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SYMPTOMS 
 
 AND THEIR INTERPRETATION. 
 
SYMPTOMS 
 
 AND 
 
 THEIR INTERPRETATIOK 
 
 Sm JAMES MACKENZIE, M.D., F.R.C.R, LL.D., | 
 Aber. & Edin., F.R.S., F.R.C.P.I. (Hon.). j 
 
 Honorary Consulting Physician to His Majesty the King in Scotland. ^ 
 
 Consulting Physician to the London Hospital and the Victoria Hospital, Burnley. ^ 
 
 Director of the St. Andrews Institute for Clinical Research. 
 
 4TH Edition. 
 
 Also translations into French, German, etc., etc. 
 
 LONDON : 
 
 SHAW & SONS, 7 & 8, FETTER LANE, E.C.4, 
 
 printers anD publisbers. 
 
 1920. 
 

 tliOLOGY 
 LIBRARY 
 
PREFACE 
 
 TO THE FOURTH EDITION. 
 
 TT Then, a dozen years ago, I wrote the first 
 edition of this book, I dimly perceived that 
 there was a field of medical knowledge essential to pro- 
 gress wliich was left almost unexplored. It might 
 seem absurd to say that the field of symptomatology 
 was in tliis state, for has not the study of symptoms 
 been prosecuted since the dawn of medicine ? 
 Nevertheless, the more I have gone into this 
 subject the more evident has it become that 
 symptoms have not been properly investigated, 
 and even the methods by which the investigation 
 should be pm'sued have not yet been understood. 
 
 Though the value of symptoms has been recog- 
 nised, yet the nature of their importance has not 
 been clearly understood, and in consequence the 
 
vi. Preface. 
 
 manner in which they should be studied was not 
 guided by a definite object or on sound principles. 
 Disease is only made manifest to us by the symptoms 
 it produces, but when a man falls ill the function 
 of every organ of the body may be disturbed, and 
 did we possess the means an infinitude of symptoms 
 would be discovered. As it is, new methods are 
 continually being devised for the detection of new 
 symptoms, and medicine is breaking up into 
 an ever-increasing number of sections. Men are 
 devoting much time to special subjects and using 
 the resources of other sciences in developing their 
 speciahty. In this way, an ever-increasing number 
 of symptoms are being revealed. Tliis kind of 
 research seems justified by the behef that because 
 a new fact is discovered knowledge is progressing. 
 
 Whereas, the reverse is the case, for this kind of 
 research only tends to defeat its object. In place 
 of advancing knowledge, it actually hampers it by 
 
Preface. vii. 
 
 clouding over the methods and the objects of the 
 science of medicine, by an ever-accumulating mass 
 of details. The progress of true knowledge is ever 
 accompanied by a simplifying of the subject. This 
 is because the laws of Nature are few in number. 
 Details, mth no understanding of the laws which 
 govern their -production, only lead to confusion. 
 The discovery of the laws, on the other hand, tends 
 to bring order out of the chaos by classifying the 
 details according to those laws which govern their 
 production. 
 
 This book is an attempt to find those laws, and 
 by indicating principles to guide research on better 
 defined Hnes. 
 
 J. M. 
 
 St. Andrews, 
 
 Scotland. 
 
 October, 1920. January, 1921. 
 
 In the foregoing preface of this edition the need 
 for understanding the laws which govern the pro- 
 
viii. Preface. 
 
 cluction of symptoms was dwelt upon, and it was 
 then stated that this book was an attempt to find 
 those laws. While the book was in the Press the 
 search for these laws was being conducted by the 
 staff of the St. Andrews Institute for Clinical 
 Research. They have been successful in dis- 
 covering that the principle governing the produc- 
 tion of manj^ symptoms is due to the disturbance of 
 normal reflexes. This idea is foreshadowed in the 
 book, and although it is impossible at this stage 
 to tell the effect it may have on medicine in general, 
 its application in practice and in research has 
 already shown it to be of service. 
 
 The description of this theory, which appears in 
 an Appendix at the end of this volume, was 
 published in the British Medical Journal of 29th 
 January, 1921, by whose kind permission it is 
 reproduced. 
 
( ix. ) 
 
 CONTENTS 
 
 Chapter 1. Pages 1 — 10. 
 
 The Importance of Symptoms in Medical Practice and Research. 
 
 1. The science of medicine. 2. The importance of symptoms 
 in diagnosis. 3. The importance of symptoms in prognosis. 
 4. The importance of symptoms in treatment. 5. The importance 
 of symptoms in research. 
 
 Chapter II. Pages 11 — 18. 
 
 The Mechanism of a Disease Process. 
 
 6. Definition of disease. 7. The detection of disease. 
 8. Definition of symptoms. 9. Methods for investigating 
 symptoms. 10. Principles of research. 
 
 Chapter III. Pages 19—29. 
 
 The Training of the Observer. 
 
 11. Medicine a science. 12. Accuracy of observation. 
 13. Clinical and laboratory observation compared, li. Limitation 
 of laboratory methods. 15. The importance of a clinical training. 
 16. The requirements of a clinical observer. 
 
X. Contents. 
 
 Chapter IV. Pages 30— ;j9. 
 
 Principles of Investigation. 
 
 17. The need for principles. 18. Differentiation. 19. Classi- 
 fication. 20. The law of progression. 21. The law of associated 
 phenomena. 22. The significance of symptoms (prognosis). 
 23. The use of laboratory methods. 24. The expectation of 
 results. 
 
 Chapter V. Pages 40 — 47. 
 
 Classification of Symptotns. 
 
 25. The anatomical classification of disease. 26. The 
 clinical classification of symptoms, 27. Structural symptoms. 
 28. Functional symptoms. 
 
 Chapter VI. Pages 48 — 56. 
 
 Reflex Symptoms. 
 
 29. The discovery of the seat of disturbance. 30. The 
 discovery of the agent causing ill-health. 31. The discovery of 
 the functions of the nervous system. 32. Methods of examination. 
 33. Mechanism of an ordinary stimulation. 34. Mechanism of 
 the radiation of sensation. 35. Mechanism of a motor reflex. 
 36. Mechanism of radiation in disease. 
 
 Chapter VII. Pages 57 — 60. 
 
 Pain. 
 
 37. Definition of pain. 38. Constitution of the nervous 
 system. 39. Difference in the functions of the two nervous 
 svstems. 
 
Conteyits, xi. 
 
 Chapter VIII. Pages 61—73. 
 The Sensitiveness of the Tissues. 
 40. The tissues sensitive and not sensitive to mechanical 
 stimulus. 41. Sensitive tissues of the external body wall. 
 
 42. Insensitiveness of the viscera to mechanical stimulation. 
 
 43. Methods for testing the sensibility of organs. 44. Testicular 
 pain. 45. Artificial production of visceral pain. 
 
 Chapter IX. Pages 74—83. 
 
 Visceral Reflexes. 
 46. The mechanism of visceral pain. (The viscero-sensory 
 reflex.) 47. The mechanism of the viscero-motor reflex. 
 48. Multiple reflexes from visceral stimulation. 
 
 Chapter X. Pages 84 — 96. 
 Diminished Resistance to Stimulation. 
 49. Focal. 50. General. 51. The soldier's heart. 52. War 
 neurosis. 53. The mechanism of symptoms. 54. Practical 
 importance of recognising the mechanism of symptoms. 
 
 Chapter XI. Pages 97—103. 
 
 Organic Reflexes. 
 55. Vomiting. 56. Dyspnoea. 57. Secretory reflexes. 
 58. Cardiac reflexes. 59. Vaso-motor and pilo-motor reflexes. 
 
 Chapter XII. Pages 104—113. 
 Preliminary Examination of the Patient. 
 60. The patient's appearance. 61, The patienlj^s sensations. 
 62. Facial aspect. 63. The general condition. 64. A revieW of 
 all the organs. 
 
xii. Contents. 
 
 Chapter XIII. Pages 114—129. 
 Affections of the Digestive Organs. 
 
 65. The nerve supply of the digestive tract. 66. Distri- 
 bution of sensory symptoms in affections of the digestive tract. 
 67. Appetite. 68. Hunger. 69. Nausea. 70. Mouth and fauces. 
 71. Tongue. 72. Swallowing. 73. (Esophagus. 
 
 Chapter XIV. Pages 130—154. 
 
 Affections of the Digestive Organs [continued). 
 The Stomach. 
 
 74. The nature of the symptoms. 75. The nerve supply of 
 the stomach. 76. The site of pain in affections of the stomach. 
 77. The character of the pain. 78. Hyperalgesia. 79. Superficial 
 reflexes. 80. Visceromotor reflexes. 81. Vomiting. 82. Pyrosis 
 and heart-burn. 83, Air suction. 84. Functional symptoms. 
 85. Structural symptoms. 86. The diagnosis of stomach 
 affections. 87. Pain in gastric ulcer. 
 
 Chapter XV. Pages 155 — 165. 
 The Liver, Gall-bladder, and Ducts. 
 
 88. Nerve supply. 89. Keflex symptoms in gall-stone 
 disease. 90. Gastric symptoms in gaU-stone disease. 91. The 
 result of reflex symptoms. 92. Functional symptoms in gall- 
 stone disease. 93. Structural symptoms in gall-stone disease. 
 94. Fever in gall-stone disease. 95. Nature of reflex symptoms 
 in affections of the liver. 96. Functional symptoms in 
 affections of the liver. 97. Structural symptoms in affections of 
 the liver. 
 
Contents. xiii. 
 
 Chapter XVI. Pages 166—179. 
 
 The Great and Small Intestine. 
 
 98. Difficulties in diagnosis. 99. Pain. 100. Appendicitis. 
 101. Affections about the anus and perineum. 102. Perineal reflex. 
 103. Functional symptoms. 104. Structural symptoms. 
 
 Chapter XVII. Pages 180—195. 
 
 Ajjcctions of the Urinary System. 
 
 105. Symptoms of affections of the kidney. 106. Symptoms 
 of affections of the pelvis of the kidney and ureter. 
 107. Symptoms of affections of the bladder. 
 
 Chapter XVIII. Pages 196—200. 
 
 Affections of Female Pelvic Organs. 
 108. The uterus. 109. The ovaries. 110. The vagina. 
 
 Chapter XIX. Pages 201—206. 
 
 Peritonitis and Peritoneal Adhesions. 
 111. Insensitiveness of the peritoneum. 112. Symptoms 
 in peritonitis. 113. Symptoms in peritoneal adhesions (parietal). 
 114. Symptoms in peritoneal adhesions (visceral). 
 
 Chapter XX. Pages 207—221. 
 
 Affections of the Lungs and Pleura. 
 115. Nature of the subjective sensations. 116. The respira- 
 tion. 117. Reflex symptoms. 118 Functional symptoms. 
 119. Structural symptoms. 120. Affections of the pleura. 
 121. Nature of the pain in pleurisy. 
 
xiv. Contents. 
 
 Chapter XXI. Pages 222—255. 
 
 Affections of the Circulatorij System. 
 
 122. Heart failure. 123. The nature of the symptoms in 
 heart failure. 124. Consciousness of the heart's action. 
 125. Breathlessness. 126. Viscero-sensory and viscero-motor 
 reflexes. 127. The viscero-sensory reflexes in dilatation of the 
 heart and liver. 128. The pain of angina pectoris is a 
 viscero-sensory reflex. 129. Evidences of the viscero-motor 
 reflex. 130. Organic reflexes. 131. Summation of stimuli 
 the cause of angina pectoris. 
 
 Chapter XXII. Pages 256 — 274. 
 
 Estimation of the Value of Symptoms. 
 
 132. The relation of the symptoms to the general state. 
 133. Kemote effects of the lesion. 134. Relation of symptoms 
 arising from different causes. 135. The bearing of symptoms 
 on prognosis. 136. The bearing of symptoms on treatment. 
 
 Index. Pages 276—308. 
 
 Appendix 309—332. 
 
 The theory of disturbed reflexes in the production of 
 symptoms of disease, page 309. 
 
( XV. ) 
 
 LIST OF ILLUSTRATIONS. 
 
 PAGE 
 
 Fig. I. Diagram of a simple reflex - - . - - 52 
 
 Fig. 2. Diagram of the radiation of sensation - - - - 52 
 
 Fig. 3. Diagram of motor reflex - - - - - - 54 
 
 Fig. 4. Diagram of radiation of sensation in disease - - - 54 
 
 Fig. 5. Diagram of the origin and distribution of the efferent auto- 
 nomic nerve fibres ------ 59 
 
 Fig. 6. The relation of cutaneous hyperalgesia to enlargement of the 
 
 liver -----... 67 
 
 Fig. 7. The relation of cutaneous hyperalgesia to gastric ulcer - - 75 
 
 Fig. 8. Diagram of an organic reflex - - - - - 76 
 
 Fig. 9. Diagram of a viscero-sensory reflex - - - - 76 
 
 Fig. 10. Diagramof a viscero-motor reflex - - - - 78 
 
 Fig. 1L Diagram of a combined viscero-motor and viscero-sensory 
 
 reflex .----.. 79 
 
 Fig. 12. Diagram of multiple reflexes - - - . - 81 
 
 Fig. 13. Shows the areas in which pain is felt in affections of the 
 
 digestive tube - - - - - - 116 
 
 Fig. 14. Shows the seat of pain, and the position of the gastric 
 
 ulcer causing the pain . . - . . 149 
 
xvi. Ldst of Illustrations. 
 
 PAGE 
 
 Fig. 15. Shows the seat of pain, and the position of the gastric 
 
 ulcer causing the pain - - - - - 151 
 
 Fig, 16. Shows the seat of pain, and the position of the gastric 
 
 ulcer' causing the pain - - - - - 153 
 
 Fig. 17. Shows the region of cutaneous hyperalgesia after an 
 
 attack of gall-stone colic - . - . . 157 
 
 Fig. 18. Shows the region of cutaneous h%-peralgesia after an 
 
 attack of renal cohc - - - - - 185 
 
 Fig. 19. Shows the region of cutaneous hyperalgesia after an 
 
 attack of renal colic - - - - - 191 
 
 Fig. 20. Shows areas of pain and hyperalgesia in diapliragm- 
 
 atic pleurisy - - - - - - 219 
 
 Fig. 21. Shows areas of cutaneous hyperalgesia in acute dilata- 
 tion of the heart and liver - - - - 238 
 
 Fig. 22. Area of pain and hyperalgesia in angina pectoris - - 240 
 
 Fig. 23. Area of eruption in a case of herpes zoster affecting the 
 
 upper thoracic nerves - - - - - - 241 
 
 Fig. 24. Shows the area of cutaneous hyperalgesia after the 
 
 first attack of angina pectoris . - . . 243 
 
 Fig. 25. Shows the areas of cutaneous hyperalgesia after a 
 
 number of attacks of angina pectoris - - - 243 
 
 APPENDIX. Figs. 1 to 8 309-332 
 
Chai>ter 1. 
 
 the importance of symptoms in 
 medical practice and researc^h. 
 
 1. The Scieiice of Medicine. 
 
 2. The l7nportance of Symptoms in Diagnosis. 
 
 3. The hnportance of Symptoms in Prognosis. 
 
 4. The Importance of Symptoms in Treatment. 
 
 5. The Importajice of Symptoms in Research. 
 
 1. The Science of Medicine. — There are many 
 matters in medicine seemingly so simple that it is 
 taken for granted that they are beyond further 
 discussion or investigation. Of these matters, 
 seemingly so simple, the symptoms common to 
 ill-health are the most prominent. Ever since 
 medicine was seriously studied symptoms have 
 received attention, and the notion is firmly held 
 by medical men, specialists, physicians and sur- 
 geons, and experts of all Idnds, that the symptoms 
 revealed by the doctor's unaided senses are so well 
 understood that the information to be gathered 
 from them has been exhausted, and that their 
 further study is not necessary to the progress of 
 medicine. Hence has arisen the belief that, for the 
 progress of clinical medicine new methods are 
 necessary for the further elucidation of symptoms. 
 
2 Chaptei' I. 
 
 This mistaken attitude towards symptoms is 
 not only misleading, but hampers medicine in 
 Practice and Research. Indeed, the importance of 
 symptoms is so imperfectly realised that a description 
 of the meaning, mechanism and significance of 
 symptoms is nowhere to be found, and this con- 
 stitutes a great defect in medical knowledge. 
 
 Although this defect in the knowledge of 
 symptoms may be recognised, it is not easy to under- 
 stand how it is to be remedied. This is due to the 
 fact that, notwithstanding the strenuous efforts that 
 have been made to advance medical knowledge, the 
 manner in which medical science should be prose- 
 cuted has never been understood. It has been 
 assumed that investigation in clinical medicine was 
 a simple matter, and that anyone with the usual 
 medical education was fitted to undertake research 
 in medicine. It has never been recognised that for 
 its resea.rch principles and methods are required 
 which are different from those necessary to other 
 sciences, and even from those used in other branches 
 of medical science, while a long training of the 
 investigator is necessary, of a kind rarely undertaken. 
 
 2. Diagnosis. — The urgent need for a better 
 knowledge of symptoms can only be realised if the 
 great defects in medical knowledge are recognised. 
 The general practitioners are the people who are 
 brought into contact with the iUnesses which impair 
 the health of the communit3^ An analysis of the 
 complaints which the general practitioner sees 
 reveals the present state of medical knowledge. If 
 we put aside the trivial ailments and consider the 
 illnesses which lower the health of the great majority 
 
Symptoms in Medical Practice and Research 3 
 
 of people, it is found that only a small percentage 
 (5-10) are capable of being diagnosed with any degree 
 of accuracy. Most of this small percentage are cases 
 of disease so advanced that the organs are damaged 
 beyond repair, such as apoplexy, chronic Bright's 
 disease, gangrene of the feet, advanced heart disease ; 
 and these are the end results of a long period of 
 ill-health, whilst the origin of the ill-health was not 
 detectable. Even such diseases as consumption, 
 and gastric ulcer, are in all probability secondary 
 or superadded diseases — at all events, their diagnosis 
 before gross changes take place cannot be made. 
 
 The backward state of diagnosis is illustrated 
 in these two latter conditions. They are such 
 common complaints and have been the subject of 
 long and careful investigation by innumerable doctors, 
 yet to-day we cannot detect consumption until the 
 lungs are damaged, usually beyond repair, while, as 
 regards gastric ulcer, Berldey Moynihan, out of his 
 great experience, states that it is disheartening 
 and huniihating to have to confess that at this time 
 we are still often unable to detect this complaint. 
 
 To appreciate the significance of this lack of 
 knowledge of diagnosis one has to see it in relation 
 to the healtli of a community. In a town of 
 100,000 inhabitants 25,000 will Ukely consult 
 doctors in one year. 5,000 may suffer from trivial 
 complaints and accidents. Of the 20,000 only a 
 small proportion will suffer from diseases that are 
 diagnosable, on a safe assumption, 2,000. We have 
 then, in a population of 100,000, 18,000 people ailing, 
 of the nature of whose complaint we are still pro- 
 foundly ignorant. 
 
4 Chapter I. 
 
 When the significance of these figures is 
 grasped it will be seen that there is an urgent need 
 for some method in the investigation of disease, 
 different from that which has been pursued in the 
 past. 
 
 3. Prognosis. — Prognosis is the judgment of 
 the significance of symptoms as indicating the future 
 course of the patient's complaint. A knowledge of 
 tliis branch of medicine is absolutely essential to the 
 intelligent practice of medicine, and it concerns every- 
 one who has to deal with the sick. Before any 
 course of treatment is taken it is necessary to under- 
 stand whether the complaint is amenable to treat- 
 ment. The fitness for the patient to do his work, 
 or to live in a given place, all depends on a Iviiowledge 
 of prognosis. It is scarcely necessary to refer to its 
 importance in regard to fife insurance and the 
 examination for military, naval, and government 
 services. 
 
 A knowledge of prognosis can only be acquired 
 by the detection of symptoms, and the ability to 
 recognise whether these symptoms are the expression 
 of a diseased state or a variation of the normal, 
 indicative neither of disease nor of impairment, is 
 required. When it is recognised that the symptoms 
 are an expression of disease it is necessary to tell 
 whether they represent a damage to the body which 
 impahs its functions, and whether the damage is 
 stationary or progressive. 
 
 The need for this kind of knowledge is readily 
 visualised if some illustration be given by reference 
 to well-estabhshed practice. ]\Iany eminent and 
 experienced surgeons have seen disastrous results 
 
Symptoms in Medical Practice and Be search. 5 
 
 from a delay in operating on a}:)pendicitis, so that 
 they strongly recommend that all suspect appendices 
 should be removed. The result of such a procedure 
 is that a great many people are subjected to the 
 operation when there is no disease of the appendix. 
 This is simply due to the fact that medical knowledge 
 has not advanced so far as to interpret correctly 
 the symptoms of appendicitis, nor to understand 
 their significance, so that large numbers are operated 
 wpon unnecessarily. Anti-toxin is believed to be 
 such a potent remedy in diphtheria that, as a matter 
 of routine, every one who contracts this disease is 
 given it. We know that diphtheria in the great 
 majority of cases is not a serious disease, yet because 
 of an absence of knowledge of prognosis, the remedy 
 is given indiscriminately to every one. 
 
