118 Heel pains, 306 Hematoma of the dura mater. See Pachymeningitis interna haemorrhagica, 179 Hematomyelia, 210 Hematuric nephralgia, 629 Hemianesthesia, 18-1, 185 impairment of senses accompany- ing, 135 transference of, in hysteria from one side of body to other, 77 Hemianopsia, 184 Hemichorea, 185 Hemicrania, eye pain from, 321 Hemicranie headache, 189, 190, 191 Hemiplegia, 184, 185 Hemopoitic system, lesions of, 233 Hemorrhage, in the adrenals, 259 of the brain. See Brain hemor- rhage, cerebral. See Cerebral hemor- rhage, easing of pain by, 26. into the meninges, differential diagnosis of, 196 pain from, in body cavities, 26 in body tissues, 25, 26 of the peritoneum, 367 of spinal cord, 209, 210 Hepatic artery, twist of, from liver displacement, 559 Hepatic congestion, 551 associated symptoms of, 552 Hepatitis, acute, 557 Hepatoptosis, 558 description of pains of, 560 posture in, effect of, 559 hereditary migraine, 286 Hernias, bowel pain with, 372 causes of pain in, 371 chronic eases of, 373 diagnostic criteria of, 375 distinguished from bowel pain, 372 epigastric, 375 femoral, 375 increased pain by tension in, 368 inguinal, 374 mesentei-y, as a factor in pain production, 372 nature of pain of, 371 neuralgia from, 142 obstruction due to, 499 of the ovary, 749 omental, 373 pain as a symptom of, 373 peritoneal irritation with, 373 pressure on ilioinguinal nerve by, 372 strangulated, 374 umbilical, 374 Herpes, accompanying sacral neu- ralgia, 171 corneal, 325 febrile, of the cornea, 320 of the pharynx, 352 neuralgic, of the cornea, 320 of ear drum, 335 of the lips, 418 of the pinna, 333 of the tongue, 421 Herpes corneae neuralgieus, 320 Herpes larjnigis, 357 Herpes zoster, causes of, 320 character of pain in, 319, 320 distinguished from intercostal neuralgia, 165 of the thorax, 763 pharyngeal, 353, 354 Heterosuggestive sensations, 75 INDEX Heterotoxie substances, causing neu- ralgia, 141 Hilton's law, 220 Hip joint, ankylosis of, 244 gouty deposits in, 245 Hip joint abscess (intra-articular), tension pains of, 244 Hip joint affections, rheumatism, 305 tuberculous, 305 Hip joint disease, distinguished from sciatica, 168 Hip joint pains, 240 functional, 241 in inflammation, 241 in movement, 242 radiating, 241 weight-bearing, 241, 242, 243 Hippocratic facias, 127 Hodgkin's disease, pain in, 261 Hourglass stomach, cause of pain in, 437 Hunger headache. 111 Hydatid disease of the kidney, 646 Hydatids of the spleen, 602 Hydrocephalus (chronic), differen- tial diagnosis of, 187, 188 Hydrocephalus internus, 187 Hydronephrosis, associated symp- toms of, 654 causes of, 653 character of pain of, 653 differential diagnosis of, 656 in pregnancy, 654 Hydrosalpinx, 744 Hyoid, reference area for pain in ear, 335 ' HyiDer blood-tension, headache due to, 273, 274 Hyperacidity, relief of, from alka- lies, 119 Hyperacidity pains in stomach. 111 Hyi^eralgesia, 47, 61, 67 accuracy of localization decreased by, 70. appendicial, 525 Hyperalgesia, areas of, 69, 70 cutaneous, relating to areas of visceral disease, 54 dilatation of pupils in, 69 following anesthesia in hysteria, 77 from intercurrent infection of vis- cera, 70 in reflected pains from tbe vis- cera, 106 of the tongue, 421 referred, in uterine segments, 734 temperature and touch in, 35 tenderness ditferentiated from, 70, 71 testing of, in a part, 68 thoracic, 761 zones of, in the skin, 69 in the viscera, 384, 385 Hyperalgesic zones, origin of, 105 Hyperchlorhydria, 434 Hyperemia, 62 of the brain, symptoms of, 181 of the ovary, 749 Hyi^eresthesia, 61, 68, 69, 70 accuracy of localization decreased by, 70 appendicial, 524 areas of, in tissues, 69 in the viscei'a (Mackenzie's), 385, 386 attention to tissues in judging of, 68, 69 following anesthesia in hysteria, 77 from influenza, 70 in neuralgia, 143 of uteiine muscle, 731 thoracic, 761 transference of, in hysteria from one side of body to other, 77 Hypernephroma of the kidney, 646 Hj'perphoria, eye disturbances due to, 331 Hypersensitiveness of sense percep- tive centers, 30 INDEX 889 Hypertension headaches, associated symptoms of, 275, 276 distention of veins of brow or scalp in, 276 general consideration of, 274, 275 pressure points in, 275 Hypertrophy of the prostate, 701 Hypnosis, pain perception under, 31 subjective pain by, 75, 80 Hypoalgesia of the viscera, 385 Hypochondriac zones of the abdo- men, 396 Hypophyseal symptoms in adiposa dolorosa, 225 Hypophysis, tumors of, 186 Hypotonia of globe, 327 Hysteria, back pains due to, 304 basis of pains in, 76 causes of, 76, 77 differential diagnosis of, 196, 197, 199 differentiated from caries of the vertebral canal, 210 differentiated from bone pains, 234 distinguished from gall-bladder colic, 572 importance of diagnosis in, 76, 79 pains of, 216 pressure points in, 79 subjective pain caused by, 74, 75, 76 symptoms of, 188 thoracic, 761 Hysterical headache, 289 Hysterical pains, abdominal pains considered with, 414 areas of, most frequent, 79 diagnosis of, 79 differentiated from real pains, 79 distinguished from pelvic pain, 710 distribution of, 78, 79 emotional shock causing, 79 in children, 79 Hysterical pains, negative evidence in diagnosis of, 79 positive evidence in diagnosis of, 79 relief of, by suggestion, 79 Hysterical states, explanation of, 76, 77 Hysterics, subjective pains of, 74 Idiocy, pain perception in, 62 Imagination of pain, 31 Incisions, abdominal, 415 Indican, presence of, in urine, 495 Indicanuria with abdominal pains, 414 Indifference, state of, 13 Induration of head muscles as cause of head pain, 265 Indurative headaches, associated symptoms of, 267 description of pain in, 265 development of the process of, 265 diagnosed from bone diseases, 267 diagnosed from meningitis, 267 diagnosed from migraine, 267 symptoms of, 266 Infancy, causes of pain in, 410 negligible diagnostic value of pain in, 410 Infarct of the spleen, 601 Infarction, renal, 626 Infection causing neuralgia, 143 Infectious diseases, backache as a symptom of, 298 Inflammation, appendicial, 517 causing affections of nerve recep- tors, 140 nerve trunks, 140 meningeal, causing headaches, 271 nasal, pain caused by, 342 of abdominal wall, 361 890 INDEX Inflammation of arteries, 250 of the bladder, 685 of bones, 229, 231 of the bowel, 484 of the breast, 258 of the cheeks, 418 of the colon, 501 of the esophagus, 424 of the gall-bladder, 563 of the hip joint, 241 of the joints, 235 of the kidney, 629 of the kidney, acute. See Ne- phritis, chronic, 632 of the lips, 418 of the peritoneum, 364 of the rectum, 506 of the tongue, 421 of the ureter, 670 of the uterus, 740 of the veins, 255 of viscera, absence of pain in, 86, 87 thoracic, 761 Inflammatory pain, 84 beginning of, in blood vessels, 84 cause of throbbing in, 85, 86 characteristics of, 87 dull ache in later stages of, 86 increased size of lumina of ves- sels in, 84 means of conveyance of, 84 reaction of, 86 systolic pressure increased in, 85 Inflammatory states, effect of mo- tion in, 116 Influenza, deranged metabolism in, 141 hyperesthesia from, 70 neuralgia in, 141 severe neck pain of, 352 slight pressure causing painful reaction in, 71 Ingestion of food, associated with pain. 111 Ingestion of food, effect of, on pain, 116 intestinal pain after, 472, 473 Inguinal hernia, case of, cited, 374 colicky pain in, referred to lower quadrant of abdomen, 375 pain in, 374 pressure on, effect of, 374 Inherited predisposition to neu- ralgia, 143 Inhibition, of pain sensation, 62 of perception, 63 Intellect, mental activity of, 13 power of, to reproduce pain by memory, 13 Intensity of pain, 114 algometers in measuring, 130, 131 amount of morpliin necessaiy as indication of, 120, 125 ai^pearance of patient indicating, 120, 125 as a stimulus, 114 blood pressure elevation indicat- ing, 120 circulation indicating, 134 complaints of patient indicating, 120, 123 depending factors of, 114 dilatation of pupil indicating, 120, 125 facial expression indicating, 127 gestures indicating, 128 in spinal cord lesions, 216 irritability of nerves a factor in, 115 loss of equilibrium indicating, 134 mechanical factors in measuring, 120, 129 minima of, table representing, 130 motion indicating, 128 motor reflexes indicating, 120, 122 nerve fibers involved a factor of, 115 INDEX 891 Intensity of pain, patient's descrip- tion indicating, 120, 128 respiratoi-y system indicating, 134 sensitiveness of patient a factor of, 115 trophic changes indicating, 134, 135 vasomotor signs of, 120. 