 It will be said, of course, that in the cases of 
 appendicitis and diphtheria it is impossible to 
 fortell which case mil become dangerous, but that 
 is merely stating in another way the fact that 
 medical knowledge has not yet advanced far enough 
 to understand the prognostic significance of certain 
 symptoms. 
 
 Not only has medical knowledge not advanced 
 so far as to permit a prognosis in such instances, 
 but it has not gone so far as to recognise either the 
 importance of the subject or the manner in which 
 the knowledge can be acquired. A little consider- 
 ation wdll reveal that this knowledge can only 
 come from long experience, yet in matters dealing 
 essentiall}^ with prognosis, such as in life insurance 
 examinations and in recruiting, a medical quahfica- 
 tion is deemed to carry mth it the ability to give 
 
6 Chapter I. 
 
 a prognosis, and young doctors with little experience 
 are supposed to be capable of doing this kind of 
 work. 
 
 When the real significance of a prognosis comes 
 to be understood, the attitude of tlie profession 
 to-day will seem amazing. There is no branch of 
 medicine which requires so profound a knowledge of 
 disease and its manifestations, a knowledge that 
 can only come through long experience and pains- 
 taking observation of symptoms. But, so far, the 
 profession have not yet awakened to the great 
 defect in knowledge of this very important subject, 
 and how httle progress is being made in its 
 development. 
 
 It is now more than 40 years since, as a young 
 graduate I was permitted to examine a lady with 
 a systolic murmur. It had been discovered acci- 
 dentally by a distinguished Edinburgh physician, 
 and he had ordered the patient to bed and prescribed 
 digitaUs, which she was taking in large quantities. 
 She and her husband were warned of the danger of 
 the heart conditions, particularly in regard to 
 pregnancy. For a time a careful hfe was led, but 
 gradually she resumed her old life, and hved for a 
 great many years an energetic hfe. Although the 
 murmur persisted, she is now well over 70 years of 
 age and shows no sign of heart failure. A short 
 time ago I was asked to see a youth, who had been 
 confined to bed for three months because a physician 
 attached to a large teaching hospital had detected a 
 systohc murmur, wliich I had no difficulty in recog- 
 nising as being physiological. This inabihty to 
 recognise the prognostic significance of a murmur 
 
Symptoms in Medical Practice and Research. 7 
 
 is not exceptional by any means, and I place these 
 two instances in juxtaposition to show how little 
 progress has been made in 40 years in even such a 
 simple matter as this. But one has evidences of 
 this lack of progress everjrwhere, and nowhere more 
 strildngly than in the matter of life insurance. The 
 medical forms in regard to the circulation have 
 scarcely altered, if at all, for over 50 years, as if 
 medical science had not advanced since then. 
 
 Nor is there any prospect of advance in this 
 important matter till a better knowledge of 
 symptoms is acquired and it is recognised that the 
 onlj^ person who can advance this kind of knowledge 
 is one who has the opportunity of seeing the progress 
 of disease in individual patients, watching them 
 intelligently through complaints from start to finish. 
 
 4. Treatment. — Treatment which consists of the 
 introduction into the body of an agent — drug, 
 vaccine, serum, electricity. X-rays, radium emanation 
 — produces reactions, often indistinguishable from 
 the symptoms produced by certain diseases, as in 
 patients with vomiting, diarrhoea, drowsiness, head- 
 ache. Certain of these remedies act by removing 
 a noxious agent, as by vomiting or purging, or by 
 killing it, as mercury in syphilis. But the vast 
 majority of remedies when they have any effect act 
 by modifying the symptoms of disease. This is the 
 justification for treatment — particularly in the case 
 of suffering — to relieve the distressful symptoms. 
 It will thus be seen how important is a Imowledge of 
 symptoms for the inteUigent investigation of drugs 
 or other remedy. The drugs which find a place in 
 the pharmacopoeia have never been studied from 
 
8 Chapter I. 
 
 this point of view, with the result that a great 
 number of utterly useless drugs are included, while 
 those which are of use have never been studied with 
 that care and accuracy necessary to recognise the 
 real effect of the drug on the diseased human being. 
 Experimental investigation shows how a drug may 
 act on healthy tissues, but drugs are not given to the 
 healthy but to the sick who show symptoms of 
 disease, and it is for the removal of the causes of 
 the symptoms or for their modification the remedy 
 is given. This is Avell illustrated by the use of 
 digitahs. For 150 years the drug was known to 
 have a beneficent effect in heart disease, but no 
 clear conception of the kind of case existed, so that 
 it was given indiscriminately to all patients who 
 had, or were supposed to have, a cardiac affection. 
 Many attempts had been made to find out its effect 
 in the human heart, including experiments on 
 animals, but it was not until the symptoms, 
 particularly the abnormal rhji^hms, w^ere recognised 
 that its effect in the human heart was chscovered, 
 and the kind of case in which it acted beneficially 
 was recognised. 
 
 The principle which guided to this discovery 
 was the intelligent perception of the symptoms with 
 a knowledge of their mechanism, and then the careful 
 observation of the effect of the drug in producing 
 or modifying these symptoms. Before an intelligent 
 investigation into the action of remedies in the 
 sick human body is undertaken a knowledge of 
 symptoms is necessary. 
 
Sy)nptotns in Medical Practice and Research. 9 
 
 5. Research. — There is to-day a recognition that 
 medical knowledge is greatly lacking in many 
 essentials, and strenuous endeavours are made for 
 the encouragement and prosecution of research. 
 Where a clear conception of the problem is attainable, 
 an orderly and well-planned investigation may result 
 in a successful issue, as in the investigation of 
 malaria and allied diseases and syphilis. An absence 
 of a clear conception of how research should be 
 pursued leads to a disorderly attack on disease, and 
 a great waste of time and energy is bound to result. 
 The vast majority of diseases which afflict a com- 
 munity in this country have not been clearly 
 recognised, so that any attempt to prevent or cure 
 such diseases is sure to lead to failure. It is therefore 
 manifest, before we can attempt to deal effectively 
 with the more common diseases, a knowledge is 
 first required of the manner in which these diseases 
 affect the human body. While the study of how 
 a noxious agent which produces disease, such as a 
 microbe, may behave in culture media or in animals, 
 may be necessary to the inquiry, yet a knowledge of 
 how the noxious agent reacts upon the human bod}^ 
 is also necessary. As this knowledge can only be 
 acquired by the study of the reactions produced in 
 the body, the importance of symptoms is apparent. 
 
 A wider view of research must also be taken. 
 As already indicated, diagnosis, prognosis and 
 treatment are essential to the practice of medicine. 
 Research in these subjects is urgently called for. 
 Such research can only be undertaken by those who 
 have the opportunity of seeing individuals in ill- 
 health, so that an investigation of the symptoms of 
 
10 Chapter L 
 
 disease, carried out systematically and with a 
 precision liitherto unattained, is urgently called for. 
 
 Investigators are recognising that they have 
 only an experience limited to certain aspects of 
 disease, and they find it necessary to associate 
 themselves in bands or teams for the prosecution 
 of research. Many of these teams include men 
 profoundly informed in their particular branch, but 
 there is one member essential to this work who is 
 invariably absent — one with a knowledge of the 
 symptoms of disease. The need of this type of 
 investigator is recognised, and one with clinical 
 experience is sometimes included in such a team, 
 but medical knowledge has not yet advanced so far 
 as to enable such an investigator to recognise that 
 his knowledge of symptoms is so imperfect that he is 
 unfitted for such work. 
 
 In the intelligent prosecution of medical re- 
 search, therefore, a knowledge of symptoms is 
 essential. 
 
( 11 ) 
 Chapter II. 
 
 THE MECHANISM OF A DISEASE PROCESS. 
 
 6. Definition of Disease. 
 
 1. The Detection of Disease. 
 
 8. Definition of Symptoms. 
 
 9. Methods for Investigating Symptoms. 
 10. Principles of Research. 
 
 6. Definition of Disease. — Before an attempt is 
 made to investigate any phase of ill-health it is 
 necessary to hold clearly in mind what disease is. 
 Attempts have been made to give a logical definition 
 to the term, but it has resulted too often in so many 
 refinements that in the end confusion exists where 
 clarity is required. 
 
 Apart from the original meaning of the word 
 as signifying a lack of ease, the term disease, as 
 commonly applied, refers to a distinct condition or 
 entity. When, for instance, a patient suffers from 
 pain in the eyeball and lachrymation, and the 
 conjunctiva is seen to be red and injected, we 
 recognise that he suffers from a disease, or a diseased 
 state. An examination by one doctor may fail to 
 reveal any further facts, and he would call the 
 disease conjunctivitis. Another doctor may recog- 
 nise that the symptoms of photophobia, lachrymation 
 
12 Chapter 11. 
 
 and injection of the capillaries are phenomena 
 produced by a foreign body acting on certain 
 tissues of the eye, and may detect a speck of coal 
 implanted on the cornea. The removal of the 
 foreign body is followed by the disappearance of 
 the phenomena. 
 
 Here we have a clear example of v^ hat constitutes 
 disease, and from such an instance disease can be 
 defined as " A state induced by an agent acting 
 injuriously on the tissues." 
 
 The speck of coal by itself is not a disease, nor 
 is the lachrymation and other signs. When, how- 
 ever, the speck of coal produces these signs the 
 whole sjmdrome (agent and attendant phenomena) 
 can be conveniently grouped under a definite term 
 a disease. 
 
 When the ailments that affect the human body 
 are carefully analysed it will be found that the 
 vast majority conform to this definition of disease. 
 The noxious agent may be a foreign body, a 
 microbic infection, or chemical in its nature, all of 
 them innocuous structures outside the body, but on 
 their entrance into the body, as soon as thej^ 
 cause a re-action, a state of disease may be said to be 
 l^roduced. 
 
 In many people who suffer from ill-health the 
 matter is much more complicated, but this is simply 
 due to the fact that with the persistence and progress 
 of the diseased state new reactions are set up until 
 the number is so great that the original disturbance 
 is lost sight of. Nevertheless, fundamentally, the 
 onset of ill-health was provoked in the manner 
 described in the definition. 
 
Mechanism of a Disease Process. 13 
 
 7. The Detection of Disease. — In the simple 
 illustration of the foreign body in the eye the noxious 
 agent and its effect upon the tissues are readily seen 
 and recognised. Unfortunately the cause of ill-health 
 in the vast majority of cases cannot be so clearly 
 ehcited. The noxious agent is more subtle ; its 
 mode of entrance into the body is undetected and 
 the original seat of disturbance obscure, and as a 
 rule there is no direct evidence of its nature, so 
 that seldom can a diagnosis be made based on its 
 detection. 
 
 While the agent which provokes the ill-health 
 is therefore not recognisable, the phenomena or the 
 symptoms it produces afford the clue by which 
 it may be detected. These phenomena vary 
 widely, but they depend in the main upon two 
 factors : — 
 
 (1) The nature of the noxious agent ; 
 
 (2) The tissue acted on. 
 
 It is scarcely necessarj^ to elaborate this point. 
 The agent may be, as already stated, a foreign body, a 
 microbe, or chemical in its nature, and it can be under- 
 stood that the action of these different agents on 
 the tissues would vary ; while the tissues acted upon, 
 as fibrous tissue, muscular tissue, nervous tissue, 
 or secretory cells, would give reactions peculiar to 
 their functions. 
 
 Direct detection of the noxious agent being 
 often impossible, we are driven to seek for it by 
 following uj) the clues afforded by the reaction of 
 the different tissues, which in the human body we 
 recognise as the signs and symptoms of disease. 
 
14 Chapter II. 
 
 8. Definition of Symptoms. — Much consideration 
 has been given to the definition of the terms — signs 
 and symptoms of disease. In this book no distinc- 
 tion is made between them. The terms symptoms, 
 signs, manifestations, phenom-ena, are used inter- 
 changeably, and mean a reaction of the tissues of 
 the hody to a noxious agent. 
 
 9. Methods for Investigating Symptoms. —Recog- 
 nising that symptoms are the reaction of the tissues 
 of the body to a stimulus by an agent, for a due 
 appreciation of their meaning certain of their 
 features have to be clearly understood. A person 
 in ill-health may present some readily detected 
 sign, as pallor, or suffer from some sensation, as 
 pain; and the custom has been, when the doctor 
 has failed to find the causes of these symptoms, to 
 diagnose the cases as anaemia and nem-algia. So 
 long as such diagnoses satisfy it is manifest no 
 progress can be made. No doubt there is a difficulty 
 in getting beyond this step, and medical science has 
 not yet advanced so far as to recognise the method 
 by which further Imowledge can be acquired. 
 
 The first step to be taken is to find the 
 mechanism by wliich symptoms are produced. No 
 doubt, many observers have attempted this study, 
 and a limited advance has been m.ade. The state 
 of the blood has been the subject of much inquiry, 
 and a great many facts have been accumulated. 
 Likewise, pain has been the subject of much study, 
 and again many facts have been accumulated, yet 
 the results have led us on but a little way, and are 
 scarcely commensurate A\4th the time and energy 
 spent on them. The reason for this comparative 
 
Mechanism of a Disease Process. 15 
 
 failure is that we do not yet understand the principles 
 which should guide research in medicine. If we 
 take one of tlie commonest of symptoms, that of 
 pain in disease of the viscera, and consider what 
 information it is capable of yielding were it 
 thoroughly investigated, we will understand some of 
 the steps necessary to be taken for advancing our 
 knowledge of disease. 
 
 Investigations have shown that the pain in 
 disease of the viscera is referred to some portion of 
 the external body wall, frequently remote from the 
 seat of disturbance. The mechanism by which this 
 is brought about seems to be as follows. A stimulus 
 of a particular Idnd arises in an organ produced by 
 some noxious agent. This stimulus passes by a 
 sympathetic nerve to its cell in the central nervous 
 system. There the stimulus passes from this cell 
 to other cells in its immediate neighbourhood, 
 and these cells, when stimulated, re-act according 
 to their function, a secretory cell modifying the 
 secretion, a muscular cell giving rise to contraction 
 in its muscle, a pain cell producing pain referred to 
 the peripheral distribution of definite nerves in the 
 external body wall. 
 
 There is thus good reason for assuming that 
 there is a relation, precise and definite, between the 
 viscera and areas of the external body wall, through 
 the nervous system. When this relation is better 
 understood it wiU then be possible to say, when a 
 patient complains of a pain in a definite region, in 
 which organ the disturbance is which produces the 
 pain. 
 
 The next step Vvdll be to recognise what tissues 
 
16 Chapter II, 
 
 of the organ are capable of giving rise to pain when 
 stimulated. We do know that certain tissues may 
 be subjecte'd to much injury and destruction mthout 
 pain, while other tissues readily cause pain when 
 stimulated in a particular manner. 
 
 The last and most important step is to recognise 
 the nature of the stimulus — it may be the noxious 
 agent which is the cause of ill-health. We know tliat 
 not all stimuh apphed to an organ will give rise to 
 pain. For instance, the cutting or tearing or burning 
 of organs may occur and no sensation be elicited. 
 Yet we do know that visceral disease is capable of 
 giving rise to pain of all degrees of severit}^ 
 Manifestly, then, it is only stimuli of a peculiar kind 
 that are capable of producing pain. 
 
 Inquiry so far has revealed that there are 
 probably but a few kinds of stimuli capable of 
 producing pain, and that these can be chfferentiated 
 in several ways, as by the character and duration 
 of the pain, by the conditions that tend to provoke 
 it, and by the presence of other phenomena, which 
 have been provoked at the same time and by the 
 same stimulus. It will be seen that this line of 
 investigation holds out the expectation that pain 
 and its associated phenomena may not only indicate 
 the (1) site of the organ, (2) the tissues disturbed, 
 but also (3) the nature of the agent producing it. 
 
 There is now sufficient evidence to show that 
 specific agents on entrance into the body produce 
 specific reactions. This is recognised in the case of 
 the exanthemata, even though the agent has not 
 been actually recognised in all cases. With a better 
 understanding of the mechanism by which sjanptom.s 
 
Mechanism of a Disease Process. 17 
 
 are produced, and ])y the detection and correlation 
 of associated symptoms, and the careful study of the 
 conditions found post-mortem, or on the exposure 
 of the viscera by operation, combined with bacterio- 
 logical and other laboratory inquiry, the morbid 
 state — provoking agent and reactions— will be eluci- 
 dated. 
 
 10. Principles of Research. — The reasons for the 
 foregoing definition of disease and of symptoms is 
 that it helps to render clear the object to be aimed at 
 in any investigation into symptoms. Hitherto 
 much chnical research has been rendered ineffective 
 because the different methods of inquiry have not 
 been clearly visualised, and much time has been 
 spent on the study of the nature of the symptoms 
 and too little on their mechanism. The distinction 
 seems, no doubt, subtle and slight, but it is funda- 
 mental. We see, for instance, that the peculiar 
 features of such symptoms as anaemia, Cheyne- 
 Stokes breathing, anoxemia, hyperchlorhydria, and 
 albuminuria have been studied with meticulous 
 care, but httle has been done to understand the 
 mechanism by which they are produced. In the 
 study of i:)ain the effects of the various drugs that 
 reheve the suffering have been the main object, while 
 the mechanism by which pain is produced has 
 been so imperfectly studied that little real knowledge 
 of this clamant symptom has been found. Yet, as I 
 have said, it is a symptom vv^hich not only calls 
 attention to the presence of disease, but if intelli- 
 gently interpreted would lead directly to the organ 
 affected, and even reveal the nature of the injurious 
 agent producing the ill-health. 
 
18 Chapter II. 
 
 I frankly confess that I have but a dim idea of 
 the method to be pm^sued in discovering the 
 mechanism of many symptoms, but success has 
 attended the inquiry in regard to some, and the 
 principles which have guided to these discoveries 
 win serve to direct the inquiries in our investigation 
 of the others. These principles are dealt with in 
 Chapter IV. 
 
19 ) 
 
 CHAPTER Til. 
 THE TRAINING OF THE OBSERVER. 
 
 11. Medicine a Science. 
 
 12. Accuracy of Observation. 
 
 13. Clinical and Laboratory Observation compared. 
 
 14. Limitation of Laboratory Methods. 
 
 15. The Importance of a Clinical Training. 
 
 16. The Requirements of a Clinical Observer. 
 
 11. Medicine a Science. — Medicine has not 
 attained that position in science which ought of right 
 to belong to her. Instead of leading in scientific 
 derelopment, and giving guides and indications to 
 allied branches, she is too often content languidly to 
 foUow in their wake, or to pursue some erratic course 
 of her o^vn. The observations made in her name are 
 frequently made more to support some vague specu- 
 lation or far-fetched theory than to reahse the actual 
 condition of the observed phenomena. The sister 
 sciences, in place of seeldng for assistance from 
 medicine, look askance at the wdld speculations put 
 forth in the name of medical science, and at the loose 
 thinldng and play of the imagination which many 
 mecUcal writers deem legitimate in dealing with the 
 phenomena of disease. To emancipate medicine from 
 
20 Chapter III. 
 
 this position of inferiority, and to secure for it that 
 status which it ought to possess, an effort must be 
 made, as far as possible, to free it from the habih- 
 ments that have hampered it in the past ; and if this 
 appears an unattainable goal at present, its votaries 
 may at least aim at greater precision in thought and 
 in observation. Although this doctrine may seem the 
 commonest of platitudes, and teachers and writers of 
 text-books are unwearied in inculcating it, neverthe- 
 less precision, in thinking and in observation, are 
 among the rarest qualities. 
 
 12. Accuracy of Observation. — The power of 
 accurate observation and precise thinking is seldom 
 acquired, because methods have become so stereo- 
 typed that many observers do not realise that they 
 are fettered in the bonds of tradition. Even in the 
 writings of those who claim to be exponents of exact 
 observation and logical reasoning, loose methods of 
 thinking and observing too often appear, even when 
 the scientist imagines himself supreme ; for tradi- 
 tional teaching influences their minds and gives a 
 bias to their deductions. What are called obser- 
 vations are often but a mixture of imperfect 
 observation and unwarranted assumption. While a 
 fact is supposed to be recorded, an opinion is at the 
 same time expressed. As an illustration let us 
 observe how the symptoms of a patient with an 
 enlarged liver are often investigated. The position 
 of the hver having been ascertained, pressure over it 
 is found to elicit pain. The surgeon or physician 
 proceeds to record the "fact" that the "liver is 
 painful on pressure," and such a description is 
 universally accepted as truthful. Yet, if the matter 
 
The Training of the Observer. 21 
 
 be carefully analysed, the statement will appear not 
 to be a fact at all. Had the statement been that the 
 patient felt pain when pressure was made over the 
 liver, then a plain fact might have been recorded, if 
 the patient's testimony was reliable. But to say that 
 tlie " hver was painful " is to make an assertion that 
 •may or may not be true, but which is not warranted 
 by the evidence, seeing that pressure was being 
 exerted on the sensitive structures of the external 
 body w^all, and no attempt was made to eliminate the 
 possibility of the painful sensation being produced 
 by their stimulation. This tendency to embody 
 assertions, warranted or unwarranted, in the record 
 of a fact is a fault common among medical investi- 
 gators, and impedes the progress of medicine. An 
 inquirer should keep his mind free from bias and 
 ready to review his most cherished beliefs. What is 
 to-day accepted as axiomatic may be shown to- 
 morrow to be but a part of the truth. The tendency 
 to be led bj^ tradition is very powerful, and it is 
 difficult to free the mind from beliefs that have been 
 inculcated with the acquisition of knowledge. In 
 consequence of this, many observations are funda- 
 mentally untrue, and only covered by a veneer of 
 science. 
 