124 Von Frey's hairs in measuring, 130, 131 Intercostal neuralgia, 147, 164 differentiation between cardiac disease and, 781 distinguished from herpes zoster, 165 distinguished from pleurisy, 165 epidemic of, 143 location of pain and tenderness in; 72 posture in, 127 respiration in, 127 Intercostal neuritis, 791 Interference with areas of pain per- ception, 64 Intermenstrual pain, 735 Intermittent claudication, descrip- tion of, 251, 252 Intestinal adhesions, ease of, cited, 370 Intestinal atony, effect of constipa- tion in, 118 Intestinal diseases, pains due to, 401 Intestinal obstruction, acute, 492, 493 associated symptoms with, 494 cause of, 493 chronic, 493, 494 Intestinal pain, associated symp- toms with, 474 colonic, 500 diagnostic points in, location of, 469 diarrhea with, 475 due to colonic involvement, 500 due to pressure on adjacent nerves, 468 Intestinal pain, due to purpura, 402 due to traction of the mesenterj-, 465 due to tuberculous intestinal le- sions and leukemia, 469 duration of, 473 etiology of, 463 general considerations of, 463 glandular enlargement with, 476 history of, 473 ingestion of food followed by, 472, 473 lesions causing, 476 localization of, 467 location of, 469 muscular acti\aty causing, 468 of the anus, 509 of the rectum, 505 onset of, indications from manner of, 471 peristalsis stimulation of, by food in, 472 position of patient in, 472 rectal, 505 referred, 468 reflected, 467 result of, 473 shock and collapse with, 475 tenderness with, deep, 474 superficial, 474 tension as stimulus for, 465 tumor formation with peristalsis in, 472 types of, 470 vomiting with, 474 Intestinal secretion, disorders of, 480 Intestinal ulcer, action of food in, 488 intervals of freedom from pain in, 487 location of, 487 relief of pain of, 488 severity of pain in, 488 tuberculous, 488 892 INDEX Intestinal ulceration, catarrhal, 489 syphilitic, 489 typhoidal, 488 Intestines, back pains due to, 302 degi'ee of sensitiveness of, to pain stimuli, 388 epigastric pain from lesions of, 397 functional disturbances of, 477 law of contrary innervation in (Meltzer), 387, 388 lesions of, causing pain, 476 mesentei-y of, 463 motor disturbances of, 478 new gi-owths of, 499 normal stimuli reactions of, 387 pain in, due to acute indigestion, 402 due to gall-stones, 402 due to hernia, 402 due to obstruction, 401 due to poisoning, 402 due to renal calculus, 402 due to uremia, 402 production of pain in, 464 secretory disturbances of, 477 spasm of, 479, 480 stimulus for pain production in, 463, 464, 465 ulcers of, 487 Intra-articular hip joint abscess, description of, 244 diagnosis of, 244 nocturnal pains of, 244 treatment of, 244, 245 Intracranial head pains, causes of, 269 Intradural suppuration, 338 Intraneural causes of neuralgia, 142 Intraparenchymatous pain, disten- tion of liver causing, 551 Intrinsic factors modifying pain production, 116 Introitus narium, pain caused by, 342 Intussusception, 496, 497, 498 lodids, uses of, 119 Iridectomy, 329 Iridocyclitis, 326 Iris, pain in the, 325, 326 Iritis, forms of, 326 light as a cause of pain in, 323 myopic, 327 source of pain in, 318 sudden exacerbation of pain in, 326 treatment of, 326 Ischemia, anesthesia by, 66 Ischiorectal abscess, 509 Jacksonian epilepsy, 184 Jacksonian fits, 183 Jacksonian spasms, 184 Joint pains, classification of, 234 infections causes of, 238 inflammatoiy, diagnosis of, 239 intensity of, 236 nonseptic, diagnosis of, 239 of the hip, 241, 242 organic, 234 radiation of, 236 redness as a symptom of, 238 rheumatic inflammation in, diag- nosis of, 239 septic, diagnosis of, 239 swelling as a symptom of, 238 symptoms of, 236, 237, 238 tenderness as a symptom of, 237, 238 traumatic causes of, 238 verification of a patient's descrip- tion of, by manipulation, 237, 238 by palpation, 237 by therai^eutie test, 238 Joints, as cause of pain from mo- tion, 117 growing, 241 hypersensitive, cessation of func- tion of, causes of, 237 INDEX 893 Joints, order of frequency of in- volvement of (Eisendrath), 239 K Kala-azar, 602 Keratitis, punctate superficial den- dritic, 325 stellate, 325 superficial, severity of pain in, 323 ulcerating, 325 Kidney, anatomical position of, 604, 608 back pains referred from, 302 congestion in inflammation of, 630 cystic disease of, 645 displaced, 620 epigastric pains from lesions of, 397 general considerations of, 604 hydatid disease of, 646 hypernephroma of, 646 hypertension of, 607 insensibility of parenchyma of, 606 location of, 608 lumbar plexus, relation with, 606 movable, 620 nerve supply of, 604 new growths of, 644 character of pain in, 645 etiology of, 644 varieties of, 645 parenchymatous infection of, 649 polycystic disease of, 645 rotation of, from liver displace- ment, 559 sarcoma of, 646 tenderness in, 615 most marked points of, 616 tuberculosis of, 642 wandering, pain of, 607 Kidney area, edema in, presence of, 618 Kidney disease, absence of pain in, CIS differential diagnosis 6f, 610, 619, 620, 621, 649, 669 of hydronephrosis in, 656 of movable kidney, 627 of perinephritic abscess, 639, 640, 641 of pyelitis or pyonephrosis, 650 of renal calculus, 668 of renal infarction, 628 of renal tuberculosis, 644 of tumor, 646 hydronephrosis in, 650 ' pain in diagnosis of, 619 Kidney inflammation, acute. See Nephritis, chronic, 632 congestion in, 629 Kidney pain, absence of, in kidney lesions, 618 character of, 607 differential diagnosis of, 620, 621 of renal calculus, 650 differential points, 610 duration of, 618 etiology of, 605 from bladder tumors, 689 local, 607 localization of, 607 motion of patient in relation to production of, CIS position of patient in, 617 production of, factors influencing, 617 psoas muscle contraction causing, 616 referred, 608 nerves involved in, 612 reflected, 614 subjective, 607 symptoms associated with, 618 894 INDEX Kidney pain, tension, intracapsular, 606 on renal capsule causing, 605, 606 Kidney rupture, 641 Kidney stones. See Renal calculus. Kidney tumor, 646 Killian operation, resection of su- praorbital nerve in, 350 Knee, radiated to, pain from flat- foot, 305 Knee pains propagated through ob- turator nerve, 241 Labor, absence of pain in, 739 first stage of pains in, 739 pain in, 738 referred pains of, 740 Labyrinth, diseases of, 340 Lacrimation, 317 Lactation mastitis, 258 Laryngeal crises of tabes dorsalis, 359 Larynx, acute affections of, 357 anesthesia of entrance to, for dysphagia, 358 carcinoma of, 358 chronic processes of, 358 inflammation of, 357 neuralgia of, 359 pain in acute affections of, 357 diseases of, 356 pus formations in, 357 referred pain of, 357 sensory nerves of, 356 tuberculous ulcers of, 358 Laws, Hilton's, 220 law of contrary innervation, 223 Lead as cause of neuralgia, 142 Lead colic, 402, 484 Leontiasis ossea, 233 Leptomeningitis, diffei'ential diag- nosis of, 196 Leptomeningitis purulenta, differen- tial diagnosis of, 195, 196 headache and other symptoms of, 180, 190, 191 Leptomeningitis serosa, differential diagnosis of, 195, 196 Leukemia, back pain of, 299 bone pains of, 231, 232, 233 myelogenous, 602 symjitoms of, 181 Limbs, localizing center for pain, 304 lower, flat-foot, 305 generalized pain in, 305 heel pains, 306 hip joint affections, 305 pain from circulatory changes, 305 upper, pain in, 304 shoulder pains, 304 Lingual nerve, 351 Lipomatosis, multiple, 224 Lips, pain in, 418 Liver, abscesses of, 553 adhesions, 553 atrophy of, acute yellow, 561 back pains refeired from, 302 cirrhosis of, 552, 554, 556 acute chronic, 561 congestion of, 551 due to acute inflammatory le- sions, 553 cysts of, 555 displacement of, 558 distention of, 551 epigastric pain from, lesions of, 397 essential diseases of, 561 examination for pain in, 543 growths of slow development in, 555 inflammation of the capsule of, 557 malignant disease of, 556 nerve supply to, 540, 543 new gi'owths of, 554 INDEX 895 Liver, painful disordefs of, 540 pain in, 545 secondaiy growths of, 555 secondary involvement of, 556 sensitive area in, 541 sensitiveness to pain of, produc- ing stimuli, 542 syphilis of, 556 tropical abscess of, 554 vagus in innervation of, 541 Liver disease, in relation to other disorders, 548 pain in right shoulder in, 542 palpation in, 544 percussion in, 544 sensibility examination in, 545 symptoms in diagnosis of, 543 tenderness as a symptom of, 543 elicitation of, 544 Liver pain, character of, 545 disturbance of liver substance proper, 550 extraparenchymatous, canses of, 550 ingestion of food and diTink in relation to, 545 intraparenchymatous, causes of, 551 movement of the body producing, 547 neuralgia, 550 position of the body in relation to, 547 time of appearance of, 549 with pregnancy, 548 Localization of pain, accuracy of, decreased by hyperalgesia, 70 deei'eased by hyperesthesia, 70 indefinite area of, 48 motion in, 48 muscles in, 48 nervi nervorum in, 48 peripheral sensory nerves in, 51 touch sense in, 48 Localized anemia, 62 Locomotor apparatus, pain of, diur- nal, 110 Locomotor ataxia, epigastric pains from, 397 projection pain in, 103 Lorenz plaster hose for hip joint abscess, 244 Lower animals, sensation in, 1, 3, 4 