 There have been many stumbling-blocks in the 
 path of medical progress. They are mainly due to 
 the lack of understanding of the distinctive character 
 of the science of medicine. The knowledge of 
 disease is so incomplete that we do not yet even 
 know what steps should be taken to advance our 
 knowledge. It has been assumed that the methods 
 which are suitable for various branches of science 
 
22 Chapter III. 
 
 ■ — as chemistry and phj^sics — should be apphed to 
 medical investigation, but the methods of these 
 sciences are not appHcable to the investigation of the 
 most important phenomena of disease. The methods 
 which have helped some sections of medicine — as 
 physiology and bacteriology — are not applicable by 
 themselves to the wider fields of clinical medicine. 
 
 The present-day conception takes too narrow a, 
 view of the field with which medical science has to 
 deal. It assumes that instrumental methods are of 
 necessity the only scientific methods. It has been 
 assumed that because recording and measuring 
 instruments and other methods have greatly ad- 
 vanced such hmited fields of medicine as physiology, 
 bacteriology, and chemistry, tliat therefore clinical 
 medicine should adopt the same methods. In 
 medicine there are phenomena which the scientific 
 instruments of to-day, however dehcate, can neither 
 register nor measure, and there are methods neces- 
 sary for the investigation of disease which no 
 laboratory experience can supply. 
 
 As an outcome of this misunderstanding, large 
 fields for investigation which are essential to the 
 progress of medicine have been ignored, methods and 
 principles have been unrecognised or imperfectly 
 apphed, while the appropriate investigator has been 
 neither trained nor encouraged to do the work 
 which he alone has the opportunity to perform. 
 
 13. Clinical and Laboratory Observation Com- 
 pared. — It is necessary to grasp fully what is required 
 of a trained chnical observer, because to-day the 
 essential qualities to a great extent have been lost 
 sight of. This has arisen through an imperfect 
 
The Training of the Observer. 23 
 
 conception of the requirements for clinical observa- 
 tion. Methods that have been found suitable and 
 necessary for other sciences have been introduced, 
 and have been substituted for those that are essential 
 and pecuHar to clinical medicine. Men are now 
 recommended to go into laboratories devoted to one 
 or other of the branches into which medicine is split 
 up, and are trained in methods that are supposed to 
 be more exact and scientific than the clinical methods. 
 This view is the one dominant to-day, so that we 
 find preference given to men trained in tliis way in 
 all matters concerned mth research, and even in the 
 teaching of medicine. This practice is based upon 
 a misunderstanding of what chnical observation 
 requnes and what chnical research means, and it 
 leads directly to incompetence of the laboratory- 
 trained man as a clinical observer and as a chnical 
 investigator. 
 
 A very brief consideration tv411 render this 
 apparent. The physiological laboratory is assumed 
 to be the most scientific of all our branches, and a 
 training there is supposed to qualify a man for 
 research in medicine. An experiment is performed 
 which produces a reaction which an instrument can 
 record. This record is carefully studied, and certain 
 conclusions — which may be of value — are drawn. 
 From a great many experiments of this kind a large in- 
 crease of valuable knowledge has been obtained. The 
 success and usefulness of this method is undoubted, 
 but its success has blinded people to its hmitations 
 as a method to be apphed in clinical medicine. Each 
 of these experiments produced a great many more 
 reactions than the one recorded, but as these 
 
24 Chajjter III. 
 
 reactions were not capable of being recorded by an 
 instrument they were ignored. The result is that a 
 laboratory-trained observer cannot recognise any 
 sign except those of a grosser kind, ^\hile the subtler 
 and more elusive signs pass unrecognised. It there- 
 fore happens that the result of an experiment is 
 only partly recognised. The clinical observer is like 
 the physiologist in this respect, that both are 
 searcliing for a reaction to a stimulus. In physiology 
 the stimulus is artificial ; in clinical medicine it is 
 natural, or the result of disease. In both cases a 
 variety of reactions follow the stimulus. The 
 grosser reactions are only noted by the physiologist, 
 and he has no means of detecting the subtler. In 
 clinical medicine the grosser kinds have also to be 
 detected, and the laboratory-trained observer can 
 detect them, but his training has not enabled him to 
 detect the subtler reactions, and hence he fails to 
 attain that skill in observation which is essential 
 to the clinician. 
 
 14. Limitation of Laboratory Methods.— The 
 bulk of the most instructive j^henomena produced by 
 disease are incapable of detection by mechanical 
 aids. Many valuable signs are only perceptible to 
 the trained eye or the trained ear or the trained 
 finger. Still more valuable signs are only revealed 
 by the sensations experienced by the patient. To 
 interpret these requires a training that can only be 
 acquired by many years of patient observation, 
 during which the mind is stored by the experiences 
 of the past, by methods which are peculiar to 
 medicine. These methods can never be acquired by 
 a laboratory-trained observer, and it is because of 
 
The Trainiyig of the Observer. 25 
 
 this that men trained in the laboratory fail as 
 cUnical investigators, however distinguished they 
 may be as physiologists, chemists, or bacteriologists. 
 15. The Importance of a Clinical Training. — 
 Before we can make progress towards the solution 
 of any problem there are certain preliminary steps 
 to be taken. The first is the perfecting of the 
 instruments to be used. Before a man shaves he 
 first sharpens his razor. Before we undertake an 
 investigation we must see we have the appropriate 
 implements. One implement essential to the success 
 of our enterprise is a trained observer. It is scarcely 
 reahsed what a difference there is between a doctor 
 Avho has S3^stematically trained himself to observe, 
 and another who has perfunctorily examined his 
 patients witliout attempting to improve his powers 
 of observation. This can be shown in a simple 
 matter like the feeling of the pulse. Many experi- 
 enced doctors fail to detect irregularities except when 
 very marked. Some physicians will recognise every 
 beat in an irregular pulse ; others will fail to detect 
 a large proportion of the beats. Indeed, so common 
 is the inability to count the beats in certain cases 
 that I view many observations with a good deal of 
 suspicion. Certain steps are necessary to train an 
 observer so that he can acquire the abihty to detect 
 the peculiarities of the pulse, and to recognise their 
 significance. He must, for instance, have seen a 
 large number of cases, and studied them with great 
 care, so as to correlate the sensations of his fingers 
 with the result of observations made by his other 
 senses. Thus he must correlate the pulse peculiarities 
 with the sounds of the heart, with the movements 
 
26 Chapter III. 
 
 of the apex and of the jugular veins, and Avith the 
 character of the sphygmogram. The significance of 
 the pulse can only be recognised by watching the 
 patient for long periods to ascertain what happens 
 to him, and the variations that take place in the 
 pulse and in the other symptoms as the case pro- 
 gresses have to be observed. 
 
 The same methods are necessary to train the 
 other senses. A glance at the face will often reveal 
 a great amount of information to the trained 
 observer. Consider the years of study and observa- 
 tion that have been necessary to acquire that know- 
 ledge — a kind of knowledge essential to medical 
 investigation, and impossible to acquire by the use 
 of instruments however scientific. 
 
 It is now well recognised that the symptoms 
 provoked in the early stages of disease are mainly 
 subjective. There are a number of these sensations, 
 and it is evident that, if the early stages of disease 
 are ever to be recognised, the nature and significance 
 of these sensations w\\\ have to be understood. 
 There is, unfortunately, a widespread belief that all 
 the information that the patients can jield is easily 
 acquired, and it is generally supjDOsed that the 
 information is often so misleading as to be of little 
 value. Moreover, the behef has obtained tha.t 
 abnormal signs revealed by an examination of the 
 patient, especially by the use of an instrument, are 
 of much greater importance, so that practically all 
 the instruction at the schools is devoted to the study 
 of physical signs. This is a great mista.ke, and is the 
 chief reason why the knowledge of the early stages of 
 disease is so defective. 
 
The Training of the Observer. 27 
 
 This aspect of medicine is brought out if the 
 sensations which indicate the onset of disease be 
 considered. Most patients, when they fall into ill- 
 health, become conscious of it by the fact that they 
 are easily exhausted — exertion which they used to 
 undertake with ease and comfort now renders them 
 tired. The questions that arise are : " What is 
 exhaustion ? " and " what is the mechanism of its 
 production ? " Put in that way it will be recognised 
 at once how little we know of this important symp- 
 tom. An inquiry which I have been making for a 
 number of years has led to a limited knowledge, and 
 I can recognise that this sensation can arise from a 
 number of causes, and where the condition of the 
 patient is carefully investigated it will be found that 
 this sensation of exhaustion can be divided into a 
 number of different kinds. 
 
 The same careful training is necessary for the 
 investigation of the most clamant of all symptoms, 
 that of pain. To understand the full significance of 
 pain in any case we have to know a great many 
 matters which are still hidden from us. The tissues 
 capable of producing pain, the nerves in whose 
 cUstribution the pain is felt, the manner in which 
 the pain spreads, and the laws governing the spread 
 of pain ; the character of the pain itself ; the manner 
 of its onset and its variations, and the phenomena 
 with which it is associated, are all matters which it is 
 necessary to understand before we are qualified to 
 undertake an investigation into disease. So with 
 all other sensations. 
 
 It is manifest that before a patient's sensations 
 are understood the doctor must have a knowledge of 
 
28 Chaj>ter III. 
 
 the mechanism of their production and of their 
 significance. As a rule, the patient is merely 
 concerned witli detailing the sensation which troubles 
 him most. It rests with the doctor to obtain hy 
 means of judicious questions the particulars of the 
 different sensations. But the doctor cannot ask 
 the proper questions unless he has sufficient experi- 
 ence and a knowledge of the nature of the sensations. 
 
 It will be gathered from this that the phj'sician 
 who would undertake the investigation of the early 
 stages of disease must not only be a man of very wdde 
 experience but must have trained himself to observe 
 on lines that have hitherto received little attention. 
 The training, amongst other things, must have 
 included the watching of patients for long periods 
 to see the outcome of the complaint. If this is 
 grasped it will be understood how vain it is to 
 expect the early stages to be revealed in hospitals, 
 where the custom is to hand the out-patient depart- 
 ment over to the junior physician, who lacks that 
 experience which should make him a competent 
 examiner. I have for many years been calling 
 attention to this error in education and showing 
 how it hampers practice and research. 
 
 16. The Requirements of a Clinical Observer. — 
 To qualify a man to be a skilled investigator in 
 bacteriology, in physiology, and in chemistry, many 
 years of special training are necessary. If it be 
 realised that before a man is qualified to undertake, 
 on the lines laid down, an investigation for the 
 prevention and cure of disease — ^the real object of 
 medical research — he must have a knowledge of 
 symptoms, it will be seen that a training is required 
 
The Trauiimj of the Observer. 29 
 
 which is bound to take a great many years. It is 
 curious that men see tlie necessity for this in 
 bacteriological, physiological, and chemical research, 
 and will undergo tlie training, but so far the necessity 
 has not been recognised for such a training before 
 undertaking research in clinical medicine. 
 
 It is necessar}^ to recognise that a competent 
 observer must ever be learning. When face to face 
 with patients and unable to detect the nature of 
 their ill-heeJth, he must not say that tlie disease 
 is not capable of recognition, but rather sa}^ that the 
 signs of disease are there, but he is incapable of 
 detecting or understanding them. This is a humilia- 
 ting confession, but a salutary one, for the recog- 
 nition of a lack of knowledge is the first step to 
 making that defect good. 
 
( 30 ) 
 
 CHAPTER IV. 
 
 PRINCIPLES OF INVESTIGATION. 
 
 17. The Need for Principles. 
 
 18. Differentiation. 
 
 19. Classification. 
 
 20. The Laiv of Progressio7i. 
 
 21. The Law of Associated Phenomejia. 
 
 22. The Significance of Symptoms {Prognosis). 
 
 23. The Use of Laboratory Methods. 
 
 24. The Expectation of Besvlts. 
 
 17. The Need for Principles. — An investigation 
 to be sj^stematic and orderl}" naust be guided by 
 principles clearly denned. There are certain simple 
 principles wliicli are useful in making observations 
 on disease. These principles are but provisional, 
 but they may be a guide until the knowledge they 
 reveal is exhausted, b}- which time an insight into 
 research and what is wanted will be gained, and 
 these principles can either be added to or supplanted. 
 It must be recognised that in this work all are but 
 learners, and while the steps taken to-day may seem 
 very important and the discoveries may bulk largely 
 in our visions, as time goes on their place in the 
 perspective may be very small. First steps are 
 alwaj^s feeble and uncertain, but they are a necessarj^ 
 prelude to the vigour of full achievement. 
 
Principles of Investigation. 31 
 
 These principles have no doubt been in use 
 during the whole history of medicine, only they 
 have been so imperfectly appreciated and applied 
 that their significance has been overlooked. 
 
 These principles are : — 
 
 First, the clear differentiation of symptoms ; 
 
 Seco7id, the classification of symptoms ; 
 
 Third, the employment of the recognition of 
 a new factiis a foothold for further advance 
 (the law of progression) ; and 
 
 Fourth, the search for other symptoms (the 
 law of associated phenomena). 
 
 18. — Differentiation. — Having detected a symp- 
 tom, whether subjective or objective, it is necessar}' 
 to separate it clearly from all others that it resembles. 
 This proposition is so self-evident that it seems 
 unnecessary to dwell upon it, yet its significance has 
 not been appreciated. The importance of this step 
 was forced upon me many years ago when I began 
 an inquiry into the significance of irregular heart 
 action. I had not gone far into the study of the 
 subject before I recognised that there were different 
 kinds of irregularity, and though others had also, 
 no doubt, recognised this, no one had attempted to 
 differentiate them with any degree of acciurac}^ on a 
 rational basis. It is manifest that no progress in 
 the knowledge of the meaning and significance of 
 heart irregularities could be made until each form 
 was clearly difterentiated. This inquiry I undertook, 
 and was able to found a differentiation based upon 
 the mechanism of their production. 
 
32 Chapter I V. 
 
 But in this inquiry I found that differentiation 
 means more than the mere recognition of the 
 mechanism of production. A differentiation based 
 on the mechanism rarely leads to a recognition of the 
 significance of a symptom. We know, for instance, 
 that physicians have for long differentiated the 
 murmurs of the heart on the basis of the mechanism 
 of their production, but not knowing how to carry 
 the inquiry further they left the matter there, and 
 a misunderstanding of the significance of the mur- 
 murs has resulted. We know to-day how widespread 
 is the misinterpretation of the significance of mur- 
 murs, and what injury has been and is being done to 
 the individual patients and to the progress of 
 medicine because of this limited differentiation. 
 
 ^Medicine calls imperatively for a further differen- 
 tiation — one based upon the significance of the sign 
 in its relation to the progress of the disease that 
 produces it. A murmur may be differentiated 
 according to the valve orifice at which it arises, but 
 it is necessary that it should also be differentiated 
 by the effect its cause has upon the functional 
 efficiency of the heart. This will at once be seen 
 to be of the first importance, not only in the practice 
 of medicine but also in the pursuit of all kinds of 
 research in which the heart is concerned. 
 
 Some y^ars after I had begun the investigation 
 of irregular heart action, other investigators took the 
 matter up and helped greatly to determine the 
 mechanism by which they were produced ; but I 
 was struck by the fact that they all stopped there, 
 and practically no one but myself undertook the far 
 m.ore difficult task of differentiating them so as to 
 
Principles of Investigation. 33 
 
 determine their significance. This could only be 
 done by applying certain principles of investigation 
 which are essential to medical research. These will 
 be described later. 
 
 It is necessary to insist that we should always 
 keep in mind that not only have we to detect the 
 symptoms of disease, but we must differentiate them 
 clearly on two principles — one on the basis of the 
 mechanism of their production, the other on the 
 bearing they have on the patient's future. 
 
 19. Classification. — The accumulation of symp- 
 toms is so bewildering in their numbers and 
 complexity that it seems impossible to obtain a 
 clear and simple comprehension of their significance. 
 So long as what is called research is but the addition 
 of new symptoms and of new methods for their 
 detection, it can safely be said that little progress 
 will be made in our knowledge of the fundamental 
 principles of research. 
 
 A classification based upon Nature's laws tends 
 towards simplicity and a fuller understanding. Such 
 a classification I have attempted, and although T 
 am far from stating that it fulfils all the requirements, 
 it is nevertheless of distinct practical use, and as it 
 is based upon natural laws it leads us to a clearer 
 understanding of symptoms. Later I give a classifica- 
 tion of symptoms showing they can be divided into 
 three groups, according to the mechanism of their 
 production, namely : 
 
 1. A Structural group. 
 
 2. A Functional group. 
 
 3. A Reflex group. 
 
34 Chapter I V. 
 
 I pointed out, in dealing with differentiation, 
 that, in addition to a differentiation based on the 
 mechanism of a symptom, another sort of 
 differentiation is required showing the significance 
 of the symptom. For instance, when we recognise 
 a sign due to a structural alteration, whether it 
 be a change in the size or shape of the organ or a 
 modified sound of the heart due to a deformed 
 valve, it should be recognised that the knowledge 
 obtained from the mere recognition is extremely 
 hmited. What is required to know is — what effect 
 has the cause of the sign upon the patient's future ? 
 This question, which should be apphed to the con- 
 sideration of every symptom, cannot be answered 
 by the study of the symptom alone, we must 
 look for other signs, being guided in our search 
 by the natural question, whether the functional 
 efficiency of the organ is affected. Thus we are 
 guided to seek for evidence of the second group 
 of symptoms. 
 
 There are a great many diseases in which we fail 
 to detect any structural sign or any functional impair- 
 ment, yet we can recognise the disease with great 
 accuracy. Most cases of gastric ulcer are recognised 
 by such signs as pain, tenderness of the skin of the 
 epigastrium, and hardness of the upper part of the 
 recti muscles. There may be no structural sign nor 
 sign of functional disturbance. Such symptoms are 
 produced by an irritation of a hmited portion of the 
 central nervous system in a reflex manner, the source 
 of irritation being in the ulcer. 
 
 While these groups form the basis of a 
 classification, there are combinations of symptoms 
 
Principles of Investigatio7i. 35 
 
 which give occasion for further grouping and 
 subdivision, which will be discussed in Chapter V. 
 
 20. The Law of Progression. — For many years 
 no advance has been made in the use of many 
 methods, such as the thermometer or the stetho- 
 scope. These and manj^ other instruments are 
 of the greatest use in clinical medicine, but it has 
 been assumed that the limits of their usefulness 
 have been reached. As a matter of fact, the 
 chnical significance of the information which they 
 yield has only been partially understood. 
 
 This restricted use has arisen because the 
 laws governing research have not been understood. 
 There has been a desire to improve a method, but it 
 has not been recognised how it could be done. 
 This has usually taken the form of modif3dng the 
 instrument, as in the different forms of stethoscope 
 that have been evolved. No doubt much benefit 
 has resulted by perfecting the X-ray methods and 
 laborator}^ methods generally, but the progress 
 has rarefy been commensurate with the time and 
 trouble spent, because it has not been guided by 
 an understanding of the principles of chnical 
 investigation. 
 
 The discovery of a new fact or a new method 
 must not be the end of the inquiry which has 
 revealed it. Rather must it be looked upon as a 
 means to an end, a stepping-stone to help a 
 further advance. Medicine has failed full}^ to 
 appreciate this aspect, cliiefiy because it was not 
 understood how progress should be made. If the 
 path had been clearly indicated, a forward movement 
 
 D 2 
 
36 Chapter I V. 
 
 would have been made in many instances where our 
 knowledge has stood still, as in the signs discovered 
 by the stethoscope. 
 
 The chief causes that have hampered progress 
 are the failure to recognise the necessity for under- 
 standing the prognostic significance of symptoms, 
 and the lack of understanding of how this knowledge 
 can be acquired. 
 