Luetic ulcers, pain of, 355 syphilitic process of, 355 Lumbago, 221, 222, 296 distinguished from neurasthenia, 297 Lumbar cord neuralgia. See sacral. Lumbar plexus, distribution of nerves from, 52 Lumbar segments, distribution of, diagram of, 57 Lumbosacral lesions, 209 Lung pain, etiology of, 790 referred, distribution of, 790 Lungs, areas of pain of, in rela- tion to location of lesion, 792 back pains due to affections of, 300 Lupus and lues, 333 Lymphadenoma ossium, 233 Lymphangitis, 442 with gastric ulcer, 458 Lymphatic headache, 290 M Malaria, spleen, enlargement of, from, 600 Mammary gland, 257 pain produced by changes in, 259 Marking code for recording pain, 136 Massage, effect of, for neuralgia, 161 Mastitis, 259 lactation, 258 pyogenic, 258 stagnation, 258 896 INDEX Mastoid, significance of suppura- tion of, 337 Mastoid process, abscess in, 336 Maximum tenderness areas, cord zones, and diagram of, 59 Meatus, external lesions of, 335 Mechanical changes, causative fac- tors of pain, 25 Mechanical factors for measuring pain, 129, 130, 131 Mechanical irritation, due to pres- sure or contraction, 25 Mediastinum, pain of, 802 Medulla, tumors of, 186 Memorj', 13 Memoiy centei-s, for pain, 24, 25 subjective pains drawn from, 75 Meningeal apoplexy, symptoms of, 209 Meningeal changes, as cause of headache, functional, 269 organic, 271 Meninges, sj^philis of, 213 Meningitis, acute, as a cause of headache, 271 spinal, 212 cerebrospinal, 212 diagnosed from indurative head- ache, 267 rigidity in, 127 tuberculous. See Tuberculous meningitis. Menstrual pain, conclusions in re- gard to, 734 intermenstrual, 735 time of occurrence of, 735 Menstruation, back pains due to, 303 contraction of uterine muscles in nonnal, 729 pain due to, 718 painful, 728 physical factor of pain in, 116 Mental activity, 13 Mental disturbances from pain, 134 Mental resultants, 14 Mental states, 14 influence of, on mental processes of the body, 124 pain and, 30, 31 relation of pain and pleasure to, 15, 30, 31 Mereuiy, as cause of neuralgia, 142 uses of, 119 Mesenteric arteries, embolism of, 253, 254 thrombosis of, 253, 254 Mesenteric glands, enlargement of, in tuberculosis, 261 pain in, 261 Mesenteiy, factor of pain produc- tion in hernia, 372 traction on, cause of pain in vis- cera, 390 Metabolism as cause of head pains, 268 Metaphysical consideration of pain, 20, 21, 22 Metastases, gastric ulcer due to, 458 Metastatic growths, 555 Metatarsalgia, 306 Middle-ear, catarrh of, 339 complications of disease of, 337 disease of, 335 pus in, 337, 338 Migraine, 189 associated symptoms of, 287 diagnosed from indurative head- ache, 267 differential diagnosis of, 196, 197, 198 due to contraction of peripheral arteries, 288 due to diminished secretion of thyroidin, 289 due to habit, 289 due to increased intracranial pressure, 287, 288 due to malaria, 289 due to stenosis of the foramen of Monroe, 288 INDEX 897 Migraine, due to syphilis, 289 eye pain from, 320 hereditary, 286 hysterical, 289 localization of headache in, 192 ophthalmoplegic, 321 premonitory symptoms of, 287 reflex, 286 scintillating scotoma as symptom of, 287 throbbing pain of, 287 Minima of sensation, table repre- senting, 130 Misplaced \dscera, neuralgia from, 142 Misreference of pain phenomena, 94 Molecular disturbance as cause of neuralgia, 142 Monomania pains, 80 Morphin, effects of, 119 on blood pressure elevation, 121 in colic, 125 measuring intensity of pain by, 120, 125 Morton's neuralgia, 169 Motion, bone cause of pain from, 117 cell areas of, 10 intensity of pain indicated by, 128 joints as cause of pain from, 117 localization of pain by, 48 muscles as cause of pain from, 117 physical factor of jDain, 116 reflex, 2, 3 Motor fibers, coui-se of, 174 Motor manifestation of pain in lower animals, 3 Motor reflexes, in measuring inten- sity of pain, 120, 122, 123 protective tendency of, 122, 123 Motor region, effect of removal of, 7, 8 focal symptoms of, 183 location of, 173 Movable kidney, anatomical consid- erations of, 620 associated sjTni^toms of, 625 character of pain in, 624 constipation with, 626 differential diagnosis of, 627 digestive disturbances with, 625 lesions with, 626 location of pain in, 623 paroxysmal pains in, 624 pathology of, 622 tenderness with, 626 tumor with, 625 urinary changes in, 625 Multiple sclerosis, differential diag- nosis of, 197, 213 symptoms of, 213 Mumps, 423 Muscle fiber, activity of, 468 Muscles, as seat of head pains, 265 causative factor of back pain, 296 causes ©f pain in use of, 117 inflammation of, 219 in localization of pain, 48 involuntary, colics of, 222 motor nerves of, 50 nei^e flbei-s of, 48, 50 pain in, 218 pain producing diseases of, 218, 219 protective tendency of, 123 sensation in, 48 sensoiy nerves of, 50 underlying, rigidity of, associated with tenderness, 72 voluntary, diseases of, 219 induration of, 222 myalgia of, 221 myositis of, 219 myositis fibrosa of, 221 myositis haemorrhagica of, 221 myositis ossificans of, 221 polymyositis of, acute, 220 DIuseular changes from neuralgia, 146 Muscular pain, abdominal, 361 898 INDEX Muscular rigidity, with abdominal pain, 413 Muscular spasm, with abdominal pains, 413 Muscular tissues, pain in, 218 Myalgia, 221 abdominal, 362 character of pains of, 222 of back, due to fatigue, 298 due to sprain, 298 due to toxemia, 297 Myelitis, 212 Myelogenous leukemia, 602 Myeloma, bones, 233 Myocarditis, 788 Myositis, description of pain of, 218 forms of, 220 Myositis fibrosa, 221 Myositis ha;morrhagica, 221 Myositis ossificans, 221 Myringitis bulbosa, 335 N Nails, absence of pain in, 113 Nasal septum abscesses, pain caused by, 342 Nasal stenosis, headaches caused by, 342 Nasal tumoi-s, headaches as symp- tom of, 347 Naunyn's sign, 565 Nausea, protective tendency of, 123 Neck, localizing center for pain, 312 Neck pains, causes of, 312 Nephralgia, hematuric, 629 Nephritis, associated symptoms of, 633, 636 character of pain in, 632 Head's zones in, 631 sensory disturbances in, illus- trative cases, 633, 635 hyperalgesia, area of, 636, 637 pain in, 631 referred pain in, 632 Nervo apparatus, 5 for receiving and conducting pain, 28 Nerve fibers, conveying deej) sensi- bility, 37, 38 convej'ing superficial sensibility, 37 extent and number involved as factor of pain intensity, 115 gray matter cells, arising in, 42 of muscles and skin, 48, 50 posterior cornua entering, 41, 42 Nerve force, 5 regenerated by adrenalin, 102 Nerve supply, of the kidneys, 604 of the pancreas, 481 of the I'ectum, 506 of the spleen, 593 to the bladder, 672 to Fallopian tubes, 707 to female genitalia, 705, 706, 712 to the heart, 774 to liver, 540, 543 to the ovaries, 707, 713 to the pleura, 769 to the stomach, 428 to the testicles, 698 to the ureter, 670 to the uterus, 707, 713, 724 to the vagina, 755 Nerve tenninals, affections of, 140 Nerve trunks, affections of, 140 Nerves, as seat of head pains, 268 destruction of endings of, 364 involved in referred kidney pain, 612 iiTitability of, 115 of nose, 341 of pain, 36 pain in diseases of, 140 sensoi-y, of the larynx, 356 of the pharynx, 351 Nervi nervorum, in localization of pain, 48 Nervous system, autonomic sympa- thetic, 12 INDEX 899 Nervous system, central, 172 evolution of, 31, 32 importance of, 79 in lower animals, 2, 3, 4 localization of pains due to dis- eases of, 175 of the ureter, 670 Nervus nasalis anterior, course of, 341 Nei'vus nasopalatinnm, scarpi, 341 Neuralgia, anesthesia dolorosa in, 144 area of pain of, 144 as cause of head jDains, 268 brachial, 147, 150 causes of, 140, 141, 142, 143, 144 character of pains of, 144 circumflex, 147, 164 consideration of, as a separate entity, 141 consideration of tenn, 158 diagnosis of, 147 differential diagnosis of, general, 106, 147 differentiated from muscular le- sions, 147 neuritis, 140, 159 tabes, 149 distant points in, 145 duration of, 146 effects of, 146 on heart, 146 epidemic of, intercostal, 143 etiology of, 142 exciting causes of, 142 extraneural causes of, 142 galvanic current for, 145 general discussion of, 141 infection, as cause of, 143 inherited predisposition to, 143 in influenza, 141 in senility, 141 intercostal, 147, 164 intraneural causes of, 142 laryngeal, 359 local points in, 144, 145 Neuralgia, massage for, 161 Morton's, 169 muscular changes from, 146 nose as cause of, 149 of abdominal organs, 409 of abdominal wall, symptoms of, 361, 362 of cheeks, 418, 419 of cortex, causing headaches, 278 of eyelid, fifth nerve, 320 diagnosis of, 321 of lips, 418 of liver, 550 of lumbar cord, 169 of ovary, 749 of pharynx, 356 of stomach nei'ves, 461, 462 of the uterus, 726 pathology of, 141 peroneal, 147 piercing pain of, differentiated from bone pains, 228 plantar, 169 predisposing factors to, 143 predisposition to, by alcohol, 143 by drugs, 143 by excessive sexual