 21. The Law of Associated Phenomena. — One 
 principle of supreme importance for the advance 
 of medicine is the law of associated phenomena. 
 This law is based on the fact that ill-health is 
 aiwa3's accompanied by a number of srmptoms, 
 and in every case it is incumbent upon us to 
 search for other symptoms besides those which are 
 most prominent. When, for instance, we detect 
 a structiural symptom, we must recognise the 
 hmited knowledge it reveals, and we must extend 
 our observation and seek for signs of functional 
 derangement. If we detect a sign and recognise 
 it as the product of reflex stimulation, we are 
 at once given a suggestion for further inquiry, 
 and we must search for other signs wliich will lead 
 us to the area of stimulation. The discovery of 
 this area will lead us to the organ at fault, and it 
 ma}^ be to the nature of the condition that provokes 
 the reflex, and thus we get nearer the actual disease. 
 
 A ver}^ little study will soon bring conviction 
 of the necessity for constantly keeping this law in 
 mind. From the simplest complaint, a headache 
 or a cough, to the most obvious phj^sical sign 
 indicating gross changes, the due appreciation of the 
 case will depend on the application of this law. 
 
Principles of Investigation. 37 
 
 22. The Significance of Symptoms (Prog- 
 nosis).— The law of associated plienomena is 
 necessary to the understanding of another main 
 objective. It is necessary to find out the effect 
 the cause of a s^^mptom has on the patient's 
 future — that is, prognosis, a part of medical 
 science which lies at the foundation of the in- 
 telligent practice of medicine. To do this, contact 
 must be kept with the patient during the remainder 
 of his life or for the duration of his ill-health, 
 and in doing this a look-out must be kept for the 
 modification of the symptom and the development 
 of new S3'mptoms — that is, the detection of all 
 associated phenomena. 
 
 It is only by this method that the early stages 
 of disease can be detected. At first we may have 
 no true conception of the cause of a symptom we 
 may detect in an individual, but in course of time, 
 as the disease develops, we may be able to recognise 
 it. B}^ referring back to our notes we will see 
 how the s\mptoms were developed, and thus 
 acquire a knowledge of the early stages. ^y 
 finding similar symptoms in other patients later 
 we ma}" be able to detect the disease earlier, and so 
 back to the beginning. Naturally in this way the 
 prognostic significance will also be revealed. 
 
 23. The Use of Laboratory Methods.— The 
 principle which should guide clinical investigation 
 is first to recognise and understand the symptoms 
 of disease, then endeavour to find out the agents 
 producing the disease. Many of the symptoms 
 will not be recognisable by the unaided senses, so 
 in applying the law of associated phenomena 
 
38 Chapter I V. 
 
 mechanical and other laboratory methods should 
 be employed such as are found in a chemical 
 laboratory and an X-ray department. 
 
 So many diseases arise from bacterial invasion 
 that no method of research into the cause of 
 disease would be complete without a skilled 
 bacteriologist. An endeavour should be made to 
 find out the nature of the symptoms provoked 
 by the different bacteria. We recognise by the 
 clinical symptoms the occurrence of a great many 
 infectious diseases, where the specific microbe 
 has been discovered, as typhoid fever and pneu- 
 monia. The recognition of other diseases is 
 dependent entirely on the clinical symptoms, as 
 measles and scarlet fever. We infer that the 
 symptoms produced by other microbes may give 
 rise to specific symptoms, and we can use 
 this idea as a guide in one field of research. 
 It is manifest that bacteriology must be greatly 
 hampered until the symptoms of invasion are 
 related to the infective agent causing the ill- 
 health. 
 
 24. The Expectation of Results. — True clinical 
 investigation holds out no expectation of results 
 in the immediate future, so far as achieving the 
 chief aim in medicine — the prevention and cure 
 of disease. A long and weary road has to be 
 travelled by those who would make clinical 
 medicine an object for research. The training 
 alone requires many years of patient toil, and the 
 practice of setting young men fresh from the 
 schools to undertake research in chnical medicine 
 shows how little the subject is understood. 
 
Principles of Investigation, 39 
 
 Such a contemplation of clinical research 
 seems discouraging, for we all like to see the fruits 
 of our endeavours. But it must be borne in mind 
 that all great enterprises are based on work that 
 has been done by individuals whose part is lost 
 in obUvion. Someone has to do the obscure but 
 necessary work of digging a foundation, and 
 whoever undertakes this kind of work must be 
 content with the knowledge that he is playing a 
 necessary part in a great enterprise. 
 
40 
 
 Chapter V. 
 
 CLASSIFICATION OF SYMPTOMS. 
 
 25. The Anatomical Classification of Disease. 
 
 26. The Clinical Classification of Symptoms. 
 
 27. Structural Symptoms. 
 
 28. Functional Symptoms. 
 
 25. The Anatomical Classification of Disease. 
 
 It is a matter of knowledge common to every 
 general practitioner that an explanation of the 
 complaints of a large majority of his patients 
 cannot be found by reference to any textbook. 
 The cases he can recognise according to textbook 
 descriptions are mainly those where the disease 
 has reached an advanced stage, as in dropsy from 
 heart disease, and consumption after the lungs 
 break down, or when some terminal affection such 
 as apoplexy occurs. In consequence the doctor 
 is often at a loss what name to give the complaints 
 from which his patients suffer, and he has to 
 resort to the substitution of symptoms in place of 
 the real cause, so that we get names such as 
 neurasthenia, gastralgia, hyperchlorhj^dria, angina 
 pectoris, tachycardia, albuminuria, which convey 
 no definite information. The reason for this is 
 that the classification of diseases is not based 
 
Classification of Symptoms. 41 
 
 upon a true knowledge of disease. It is tlie out- 
 come of the time when pathology was dominant. 
 With the introduction of accurate methods of 
 observation, the nature of the diseases found 
 after death was clearly demonstrated, and a 
 classification of the different diseases that affected 
 the different organs was made. This classification 
 was so precise and definite, and seemingly so 
 accurate and scientific, that it was adopted not 
 only b}^ the pathologist but by the clinician. 
 The latter used this classification as a guide to 
 search for and explain the physical signs which 
 he detected in the living patient, and thus this 
 classification became the standard for clinical 
 medicine. 
 
 For a long time this seemed quite satisfactory, 
 and was of value, but time has shown that for 
 the practice of medicine it is not only faulty but 
 misleading, in that it diverts attention from the 
 real causes of disease and from the more important 
 sjmiptoms — those that are not included in w^hat 
 are called physical signs. 
 
 The need for a presentation of disease wiiich 
 describes the phenomena in the living human being 
 is urgently called for, and an endeavour is made 
 in the following pages to meet this need. 
 
 I have already pointed out that there has 
 been no orderly arrangement of the large mass of 
 symptoms which have been recognised. So long 
 as facts are accumulated with no orderly arrange- 
 ment the progress of medicine will be hampered 
 and matters essential to its progress will be 
 
42 Chapter V. 
 
 obscured. I have therefore attempted a classifica- 
 tion Avhich is simple, yet helps greatly in under- 
 standing the nature of symptoms. This classifica- 
 tion of S3^mptoms is based upon the mechanism of 
 their production. 
 
 26. The Clinical Classification. — In searching 
 for a basis I have adopted one which in my 
 present state of knowledge fulfils certain essential 
 requirements, inasmuch as it is based upon natural 
 laws, and gives at the same time information of 
 a kind that is necessary in practical medicine, 
 while its application guides one to an efficient 
 examination of the patient. 
 
 ,,To understand on what basis a classification 
 of disease should be made we have to consider the 
 manner in which symptoms are produced. Dis- 
 ease, where it impairs the health of the bodj^, is due 
 to a noxious agent producing a variety of pheno- 
 mena or symptoms. Some of these may result 
 from the agent, causing a structural change in the 
 tissues, producing what is called a physical sign 
 of disease. In every case of impaired health, 
 the agent acts, directty or indirectly, upon the 
 organs, causing a disturbance in their function. 
 Such disturbances may be more evident than the 
 structural signs or the agent of disease, and because 
 of their prominence the}^ ma}^ be mistaken for 
 the disease itself. Amongst these disturbances of 
 organs there is one class so distinctive and peculiar 
 in its mechanism that it can be separated into 
 a group by itseK, particularly as its function is 
 in many cases protective. The symptoms of this 
 class arise from stimulation of the central nervous 
 
Classification of Symptoms. 43 
 
 system, and their appearance is often the first to 
 direct attention to the fact that the individual is 
 ill, and they also indicate the source of the trouble. 
 Taking the mechanism of their production as 
 a basis, symptoms can thus be classified in three 
 groups : 
 
 (1) Structural sj^mptoms. 
 
 (2) Functional symptoms. 
 
 (3) Reflex symptoms. 
 
 27. Structural Symptoms. — Before we can 
 detect a change in an organ we must have 
 a knowledge of its position, its shape, and size, 
 and other characteristics as revealed in the 
 healthy body. A deviation from what we recog- 
 nise as its appearance in health is called a physical 
 sign, and phj^sical diagnosis is the term applied 
 to the detection of disease by the presence of these 
 signs. It is necessary to hold clearly in mind 
 what is revealed when we detect a physical sign, 
 either by the unaided senses, or by means of the 
 many mechanical means employed. In the main, 
 a phj^sical sign is due to an alteration in the 
 structure of the organs; though in this class is 
 included also such signs as the modification in 
 the sounds and movements of the heart, and 
 altered sensations. The detection of a phj'sical 
 sign gives httle information beyond the fact that 
 a change has taken place in an organ. There 
 may, from experience, arise a knowledge that 
 certain signs are associated with conditions of a 
 definite nature bearing upon the health of the 
 patient, as an enlarged heart is often associated 
 
44 Chapter V. 
 
 with heart failure, or a mahgnant tumour is 
 accompanied bj^ ill-health ; but, properly speaking, 
 the signs of heart failure and impaired health are 
 not revealed by the physical sign. It might seem 
 to be a needless refinement to insist upon such a 
 distinction, but for the purpose of keeping clearly 
 in mind the limitations of knowledge revealed by a 
 j)hysical sign, such a distinction is necessar}^, for 
 we find that in practice the detection of a physical 
 sign is often thought to convey information far 
 beyond what it actually reveals. Thus for the 
 last 100 3^ears the detection of a murmur in the 
 examination of the heart has led to the assumption 
 that the heart was seriously affected, and we see 
 to-day how this view misleads the profession. 
 
 This failure to appreciate the significance of a 
 physical sign is found in connection with most 
 diseases. The detection of an impaired percussion 
 note, or of a shadow in the lungs revealed by the 
 X-raj's, is judged to be sufficient evidence for a 
 prolonged course of treatment. Totally unnecessary 
 fears are frequently raised by the findings in an 
 X-ray examination, or b}^ other instrumental 
 methods. 
 
 The limited knowledge and the peculiar kind 
 of knowledge revealed by a physical sign must 
 always be kept in view, as the neglect of this 
 misleads, particularly in the use of mechanical 
 devices in the detection of symptoms, as I shall 
 point out later. Another matter to be kept in 
 view is that a physical sign, due to some structural 
 alteration in an organ, may be the result of a 
 functional disturbance of another or2;an, as in 
 
Classification of Sym'ptoms. 45 
 
 the e3-e signs and circulatory disturbances in 
 disease of the th^Toid gland. 
 
 28. Functional Symptoms. — The essential 
 matter in the maintenance of health is the 
 functional efficiency of the organs of the body. 
 A structural modification may take place and 
 leave the efficienc}^ unimpaired. Thus it arises 
 that after the detection of any physical sign, a 
 careful inquiry must be made into the efficiency of 
 the affected organ. The evidences of function are 
 not always easy to detect, but it may be taken 
 for granted that the disease of any organ will 
 never be properly recognised until the function 
 of the organ, and the part it plays in maintaining 
 the health of tlie body, is understood. While a 
 certain amount of knowledge may be obtained by 
 studj-ing the activity of the organ during health, 
 a far better understanding will be obtained by 
 studying the modifications of functions. These 
 modifications can onty be recognised b}^ detecting 
 the manifestations they produce on the body — 
 i.e.y functional symptoms. 
 
 Functional symptoms are rarely detected from 
 direct evidence in the organ affected, but rather 
 from the effects produced on other organs. This 
 is seen in its simplest form in certain affections of 
 the thj'roid gland. The structural signs give no 
 indication as to the serious or simple nature of the 
 affection ; this is only found out by the effect of 
 the perverted activity of the gland upon the heart, 
 eye, and nervous system, and in the increased 
 oxidation of the tissues. Diminished functional 
 
46 Chapter V. 
 
 activity, as in myxoedema, is shown also only by 
 its effects on remote organs and tissues. 
 
 Even in an organ like the heart, whose con- 
 chtion and activity can be so easily studied, the 
 information essential to a knowledge of its con- 
 dition can only be made out by the reaction on 
 other organs. The study of its various mani- 
 festations gives no idea of its functional efficiency, 
 and this knowledge can only be acquired by 
 observing how the circulation is maintained in 
 other organs, as shown by dropsy or enlarged 
 liver due to heart failure. Even in the early 
 stages of heart weakness, the essential signs are 
 brought about by a failure of the heart to supply 
 sufficient blood to remote organs. 
 
 In affections of tlie kidney, the symptoms 
 essential to a knowledge of the state of the kidney 
 are not elucidated by an examination of the 
 kidney, and even the elaborate chemical and 
 microscopic examination of the urine fails to 
 vield information so important as the presence 
 or absence of changes in the heart and blood 
 vessels. 
 
 It will be seen that not only do organs remote 
 from the original disease exhibit the essential 
 symptoms produced by depraved function, but 
 organs thus affected in this secondary manner may 
 show such signs from this cause that they form 
 the principal feature in the picture of impaired 
 health. Indeed, it will be found that a great many 
 diseases, which are described as independent and 
 distinct, are but the reaction to the depraved 
 function of another organ. This is best seen in 
 
Classification of Stjmptoms. 47 
 
 the response of the heart. Probably the depraved 
 function of every organ reacts upon the heart, either 
 through the nervous mechanism of the heart, or 
 from its nutrition being impaired, as in anaemia. 
 
 The importance of recognising this class of 
 symptoms as distinct is because it gives a line of in- 
 vestigation in each case. Already we know of man}^ 
 symptoms produced by different organs wliich are 
 associated in their appearance, and we recognise 
 certain groups of sj^mptoms as being due to the altered 
 or impaired function of an organ, so that the appear- 
 ance of one of a group leads to a search for others. 
 Moreover, the increase in our knowledge of the 
 mechanism of the individual symptom will inevitably 
 lead to a better understanding of the organ whose 
 depraved function is the cause of the disturbance, 
 and thus contribute largely to that very necessary 
 branch of knowledge — the pathology of function. 
 
 It might seem umiecessary to point out how 
 Important this view is from the standpoint of 
 treatment. It is manifest that if such an organ 
 as the heart is disturbed by the depraved functions 
 of other organs, any treatment which is devoted to 
 the heart wiU be useless. Yet this view needs 
 emphasising, for to mj^ knowledge, large numbers of 
 individuals are submitted to prolonged treatment 
 for cardiac symptoms in which the organ is only 
 secondarih^ affected. Indeed, so important is tliis 
 aspect of the matter that the question should arise 
 in connection with every disease, whether the 
 symptoms are not manifestations of a disease 
 provoked by some other organ. The importance of 
 this point of view will be more fulh' considered later. 
 
( 48 ) 
 
 Chapter VI. 
 
 REFLEX SYMPTOMS. 
 
 29. The Discovery of the Seat of Disturbance. 
 
 30. The Discovery of the Agent causing ill-heaWh 
 
 31. The Discovery of the Function of the Nervous 
 
 System. 
 
 32. Methods of Examination. 
 
 33. Mechanism of an Ordinary Stimulation. 
 
 34. Mechanism of the Radiation of Sensation. 
 
 35. Mechanism of a Motor Reflex. 
 
 36. Mechanism of Radiation in Disease. 
 
 29. The Discovery of the Seat of Disturbance. — 
 
 I have already remarked that much vahiable time is 
 often spent in research work which fails to achieve 
 results at all commensurate with the labour devoted 
 to it. One half of the battle in all research work 
 consists in having a definite object, with a clear 
 conception of how the object is to be achieved. 
 The study of reflex symptoms leads directh^ to the 
 organ at fault, and may discover the agent causing 
 the ill-health. The inquiry into the nature of reflex 
 symptoms has not only helped in the discovery of 
 facts of great value, but has revealed the methods 
 by which other objects essential to the progress 
 of medicine may be pursued. It has demonstrated, 
 
Reflex Symptoms. 49 
 
 for instance, that there is an intimate relation 
 between the organs and definite areas of the skin, or 
 rather between the organs and the distribution of 
 the sensory nerves in those areas, and between the 
 organs and parts of the skeletal muscular system. 
 A knowledge of this relation at once reveals which 
 organ is at fault. When we detect sensory dis- 
 turbances — pain or hyperalgesia — in these parts, 
 or when we find a persistent contraction of the 
 muscles, we are able to relate these to a definite 
 structure within the body. In this way we seek to 
 link up the organ with the disturbed region in the 
 external body wall. This can be accomplished by 
 the careful examination of the disturbed regions and 
 correlating them with the disease discovered on the 
 operation or j)ost-morte7n tables. 
 
 30. The Discovery of the Agent causing Ill- 
 health. — In addition to the discovery of the organ 
 at fault, we have the opportunity of discovering 
 another very important matter — namely, the nature 
 of the stimulus which is capable of producing these 
 disturbances in the external body wall. It requires 
 a stimulus of a peculiar kind to produce these 
 reactions. 8ome disease processes produce one form 
 of reaction and others produce other reactions. The 
 careful noting of the different reactions and their 
 correlation with the disease process will reveal the 
 nature of the stimulus which may be acting, and so 
 we get, at a very early stage, from the symptoms 
 produced in the external body wall, a sure indication 
 not only of the organ at fault but of the kind of 
 disease present in the organ. 
 
50 Chapter VI. 
 
 31. The Discovery of the Functions of the 
 Nervous System.— The recognition of the phenomena 
 produced by reflex stimulation hj disease will be 
 found to open new fields of investigation in the 
 central nervous system. The radiation of stimula- 
 tion, for instance, shows there are paths in the central 
 nervous system hitherto unrecognised. The peculiar 
 fields of cutaneous hyperalgesia and of the radiation 
 of pain in diseases of such organs as the heart, gall 
 bladder, ureter, and bowel, shows that the stimulus 
 entering the central nervous system pursues a very 
 definite course. This is also seen in the area of 
 cutaneous hyperalgesia in renal colic, as represented 
 in Fig. 18, page 185. 
 
 In addition, it is only by the study of these 
 symptoms that a full knowledge of the afferent 
 system of the nerves belonging to the involuntary 
 nervous system can be acquired. 
 
 32. Methods of Examination. — As we know, ill- 
 health leads to the production of a great variety of 
 symptoms, and we also know that some simple 
 cause is capable of producing these symptoms. The 
 trained investigator may detect the cause in a 
 variety of ways^by the intelhgent questioning of 
 the patients as to the onset of their ill-health and 
 t.heir sensations, by the recognition of the peculiar 
 character of the symptoms and in the way they are 
 grouped. Certain toxins give rise to reactions 
 pecuhar to them, and we may recognise the diseases 
 they represent by the grouping of the symptoms. 
 These reactions are shown not onJy by the pecuhar 
 association of phenomena but also by specific effects 
 upon individual organs. The recent observations 
 
Be flex Symptoms. 51 
 
 of Marris and R. M. Wilson, for instance, demonstrate 
 that certain microbes produce toxins that have a 
 peculiar effect upon the heart. By such means there 
 is every reason to expect that we will recognise that 
 groups of symptoms are indications of and peculiar 
 to certain diseased states, although at present our 
 outlook is cdn;fused by an inabihtj^ to distiaguish 
 these groups. It will thus be seen how incumbent 
 it is to note carefulh^ each individual symptom, 
 to watch the development of symptoms by keeping 
 in touch with the patients, and applying the prin- 
 ciples which are the basis of any scheme for the 
 investigation of disease. 
 
 33. Mechanism of an Ordinary Stimulation. — 
 Before discussing the nature of these reflex symptoms 
 it is necessary to appreciate the mechanism by which 
 many symptoms are produced. When a common 
 sensation arises in any part of the body, no matter 
 how it is produced, it is always accompanied by a 
 sense of locality. This sense of locality may be 
 precise and definite, or it may be vague and diffuse, 
 but it has a reference to some particular part of 
 the body. Fig. 1 represents diagrammatic ally the 
 simplest form of sensation with its attendant 
 locaUzation. It represents a portion of skin (a) which 
 is stimulated and from which a sensation passes into 
 the central nervous system and reaches the sensorium 
 (s), where the sensation is not only perceived, but 
 the part of the body recognised to which the stimu- 
 lated nerves are distributed. 
 
 34. Mechanism of the Radiation of Sensation.— 
 The place in which the sensation is felt is not neces- 
 sarily the place which received the stimulus. In most 
 
52 
 
 Chapter VI. 
 
 instances a local stimulus applied to the external 
 body wall gives rise to a sensation wliose localization 
 by the sensorium corresponds to the part stimulated. 
 It often happens that the area in which the sensation 
 is felt is greater than the part stimulated, and it is 
 then difficult to explain the radiation. An experi- 
 ence related by Professor Sherrington supplies a 
 
 Fig. 2. 
 
 Fig. 1. 
 A stimulus applied to the skin, a, is not only recognised by the sensorium, 
 S, but is referred to a definite area, a. 
 
 Fig. 2. 
 Illustrates tlie radiation of sensation. A stim\ilus applied at a is felt 
 not only at a, but in a part of the skin,B, at some distance. This is repre- 
 sented as taking place in some part of the central nervous system where 
 the cells a' and b' lie in close proximity. 
 
 fitting explanation. The application of a mustard 
 plaster to his chest over the region of the upper 
 part of the sternum gave rise to an unpleasant 
 sensation on the inner side of each arm just above the 
 internal cond3des. 
 
 It is known that the nerves supplying the skin 
 of the upper part of the chest and the skin on the 
 
Reflex Symptoms. 53 
 
 inner side of the elbow arise from cells situated 
 close together in the spinal cord, and leave the cord 
 by the second thoracic nerve — one branch of this 
 nerve going to the chest and the other to the arm. 
 
 The manner in which the radiation of the 
 sensation takes place is shown diagrammatically in 
 Fig. 2. The stimulus conveyed from a enters the 
 cell a' in coimexion with the nerve fibre, and not 
 onh' gives rise to a sensation referred to a, the part 
 stimulated, but affects the cell b' in its immediate 
 neighbourhood. The sensorium recognises the ex- 
 tended stimulation, and refers the resulting sensation 
 to that portion of the skin, b, suppUed by the nerve 
 b'. There are many other instances of this kind of 
 referred sensation — for example, the well known 
 instance of the knee pain in hip-joint disease. 
 
 From these facts another principle can be 
 deduced — namety, that if any part of the nervous 
 system which conveys the sensation of pain from the 
 skin to the sensorium be stimulated, the resultant 
 sensation is referred not to the part stimulated but 
 to the distribution of the nerve at its periphery. 
 Thus, when the cell b' was stimulated, the brain 
 became conscious of the stimulation, but the sensa- 
 tion was felt in the skin at b. 
 
 35. Mechanism of a Motor Reflex. — A stimulus 
 applied to the sole of the foot ma}^ give rise to 
 a sensation of touch, or tickling, or pain, and 
 at the same time may produce a contraction of 
 certain muscles. It is not necessary to infer that 
 it requires a special peripheral end- organ and a 
 separate nerve fibre to receive and convey the 
 stimulus to the sensorium, and another to convey 
 
54 
 
 Chapter VI. 
 
 the stimulus to the motor centre in the spinal cord. 
 A simple diagram (Fig. 3) shows how this comes 
 about. The stimulus appHed to the skin, a, passes 
 into the cell a', and from this cell one stimulus 
 proceeds to the sensorium, and another to the motor 
 cell c\ causing a contraction of the muscle, c. 
 
 Ftg. 3. Fig. 4. 
 
 Fig. 3. 
 Illustrates the mechanism of a motor reflex. The stimulus to the skia 
 A produces not only a sensation and its locaUzation, but the stimulus 
 passing through a' affects the cell c' and produces a contraction of the 
 muscle c. 
 
 Fig. 4. 
 Illustrates the radiation of pain set up by disease. The diseased tooth 
 A causes pain not only in the neighbovu-ing tooth, b, but also in the skin 
 of the cheek, c. 
 
 This reflex stimulation may affect many other 
 centres, some of them easily recognisable, others so 
 elusive that their presence can only be inferred. 
 Later on, when deahng with the reaction produced by 
 visceral disease, it will be shown that a stimulus 
 arising at the periphery may provoke a variety of 
 demonstrable reactions differing widely in character. 
 
Reflex Symptoms. 55 
 
 36. — ^Mechanism of Radiation in Disease. — These 
 simple illustrations give a clue to the manner in 
 wliich symptoms are produced bj^ disease reacting 
 on the central nervous system. This is shown in 
 the simplest way when a demonstrable disease gives 
 rise to symptoms that are easily recognised. Most 
 of us know from personal experience what toothache 
 is, and we have often the opportunity of stud^'ing 
 its symptomatology on our patients, if not on 
 ourselves. It frequently happens that the pain set 
 up b}' a diseased tooth is not hmited to the offending 
 tooth, but is felt along the jaw, in the other teeth, 
 and sometimes in the cheek. Indeed, the sound 
 teeth may be so painful, on pressure being applied 
 to them, that the dentist may pull a sound tooth in 
 place of the diseased one. Pain may not only be 
 felt in the cheek, the skin may be so hypersensitive 
 that on brushing the hair pain is produced in place 
 of the normal sensation of touch. 
 
 It is to be noted that the spreading of the pain 
 and tenderness in such an instance is not due to the 
 extension of any morbid condition at the peripherj^ — 
 inflammation, for instance — to the neighbouring 
 teeth, for there is no sign of an}i:hing the matter 
 with those teeth, while the skin of the cheek is 
 demonstrabl}^ free from any diseased condition. 
 Moreover, the discovery and removal of the diseased 
 tooth is followed b}^ the complete disappearance of 
 all pain and tenderness from the other teeth and from 
 the skin of the cheek. 
 
 Seeing tliat these phenomena are produced by 
 one diseased tooth, and seeing that the pain and 
 tenderness of the sound teeth' and of the skin of the 
 
56 CJmpter V I. 
 
 cheek is not due to any connection with the offending 
 tooth at the periphery, we are driven to look else- 
 where for some connection between these widely 
 separated parts. As there is no communication 
 between nerves except at the cells in the central 
 nervous system from which they arise, we seek for 
 a relation between the nerves of these teeth an(^ the 
 skin of the cheek in the central nervous system. 
 In the case of the diseased tooth the pain was felt 
 not only in the diseased tooth or its immediate 
 neighbourhood, but also in other teeth and in the 
 skin of the cheek, and tliis radiation is explained bj^ 
 a reference to the diagram Fig. 4, where it is shown 
 that a stimulus arising from the diseased tooth a 
 sends a stimulus into the central nervous system 
 affecting the cell a' belonging to the nerve of the 
 diseased tooth, so that the sensorium refers the 
 resultant pain to the diseased tooth ; but the 
 stimulus also spreads from the cell a' to the cells b' 
 and &, and the resultant pain is referred by the 
 sensation to the healthy tooth b and the health}^ 
 skin of the cheek c. 
 
CHAPTP]R VIL 
 PAIN. 
 
 37. Definition of Pain. 
 
 38. Constitution of the Nervous Systeyn. 
 
 39. Difference in the Functions of the two Nervous 
 
 Systems. 
 
 37. Definition of Pain. — The due recognition 
 of the factors concerned in the production of pain is 
 of the first importance in the stud}^ of disease. Not 
 only is pain the most important of complaints, but 
 it is the most instructive diagnostic sign, for the 
 study of its mechanism gives often the key to the 
 best means for attaining relief. The term " pain " 
 used here is easy to understand though difficult to 
 define. It is beside my purpose to enter into abstruse 
 metaphysical considerations regarding the conscious- 
 ness of pain and its mental affinities. Nor do I 
 include other disagreeable sensations, which are 
 sometimes spoken of as pain, as when a brilliant 
 light or a piercing noise unpleasantly affects the 
 sense of sight or hearing. The term is limited to 
 that very definite form of disagreeable sensation 
 which everyone has experienced, and we all recognise. 
 
58 Chapter VII. 
 
 The meaning attached to the term pain in this book 
 may be summarised shortly as follows : — 
 
 Pain is a disagreeable sensation due to stimula- 
 tion of some portion of the cerebro- spinal nervous 
 system and referred to the periplieral distribution 
 of cerebro-spinal sensory nerves in the external body 
 wall. 
 
 38. Constitution of the Nervous System.— The 
 nervous system consists of two great divisions, which 
 are distinctly separated in their functions, viz., the 
 cerebro-spinal and the sympathetic or autonomic. 
 The former of these divisions consists of the brain 
 and spinal cord, and the peripheral nerves which are 
 distributed to the external body wall and subserve 
 the functions of sensation and muscular contraction. 
 Incorporated within the cerebro-spinal system is the 
 other division, the sympathetic or autonomic nervous 
 system, which includes the origin of such nerves as 
 the vagus and the sympathetic. The position and 
 distribution of the efferent fibres of the autonomic 
 S3^stem is shown in Langley's diagram (Fig. 5, page 
 59). It will be seen that this system presides over 
 the functions peculiar to the different organs. While 
 much experimental work has been done to establish 
 the distribution and functions of the nerves that pass 
 from the centres to the periphery (efferent nerves), 
 little has been done to examine the nerves that pass 
 from the viscera to the central nervous system 
 (afferent nerves). The reason for this is that the 
 nerves passing from the organs to the nerve centres 
 afford little direct evidence of their function, and 
 it has not yet been understood in w4iat way these 
 afferent nerves react to stimulation. 
 
Paitu 
 
 59 
 
 Sphincter of iris\ 
 Ciliary muscle j 
 
 Dilator of iris. Orbital muscle 
 
 Heart. Blood-vessels of mucous 
 membrane of head. 
 
 Walls of gut from mouth to de- 
 scending colon. 
 
 Outgrowths from this region of the 
 gut (muscle of trachea and 
 lungs ; gastric glands, liver, 
 pancreas). 
 
 The skin (arteries, muscles, glands). 
 Blood-vessels of gut between 
 
 mouth and rectimi, of lungs 
 
 and of abdommal viscera. 
 Arteries of skeletal muscle. 
 Muscle of spleen, ureter, and of 
 
 internal generative organs. 
 Walls of stomach, intestine, gall 
 
 bladder and ducts, urinary 
 
 bladder. 
 
 Arteries of rectum, anus and- 
 external generative organs. 
 
 Walls of descending colon to end 
 of gut. 
 
 Walls of bladder and urethra. 
 Muscle of external generative 
 organs. 
 
 Mid-brain autonomic. 
 
 Bulbar autonomic. 
 
 Sympathetic. 
 (T. Th. to 11. or III. L. in man.) 
 
 Sacral autonomic. 
 (II. to TV. Sacral in man.) 
 
 Fig. 5. 
 Diagram to show the general origin and distribution of efferent autonomic 
 fibres. By "muscle" is, of course, meant unstriated muscle only. By 
 the " walls " of a structure are meant all the unstriated muscle in it. 
 The irmervation in some cases is still a matter of controversy (gastric 
 glands, liver, and pancreas ; vessels of lungs ; small arteries of skeletal 
 muscles, and arteries of the central nervous system). (Langley. ) 
 
60 Chapter VII. 
 
 39. Difference in the Functions of the two 
 Nervous Systems. — In the scheme put forth here, 
 pain and other sensations are regarded as functions 
 pecuhar to the cerebro-spinal system, and that for 
 the production of visceral pain it is suggested 
 that under certain circumstances these afferent 
 nerves of the autonomic system convej^ a stimukis 
 to the cerebro-spinal nerves, so that such phenomena 
 as pain, hyperalgesia and muscular contraction in the 
 external body wall are the evidences of stimulation 
 of the cerebro-spinal nerve centres by the afferent 
 autonomic nerves. 
 
( 61 
 
 CHAPTER VIII. 
 THE SENSITIVENESS OF THE TISSUES. 
 
 40. The Tissues Sensitive and Not Sensitive to 
 
 Meclmnical Stimulus. 
 
 41. Sensitive Tissues of the External Body Wall. 
 
 42. Insensitiveness of the Viscera to Mechanical 
 
 Stimulation. 
 
 43. Methods for Testing the Sensibility of Organs. 
 4:4:. Testicular Pain. 
 
 45. Artificial Production of Visceral Pain. 
 
 40. The Tissues Sensitive and Not Sensitive 
 to Mechanical Stimulus.— A step preliminary and 
 necessary to understanding the nature of the 
 symptoms of disease is a knowledge of the sensibility 
 of the different tissues of the body. A great field 
 for investigation still lies unexplored, and so long 
 as it is neglected the understanding of the symptoms 
 of disease will be defective. In the attempt to 
 investigate this field I have only been able to make 
 a slight advance, but such as it is, it has thrown new 
 and unexpected light on a great many problems 
 connected with the symptomatology of disease. 
 
62 Chapter VIII. 
 
 If we inquire into the response of the different 
 tissues to such mechanical stimuli as produce the 
 common sensations of pain, touch, heat, pressure, etc., 
 we discover that these sensations are limited to cer- 
 tain portions and organs of the body, and that there 
 are large portions of the body totally insensitive to 
 all such stimuH. Looking at the matter broadlj^, we 
 find that while all the structures which make up the 
 external body wall are more or less sensitive to such 
 stimuli, the viscera and the serous lining of cavities 
 are, with one exception, irresponsive to this kind of 
 stimulation. 
 
 Thus, if we appty a mechanical stimulus to the 
 skin we produce a sensation peculiar to the nature of 
 the stimulus, as, for example, touch, pain, heat, or 
 cold. If we apply the same stimuh to the viscera 
 or to the serous surfaces or internal struct\u:es of 
 organs we get no response, or rarely a response of a 
 different nature. Thus, if we prick the skin near 
 such an orifice of the body as the anus, we can 
 produce pain, but as soon as the mucous membrane 
 is reached the pricking no longer produces pain. 
 In testing other orifices of the body — for example, 
 the mouth — a modified sensation is felt, but a.t a 
 certain depth of the gullet all sensation ceases. 
 
 If we inquire into the reason for this difference 
 in the response to stimulation we wiU find it in the 
 nerve supply of these different tissues. Thus the 
 tissues which give rise to sensation in response to 
 mechanical stimuli are supphed by the cerebro-spinal 
 nerves, wliile the tissues wliich do not respond receive 
 no nerves from the cerebro-spinal nervous system, 
 but are supplied only by the sympathetic nervous 
 
The Sensitiveness of the Tissues. 63 
 
 system, or what is sometimes spoken of as the in- 
 vohmtarv' nervous system. 
 
 41. Sensitive Tissues of the External Body 
 Wall. — If we take the abdominal wall we find three 
 great layers endowed with exquisite sensibilit}' to 
 pain. The first of these, the skin, I need not dwell 
 upon, save to point out how its sensibility frequently 
 becomes increased in visceral disease, and how this 
 increased sensitiveness is united to an exalted 
 muscular reflex. The second of these sensitive layers 
 is the voluntar}' muscular system, best observed in the 
 flat muscles of the abdomen. It is the sensitiveness 
 of this muscular layer which is most commonly 
 exalted in visceral disease, its sensibilit}^ being very 
 readily increased. Muscular hyperalgesia is such a 
 striking phenomenon, is so frequently present and 
 pla.ys such an important part in the protective 
 mechanism, that it is astonisMng to find it almost 
 universally overlooked. One can read elaborate 
 treatises devoted to special organs, in which this 
 symptom is the most striking and the most instruc- 
 tive feature, but its presence is nevertheless over- 
 looked or misinterpreted. In an ordinary case of 
 stomach ulcer, appendicitis, gaU-stone, renal colic, 
 or enlarged liver, if one notes the tenderness of the 
 abdominal wall, and observes how this deep tender- 
 ness extends far beyond the site of the organ affected, 
 one can appreciate the nature and significance of this 
 sensitive lajfer. Vv^ith a little care one will be able to 
 distinguish tliis muscular hyperalgesia from cutane- 
 ous hyperalgesia and from hyperalgesia of the deeper 
 tissues. The third sensitive layer is one of which 
 anatomists and physiologists Avere quite ignorant till 
 
64 Chapter VIII. 
 
 recently, though it has long been suspected from 
 clinical observations. It is the layer of loose 
 connective tissue lying immediately outside the 
 peritoneum. I suspected its presence for a long time as 
 I could frequently get exquisite tenderness in pushing 
 my fingers between the recti muscles, for instance in 
 cases of gastric ulcer, the stomach not being affected 
 by the pressure. Its existence can be shovxii in an 
 operation for the radical cure of hernia under cocaine 
 anaesthesia. The skin and muscles can be cut 
 tlirough, and the patient experiences no pain. When 
 the loose connective tissue outside the peritoneum is 
 gently torn tlurough the patient may experience most 
 exquisite pain. After the peritoneum is exposed it 
 can be incised, its visceral layer scratched and after- 
 wards stitched, and the patient feels no pain. I have 
 verified this observation on several occasions. 
 Ramstrom has made a careful histological exam- 
 ination of the abdominal wall of man and other 
 mammals, and showed that this region is riehh^ 
 endowed with nerves and nerve endings, the nerves 
 being derived from those which supply the muscles of 
 the abdominal wall. This observation may probably 
 afford a clue to the confused statements that exist in 
 regard to the sensitiveness of the peritoneum. I can 
 only say this, that I have on numerous occasions in 
 the course of operations scratched and cut the serous 
 surface of the peritoneum on conscious subjects Avith- 
 out anv analgesic, local or general, and have never 
 known the slightest sensation ehcited. One can 
 understand, however, that the inflamed peritoneum 
 and adhesions might readily affect this remarkable 
 nervous laver. Peritonitis, however, so readity 
 
The Sensitiveness of the Tissues. 65 
 
 produces muscular lipj^eralgesia and tonic muscular 
 contractions (viscero- motor reflex), that the pain and 
 tenderness are demonstrably, in the majority of cases, 
 of spinal origin. 
 
 42. Insensitiveness of the Viscera to Mechanical 
 Stimulation. — The insensitiveness of the viscera to 
 mechanical stimulation has been repeatedly demon- 
 strated. Haller described a series of experiments 
 where he exposed in animals certain viscera by 
 operation, leaving an opening by which they could 
 be reached. Afterwards, while the animal was 
 feeding, he introduced through the opening instru- 
 ments that cut and burnt the organ, and the animal 
 paid no attention to what he was doing. I have 
 myself repeatedly tested in the conscious human 
 subject the various organs by cutting, stitching, and 
 tearing, and no sensation was elicited. 
 
 The insensitiveness of the viscera and its full 
 significance has not been grasped. Indeed, the 
 belief is common that the viscera are endowed with 
 common sensations, and w^iat is supposed to be 
 evidence is easily obtained. 
 
 43. Methods for Testing the Sensibility of Organs. 
 The sensitiveness of tissues to stimulation is one 
 of those apparently simple problems which it is 
 assumed anyone can solve. As a matter of fact, no 
 one has been sufficiently trained to undertake such 
 an investigation. A large amount of work has been 
 done on the subject by physiologists, neurologists, 
 psychologists, phj^sicians, and surgeons, yet, notwith- 
 standing their opportunities, they have failed to inves- 
 tigate the matter in a manner calculated to reveal 
 the true facts, and so the conclusions Avhich are 
 
66 Chdjyter VIII. 
 
 current to-day are based on imperfect observations, 
 and in consequence are misleading. I comment on 
 this fact as one of many instances where the progress 
 of medicine is hampered by a lack of understanding 
 of the manner in which investigation should be 
 conducted. I do not at present wish to enter fully 
 into the matter, but mention a few points to show 
 the imperfect methods which have been used. 
 
 The first point which arises is, that no conclusion 
 should be drawn as to the sensitiveness of an organ 
 which has been stimulated through a structure itself 
 sensitive. Nearly all conclusions have been drawn 
 from observations made by pressing on the organs 
 through the sensitive abdominal wall. Many ob- 
 servers state that they have demonstrated the 
 sensitiveness of an organ by first observing its 
 position by various methods, such as the x rays, and 
 later by pressing over it and ehciting pain. The 
 error here lies in the failure of the observer to take 
 the precaution of excluding the sensitive external 
 bodj^ wall. If, for instance, when such sensitiveness 
 has been detected, an attempt is made to delimit the 
 area that is sensitive, it will be found that the size 
 and shape of the area painful on pressm^e bears no 
 relation to the size and shape of the organ supposed 
 to be tender. I discussed this matter with a very 
 skilled physician. He demurred to my statement 
 that there was no evidence of the sensitiveness of 
 organs. He declared that he had a patient with a 
 large liver which he could demonstrate to me was 
 extremely tender. I asked to see this patient and 
 was shown him. The enlarged liver was easily 
 palpated, the lower margin being sharp and well 
 
The Sensitiveness of the Tissues. 
 
 67 
 
 Fig. 6. 
 
 The shaded area represents the liver, the dotted area the extension of 
 hyperalgesia beyond the liver margin, showing the pain elicited by pressure 
 over the liver was due to an increased sensitiveness of the tissues of the 
 external body wall. 
 
 defined. On gently pressing over the liver the 
 patient winced from the pain. I asked the phy- 
 sician to map out the region that was so manifestly 
 tender, and to his surprise he found the tenderness 
 extended 3 in. lower than the margin of the liver 
 (Fig. 6). 
 