indulgence, • 143 by tobacco, 143 from senility, 143 projected pain causing, 144 referred pain causing, 144, 149, 158 diffei'entiated from, 102 reflex irritations causing, 143 relieved by endonasal operation, 350 sacral, 169 sinus suppuration producing, 345 skin as the seat of, 265 supraorbital, 143 sympathetic pain causing, 144 symptoms, 143 syphilitic, 147 teeth affected by, 148 thoracic, 760, 763 900 INDEX Neuralgia, toxic materials causing, 141, 142 traumatism as cause of, 143 trigeminal, 146, 147, 148, 149 trophic changes in, 146 types of, according to localiza- tion, 147 sciatic, 147, 166 Valleix's points, 144, 145 vasomotor changes in, 145 visceral, 147 Neuralgic pains from spinal cord tumors, 211 Neurasthenia, abdominal pain in, 409, 410 differential diagnosis of, 196 differentiated from caries of the vertebral canal, 210 lumbago, 297 due to long continued lesion of female genitalia, 712 headache and other symptoms, 189, 190 pains of, 215. predisposing to neuralgia, 143 sense of pressure in head with, 264 symptoms of, 216 Neurasthenics, diurnal pain of, 110 Neuritis, abdominal, of intercostal nerves, 362 as cause of head pains, 268 brachial neuralgia in, 150 causes of, 140, 141 differential diagnosis of, 147 distinguished from neuralgia, 140, 141, 142, 159 localization of, 153 of the esophagus, 424 symptoms of, 143 thoracic, 762 Neuropathic conditions, effect of constipation in, 118 Neurosis, effect of ingestion of food in, 116 occupation, cause of, 30 Neurotic ostalgias, distinguished from bone pains, 233 Neutral sensations, 14 New growths, abdominal, 362 causing bone pains, 230 intestinal, 499 of the gall-bladder, 571 of the liver, 554 of the rectum, 507 of the stomach, 455 of the uterus, 743 Nicotin as cause of neuralgia, 142 Nociceptors, 29 Nocturnal ostalgia, 228 Nocturnal pains, 110, 244 Nocuous ceptors, 29 Nose, adenoid vegetation of, 343 diseases producing pain in, 342 empyema of the smuses, 343 headaches from obstructed sinuses, 345 from tumors of, 347 from sphenopalatine diseases of, 345 hypertrophy of middle turbinate causing headaches, 349 in neuralgia, 149 local pains in cavities of the sinuses of, 344 neuralgia of, from suppuration of the sinuses, 345 obstructed sinuses in, 345 pain in diseases of, 341 reflex neuroses of, 344 sensory nerves of, 341 tumors of, 347 Numbness. See Paresthesia. Objective pain, 82 abdominal, 360 central, 82 origin for, 82 thalamic, 83 peripheral, 83, 89 INDEX 901 Obstruction, appendicial, 517 due to hernia, 499 in the gall-ducts, 572 of intestines, 492 Occupation neuroses, 80, 81 Ocular headaches, 282 Omental hernias, 373 Oophoritis, remission of constant pain in, 109 Ophthalmoplegic migraine, 320 Optic nerve, pain in, 328 Optic thalamus, origin for central objective pains, 82 Organ, structures of an, 84 Organic disturbances causing head- aches, 277 Organs of sense, 5, 11 of sense perception, 11 Ostalgia, nocturnal, 228 Ostalgias. See Bone pains. Osteitis deformans, 233 Osteomalacia, 232 back pains of, 300 description of, 232 distinguished from spondylitis, 232 symptoms of, 227 Osteomyelitis, 231 acute, 231 chronic, 231 of the thorax, 764 symptoms of, 227, 228, 231, 236 Otalgia excarie dentium, 340 Othematoma, 332 Otitis externa diffusa, 334 Otitis media, acute, 335 differential diagnosis of, 195, 196 forms of, 336 Otosclerosis, 339 Ovarian diseases, transferred pain in, 107 Ovarian dysmenorrhea, 734 Ovarian pain, causes of, 748 characteristics of, 748 local point of, 748 Ovaries, abscess of, 751 adhesions of, 752, 754 back pains, referred from, 303 cysts of, 753 displacement of, 749 hernia of, 749 hyperemia of, 749 nerve supply to, 707, 713 neuralgia of, 749 pain in, 747 relation of, to parotids, 752 tuberculosis of, 752 Pachymeningitis externa, 337 Pachymeningitis haemorrhagica in- terna, differential diagnosis of, 198 etiology of, 179 headache and other symptoms of, 179, 180, 190, 191 Pachymeningitis interna as a cause of headache, 271 Pachymeningitis spinalis hyper- trophica, 212 Pain, character of, 108, 109 classification of, 74, 89 conditions associated with, 132 constant, 109 definitions of, 13, 18, 19, 20 description of, by patient, 108, 109 orientation of cause of, 262 Pain filaments, unequal distribution of, 48 Pallor, indicating shock, 124, 125 indicating intensity of pain, 124 Pancreas, back pains, referred from, 303 cancer of, 579, 591 character of pain in, 485 cystic diseases of, 491 diagnostic importance of pain in, 484 diseases of, causing pain, 587 902 INDEX Pancreas, epigastric pains fx-om le- sions of, 397 general considerations of, 480 location of pain in, 485 nen'e supply of, 481 pain in, 580, 587 peritoneal covering of, stretching of, 483 position of patient in diseases of, 487 reaction to pain stimuli in, 484 relationship of, to other parts, 484 structure of, 482 tenderness in lesions of, 486 Pancreatic calculi, 489 Pancreatic lesions, possibility of, in apparent peritonitis or intes- tinal obstruction, 485 Pancreatitis, acute, distinguished from gastric ulcer, 451 hemorrhagic, 487 symptoms of, 488 chronic, 489 Fitz's rule for, 488 subacute, 488 associated symptoms of, 489 tenderness in, 488 tenderness in, 487 Panophthalmitis, pain of, 330 Papilledema, associated with tu- mors, 183 Papillitis of the tongue, 422 Paracentesis, 336 Paralysis, areas of, 59 from tumors, 183, 184, 185 Paraparesis, 184 Paraphasia from tumors of frontal lobe, 184 Parasites of the brain, 187 Parenchymatous infection of the kidney, 649 Parenchymatous pains, 83, 84, 140 causes of, 84 chemical initations producing, 88 Parenchymatous pains, due to in- flammation of the viscera, 86 inflaunnatory, 84 in glandular organs, 87 radiation of, 86 thermic irritations producing, 88 torsion producing, 88 traction producing, 88 Paresis, causing anesthesia, 65 differential diagnosis of, 197 Paresthesia, simulated pain in, 61, 73 Paresthesias, 183 Parietal lobe, tumors of, 184 Parotid gland as cause of pain, 423 Parotids, relation of ovaries to, 752 Paroxysmal pains, 109 crises in, 109 Pedicle, toi-sion of, 399 Pedunculi cerebri, tumors of, 185 Pelvic adhesions, cases cited, 370 pain of, when present, 370 Pelvic diseases, diagnosis of, 722 importance of considering the l^atient in, 724 discharge in, 723 epigastric pains from, 398 history of case of, 722 menstrual flow in, character of, 723 pain production in, predisposing factors to, 723 Pelvic pain, diagnosis of, from hysterical, 709, 710, 711 examination, bimanual vaginal, importance of, in, 722 functional acts, relation to, 717 motion causing, 718 on coitus, 717 on menstruation, 718 position assumed by patient suf- fering from, 716 position, change of, causing, 718 symptoms of, 709 tenderness areas of, 720 tenderness due to, 719 varieties of, 712, 715 INDEX 903 Pemphigi of the mucosa, 356 Penis, pain in, 703 referred pain in, 703 Perception, inhibition of, 63 centers for, 30 degrees of, 61 drugs, effect of, on, 63 idiocy, effect of, on, 62 inhibition of, 62, 63 in thalamic lesions, 199, 200, 201, 202 loss of, by interference with areas of, 64 in anesthesia, 63 of pain, analgesia of, 61 perversion of, 61 psychosis, effect of, on, 62 single impression of, at one time, 71 toxemia, effects of, on, 62 Perceptive apparatus for pain, 30 Perceptive centers of pleasure and pain, 21, 22, 23 Perforating ulcers, 419 Perforation, ^n typhoid, 402, 403 of a viscus, effect of, 416 Perianal abscess, 512 Pericardium, disease of, 788 Perichondritis, 332, 333 Pericystitis, 689 Perigastric adhesions, 459 localization of, in the abdominal wall by palpation, 460 symptoms of, 461 Perihepatitis, 557 adhesions following, 560 Perimysium, sensitiveness to pain of, 113 Perinephritie abscess, differential diagnosis of, 639, 640, 641 Perinephritis, associated symptoms in, 640 character of pain in, 637 location of pain in, 638 posture in, 640 Perinephritis, referred pain in, 638 tenderness in, 638 Periosteal lesions, 229 Periosteum, condition of, in pain from motion, 117 dull aching character of pain of, 228 sensitiveness to pain of, 113 Peripheral causes of anesthesia, 65 Peripheral distribution, of nerve fibers, interpretation of pain as coming from, 393 of sensory fibers, 50, 51 Peripheral nerves, section of, in neuralgia, 65 Peripheral pains, associated, 90 causes of, 83 character of, 108, 109 extrinsic causes of, 83 functional causes of, 84 intrinsic causes of, 83 objective, 83, 89 organic causes of, 83 persistency of, 109 projected, 103 propagation of, 89 referred, 95 reflected, 104 sympathetic, 102, 103 time of, 110 transferred, 106 Periphlebitis of lateral sinus, 337 Perisinus abscess, 338 Perisplenitis, 600 causes of, 601 degrees of pain in, 594, 600 friction sounds in, 601 Peristalsis, relation between gastric and intestinal, 486 relation to pain production, 499 Peritoneal