68 Chapter VIII. 
 
 It is well known that pain does occui' in disease 
 of the viscera, and in animals distress has been 
 provoked by certain experiments. But here the 
 experimenter never realised that the evidences of 
 suffering, even if these were due to pain, gave no 
 information as to the locality of the pain — a fact 
 absolutely essential to the understanding of the 
 mechanism hy which visceral pain is produced. The 
 same neglect of this essential matter is found in the 
 observations of surgeons and others who have 
 studied pain in the exposed organs of the human 
 subject. 
 
 With the recognition of these sensitive struc- 
 tures — frequently rendered exquisitely sensitive to 
 painful stimuli in visceral disease — it ^^ ill be under- 
 stood how impossible it is to judge of the sensitiveness 
 of the viscera from external exploration. When, 
 therefore, we find the surgeon or phj^sician demon- 
 strating the sensitiveness of any viscus, it will be 
 realised that he is in reality stimulating, in his 
 examination, those extremely sensitive structures of 
 the external abdominal wall, and referring the pain 
 he elicits to an organ that is totally insensitive to 
 any such stimulation. 
 
 44. Testicular Pain. — On the other hand, one 
 cannot always be sure of the soiu'ce of pain, as 
 when pressure is applied over a movable kidney or 
 readily palpated abdominal tumoiu*. That pain 
 arises on pressure on a viscus is undoubted, but the 
 pain does not seem to arise from the direct stimula- 
 tion but by reflex stimulation of a sensory cerebro- 
 spinal nerve. This can be demonstrated in the case 
 of the testicle. In ordinarv cases when the cord is 
 
The Sensitiveness of the Tissues. 69 
 
 short the pains felt on applying pressure to the 
 testicle are not readily differentiated. If, however, 
 an individual with a long cord, where the testicle 
 hangs down a long way from the groin, be examined, 
 the pains resulting from pressure on the testicle can 
 be separately recognised. In such an instance a pain 
 is felt at once readily localised over the point of 
 pressm-e. A few seconds later another pain is felt 
 gradually increasing in intensity, and gradually 
 passing away and referred to the groin. Accom- 
 panying the pain there is sometimes a sensation of 
 faintness, very slight with light pressure, but 
 evidently of the same nature as the intense 
 depression following on a blow on the testicle. 
 This dej)ression and pain are similar to those which 
 are evoked by pressure on the kidney and ovary. 
 Concerning the first of these pains when it is felt 
 at once and referred to the place of stimulation, a 
 curious question arises bearing on the sensibility of 
 serous membranes. As I have already pointed out, 
 I have scratched the serous surfaces of both visceral 
 and parietal peritoneum and pleura, and elicited no 
 sensation of pain, but exquisite pain may be elicited 
 by scratching the tunica vaginalis. In certain cases 
 in tapping a hydrocele, if the testicle be gently held 
 with one hand and the visceral laj^er of the tunica 
 vaginalis lightly scratched with the canula, the 
 patient at once experiences pain and refers the pain 
 imerringty to the region scratched. However lightly 
 the stimulus is made no sensation is experienced 
 beyond that of pain, resembling in this respect the 
 sensibility of the cornea. As demonstrating the 
 difference between the sensibility of the tunica 
 
70 G}iaj>ter VIII. 
 
 vaginalis and the peritoneum, I cite the following 
 experience. A patient consulted me with his 
 scrotum greatly enlarged and full of fluid, which I 
 took to be a hydrocele. I tapped him and tested the 
 sensibility of the testicle. I found the patient did 
 not feel pain when I scratched what I took to be 
 his tmiica vaginalis. I scratched rather roughl}^ jet 
 no painful sensation was experienced. Finding I 
 could not reduce the whole of the swelling I 
 concluded that the case was not one of hydrocele, 
 and on operating I found the case was one of 
 omental hernia with the sac distended by peritoneal 
 fluid. What I had been scratching was the 
 peritoneum. 
 
 As the tunica vaginalis and the peritoneum 
 have the same origin it appeared strange that there 
 should be this difference in sensation, until on 
 inquiry I found that a cerebro- spinal nerve is 
 distributed to the tunica vaginalis, viz., a twig of the 
 genital branch of the genitp- crural nerve. The tunica 
 vaginalis is the only sensitive serous membrane 
 covering an organ that I have detected, and it is the 
 only one to which a branch of a cerebro- spinal nerve 
 has been traced. 
 
 In certain cases the tunica vaginalis becomes 
 hj^peralgesic {see page 183). Professor Waterston 
 tells me that the visceral layer of the tunica 
 vaginalis is not of the same origin as the parietal, 
 but is looked on as a persistence of the germinal 
 epithelium. This may have some bearing on the 
 sensibility of the testicle, and my suggestion as to 
 the nature of the testicular sensitiveness is therefore 
 provisional. 
 
The Sensifive7ies.9 of the Tissues. 71 
 
 45. Artificial Production of Visceral Pain. — 
 
 It is ta cimoiis fact tliat altliough the belief is so 
 universally held that the viscera are endowed with 
 " sensory " nerves, and that physiologists refer to 
 afferent s^'mpathetic nerves as " sensory " in func- 
 tion, not a single authentic observation has been 
 rendered to sho^^' that the viscera have a direct 
 sensibility of their own, i.e., a sensibility derived 
 from the possession of nerves which when stimulated 
 produce a sensation. Of course, a great deal 
 depends on what is considered evidence, many people 
 being perfectly satisfied if they elicit pain by pressing 
 over i\n organ. Pli3^siologists have interpreted 
 certain movements as an expression of pain after 
 stimulating afferent S3^mpathetic nerves. But this 
 does not prove that pain was evoked nor does it prove 
 that the pain was a direct pain, nor does it show in 
 what situation the pain was felt, for the location of 
 the pain is the key to the problem. It is therefore 
 necessary in investigating this matter to be sure of 
 the tissue stinaulated, and the region in which the 
 resultant pain is felt. It is because of the absence 
 of the specification of the locus of the pain that many 
 otherwise important observations are rendered of 
 little value in respect to this investigation. 
 
 That pain can be produced by visceral stimula- 
 tion is easily demonstrated if one emplo^^s an 
 adequate stimulus. It is now many 3'ears since I 
 pointed out that the most \iolent pains of which we 
 are conscious are associated with hollow muscular 
 organs, and that by producing violent contraction 
 of a hollow viscus pain can be elicited. The easiest 
 way to do this is to give a distending enema of warm 
 
72 Chapter VIII. 
 
 water, and to retain the enema until painful peri- 
 stalsis results. That the pain is really due to the 
 contraction of the muscle wall of the bowel is evident 
 from the fact that with the relaxation of the 
 sphincter during the pain the contents of the bowel 
 are expelled with considerable force, and the pain at 
 the same time subsides. Here it is evident that a 
 considerable portion of the descending colon and 
 rectum must have contracted, but the pain is not felt 
 along the position occupied by these structures, but, 
 in the majority of people, it is referred across the 
 middle line immediately above the pubis. 
 
 The following observation demonstrates an 
 exactly similar series of facts : — 
 
 I had occasion to resect a small portion of the 
 small intestine in a conscious subject, for umbilical 
 fistula, w^hose abdominal cavity I laid open. He 
 refused to take an anaesthetic, and no analgesic, local 
 or general, was administered. There were numerous 
 peritoneal adhesions, and while I cut and tore these 
 the patient was unconscious of any sensation. I cut 
 and stitched the serous surfaces of parietal and vis- 
 ceral peritoneum, I tore adhesions from the liver, I 
 cut and sutured the bowel and mesenterj^, and no 
 sensation was felt. After preparing the upper part 
 of the bowel it was wrapped in a warm cloth and 
 laid on one side. Dmring the subsequent steps the 
 patient frequently" moaned. I asked him if he felt 
 pain, and he replied that he did. I asked him where 
 he felt the pain, and he indicated with his hand 
 that it was across the middle line at tlie level of the 
 umbilicus. I at first felt that it might be due to the 
 part that I was manipulating, but the pain was 
 
The Sensitiveness of the Tissues. 73 
 
 intermittent. Chancing to look at the prepared 
 upper part of the bowel that lay on the left side of 
 the abdomen, I observed that every few minutes a 
 peristaltic wave passed over the lower portion of it, 
 and when this occurred the patient moaned in pain. 
 I made certain that the pain was connected with 
 the peristaltic wave, and I produced the peristalsis 
 several times by lightly j)inching the bowel. I also 
 made sure the patient had no doubt as to the place 
 in which it was felt, with the result that here before 
 my eyes was the cause of the pain wiiich the patient 
 felt, and yet the patient referred the site of the pain 
 with precision to an area ten inches or twelve inches 
 away from the contracting bowel. 
 
( 74 ) 
 
 CHAPTEK IX. 
 VISCERAL REFLEXES. 
 
 46. The Mechanism, of Visceral Pain {the Viscero- 
 
 sensory Reflex). 
 
 47. The Mechanism of the Viscero-motor Reflex, 
 
 48. Multiple Reflexes from. Visceral Stimnlation. 
 
 46. The Mechanism of Visceral Pain (the 
 Viscero-sensory Reflex). — The remarkable difference 
 between the sensitiveness of the external body wall 
 and the viscera in response to mechanical stimulation 
 brings out clearly the difference in function of the 
 two divisions of the nervous S3^stem — a difference 
 which it is necessary clearly to understand if the 
 symptoms of disease are to be fully comi)rehended. 
 It shows that when pain is evoked from the organs 
 or tissues which are not supplied by the sensory 
 nerves of the cerebro- spinal system some other 
 mechanism must take part in its production. 
 
 The nature of this mechanism is revealed by tlie 
 study of the symptoms produced in certain forms of 
 visceral disease. If we take the symptoms that are 
 present in certain simple diseases — for example, a 
 gastric ulcer, appendicitis, or renal colic — the 
 mechanism by which a number of symptoms are 
 produced will become clear. In many cases of 
 gastric ulcer there is pain, limited to a small area. 
 
Visceral Be flexes. 75 
 
 Fig. 7. 
 The shaded area in the centre shows the position of pain and hyper- 
 algesia in a case of ulcer of the pjlorus situated at x. 
 
 in the epigastric region. This pain has a different 
 location from the nicer. Thus the pain may be 
 situated in the middle line, as in Fig. 7, where the 
 shaded area indicates the site of pain, while 
 the ulcer revealed at the post-mortem examination 
 is situated at the p^dorus, which was found at x in 
 Fig. 7. Moreover, if a patient with this pain 
 breathes deeph% the stomach, with the ulcer, shifts 
 its position, but the site of pain remains fixed. 
 With these facts before us, the mechanism of 
 pain in visceral disease becomes clear. When the 
 disordered sensations of toothache were considered 
 
76 Chapter IX. 
 
 it was seen that the only reasonable explanation 
 Avas that from the offending tooth a stimulus had 
 been sent into the central nervous system (page 54). 
 The effects of this stimulus were not limited to the 
 cells of the nerve supplying the tooth, but spread to 
 the ceUs of sensory nerves in the immediate neigh- 
 bourhood, w-ith the result that there was pain and 
 
 fA 
 
 -<fe: 
 
 Fig. 8. Fig. 9. 
 
 Fig. 8. 
 The normal movements of a viscus, X, pass into the central ner\'ous 
 sj'stem, x', but produce no sensation. 
 
 Fig. 9. 
 Shows the mechanism of a viscero -sensor j' reflex. A stimiilus arising 
 in a diseased organ, x (as in gastric ulcer), passes into the central nervous 
 system, x', and if the stimiilus be of a particvilar quality or strength it wiU 
 affect a neighbouring sensorj^ cell, b', which is recognised as pain and 
 referred to the peripheral distribution of the nerve at B. 
 
 hyperalgesia in neighbouring teeth and in the skin 
 of the cheek. 
 
 From the stomach a stimulus is conveyed by the 
 sj^mpathetic nerves into the central nervous SA'stem. 
 But as these nerves are not " sensor}' " nerves in 
 the sense that they are directly connected with any 
 perceptor in the brain, no sensation is felt (Fig. 8). 
 
Visceral Reflexes. 77 
 
 In like manner, so long as the impulses conveyed 
 from the ulcer do not spread no pain is felt. When, 
 however, the stimulus is of such a nature that it 
 spreads to other cells, then we get a reaction peculiar 
 to the cells stimulated. In this case the stimulus 
 reaching the nearest sensor}^ cells of the cerebro- 
 spinal system irritates them, and the pain which 
 results is referred to the peripheral distribution of 
 the nerve stimulated — that is, the nerves supphdng 
 the area of skin as already described in paragraph 34 
 on referred pain. Fig. 9 illustrates the mechanism 
 by which pain is produced in visceral disease, 
 showing how an organ itself insensitive and supplied 
 only by sympathetic nerves can produce pain by 
 reacting upon the cells of the cerebro-spinal sensory 
 S3^stem. The stimulus arising in the organ x passes 
 to the central nervous system, where its cell, x', 
 has no direct connection with the sensorium, s, 
 but when an adequate stimulus arises it affects the 
 neighbouring cell, b", which, being a pain nerve, 
 gives rise to the sensation of pain which is localised 
 at its peripheral distribution. 
 
 47. The Mechanism of the Viscero-motor Reflex. 
 Before dealing with other phenomena produced 
 by visceral disease it is necessary to consider the 
 mechanism of the reflex which produces contraction 
 of voluntary muscles as a result of a stimulation 
 from the viscera. When we carefuUy palpate the 
 abdominal waU in patients with disease of some 
 abdominal organ, we wiU frequently find certain 
 portions of the body wall hard and resistant. This 
 manifestly is due to a contraction of a portion of 
 one or more of the broad muscles which form the 
 
78 
 
 Chapter IX. 
 
 abdominal wall. It is a reflex contraction produced 
 b}^ a stimulus arising in the diseased viscus and 
 sometimes referred to as " protective rigidity " of 
 the muscles, as its purpose is obviously to protect 
 the diseased organ. Every doctor is aware of this 
 hardness in the epigastrium in gastric ulcer, due to 
 rigidit}^ of the upper portion of the recti muscles. 
 The manner in which it is produced is similar to that 
 operating in the case of the cutaneous reflex con- 
 traction and may be cliagrammatically represented 
 
 rQ 
 
 Fig. 10. 
 Shows the mechanism of the viscero-motor reflex. A stimulus arising 
 in a diseased organ, x, passes into the central nervous system, x', and 
 affects a neighbouring cell, c', which cavises a contraction of skeletal 
 muscles, c. 
 
 as in Fig. 10, where the stimulus from the viscus x, 
 passing to the cell x' in the central nervous system, 
 excites the motor cell c', which produces a contrac- 
 tion of the muscle c. 
 
 There are different forms of reflex muscular 
 contraction. The cutaneous reflex contraction is 
 accompanied by a sensation; viscero-motor con- 
 traction is not necessarily accompanied by a sensa- 
 tion. The cutaneous reflex results is a momentary 
 
Visceral Reflexes. 79 
 
 contraction of the muscle. The contraction of the 
 muscle which arises from the visceral stimulation 
 is persistent. In this persistent contraction of the 
 muscle we get an insight into several processes of a 
 ver}' instructive kind. Light is tln*own on some 
 functions of the sympathetic system at present 
 obsciu'c, and some characteristic features of muscular 
 contraction which have been overlooked are revealed. 
 From the study of this contraction it can be 
 demonstrated that the tone maintained bv the flat 
 
 Fig. 11. 
 ShoMS the mechanism of a combined viscero -sensory and viscero-motor 
 reflex. (See Figs. 9 and 10.) 
 
 muscles of the abdomen is partly dependent on the 
 stimuli reaching the motor cells of the muscles from 
 the viscera. If we carefully Avatch certain cases of 
 visceral disease, such as gastric ulcer, we will often 
 find a varying degree of muscular rigidity. It may 
 scarcely be possible to distinguish this increased 
 resistance from that of the normal tone and resistance 
 to palpation in unaffected muscles. This resistance 
 often increases until the muscle is felt hard and 
 
80 Chapter IX. 
 
 board-like, and after a time it may subside and 
 disappear. When the increased resistance is scarcely 
 perceptible, it can be increased by rubbing gently 
 along the muscle. Sometimes in walking the con- 
 traction of the muscle may be increased so that 
 the patient wallas with a stoop. The varying 
 degrees of contraction are in all likelihood associated 
 with varying degrees of activity of the disease, and 
 I have at times found them of value in the manage- 
 ment of such diseases as gastric ulcer. But the 
 point I wish to make here is that this increase in 
 contraction is evidently but an exaggeration of that 
 condition called tone which is normally present in 
 health. 
 
 Frequenth^ these muscle contractions are asso- 
 ciated with hyperalgesia of the skin overlying them, 
 and the muscles themselves may be hy peralgesic. When 
 this cutaneous hyperalgesia is present the cutaneous 
 reflexes show some interesting variations. If the 
 muscle is not contracted, or only shghtly contracted, 
 the reflexes may be much more lively in response 
 to stimulation of the hyperalgesic skin. If the 
 muscles are hard and board-hke, the reflexes may 
 seem .to be abolished ; little or no movement is 
 obtained from stimulating the hyperalgesic skin, 
 for the reason that the muscles are akead}' contracted 
 to their full extent. 
 
 It occasionally happens that we find the muscle 
 distinctly contracted, with no cutaneous nor muscular 
 hyperalgesia, as shown in Fig. 9. At other times 
 we may find hyperalgesia of the skin only. ]\lost 
 frequenth' there is both cutaneous and muscular 
 hyperalgesia along with a contracted muscle, as 
 
Visceral Be flexes. 
 
 81 
 
 shown in Fig. 11, where the stimuH from x affect 
 b' and c', producmg in the one case pain referred 
 to B and in the other contraction of the muscle c. 
 48. Multiple Reflexes from Visceral Stimulation. 
 
 So far, in speaking of reflexes, I have referred to 
 some as occm-ring singly. As a matter of fact, no 
 stimulus produces onty one reflex ; there are always 
 others. Some of these are so slight as not to be 
 recognisable ; others, quite a number of them, can 
 be recognised. 
 
 Fig. 12. 
 Illustrates the mechanism of multiple reflexes produced by visceral 
 stimulation. An adequate stimulus arising in an organ, x, passes to x' 
 in the central nervous system and affects a series of neighbouring cells, 
 thus giving rise to pain (by stimulating b'), muscle contraction (by stimu- 
 lating c'), vomiting (by stimulating the centre for vomiting, vo), cardiac 
 depression (by stimula.ting the vagus, h), pallor and sweating (by stimulating 
 the vasomotor centres, vm). 
 
 If, for instance, we consider the symptoms 
 provoked by the peristalsis of a hollow muscular 
 organ the origin of a number of phenomena will be 
 revealed. The presence of a small calculus in the 
 X^elvis of the kidney ma^^ set up a strong peristalsis of 
 
82 Chapter IX. 
 
 the ureter, giving rise to an attack of renal colic. 
 With the onset of the attack uneasiness or pain 
 is first felt, and the muscles of the abdomen become 
 hard. In one patient the testicle was pulled up 
 by the contraction of the cremaster muscle. The 
 pain passes from the loins downwards into the 
 testicle. It comes on in wave-like periods of 
 intensity. Other symptoms arise — for example, 
 vomiting, great prostration, with feeble action of the 
 l^gart — so that partial loss of consciousness may 
 follow. There is also pallor and profuse sweating. 
 All these phenomena are produced by a stimulus 
 reaching the central nervous system and there 
 reacting on a number of special centres, such as the 
 vomiting centres, the centre for regulating the 
 vasomotor nerves, the centre of the vagus (Fig. 12). 
 When the attack passes off there is left a variety 
 of phenomena, such as an area of cutaneous hyper- 
 algesia with contraction of certain of the muscles 
 of the abdomen. In addition there is usually 
 ushered in a period of great exhaustion or prostration, 
 lasting, it may be, for a number of days. I wish 
 here to clear away one of those beliefs which does 
 so much to darken understanding and hamper 
 investigation. Phenomena, such as exhaustion and 
 vomiting, when they accompany such an attack, are 
 usually attributed to the pain. This is a pure 
 assumption, for the centres which control vomiting 
 and exhaustion are as distinct as the pain centres, 
 and a stimulus which excites pain may, under 
 certain circumstances, also excite those centres. 
 When pain of great severity occurs without vomiting 
 or exhaustion, it simply means that the stimulus 
 
Visceral Reflexes. 83 
 
 which excited the pain did not affect those other 
 centres. On the other hand, those centres may be 
 stimulated, and vomiting and exhaustion may be 
 produced without pain. Thus, it frequently happens 
 that a sudden movement of the bowels resulting 
 in the evacuation of a large loose motion is accom- 
 panied by vomiting and fainting without pain. 
 
 G 2 
 
( 84 ) 
 
 Chapter X. 
 
 DIMINISHED RESISTANCE TO 
 STIMULATION. 
 
 49. Focal 
 
 50. Geyieral. 
 
 51. The Soldier's Heart. 
 
 52. War Neuroses. 
 
 53. The Mechanisin of Sym2otoms. 
 
 54. Practical Imijortance of Recognising the 
 
 Mechanism of Symptoms. 
 
 49. Focal. — Another feature of the nervous- 
 systena which has not received from chnical observers 
 the attention it merits — namely, the lowered resist- 
 ance to stimulation which is produced by disease and 
 other agencies. 
 
 In describing the phenomena of toothache, the 
 well-known facts of tenderness of the neighbouring 
 healthy teeth and of the hyperalgesia of the skin 
 of the cheek were commented on. A similar state 
 of affairs is met with in connection with visceral 
 disease, for we often find in this condition that 
 pressure over certain regions of the abdomen of a 
 degree which in other parts of the body produces 
 only the sensation of touch or pressure, giA^^es rise 
 to pain. In lightly pinching the skin, too, pain is 
 caused over particular areas, whereas no pain is 
 
Diminished Resistance to Stimidation. 85 
 
 felt in other areas. Frequently the skin itself is 
 not hypcralgesic, but the deeper structiures of the 
 abdominal wall, especially the muscles, are painful 
 on pressure. 
 
 In normal circumstances a stimulus has opposed 
 to it a degree of resistance in producing pain. Its 
 entrance into the pain centres is hindered, so that 
 it must be of a certain strength or quality before 
 it can pass. In these hyperalgesic areas which I 
 have described the resistance to stimulation is 
 greatly diminished, so that a stimulus much weaker 
 than that wliicli produces pain in other regions is 
 sufficient to produce pain in these regions ; in techni- 
 cal language, the "threshold of stimulation" is 
 lowered. A similar lowering of the threshold is 
 shown b}- the cutaneous reflexes. Thus when a 
 hyperaesthetic area of skin is stimulated so as to 
 produce a contraction, a slighter stimulus suffices 
 for the act, and the contraction of the muscle 
 produced is greater than in corresponding parts on 
 the opposite side of the abdomen. 
 
 But the evidence of the diminished resistance is 
 not limited to sensory and motor regions in the 
 spinal cord. This may affect the whole nervous 
 regulating mechanism of an organ. The phenom- 
 enon is best demonstrated in the circulatory 
 S3^stem. In certain cases the movements of the 
 heart and the vasomotor mechanism may respond 
 to mild stimulation in an excessive manner — for 
 example, an excessive rate of the heart on mild 
 exertion or an excessive contraction of the blood 
 vessels from some slight stimulus as, for instance, 
 mental effort or exposure to cold. Thus, in a patient 
 
86 Chapter X. 
 
 with aortic regurgitation, I have seen the blood 
 pressure rise when the patient was engaged in a quiet 
 conversation, and I have seen this rise followed by 
 a violent attack of pain. Indeed, in certain sufferers 
 from heart disease the nervous mechanism of the 
 organ may become so sensitive to stimulation that 
 this may provoke attacks of palpitation or of pain. 
 Tliis stimulation may consist of factors which do not 
 directly affect the heart. — for example, mental excite- 
 ment, the excitation of the skin of the left chest by 
 pressure of a stethoscope, or a mere movement of 
 the left arm of the patient. Numerous instances 
 of the lowering of the tlu^eshold of stimulation will 
 occur. People in whom the fingers become cold, 
 pale, and numb, on exposure to a very moderate 
 degree of cold, have an excessive sensibihty of certain 
 vasomotor centres. Some people, again, when 
 worried or fatigued suffer from persistent vomiting. 
 
 50. General. — The purpose of these illustrations 
 is to call attention to a factor which has only been 
 dimly perceived, but which is a very important 
 element in the production of a large class of 
 symptoms. This factor is diminished resistance to 
 stimulation. So far instances of it have been 
 confined to diseases of a simple kind — for example, 
 toothache, gastric ulcer, disturbances of the heart 
 and vasomotor system, and of the vomiting centre. 
 It will now be profitable to inquire whether there 
 are not conditions in which the diminished resistance 
 may be of a much greater extent, for if such con- 
 ditions be found we may find at the same time a 
 clear explanation of the manner in which many 
 symptoms are produced. 
 
Diminished Resistance to Stimulation. 87 
 
 We kno^y that when a patient becomes the 
 subject of a microbic infection there is speedily- 
 induced a loss of the sense of well-being and the 
 appearance of sensations of discomfort or suffering. 
 The daity routine becomes laborious and difficult ; it 
 is accompanied b}^ loss of appetite, and fatigue is 
 easily brought on. Indeed, so readily may ex- 
 haustion be produced that, even with a mild infection, 
 collapse of an extreme kind may occur — as, for 
 instance, in the case of a youth training for a race 
 who fell and lost consciousness in running a short 
 distance. Before starting he felt seedy, but thought 
 he could throw the feeling off by the exercise. He 
 was found to have a slight rise of temperature ; 
 in a few days he was well and resumed his training, 
 which he completed without mishap. If patients 
 with a mild infection be observed it will often be 
 found that their heart's rate is increased, and that 
 their response to effort is accompanied by an undue 
 acceleration of the heart's rate, while breathlessness 
 and fatigue are more readily induced than in health. 
 These facts are well known to ever}^ observing 
 doctor, and their interpretation seems to be that 
 something has occurred which has lowered the 
 resistance to stimulation. As a result the heart is 
 more readih^ stimulated to rapid action, and a 
 disturbance of the vasomotor mechanism takes place 
 which leads to exhaustion or loss of consciousness. 
 
 If an individual, the victim of a mild infection, 
 persists in leading the strenuous life he may have 
 pursued when enjoying vigorous health, other 
 manifestations develop. The heart's exhaustion 
 may proceed apace till breathlessness is readity 
 
88 Chapter X. 
 
 produced on moderate exertion. Pain, too, may be 
 experienced, sometimes of such severity that it is 
 diagnosed as angina pectoris, while the skin of the left 
 side of the chest may become extremely hyperalgesic. 
 
 The following experiences show what I am trying 
 to demonstrate. A woman fell into ill-health of a 
 vague kind, but developed attacks of pain in the left 
 chest, evidenth' of cardiac origin, of such severity 
 that several experienced physicians diagnosed the 
 condition as one of angina pectoris of a very grave 
 type. Little relief was obtained, and the case 
 dragged on for months. When I saw her I felt 
 confident that the attacks of pain, though cardiac 
 in origin, were not due to organic disease of the 
 heart, but that she was suffering from some toxic 
 condition, and a search was made for some source 
 of infection. The only suspicious circumstance was 
 an obscure swelling in the pelvis, whose nature an 
 expert gynecologist could not determine. After a 
 few weeks an abscess burst into the bladder, and 
 after the discharge of pus the attacks of " angina " 
 gradually disappeared, and she made a good recovery. 
 
 A man fell into poor health. He became 
 depressed in spirits ; his brain was readily exhausted 
 after reading a short time ; he was short of breath 
 on exertion, and easily tired. He flushed readily, 
 and his heart beat rapidly on the slightest exertion. 
 Nothing amiss could be detected on physical exam- 
 ination till, after some months, a certain degree of 
 discomfort directed attention to his mouth, and he 
 was found to have an abscess in his antrum. The 
 evacuation of the pus was followed by a speed}^ 
 recoverv. 
 
Diminished Resistance to Stimulation. 89 
 
 It is manifest, from a liiston- of such cases, that 
 the primary cause of trouble ^vas an infection which 
 poisoned certain structures of the bocty, in particular 
 the nervous system and regulating mechanism of 
 the heart and blood vessels, and rendered those parts 
 abnormally sensitive to stimulation, so that bodily 
 or mental effort, which in health could be undertaken 
 without distress, now induced the signs of exhaustion 
 peculiar to each organ. 
 
 What* is true of the circulatory system is true 
 also of ever}' other S3^stem. When we meet with 
 symptoms of the disturbance of one organ a system- 
 atic inquiry will often lead to the detection of. 
 evidence of functional disturbance in other organs. 
 
 This matter can be illustrated by a consideration 
 of experiences that have lately been familiar to most 
 doctors in the so-called " soldier's heart " and the 
 neuroses of v/ar. 
 
 51. The Soldier's Heart. — For a long time before 
 the war I had puzzled over the description of the 
 condition called the " irritable heart of soldiers." 
 JMany 3'ears ago I had seen men in good health who 
 had been invalided out of the army because of this 
 affection, and I could find nothing the matter with 
 their hearts. When the war broke out I seized the 
 opportunity to find out the nature of this condition. 
 At the suggestion of the Medical Research Com- 
 mittee a S3^stematic investigation was undertaken 
 by Dr. R. M. Wilson and myself, and we produced 
 a preliminar}^ report on the subject. The work was 
 ultimately carried on at hospitals set apart for the 
 purpose ; but I continued my own. investigations, 
 and briefly the following are the conclusions to 
 
90 Chapter X. 
 
 which I came : The condition which goes now under 
 a variety of names — as the soldier's heart, the 
 irritable heart of soldiers, disordered action of the 
 heart, effort syndrome, and neuro- muscular asthenia 
 — is not pecuhar to soldiers, but is of frequent 
 occurrence in civil life. The ill-health or incapacity 
 which is present is not limited or only due to the 
 cardiac condition, for other organs are also affected, 
 so that the cardiac manifestations form but a part 
 of the picture of ill-health. The main symptoms of 
 which the soldiers complained were shortness of 
 breath or exhaustion or palpitation easily produced 
 on moderate effort. In some cases pain in the chest 
 was felt, sometimes of great severity, coming on in 
 response to effort or when at rest. An examination 
 revealed in some an increased rate of the heart, 
 and in many an excessive increase in response to 
 effort. Occasionally there was a sUght enlargement 
 of the heart. 
 
 In the limitation of the response to effort (shown 
 by breathlessness easily produced) and in the in- 
 creased rate of the heart we get evidences of increased 
 susceptibility to stimulation on the part of the organ. 
 
 A heart in this condition of undue excitability, 
 compelled to do the same amount of work as it did 
 when the health was good, wiU become sooner or 
 later exhausted, and so we will find a series of 
 sj^mptoms arise which are the outcome of exhaustion. 
 
 While the over- excitability of the heart is 
 brought about mainly by a disturbance affecting 
 its nervous mechanism, in all probability the same 
 injurious influence affects the myocardium itself, 
 so that the efficiency of the heart may be impaired. 
 
Diminished Resistance to Stimulation. 91 
 
 52. War Neuroses. — Tlie foregoing are, in brief, 
 the chief manifestations of the irritable heart of 
 soldiers. But if the patient be more carefully 
 scrutinised other symptoms will be found. His face 
 is often lined and drawn ; he is often nervous in 
 manner, and occasionally he shows fine tremors in his 
 hands and fingers. Inquiry reveals a varying degree 
 of mental disturbance, apathy, disinclination for 
 exertion, mental depression, and irritability of 
 temper. The memory is not retentive, and on 
 mental effort — for example, reading — fatigue is 
 readily induced. In many cases other phenomena 
 are detected, but these are sufficient to show that 
 in nearly all these cases there is a mental side to 
 the ill-health as well as a cardiac. 
 
 If one were to concentrate the attention on the 
 nervous phenomena in a great many of these cases, 
 the conclusion arrived at w^ould be that the patient 
 suffered from a neurosis. Indeed, this is what is 
 constantly happening, for certain doctors would 
 unhesitatingly class some soldier patients as suffering 
 from neurasthenia, or some other form of war 
 neurosis, while others would class the same patients 
 as suffering from the irritable heart of soldiers. 
 
 If the inquiry be carried further definite 
 symptoms of derangement of other organs can be 
 obtained. Thus a rapid respiratory rate, not due 
 to any lung or heart affection, may probably, as 
 Haldane pointed out, be due to an excessive 
 irritability of the respiratory reflex. Digestive 
 disturbances are present in the great majority. Did 
 we possess the knowledge we might almost certainly 
 discover signs pointing to the deranged function 
 
92 Chapter X. 
 
 of every organ of the body. Indeed, some physicians 
 have detected signs of hyperthyroidism in so many 
 of these cases that they attribute most of the 
 circulator}^ disturbances to this condition. 
 
 53. The Mechanism of Symptoms. — The 
 inference drawn from such experiences was that a 
 condition of diminished resistance to stimulation 
 had been induced, and the attempt to lead the life 
 and do the work of healthy vigorous men had proved 
 unavaiHng. Health had given way from exhaustion. 
 The manifestations of this exhaustion were exhibited 
 by the different organs that had been submitted 
 to the strain ; in one case the heart and circulatory 
 system were most affected, in another the nervous 
 system. Thus we get the variety of phenomena 
 which these soldiers exhibit. 
 
 This way of looking at the matter illustrates a 
 method of investigation that has not been so fully 
 appreciated or utilised in medical research as it 
 deserves. It shows the importance of applying 
 the " law of associated phenomena " in all medical 
 examinations. This law is based upon the fact that 
 in ill-health there are a great variety of phenomena. 
 It has been the habit to a large extent to give 
 consideration to the more prominent signs and to 
 label the disease by the names of such dominant 
 signs. We constantly met soldiers invalided and 
 pensioned on account of so-called aortic or mitral 
 disease, because a systohc murmur had been detected, 
 yet in the vast majority of these cases there was 
 absolutely nothing the matter with the aortic or 
 mitral valves. If the principles underlying the 
 classification of symptoms and the law of associated 
 
Diminished Resistance to Stimiildtion. 93 
 
 phenomena had been understood such mistakes 
 would not have arisen. 
 
 Physicians who have been engaged in war work 
 are now pubhshing their experiences, and we 
 find in the medical jom^nals that the old method 
 of docketing the soldiers' complaints according to 
 the organ supposed to be affected is pursued. Thus 
 we have sick men described as cases of irritable 
 heart, of nem-asthenia, and of hysteria ; that is to 
 say, the complaints are attributed to the organ whose 
 symptoms are most prominent to the observer. 
 
 54. Practical Importance of Recognising the 
 Mechanism of Symptoms. — It may seem that 
 tliis aspect of the matter is already recognised, and 
 that the presentation of it in this way is unnecessary^ 
 But it frequently happens that what is supposed 
 to be Avell known and commonplace is in reality 
 so imperfectl}^ known that its true significance has 
 been entireh^ missed. In the cases to Avhich I am 
 referring it wiU be seen that the procedure usually 
 employed in medicine, of describing diseases as 
 limited to one organ or system, is misleading. 
 
 Recognition of this general lowering of resistance 
 to stimulation enables one to perceive that the 
 manifestations of the different organs are but an 
 expression of the irritability of their nervous 
 mechanism, and compels an inquiry into the con- 
 dition which has induced it. In many cases such 
 an inquiry will result in the discovery of some focal 
 disease or in the detection of some infection — for 
 example, malaria or dysentery, or tubercle. 
 
 Another important result of this recognition 
 is that we are no longer so likely to be misled in the 
 
94 Chapter X. 
 
 estimation of the significance of some abnormal 
 sign. A large number of these cases of " soldier's " 
 heart are labelled " valvular disease of the heart " 
 because there is a systolic murmur present, and the 
 limited response to effort, breathlessness on exertion, 
 or increased rate of the heart, is taken to be evidence 
 of an organ impaired b}^ mitral or aortic disease. 
 I know that large numbers of cases have been 
 invalided out of the army and granted pensions 
 because of misapprehension of the significance of 
 murmurs, particularly when these murmurs were 
 associated with the phenomena I have described. 
 The same thing applies to affections of the nervous 
 system. We often find this type of case called 
 " neurasthenia " or some other form of neurosis, and 
 subjected to various methods of treatment based 
 upon an erroneous conception of its nature. 
 
 Furthermore, the necessity of recognising the 
 nature of the phenomena which lowers resistance is 
 seen in the tests which are recommended by the 
 military authorities for determining the fitness of a 
 man. To ascertain the functional efficiency of the 
 heart certain exercises are enjoined. If, in response 
 to these, there is an increase in the rate of the heart 
 or of the breathing, it is assumed that the organ is 
 impaired. The evil symptoms are taken as indica- 
 tions of such impairment. If the principles I have 
 been enunciating be grasped, it will be seen that it 
 is not the heart condition that is being tested by 
 these exercises but the susceptibility of the heart to 
 stimulation. In some cases the increased rate may 
 represent cardiac inefficiency, but in the vast majority 
 of cases it represents nothing of the sort, for the 
 
Diminished Resistance to Stimulation. 95 
 
 cardiac irritability is but one of many phenomena 
 the detection of which would afford a clue to the real 
 natm-e of the trouble. 
 
 I have had plenty of experience showing the 
 widespread harm of this limited studj' of patients' 
 symptoms. I have been frequently consulted by 
 men who have been rejected for the army and 
 pensioned because of a misconception of their 
 S3anptoms. I saw recently a man who w as invalided 
 out of the army and told he had got aortic disease, 
 and that his heart was so damaged that he would 
 never be able to undertake any occupation requiring 
 phj'^sical effort. He was given a full pension. When 
 I saw him he was leading a miserable existence, 
 creeping about a few^ hours a da}^ He was easily 
 tired, and he attributed his exhaustion to his heart 
 complaint. His heart was easily stimulated to 
 rapid action, and there was present a systolic murmur 
 at the base. When I tried to assure him that 
 there was no aortic disease and that his heart w^as 
 perfectly sound, I found it w^as impossible to con- 
 vince him. When in the army these sensations of 
 exhaustion came on and the army doctors had 
 detected the murmur and called it aortic disease 
 and had treated him for a time in bed and then 
 invalided him out. The pensions doctors had 
 repeatedly confirmed this view^ of his condition, and 
 had backed up their opinion by giving the largest 
 pension allowance. Is there little wonder tliat this 
 man canntJt be convinced as to the true nature of 
 his condition ? He is made a miserable wTeck on 
 account of a defect in medical knowledge — namely, 
 ignorance of the nature and significance of sym^^toms. 
 
96 Chapter X. 
 
 In a careful inquiry into the origin of ill-health 
 in over 2,000 soldiers I found that in the case of 
 about 80 per cent, the first onset of their illness 
 began with some complaint of an infectious nature, 
 such as measles, influenza, trench fever, typhoid 
 fever, malaria, dysentery, or " P.U.O." In other 
 cases one could gather that the onset was due to an 
 ill- defined illness suspiciously like an infection. 
 
 In a number of cases there was no history of 
 infection, and the onset of the illness seemed to be 
 due to a variety of circumstances. Home of the men 
 were weakly before they entered the army, and the 
 unaccustomed strain had seemingly been the cause. 
 Others, originally quite healthy, had been exposed 
 to a long and continued bodily and mental strain ; 
 want of rest had evidently been the provoking agent 
 in these instances. 
 
 The history of the origin of these complaints 
 and the manifestation of ill-health accorded with the 
 experience of civil practice. We repeatedly meet 
 with patients who, on recovery from a febrile illness, 
 suffer in the same way for varying periods. 
 
( 97 
 
 Chapter XI. 
 
 ORGANIC REFLEXES. 
 
 55. Vomiting. 
 
 56. Dyspnoea. 
 
 57. Secretory Reflexes. 
 
 58. Cardiac Reflexes. 
 
 59. Vaso-motor and Pilo-motor Reflexes. 
 
 There are a number of reflex acts, apart from 
 the viscero- sensory and viscero-motor reflexes, pro- 
 duced by the stimulation of centres in the spinal 
 cord and medulla from a viscus, as shown in the 
 diagram of multiple reflexes (Fig. 12, page 81). 
 These acts may be very complicated, bringing into 
 plaj^ a large number of subsidiary centres as in the 
 reflex act of vomiting, or they ma}^ result in the 
 stimulation of some gland as the salivarj^ glands or 
 the kidney. Many of these reflex acts are obscure, 
 as the vaso-motor, and there are probably others 
 we have not yet attained the means of detecting. 
 I refer here to a few of these reflexes, to draw atten- 
 tion to a field of observation and not to give a full 
 explanation — which, indeed, I am not capable of 
 doing. 
 
98 - Chapter X I. 
 
 56. Vomiting. — Vomiting is due to the stimula- 
 tion of a centre in the medulla, and this ma}^ be 
 played upon from a great many sources, as from 
 irritation of the stomach, from disturbances in the 
 brain, impressions made on the senses of smell and 
 sight. It is frequently set up reflexly from stimula- 
 tion of the viscera of the abdominal cavit}^ as in 
 affections of the liver or bile ducts, kidney, ureter, 
 uterus, ovaries, testicles. Its occurrence with con- 
 traction of non-striped muscle is a curious feature. 
 In labour an attack of vomiting may be induced at 
 the same time as a uterine contraction. Colic due to 
 renal calculus and gall-stone — the pain arising from 
 contraction of the ureter or gall duct — is often 
 accompanied with vomiting. This association of 
 vomiting with the contraction of hollo^^' muscles, so 
 common in abdominal organs, never occurs in affec- 
 tions of the heart or lungs, nor in affections limited 
 to the bladder or rectum. I do not remember ever 
 seeing vomiting arise as a reflex in heart affections, 
 nor for that matter from a lung affection. One may 
 get vomiting from the stress of coughing, as in 
 phthisis or whooping cough, but it is doubtful if it 
 arises as a reflex from stimulation of the lungs or 
 pleura. In acute febrile conditions vomiting may 
 arise, as in kidney disease, from some general 
 poisoning effect. 
 