adhesions, general pain of, when present, 371 Peritoneal irritation with hernia, 373 Peritoneum, absence of pain per- ception in, 363 904 INDEX Peritoneum, adhesions of, 367, 368 diseases of, producing pain in, 364 hemon'hage of, 367 inflammations of, 364 layers of, 363 painful impulses of, seated in subperitoneal layer, 362, 363 sensitiveness to pain of, 113 tumors of, 367 Peritonitis, absence of muscular movement in, 126 acute, absence of pain in, 364 pain in, 364 chronic, causes of pain in, 366 location of pain in, 367 diagnostic criteria for, 365 facies of, 127 onset of, 365 posture in, 126 production of pain in, 366 tenderness in, 365 tuberculous, pain in, 365 Peritonsillar abscess, 340 incision of, 351 Pernicious anemia, symptoms of, 181 Peroneal neuralgia, 147 Persistency of pains, 109 Pharyngeal tuberculosis, pain of swallowing in, 355 Phai-yngitis, types of, 423, 424 Pharyngodynia, pain of, 352 Pharynx, acute diseases of, 351 carcinoma of, at base of tongue, 355 chronic diseases of, causing pain, 354 febrile herpes of, 352 herpes zoster of, 353, 354 infectious diseases of, causing pain, 352 cases cited, 353 inflammatory processes of, 351 luetic ulcers of, 355 neuralgias of. 356 Pharynx, pains in diseases of, 351, 423 sensoiy nerve of, 351 tuberculous ulcers of, 354 Phlebitis, deep pressure causing painful reaction in, 71 pain from, 255 Phlegmonous angina, pain of, 351 Phlegmonous pharyngitis, 423 Photochemical changes causing pain, 28 Photophobia, explanation of, 323 Phthisis of the eye, 328 Physical consideration of pain, 20 Physical deterioration from pain, 133, 134 Physical factors of pain : change of position, 117 defecation, 117 digestion, 116 drugs, 119 electricity, 118 extrinsic, 116^ 118 intrinsic, 116 menstruation, 116 modifying production of, 116 motion, 116 pressure, 118 respiration, 116 temperature, extremes of, 118 urination, 116 weather, 119 Pinching, measuring pain by, 129 Pinna, herpes of, 333 Plantar neuralgia, 169 Pleasure, differentiation between pain and, 16, 17, 18 pain related to, 132 relation of, to mental state, 15 sensations causing, 13 transition to pain from, 15, 16 Pleura, inflammation of, 793 innervation of, 769 painful area of, not necessarily indicative of pleural involve- ment, 770 INDEX 905 Pleura, parietal inflammation of, 791 reflected pain in, 771 sensitiveness to pain of, 113 visceral, inflammation of, 792 Pleural pain, 764 Pleurisy, character of pain in, 770 diagnostic value of pain as a symptom of, 770 distinguished from intercostal neuralgia, 165 posture in, 127 respiration in, 127 serous, absence of pain in, 793 transferred pain in, 107 Plumbism, 484 Pneumococci causing neuralgia, 143 Pneumonia, abdominal pain of, 392 association of, with pleurisy, 797 differential diagnosis of, 196 epigastric pains of, 398 mistaken for appendicitis, 797 pain of, 797 referred pain in, 799 slight pain in, 113 transferred pain in, 107 Pneumothorax, 802 Podalgia, 688 Points, distant, in neuralgia, 145 douloureux apophysaires, 145 in neuralgia, local, 144, 145 of pressure, 144, 145 of tenderness, 161 Valleix's, 144, 145 in trigeminal neuralgia, 150 Signorelli's spleen, 596 Poliomyelitis of children, 212 Polycystic disease of the kidney, 645 Polycythemia, 602 Polymyositis, acute, differentiated from eosinophilia, 221 sj'mptoms of, 220 Polyneuritis, differentiated from poliomyelitis, 213 Polypoid growths inside of uterus, 734 Polyuria, with abdominal pains, 414 Pons, tumors of, 185 Portal vein, twist of, from liver dis- placement, 559 Position assumed in lesions of the middle-ear, 334 Posterior comua, nerve fibers en- tering, 41, 42 Posterior cranial fossa, tumors of, 186 Post-hoc neuralgia, 142 Postures, indicating pain, in colic, 126 in disease of joint, 127 in distention of vesical bladder, 127 in intercostal neuralgia, 127 in peritonitis, 126 in pleurisy, 127 Pregnancy, back pains caused by, 303 hydronephrosis in, 654 liver pain during, or after, 548 normal, 736 osteomalacia, associated with, 232 pain in, causes of, 736, 737 pyelitis in, 651 Preprotective functions associated with pain, 135 Prepuce, inflammation of, 703 Pressure, anesthesia by, on a nerve trunk, 66 within nerve sheath, 66 aneurysm indicated by, 127 blood, pain by sudden alterations of, 26 by new gi-owths, 25 causing affections of nerve recep- tors, 140 of nerve trunks, 140 causing neuralgia, 142 constant pain caused by, 109 deep, causing painful reactions, 71 effect of, in neuralgia, 144, 145 in neurasthenia, 216 906 INDEX Pressure, effect of, on pain centers, 64 from inflammatory exudate, 25 in colic, 126 in distention of vesical bladder, 127 measuring pain by, 129 physical factor of pain, 118 projected head pains due to, 269 reaction to, in influenza, 71 in phlebitis, 71 sense of, in head, 264 slight, causing painful reactions, 71 superficial, painful reaction to, 72 tenderness produced by, 70 three painful reactions to, 71, 72 tumor indicated by, 127 venous, headache due to increase of, 274 Pressure points, in hysteria, 79 in neuralgia, 144, 145 Pressure sense, 46 Pricking, 73. See Paresthesia. Primary paths in spinal cord, 42 Proctitis, dysenteric, 507 Production of pain, causative fac- tors in, 25 change of position in, 117 diversion of attention in, 116 drugs in, 119 electricity in, 118 emotions in, 115 factors modifying, 115 in consciousness, 115 in defecation, 117 in digestion, 116 in menstruation, 116 in motion, 116 in respiration, 116 in urination, 116 physical factors modifying, 116 pressure in, 118 psychical factors modifying, 115 serous membranes not the seat of, 363 Production of pain, suggestion in, 116 temperature in, extremes of, 118 weather in, 119 Projected pains, in head, 268 in neuralgia, 144 Projection pain, 103 relief of, in stump of amputated limb, 103 Propagation of pain, 89 Pro i^hy seal disease (Marbui'g, Jel- liffe), 224 Proprioceptive system of Sherring- ton, 12 Prostate, congestion and inflamma- tion of, 700 congestion of, without inflamma- tion, 700 hypertrophy of, 701 lesions of, 701 i pain in, 700 referred pain from, 701 tuberculosis of, 702 tumors of, 702 Prostatic involvement, associated symptoms of, 702 Protective reflexes, reason for, 123 Protopathic fibers, 37, 38 Protopathic system of Head, 11, 12, 37, 39, 46, 47 Pseudo-anginal pain, 784 Pseudoleukemia, 602 bone pains of, 231, 232, 233 Psoas abscess, causing pain in groin and thigh, 97, 98 Psychical factors of pain: con- sciousness, 115 diversion of attention, 116 emotions, 115 modifying pain production, 115 suggestion, 116 Psychosis, pain perception in, 62 Pulse rate, indicating pain, 134 Purpura haemorrhagica, pain from, 249 INDEX 907 Pyelitis, causation of pain in, 647 character of pain in, 647 in pregnancy, 651 localization of pain in, 647 pyonephrosis with, 651 symptoms associated with, 651 Pyelonephrosis, 649 Pyemia, differential diagnosis of, 196 Pyloric spasm, 436 character of pain in, 438 contraction in, 437, 438 tension j^ains of, 437 Pyloric ulcer, distinguished from duodenal ulcer, 450 severity of pain in, 445 Pyogenic mastitis, 258 Pyonephrosis, 652 symptoms associated with, 653 Pyosalpinx, pain production in, 745 B Ranulus, 423 Raynaud's disease, 248 Reaction, of animals to pain, 3 to stimuli without pain, 4 Recalled sensations in subjective pains of hysteria, 75 Receptive apparatus of pain, 28 Receptors, abrogation of action of, 29 lowering of threshold values of, 30 of sensation, 11, 12 •ense receptive organs, 28, 29 temperature, 35 terminal filaments, 28, 29 Recording pain, 135 Rectal pain, local, 505 refen-ed, 506 Rectal tenesmus, 688 Rectum, carcinoma of, 507 gummata of, 507 hemorrhoids of, 508 inflammation of, 506 new growths of, 507 Rectum, pain in, 505 ulceration of, 508 varicose ulcers of, 508 Recurrent paralysis, relation to sen- sibility of the phaiynx, 357 Referred pain, 95 adrenalin for, use of, 102 abdominal, 391, 392 appendiceal, 516, 519 characteristics of, due to pres- sure on a nerve trunk, 100, 101 coal-tar products for, use of, 101 compared with gastric, 461 cord in'itations producing, 95 distal to originating area, 95 from the prostate, 701 from viscera to head, 290, 291, 292, 293, 294, 295 in alimentary tract, 425 in back, 300 in ear, 340 in head, 269 in heart disease, 775 in labor, 739 in laryngeal diseases, 357 in nephritis, 632 in penis, 703 in temples, from carious teeth, 264 incidents of, in groin from above and below, 96, 97 intestinal, 468 localization of viscus producing, 388 locations of, 95 morphin, use of, for, 101 nerv^e circuit lesions causing, 95 neuralgia differentiated from, 102, 106 of cystitis, 687 of the gall-bladder, 567 of kidney, 608 nerves involved in, 612 of neuralgia, 144, 149, 158 908 INDEX Referred pain, of renal calculus, 659 of thoracic walls, 764 posterior root lesions causing, 95 principal causes of, 95 proximal to originating area, 95 psoas abscess causing, in thigh and groin, 97, 98 rectal, 506 reference of, downward, 97, 98, 100 upward, 97 upwai'd and downward, 95, 96 reflected pains differentiated from, 104 section of nei-ves causing, 101 to extraabdominal regions, 416 Reflected pains, 104 abdominal, 391, 392 anatomical basis of, 105 hypogastric, 500 in pleura, 770 intestinal, 467 localization of viscus causing, 106 producing, 388 lowered vitality causing, 106 neuralgia differentiated from, 106 of bladder, 679 of kidney, 614 of thoracic walls, 764 referred pains differentiated from, 104 visceral irritation causing, 105 Reflected stimuli in viscera (Head's law), 384, 385 Reflex headaches, diseases produc- ing, 281 Reflex irritations in neuralgia, 144 Reflex migraine, 286 Reflex neuroses of nose, 344 Reflex organs, of muscles, 123 of sense, 123 Reflex pains, 104 appendiceal, 517, 521 in gastric area, 433 in bead, 269, 277 Reflex pains, of anal fissure, 512 of the viscera, 388 Reflexes, motor, protective tendency of, 122, 123 Regional pains, 262 abdominal, 393, 394 clavicular, 310 in abdomen, 307 in back, 296, 312, 313, 314, 315 in chest, 310 in head, 262 in limbs, 304 in neck, 312 Remittent pains, 109 Removal of calcareous teeth, pain after, 142 gall-stones, pain after, 142 Renal calculus, 655 blocking of ureter in, 657 blood pressure, increase of, in, 667 character of pain in, 658 chills in, 667 collapse in, 667 differential diagnosis of, 668 digestion, causing pain in, 666 digestive symptoms of, 667 duration of the attack of, 659 etiology of pain of, 655 factors influencing pain of, 665 hyperalgesic zones in, 661 intermittent pain of, 658 localization of stone in, 664 location of pain in, 659 manipulation of kidney inciting attack of, 666 micturition, frequency of, 666 motion inciting to attack of, 666 pain of, associated with healthy instead of diseased kidney, 662, 663 paroxysmal pain of, 658 position of patient in, 665 refeiTed pain of, 659 renorenal reflex in, 662 secondary pain in, 657 INDEX 909 Renal calculus, sensations of cold in, 667 spasms in, 667 symptoms associated with pas- sage of, 666 previous to attack of, 667 temperature, elevation of, in, 667 tenderness in, 664 urine changes in, 667 Renal colic, hyperalgesia condition of testicle in, 106 Renal infarction, associated symp- toms of, 628 causes of pain in, 626 differential diagnosis of, 628 type of pain in, 628 Renal pain. See Kidney pain. Renal tuberculosis, character of pain in, 642 diagnosis of, 644 types of pain in, 643 Renorenal reflex in renal calculus, 662 Reproduction of pain, manual, 132 Respiration, indicative of pain, 127 physical factor of pain, 116 Respiratory organs, pain in, 790 Respiratory system, how affected by pain, 134 Retina, pain in, 328 RetropharjTigeal abscess, pain of, 352 Rheumatic headaches, 279, 280 Rheumatism, confused with myositis ossificans, 221 neuralgia associated with, 143 of abdominal wall, 362 of back muscles, 296 of eye muscles, 328 of hip joint, 305 of shoulder joint, circumflex neu- ralgia mistaken for, 164 Rhinological examination, impoi-- tance of, as a diagnostic measure, 350 Rhinostenoma, symptoms of (Piorry), 342 Rigidity of underlying muscles, ten- derness associated with, 72 Robson's point, 565 Rules, Fitz's, in pancreatitis, 488 Rupture, of bladder, 685 of kidney, 641 of spleen, 602 of urethra, 696 Sacral neuralgia, 169 differential diagnosis of, 171 general discussion of, 170 herpes accompanying, 171 symptoms of, 169, 170 Sacral plexus, distribution of nerves from, 53 Sacroiliac dislocation, back pains of, 299 Sacrovertebral joints, diseases of, 299 Salivary glands, pain in, 422 Salpingitis, chronic, pain produc- tion in, 745 remission of, 109 Saponin, terminal anesthesia by, 67 Sarcoma, 233 distinguished from sciatica, 168 of gall-bladder, 571 of kidney, 646 Sciatic neuralgia, 147, 166 Sciatic pains from spinal cord tu- mors, 211 Sciatica, 166 character of pain of, 166 diagnosis of, 168 differential diagnosis, 168, 169 distinguished from gouty hip joint, 245 pains of intermittent claudica- tion, 252 location of pain of, 166 and tenderness in, 72 910 INDEX Sciatica, method of eliciting pain in, 169 Valleix's points in, 167, 168 Scleritis, pain of, 327, 328 Sclerosis, multiple, 213 See Multiple sclerosis. Sclerotic coat of eye, 327 Secondary paths in spinal cord, 42 Seminal vesicles, pain in, 699 Senility, deranged metabolism in, 141 neuralgia in, 141 predisposing to neuralgia, 143 Sensation, absence of, 61 acute, 61 allied to pain, 132 autosuggestive, 75 causing pain, 13 cell areas of, 10 complexity of constituents of, 11 conveying channels for, 35 definition of, 4 duration of, 7 general consideration of, 1, 4 heterosuggestive, 75 in lower animals, 1, 3, 4 in muscles and skin, 48 intensity of, 7 interpretation of, 12 minima of, table representing, 130 neutral, 14 objective, 4 pain and tactile, 8 pain, considered as an attribute of, 25 distribution of, 46 in relation to other sensations, 31 inhibition of, 62 perception of, 61 superficial, 46 perversion of, 61, 62 properties of, 6, 7 quality of, 6, 7 Sensation recalled, in subjective pains of hysteria, 75 subjective, 4 Sense-conveying organs, 5 Sense organs, centers for, 7 classes of, 11, 12 Sense-perceptive centers, 30 hypersensitiveness of, 30 Sense-perceptive organs, 5, 11 Sense-receptive organs, 5 Senses, external, 5 internal, 5 Sensibility, abnormal. See Hyper- algesia. Sensibility, loss of, in lesions of the thalamus, 200 mental activity of, 13 Sensitiveness of patient, factor of intensity of pain, 115 Sensiti\eness to pain, development of, 112 individual, 112, 113, 115 in infancy, 111 Sensorimotor area, 10 Sensory area, 10 convolutions of, 10 effect of destruction of, 10 location of, 10 Sensory examination, method of making a, 131, 132 Sensoi-y fibers, 10 arising in gray matter cells, 42 ascending path of, 45 association with vasomotor fibers, 380, 381 conducting, course of, 174 coui-se of, 40, 41, 42, 43, 44, 45 entering posterior eornua, 41, 42 l^eripheral distribution areas of, 50, 51 Sensory mental activities, states of, 13 Sensory nerve receptors in muscleSj 218 Sensory nerves, areas of distribu- tion, 47, 48 INDEX 9U Sensoiy nerves, of the larynx, 356 of muscles^ 50 of nose, 341 Sensory neurology, importance of, 201 Sensory organs, 5, 11 Sensoiy perception, active agents of, 10, 11 centers for, 7 Septic involvement of osseous sys- tem, 231 Serositis, universal chronic, 561 Severance of posterior roots, anes- thesia produced by, 66 Sexual act inducing loss of con- sciousness, 133 Sexual connection, importance of cure of abnormality in, 758 pain in the male during, 759 pain, vaginal, at beginning of, 758 duiing, 759 on, 756 Sexual indulgence, excessive, pre- disposing to neuralgia, 143 Shock, indications of, 124, 125 susceptibility to, 125 with intestinal pain, 475 "without consciousness, 125 Shoulder, pains above, 769 pains in, 304 reflected pains in, 304 Shoulder joint, gonococcus infection of, 304 rheumatism of, 304 Shoulder pain in abdominal lesions, 392 Sigmoid, obstruction of, 505 volvulus at, 496 Sigmoid colon, lesions of, causing pain, 494 Signorelli's spleen point, 596 Simulation of pain, blood pressure elevation important in dis- tinguishing, 120 Sinus disease, area of, 262 tenderness in, significance of lack of, 262 Sinus thrombosis, differential diag- nosis of, 195 Sinuses, local pains in cavities of, 344 obstructed, 345 Skin, as seat of head pains, 265 effect on, of neuralgia, 146 Sleep, reflex protective action in, 122 Sleeping pains, 305 Smallpox, back pain with, 297 Smell, protective reflex action of, 123 Soft tissues, neuralgia from, 142 Solar plexus as seat of epigastric pain, 469 Somatic areas, visceral fibers re- lated to, 54 Somatic pain, visceral, 391 Somatic sense organs, 12 Sore throat, gouty, 423 streptococcic, 423 Spasm in intestines, 479 Special pain nerves, 25 Sphenopalatine ganglion, headaches from diseases of, 345 Sphincter, pain in disease of, from defecation, 117 "Spill" hypothesis of perversion of sensation, 62 Spinal cord, back pains of, 207 back pains of, due to visceral dis- eases, 207, 208 caries of vertebral canal, 210, 211 conditions of, causing pain, 208 diagnostic value of pains in, 207, 208, 216 diseases of, 207 in which pain is absent, 207 entrance of nerve fibers into, 41 general summary of pains of, 216 hematomyelia, 210 hysteria, 216 912 INDEX Spinal cord, injury to pain conduc- tion paths in, 38, 39 irregular distribution of pain in, 39, 40 meningeal apoplexy, 209 meningitis of, 212 multiple sclerosis, 213 myelitis, 212 neurasthenia, 215 pachymeningitis spinalis hyper- trophica, 212 pains produced by diseases of, 207, 216 poliomyelitis of children, 212 primary paths in, 42 radiating pains of, 207 secondary paths in, 42 syphilis of, 213 syringomyelia, 214 tabes dorsalis, 214 traumatic neuroses, 216 tmnors of, 211 unilateral lesions of, 39, 40 vertebra, luxation and fracture of, 209 Spleen, abscess of, 601 anatomy of, 593 back pains referred from, 303 blood diseases causing pain of, 602 character of pain in, 594 congestion of, 599 causes of, 600 cysts of, 602 differential diagnosis of, 603 diseases of, causing pain, 598 displaced, 598, 599 enlargement of, from infectious diseases, 600 . epigastric pains from lesions of, 397 general considerations of, 593 hydatids of, 602 infarct of, 601 inflammation of, causes of, 600 movable, 598 Spleen, nerve supply of, 593 pain in, 594 factors influencing, 596 rupture of, 602 Signorelli's point, 596 stimuli of, 594 symptoms associated with pain or tenderness of, 598 tumors of, 602 Spleen pains, circulatory changes, effect on, 597 diaphragmatic movements, effect on, 597 Splenitis, degrees of pain in, 594 position of patient in, 596 tenderness in, 595 localized points of, 596 Spondylitis, distinguished from osteomalacia, 232 Spurs, bone pain of, 233 Stagnation mastitis, 258 State, of indifference, 13 of sensory mental activities, 13 Static foot errors causing backache, 304 Stenosis, nasal, 342 pyloric, benign, distinguished from carcinomatous, 457 Stimulated surface, extent of, 26 Stimuli, adequate, of the viscera, 387 as factor of intensity of pain, 114 as means of sensation, 2, 3, 4, 5 continuous, 114 due to mechanical changes, 25 excessive response to, in diseases of the thalamus, 200, 201, 202 intermittent, 114, 115 nature of, 5 necessaiy to pain reaction, 12 sensoi-y reaction, 12 of reflected abdominal pain, 392 pain, by frequent repetition of, 26 INDEX dl3 Stimuli, pain from excess of, 24 without presence of, 141 Stomach, acute dilatation of, 439 areas of maximum tenderness in, 428 of referred pain, caused by dis- orders of, 427 back pains due to affections of, 301 causes of pain in, 427 dilatation of, from pyloric spasm, 438 displacement of, 431 epigastric pain from lesions of, 397 hourglass, cause of pain in, 437 lesions of, causing pain, 431 nerve supply to, 428 neuralgia of, 461, 462 new growths of, 455 nonresponse of, to chemical stim- uli, 426 to tactile stimuli, 426 pain in, from change of position, 117 pain sensation of, 426 See Gastric, sensations of, 426 Strangulated hernia, mistaken diag- noses of, 374 pain in, 374 Streptococci causing neuralgia, 143 Streptococcic sore throat, 423 Stroking, measuring pain by, 129 Subjective pain, 13, 24, 74 abdominal, 360 by hypnosis, 75, 80 conditions giving rise to, 74 from emotional states, 74, 76 from hysteria, 74, 76 habit pains, 80 monomania pains, 80 occupation neuroses, 80, 81 Suggestion, psychical factor of pain in, 116 Sunken globes, 329 Suppuration of middle-ear, 337, 338 Supraclavicular pains, causes of, 310, 312 Supra-orbital neuralgia, epidemic, 143 Susceptibility, of tissues, to pain, 113 to pain, 123, 124 individual, 115 Sympathetic fibers, abdominal pain due to, 399 of abdominal viscera, 378, 380 Sympathetic ophthalmia, 328, 329 Sympathetic pains, 102, 103 abdominal, 393 of neuralgia, 144 Sympathetic system, carrying stim- uli, causing headache, 176 Symptom, importance of pain as, 1 Syncope, causes of, 132, 133 indicating intensity of pain, 124 indicating shock, 124, 125 Synovitis, acute, symptoms of, 234, 236, 238, 240 Syphilis, nocturnal pain of, 110 of the brain, 188 headache and other symptoms of, 190 See Brain syphilis. of liver, 556 of meninges and cord, 213 of tongue, 421 relief of, from mercury and iodids, 119 Syphilitic neuralgia, 147 Syphilitic process of luetic ulcers, 355 Syphilitic ulceration of intestines, 489 Syringomyelia, producing anal- gesia, 62, 66 symptoms of, 214 System, epicritie, 12 nervous, 2, 3, 4 autonomic, sympathetic, 12 proprioceptive, 12 914 INDEX System, protopathic, 11, 12 vestibular, 12 Tabes, analgesia produced by, 66 differentiated fro m multiple sclerosis, 213 distinguished from neuralgia, 149 sciatica, 168 Tabes doi-salis, 95 associated symptoms of, 215 delayed pain sensation in, 111 laryngeal crises of, 359 location of pain and tenderness in, 72 pains of, 214 tabetic crises of, 214, 215 Tabetics, dissociation between pain and touch in, 34 Taste, protective reflex action of, 123 Teeth, destruction of, 420 pain in, 419 destruction of, 420 from neuralgia, 148 reference areas of, 420 sensitive part of, 419 Temperature, sensibility to changes of, 35, 46 effect on pain pf changes in, 119 elevation of, from pain, 135 extremes of, physical factor of pain, 118 Temperature receptors, 35 Temperature senses, pain related to, 32, 33, 34, 46 Temporal lobe abscess, 339 Tenderness, 70, 71, 72 abdominal, 403. See Abdominal tenderness, in tubal disease, 720 area of, 72 associated with enterospasm, 483 chronic, 405 deep, 405 Tenderness, hyperalgesia differen- tiated from, 70, 71 in appendicitis, 529 in kidney disease, 615 in occupation neuroses, 81 in pelvic pain, 719 of the gall-bladder, 563 point of, in pelvic adhesions, 405 points of (Cumston), 405 (Hubbard), 406 (McBurney's), 405, 406 (Mori'is'), 405, 406 reflected, 405 rigidity of underlying muscles as- sociated with, 72 superficial, 405 temporary, 405 types of, 405 with intestinal pain, diagnostic value of, 474 Tendon spindles, 46 Tension, as cause of hollow visceral pain (Hertz), 223 as cause of visceral pain, 388 Tension pains of viscera, 388 Terminal anesthesia by toxic agents, 67 Terms, careless use of, 409 Testicles, deep pressure pain ip, 698 enlargement of, 699 inflammation of, 698 nerve suj^ply to, 698 pain in, 698 reflected kidney pain in, 615 trauma of, 699 Tests, for diseased sinus (Glas' tun- ing fork), 349 for eliciting pain in sacroiliac region (Goldthwaite), 300 Thalamic center, 202 Thalamic functions, 198, 201 Thalamic pains, 198 severity of, 83 Thalamic syndrome, 199 loss of sensibility in, 199, 200 INDEX 915 Thalamic syndrome, overresponse to stimuli in, 200, 201, 202 symptoms of, 199 Thalamus, differential diagnosis be- tween lesions of the cortex and, 203, 204, 205, 206 essential organ of, 201, 202 functions of, 201 interrelations between the cortex and, 202 lesions of, 199 loss of sensibility in lesions of, 199, 200 overresponse to stimuli in lesions of, 200, 201, 202 pains of, 198 paths of, 201 Theories of pleasure and pain, 18, 19, 20 Therapeutic measures applied to empyema, 348 Theniial sensibility, 47 Thermic irritations, parenchymatous pains from, 88 Thigh pains, referred from kidney lesions, 610 Third nerve palsy, 321 Thoracic organs, diseases of, caus- ing pain, 795 Thoracic pains, transferred from distention of the stomach, 766 Thoracic walls, referred pains of, 764 reflected pains of, 764 structures composing, 760 transferi'ed pain in, 765 Thorax, bone pain in, 764 facial pain of, 762 fractures of, 764 herpes zoster of, 763 hyperalgesia of skin of, 761 hyperesthesia of skin of, 761 hysteria, tenderness of skin in, 761 inflammation of skin of, 761 muscle pain of, 762 Thorax, nerve pain of, 762 neuralgia of, 760, 763 neuritis of, 762 osteomyelitis of, 764 pains within, 769 pleural pain of, 764 skin affections of, 760 Threshold values of pain, loweriog of, 30 Throat, pain in diseases of, laryn- geal, 356 pharyngeal, 351 Thrombo-endarteritis obliterans, 249 Thrombosis of arteries, 248 differential diagnosis of, 196, 198 of mesenteric arteries, 253, 254 of veins, 256 Thymus gland, pain in, 261 Thyroid gland, pain in, 261 Tic douloureux, 420 of herpes zoster, 354 douloureux. See Trigeminal neu- ralgia. Tickling, 73. See Paresthesia. "Time of life" pains, 410 Time of pain, 110 Tingling, 73. See Paresthesia. Tissue susceptibility to pain, 113 Tissues, fatty, pain in, 224 glandular, 257 muscular, pain in, 218 Tobacco, predisposing to neuralgia, 143 Tongue, carcinoma of base of, 355 lesions of, an indication of a noc- turnal epileptic attack, 422 causing pain, 421, 422 pain in, 421 reference areas in diseases of, 422 ulcer of, 419 Tongue pains. See Glossodynia. Tonsils, pain in, 423 Toothache, causes of, 419 trigeminal neuralgia mistaken for, 420 S16 INDEX Torsion, parenchymatous pains from, 88 Torticollis, 221, 222, 296 Touch, dissociation of, from pain, 32, 33, 34 perception of, in anesthesia, 63 Toach sense, in localizing pain, 48 Toxemia, causing affections of nerve receptors, 140 causing affections of nerve trunks, 140 pain, cause of, 26, 27 pain perception in, 62 with abdominal pains, 414 Toxemic headaches, due to en- dogenous poisons, 271 due to exogenous poisons, 271 due to starvation products, 272 Toxic agents, anesthesia by, 67 Toxic analgesia, 62 Toxic materials, pain from, 142 Toxic products, pain from accumu- lation of, 27 Traction, cause of pain in viscera, 390 parenchymatous pains from, 88 Transferred pains, 95, 106 abdominal, 392 appendiceal, 516, 520 cause for persistency of, 108 in breast, 258 in homologous segments, 107 in thoracic walls, 765 in urethral disease, 696 neuralgia differentiated from, 106 occurring in cord, 107 reference higher and lower, 107 sympathetic pain, differentiated from, 102 Transverse myelitis, 95 anesthesia produced by, 66 Trauma, habit pains resulting from, 80 Traumatic neuroses, 216 differential diagnosis of, 196 Traumatism, causing affections of nerve trunks, 140 neuralgia, 143 of bones, 229 Trigeminal neuralgia, 146, 147, 148, 149 area of, 262 associated with tumors, 183 characteristics of, 149 mistaken for toothache, 420 Valleix's points in, 150 Trigeminus, pains in head due to action on receptors of, 82 Trophic changes, from neuralgia, 146 in skin, causing pain, 28 resulting from pain, 134, 135 Tropical abscess of liver, 554 Tubal inflammation, adhesions from, 746 functional acts, pain in, 745 uterine colic from, 746 Tuberculin, use of, 119 Tuberculosis, effect of tuberculin in, 119 of hip joint, 305 of kidney, 642 of ovary, 752 of prostate, 702 of tongue, 421 of vertebrae, 211' of vulva, 756 pain from enlargement of mesen- teric glands in, 261 pharyngeal, 355 pulmonai*y, 800 causes of thoracic pain in, 802 character of pain in, 800 pleurisy during, 802 pneumothorax during, 802 tenderness in, 800 Tuberculous caries, back pain of, 299 Tuberculous hip diseases, symptoms of, 241 treatment, 243 INDEX 917 Tuberculous meningitis, differential diagnosis of, 197 headache in, ISO symptoms of, 180 Tuberculous peritonitis, 365 Tuberculous ulcers, intestinal, 488 of larynx, 358 phaiyngeal, 354 Tumor, brain, 270. See Brain tumor. cerebral, 269 distinguished from sciatica, 168, 169 gummatous masses similar to, 211 nasal, 347 neuralgia due to, 142 of base of brain, 186 of bladder, 689 of brain, 182 of breast, 259 of central ganglion, 185 of cerebellopontine angle, 183 of cerebellum, 185 of chiasma, 183 of corpora quadrigemina, 185 of corpus callosum, 184 of frontal lobe, 184 of hypophysis, 186 of kidney, 646 of medulla, 186 of parietal lobe, 184 of pedunculi cerebri, 185 of peritoneum, 367 of pons, 183, 185 of posterior cranial fossa, 186 of prostate, 702 of spinal cord and vertebra, 211 of spleen, 602 pressure indicating, 127 visceromotor reflex mistaken for, 445 Twisted pedicle, cysts from, 399 diagnosis of, 399 Tympanum, pain in, 335 Typhoid fever, differential diagnosis of, 196 Typhoid fever, neuralgia associated with, 143 neuritis of toes in, 169 nocturnal ostalgia with, 228 perforations in, 402, 403 spleen, enlargement of, from, 600 Typhoidal ulceration of intestines, 488 U Ulceration, of intestines, catarrhal, 489 syphilitic, 489 typhoidal, 488 rectal, 508 Ulcerative colitis, 501 Ulcer of stomach, chronic, distin- guished from gastric ulcer, 451 distinguished from cancer and nervous gastralgia, 452, 453, 454, 455 Ulcers, duodenal, 489 following burns, 489 of intestines, 487 of tongue, 419, 421 perforating, 449 tuberculous, of intestines, 488 of pharynx, 358 Umbilical hernia, local and referred pain of, 374 Umbilical pain in intestinal lesions, 469 Universality of pain, 20 Uremia, colic with, 484 differential diagnosis of, 197 nocturnal pain of, 110 Ureter, inflammation of, 670 location of pain in inflammation of, 671 muscular spasm in, 670 nerve supply to, 670 obstruction of, 670 complete, 671 pain associated with, 670 tumor of, 671 918 INDEX Ureteral colic, cause of pain in tes- ticle in, 105 Ureteral disease, route of pain ref- erence in, 671 Ureteral stone, reference pains in groin from, 671 Ureteritis, 670 Urethra, pain in, 695 Urethral calculus, 696 Urethral caruncles, 695 Urethral disease, transfeiTcd pain in, 696 Urethral rupture, 696 Urethritis, 695, 703 epididymis involved in, 699 Urine, irritating constituents in, 696 Urination, burning sensation dur- ing, 697 pain after, causes of, 697 pain during, due to inflammatory changes, 697 pain on, 696 painful in bladder diseases, 682 physical factor of pain in, 116 Uterine colic from tubal inflamma- tion, 746 Uterine muscle, hyperesthesia of, 731 Uterine pain, character of, 716, 724 constant, 716 disorders causing, 726 due to cervical stenosis, 729 due to hindrance to the separa- tion of the decidual mem- brane, 730 due to spasmodic contraction of cervix, 730 in childbirth, 738 in pregnancy, 736 intensity of, 726 intermittent, 716 irregular intensity of, 724 tenderness with, area of, 721 Uterus, back pains referred from, 303, 304 benign growths of, 743 Uterus, cancer of, 744 correlation of, through nervous system with breast, 715 displacement of, 726 character of, 727 enlarged, pain in ovaiy from, 752 fibroids of, 744 functional disorders of, 728 inflammation of, 740 maldevelopment of, 731 malignant growths of, 743 menstruation, painful, to, 728 nerve supply to, 707, 713, 724 neuralgia of, 726 new growths of, 743 Ijolypoid growths inside of, 734 Vagina, affections of, causing pain, 755 cancer of, 756 hemorrhage into the soft parts surrounding, 756 nerve supply to, 755 nodule on, 756 pain in, 755 Vagus and greater splanchnics, pain conductivity of, 383 Valleix's points, 71 in neuralgia, 144, 145 in sciatica, 167, 168 in trigeminal neuralgia, 150 Varicose veins, 256 Varieties of i^ain, origin and ti'ans- mission, diagrams of, 89, 90, 91 Vas deferens, pain in, 699 Vasomotor changes in neuralgia, 145 Vasomotor fibers associated with sensory fibers, 380, 381 Vasomotor paresis, 133 Vasomotor signs of intensity of pain, 120, 124 INDEX 919 Vasoneurosis, 72 Veins, diseases of, causing pain, 255 inflammation of, 255 thrombosis of, 256 Vena cava, pull on, from liver dis- placement, 559 VeiTuiform appendix, diseases of, . 529 Vertebra, caries of the canal of, 210, 211 luxation and fracture of, pains produced by, 208 symptoms of, 209 tumors of, 211 Vertebral diseases, dislocations, 299 leukemia, 299 of saei'o vertebral joints, 299 tuberculous caries, 299 Vertebral pains, indications from, 312 Vesical calculus, absence of pain in, 695 causes of pain in, 692 character of pain in, 693 digestion in, 695 location of pain in, 694 motion, causing pain in, 694 position of patient in, 694 production of pain in, factors in- fluencing, 694 Vesical jilexus, contributing to blad- der, 674 Vesicles, in cheeks, 419 on tongue, 421 Vesicourethral fissure, 684 Vestibular nerve, 12 Vestibular system, 12 Vibration as stimulus of sensation, 5, 6 Viscera, abdominal, absence of pain in lesions of, 390 adequate stimuli (Hertz), 387 areas of hyperesthesia in (Mac- kenzie's), 385 cocain anesthesia in, 382 Viscera, abdominal, examples of ir- sensitiveness of, 381 gangrene of, 417 hyperalgesia, persistence of, 386 hypoalgesia in (Wilamowski's), 385 innervation of, 378 insensitiveness of, to pain, 381, 382 irritable foci produced in cord by lesions of, 386 lesions of, producing pain, 390 location of pain in diseases of, 383, 384 manner of pain production and conduction, 383 maximum points of tenderness of, 393 nonpainful diseases of, 393 pain conductivity of vagus and greater splanchnics, 393 pain of, due to contraction and dilatation of, 390 due to spasmodic contrac- tions and dilatations of, 391 due to traction on mesentery, 390 from passive dilatation of, 390 perception in, 377 perforation of, 416 phenomena present with inflam- mation, 378 reflection of stimuli in (Head's law), 384, 385 reflex changes in, 389 sensitiveness of, to deep pres- sure stimuli, 387 sensory fibere of, 380 shock production of painful stimuli, 387 stimuli in, pain producing, 380 920 INDEX Viscera, abdominal, transference of pain, manner of (Head), 384 zones of hyperalgesia in (Head's), 384, 385 Viscera, absence of pain in inflam- mation of, 8G, 87 back pains due to lesions of, 208 causing referred pain in head, 290, 291, 292, 293, 294, 295 inaccuracy of localization of ten- sion pains in, 388 irritation of, causing reflected pain in, 105, 106 pain in involuntary muscles of, 222 referred pains to back from, 300 Visceral diseases, surface zones re- lated to, 54 Visceral nerves, 41 Visceral neuralgia, 147 Visceral pain, mobility of organ in localization of, 470 produced by traction of mesen- teiy, 381 Visceral pain, tension only true cause of (Hertz), 388 Visceromotor reflex, mistaken for a tumor (Mackenzie), 445 Visceromuscular reflex, 413 Volition, mental activity of, 13 Voluntary analgesia, 62, 63 Voluntary lameness, symptoms of, 241 Volvulus, 496 Vomiting, protective reflex action of, 123 with intestinal pain, 474 Von Frey hairs, measuring pain by, 130, 131 Vulva, cancer of, 756 cysts of, 756 tuberculosis of, 756 W Weather, effect of, on pain pro- duction, 119 (7) Date Due PRINTED IN U.S.A. CAT NO. 24 161 BBS A 000 510 153 vmiT6 eU19p 1920 Behan, Richard J Pain . . . "Behan, Pichard J Pain . . . B^lPp 1920 MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92684