 56. Dyspnoea. — The centre for respiration is 
 also in the medulla, quite close to the vomiting 
 centre. Dyspnoea may arise directly from the pre- 
 vention of the entrance of air into the lungs, or 
 because the blood does not take up a sufficient amount 
 of oxygen. It may be excited reflexly also, as seen 
 
Organic Rejhxes. 
 
 90 
 
 on the application of a peripheral stimulus (immer- 
 sion in cold water causing a deep inspiration). In 
 affections of the lung, as pneumonia, pulmonary 
 apoplexy or infarcts, intense dyspnoea may arise, far 
 greater than the mere occlusion of the air cells 
 would account for, and it is generalty assumed that 
 this breathlessness is due to a reflex stimulation of 
 the res2:)iratory centre. Thus I have seen a patient 
 seized with an attack of pulmonarj^ apoplexy of 
 small extent, and breathlessness of great severity 
 supervene. After lasting a few hours the dyspnoea 
 would suddenly cease, and the patient breathe com- 
 fortably. Some forms of asthma are difficult to 
 explain. Some seem to be due to a peculiar sen- 
 sitiveness to certain proteids, emanations from 
 animals or flowers. Others are due to reflex 
 stimulation from different parts of the body. The 
 mechanism by which attacks of asthma are produced 
 is still obscure. The condition called cardiac asthma 
 is usually induced after a long apnoeic period in 
 one having Cheyne- Stokes breathing. Its character 
 is similar to attacks of asthma arising from other 
 causes, and it yields often to an injection of morphia. 
 Breathlessness in response to effort is of great value 
 in estimating the functional efficiency of the heart. 
 
 The possibility of a reflex spasm of the bronchial 
 muscles should be kept in mind, in view of the fact 
 that all non-striped muscles are liable to be pla^'ed 
 upon, and a prolonged contraction produced. 
 
 57. Secretory Reflexes. — When the stimulus 
 from a viscus reaches a part of the spinal cord where 
 arise nerves supplying glands, increased flow of 
 secretion occurs. This is best seen in the kidney and 
 
100 Chapter XI. 
 
 salivary glands. In a number of cases of angina 
 pectoris the pain may extend to the jaws, and the 
 saliva may dribble from the mouth. A similar reflex 
 affects the kidney. Some individuals, after an attack 
 of severe pain, as angina pectoris or headache, or 
 after some stimulation of an organ, such as paroxys- 
 mal tachycardia or mental excitement, have a desire 
 to micturate and pass a large quantity of pale urine 
 of low specific gravity. These two reflexes are due 
 to stimulation of centres in the medulla. Wherever 
 the nerve centres supplying separate organs are in 
 close approximation, the stimulation of one viscus 
 may affect another. In many cases of sub-acute 
 appendicitis, for instance, there is frequent micturi- 
 tion though the appendix may be situated at some 
 distance from the bladder. 
 
 From the consideration of these organic reflexes 
 it is clear that there must be some special connection 
 from such remote organs as the testicle and ureter 
 (severe vomiting ma;/ occur in orchitis and in renal 
 coHc) and the medullary centres, probably by some 
 special path in the spinal cord. In certain cases the 
 stimulus may reach the medulla by the afferent fibres 
 of the vagus. 
 
 58. Cardiac Reflexes. — Of all viscera the heart 
 is the most sensitive to stimulation, and the result of 
 stimulation is most readity recognised. This readi- 
 ness to respond to stimulation is necessary to the 
 demands of the economy, for it is on this account 
 that effort can be undertaken with ease and comfort, 
 the heart rate increasing with the demand made hj 
 effort. The heart rate is readily susceptible to so 
 many influences that it is often impossible to deter- 
 
Organic Beflexes. 101 
 
 mine the mechanism by which its changes in action 
 are brought about. Mental impressions have so 
 powerful an effect that reactions pla^ ing first upon 
 the mind may secondarily affect the heart, and it is 
 difficult in many cases to tell whether the heart's 
 stimulation is direct or secondary to the mental 
 stimulation. Temperature has also a very marked 
 influence on the heart apart from the toxins which 
 cause the rise of temperature. Toxins may at the 
 same time have an influence on the heart, so that it 
 is impossible in manj' cases to tell how much of the 
 heart's reaction is due to the rise in temperature, 
 and how much to the infection. Experimentally it is 
 known that by such means as pinching the stomach 
 Avail, reflex stimulation of the heart takes place 
 through vagus excitation, and even the act of 
 swallowing in man can sometimes be shown to affect 
 the heart. Hence it is often assumed that many ab- 
 normalities in rate and rhythm of the heart are of 
 visceral origin, and this may be so, as one sometimes 
 finds certain irregularities increased by stomach 
 disorders. Xevertheless one has to be very careful 
 before accepting such conclusions, as a ver}^ great 
 many abnormalities in the heart's action are attri- 
 buted to reflex stimulation when the real cause is in 
 the heart itself. There is a curious complex which 
 gives rise to sensations of distress when the heart 
 muscle is exhausted. When effort is carried on 
 till distress is produced, the suffering is, as a rule, 
 due to one of two conditions, breathlessness or a 
 sensation of pressure and suffocation over the upper 
 part of the chest, accompanied b}' pain in man}' 
 elderh" people or others suffering from certain forms 
 
102 Chapter X I. 
 
 of heart disease, giving rise to Avliat is called angina 
 pectoris. It is this mechanism which restricts the 
 young and healthy in effort as well as the elderly. 
 The difference is that from childhood to vigorous man- 
 hood the field of response is continually expanding 
 and after middle age it is continually diminishing. 
 
 59. Vaso-motor and Pilo-motor Reflexes. — 
 The peripheral circulation is also susceptible to 
 reflex stimulation through the influence of the vaso- 
 motor nerves. Except in flushing and the redness 
 of the face in acute pulmonary affections and 
 fevers, vaso-dilator reflexes are not often recognised. 
 Vaso-constrictor effects are more common though 
 they have not been sufficiently investigated. Many 
 people suffering from toxemia from intestinal stasis 
 or after a febrile iflness (such as malaria), develop 
 a tendency to spasm of the vessels of the fingers, 
 resembling Raynaud's disease. 
 
 Vaso-constriction is often accompanied by the 
 pilo-motor reflex, and a confusion may arise in 
 distinguishing the sensations which that produces. 
 Thus the sensation accompanying the appearance 
 of " goose-skin " is usually put down as a goose- 
 skin sensation. Goose-skin is due to the con- 
 traction of the muscles attached to the hair roots, 
 and, doubtless, their contraction does give rise to 
 a sensation as when one feels the hair rise on 
 the scalp. But the curious chilly sensation is 
 due to a vaso-constrictor effect, for it can be felt in 
 regions where there are no pilar muscles, as on the 
 ulnar border of the hand. The explanation I suggest 
 is that the stimulation which causes the pilar 
 contraction causes also a vaso-constriction, for the 
 
Organic Re flexes. 103 
 
 pilar and vaso-constrictor nerves botli belong to the 
 autonomic system, and are associated in their origin 
 and distribution. This association is well brought 
 out in the following experiment. If in a suitable 
 case the skin under the nipple be given a smart rub 
 with a piece of flannel, the goose-skin will be seen 
 to arise over the part rubbed, then to spread up the 
 chest to near the clavicle, and on to the inner side of 
 the upper arm and forearm. At the same time the 
 individual may feel the curious chilly sensation 
 passing from his chest into his arm and to the ulnar 
 border of the hand. The reason for this distribution 
 is that the stimulus produced b}' the rubbing has 
 reached in the spinal cord the centres of origin of 
 the pilo-motor and vaso-constrictor nerves, and 
 passed up this region for some little distance. That 
 this is so can be inferred from the fact that the 
 pupil will be seen to dilate at the same time. The 
 dilator pupillae nerve, according to Langle}^ leaves 
 the cord at the place* where this stimulation has 
 taken place — that is to say, by the upper thoracic 
 nerves. In one instance, a patient described alwa^^s 
 a chilly sensation in his cheek when I tried this ex- 
 periment on him, and Sherrington sa3^s that in 
 stimulating the sympathetic fibres issuing with the 
 third thoracic nerve in the monke}', he produced 
 elevation of the hair of the cheek. 
 
 The pilo-motor reflex is of two kinds, one local 
 appearing after the skin is rubbed and limited to the 
 part rubbed, the other reflex spreading wideh\ 
 Tlie latter cannot always be produced. 
 
( 104 
 
 Chapter XIL 
 
 PRELIMIXARY EXAMINATION OF THE 
 PATIENT. 
 
 60. The Patient's Ap'pearance. 
 
 61. The Patient's Sensations. 
 
 62. Facial Aspect. 
 
 63. The General Condition. 
 
 64. A Review of all the Orgaiis. 
 
 60. The Patient's Appearance. — Before enter- 
 ing upon the physical examination of the patient, the 
 physician ought to obtain a clear and comprehensive 
 appreciation of the patient's own sensations. I 
 therefore wish to insist upon the importance of the 
 prehminar}^ examination, which may be of more 
 value in arriving at a correct estimation of the 
 patient's condition than the most elaborate methods 
 of phj^sical examination. Tlie attempt to appreciate 
 the patient's condition should begin when first he 
 presents himself. On his appearance in the con- 
 sulting room, his bearing, his gait, the condition of 
 his respiration, the colour of his face, any nervous 
 peculiarity in his manner of speech and behaviour, 
 and so forth, should be noted. If he is in bed, note 
 the position he assumes, and any change in his colour 
 or respiration in response to such exertions as talk- 
 ing or turning over. B}" habit one unconsciously 
 
Preli))iuiar// Examination of the Patient. 105 
 
 notices these things, and as the examination pro- 
 ceeds, first one trivial matter, then another, ma}^ 
 arise, wliicli lielps materially in guiding the exam- 
 ination, and in forming the final opinion. 
 
 61. The Patient's Sensations. — After ascertain- 
 ing the patient's name, age, and occupation, ask 
 him to describe briefly his chief symptoms. After 
 this inquire into the historj^ of any previous illnesses 
 or circumstances that may have a bearing on his 
 present condition, as the nature of his work, condi- 
 tion of worry, bygone adventures, and hereditary 
 pre-disposition. The data thus elicited will serve as 
 a guide to a further inquiry' into the s\'mptoms 
 of which the patient complains. This should be 
 undertaken with the greatest minuteness, and the 
 answers should be precise and definite. When the 
 patient refers to his sensations, get him to indicate 
 the locatioii by placing his hand over the region, and 
 on no account be content with his assertion that his 
 sensation has been felt in some viscus, as the 
 stomach, heart, bladder. When any disagreeable 
 sensation as pain is complained of, get a clear know- 
 ledge of the very earliest circumstances under which 
 it was produced, the situation in which it was first 
 felt, and the areas into which it spread. In 
 the sxme m ay, if it is breathlessness, the first sign of 
 its appearance and the circumstances that induced 
 it. In putting the questions the doctor should have 
 a definite purpose in view, based on the statements 
 made, but the questions must not be put in 
 such a manner that the patient will di^dne the drift. 
 It may be necessarj^ however, to ask leading ques- 
 tions, when it is suspected that other symptoms may 
 
106 Chapter XI I. 
 
 have been present which the patient has overlooked. 
 For instance, I have found patients dwell upon 
 symptoms referable to the epigastric region and 
 assumed to be gastric in origin ; further inquiry as 
 to whether there had been any pain in the shoulder 
 has frequently brought forth the answer that severe 
 pain had been felt on the top of the right shoulder, 
 but it was thought to be rheumatic or neuralgic. The 
 recognition of this pain then leads to the suggestion 
 that all the symptoms may be due to gall-stones. In 
 the same way, in obscure cases of pain in the lower 
 part of the abdomen, the question whether the 
 testicle was ever sore and tender has sometimes 
 brought out the answer that the breeches seemed at 
 times too tight, and were supposed to be the cause of 
 the testicular pain. The presence of this testicular 
 pain in such cases is often suggestive of renal 
 calculus. 
 
 It will be frequently found that the symptom, 
 such as pain even of the most severe type, is described 
 so vaguely that no definite idea can be obtained in 
 regard to its manner of onset, site, or radiation. In 
 such cases, if the patient be asked to note these par- 
 ticulars next time the suffering arises, he will often 
 be able to give a very clear and instructive account 
 of his symptoms. 
 
 I have said that a patient's answer that pain, or 
 any other sensation, was felt in an organ should 
 never be taken. I may add a warning to the doctor 
 not to make a note of the sensation by attributing 
 it to any viscus ; thus, a pain should not be noted as 
 felt in the heart, stomach, liver, or lungs, but only 
 in the region indicated by the patient's hand, for 
 
Preliminary Examination of the Patient. 107 
 
 it will probably be found, on later examination, that 
 the disease was not in the supposed viscus. In other 
 words, lie should make no notes that might prejudge 
 the nature of any symptom until he has all the evi- 
 dence before him. The results of this inquiry will be 
 a guide in the physical examination of the patient, 
 when corroborative evidence may be found in areas 
 of hyperalgesia of the skin and muscles, in con- 
 tracted muscles, or in functional or structural 
 symptoms in certain of the viscera. 
 
 62. Facial Aspect. — The first glance may at 
 once dispel the consideration of a large group of 
 complaints, as when a face is healthy-looking and 
 well-nourished there is no need to fear the presence 
 of any malignant or exhausting complaint. When 
 there is an absence of this healthy tinge the recogni- 
 tion of faint and subtle changes is useful. A 
 slight duskiness of the cheeks or lips indicates 
 imperfect aeration of the blood, and leads first to the 
 consideration of the pulmonary or circulatory con- 
 dition. A faint tinge of yellow in the duskiness raises 
 the suggestion of liver engorgement. This faint yellow 
 tinge is present in many conditions, as in pernicious 
 anaemia, malarial cachexia, and the cachexia of malig- 
 nant disease. A mere suspicion of jaundice of the 
 skin and conjunctiva, as in certain cases of gall-stone 
 disease, may give to the face the suspicious look of a 
 malignant cachexia, and so also will certain forms of 
 heart failure, particularly that form which is often 
 accompanied with wasting. In the latter case the 
 evident heart trouble gives a key to the nature of the 
 enlarged liver, which is usually present. A dirty 
 gre3dsh aspect is sometimes seen in aortic disease. 
 
108 Chapter XI I. 
 
 Pallor is a common feature, and while it may 
 inclicate an anaemia (as chlorosis), yet it is natural 
 to many families, and one not infrequently sees such 
 people undergoing treatment for " anaemia." In 
 elderl}^ people the pallor may indeed be associated 
 with various complaints, and it is often difficult to 
 tell what importance should be attached to the symp- 
 tom. I think on the whole the presence of a sallow 
 tinge is the most constant sign of malignancy — 
 bearing in mind what I have just said of the presence 
 of a slight jaundice in heart affections and gall-stone. 
 When people past the middle age suddenly develop 
 a pallor, the sign is one of grave significance, and 
 may be the first clue to the beginning of some 
 malignant affection (pernicious anaemia). Other 
 conditions should be recognised, as the flushed 
 turgid countenance of Graves' disease. Staring eyes, 
 while manifestly indicating the nature of the com- 
 plaint, m.Sij not be very distinctive, but a slight 
 prominence, which may momentarily increase w^hile 
 the patient is being questioned, may be detected. 
 
 It is not possible here to detail the many other 
 instructive signs which the facial aspect presents, 
 but I quote the foregoing as being the most 
 common, and w^ould insist on the routine study 
 of the face all the time the patient is being 
 questioned. As a disease progresses the facial 
 aspect should be watched. In some, particularly in 
 children, a sunken expression may appear in the 
 course of an attack of diarrhoea or pneumonia, due 
 to the shrinking of the contents of the orbit and of 
 the cheeks — often heralding a fatal issue. In the 
 course of tj^phoid fever the dull look of indifference 
 
Preliminary Examinaiion of the Patient, 109 
 
 may graduallj^ be seen to creep over the face. A 
 gradual change in colour may be imperceptible to 
 the doctor who sees the patient day by day, but 
 is marked at once by one who sees the patient for 
 the first time, and this change — a shght pallor, or a 
 slight yellow tinge — may be the earliest sign of a 
 malignant disease (pernicious anaemia, cancer). 
 
 63. The General Condition. — It is undoubtedly 
 a misfortune that the stud}^ of what is called " tem- 
 peraments " has fallen into disuse. My own experi- 
 ence tells that the neglect of this basis of observation 
 is continuall}" leading physicians and surgeons astray. 
 This is particularly the case with those who devote 
 themselves to some speciality. The possession of 
 certain temperaments, particularly the neurotic, 
 leads to exaggeration of the reflex S3anptoms, and a 
 trifling complaint is thus often mistaken for some- 
 thing more serious. We find such patients passing 
 from one specialist to another, each one attributing 
 the complaint to the fault of some organ which came 
 under his special purview. 
 
 Although it may not be possible to differentiate 
 exacth^ the six temperaments of Laycock (nervous, 
 sanguine, phlegmatic, bilious, lymphatic, and melan- 
 cholic), yet the consideration of each individual's 
 temperament should help us to estimate at its due 
 value the patient's symptoms and the account of his 
 or her sufferings. While we may not be able to 
 classify temperaments with accuracy, yet in every 
 case the mental attitude of the patient to his com- 
 plaints should be borne in mind. Although, in a 
 general way, each individual is so constituted that 
 his temperament is a matter of inheritance, 3^et it 
 
110 Chapter XI I. 
 
 can be modified by circumstances. This is particu- 
 larly seen in people who become " neurotic " in 
 consequence of mental worry or long continuous 
 bodily suffering. 
 
 I am not at all sure, however, that most of the 
 states called temperament may not be acquired and 
 the result of some obscure illness. At all events I 
 have repeatedly seen the " nervous " temperament 
 develop in people who have undergone long and 
 painful illnesses. Toxins can produce many forma 
 of mental disturbance from simple depression to 
 insanity (as in bacillus coli infections and alcohol). 
 The phlegmatic, bilious and lymphatic tempera- 
 ments ma}^ have a similar origin, or they may be 
 the outcome of some defective internal secretion. 
 
 64. A Review of all the Organs. — In the examina- 
 tion of patients the need for a thorough inquiry 
 may demand that all organs should be inquired 
 into. It is, however, not feasible or even necessary 
 in the great majority of cases to make a systematic 
 examination into the condition of each organ. 
 
 In an obscure case, and in cases where there is 
 some complication, and when there is time and 
 opportunity, no examination can be too careful or 
 too thorough. But the great majority of cases with 
 which the general practitioner has to deal do not 
 present such complicated features, and the pre- 
 liminary inquiry into the patient's symptoms gives 
 a clue to the organ chiefly at fault, so that it is 
 unnecessary that all the other organs should be 
 submitted to a detailed physical examination. It 
 is difficult to be certain when such thorough exami- 
 nation may be considered unnecessary, since, through 
 
Prel'nninarn l^xamination of the Patient. Ill 
 
 its neglect, many aihuents may be overlooked. To 
 guard against this, man}' general practitioners have 
 devised for themselves methods which serve to guide 
 them in the detection of affections of organs other 
 than that of which complaint is made. 
 
 In the logical and thorough cross-examination 
 to Avliich the patient is first submitted, a fair idea 
 can generally be obtained of the organ or region in 
 which there is trouble. Before examining more 
 specially that part, inquiry should be made into the 
 functions of other organs. These may be at fault, 
 and may in reahty be the real seat of the trouble, 
 and the patient, in describing the more prominent 
 features of his complaint, ma}^ have ignored some, 
 to him, trivial sign, which the systematic interroga- 
 tions ma}^ bring out. This inc^uiry need not be time- 
 robbing if the phj^sician makes his questions clear 
 and distinct, and insists tlmt the patient's repHes 
 should be precise and to the point. In his inquiries 
 the physician should have some system in his own 
 mind, so that each question bears upon the symp- 
 toms of a single organ and has a definite significance. 
 Thus, after having exhausted the information of the 
 particular complaint, and having observed in the 
 course of his inquir}^ the general aspect of the 
 patient, as already described, he should then care- 
 fully inquire into the condition of other organs, 
 beginning as a rule with those related by position or 
 function to the complaint of the patient. Step by 
 step each organ is considered, and any that may 
 show evidence of derangement are reserved for fuller 
 investigation. To do this the essential symptoms of 
 derangement of any organ must be kept in view. 
 
112 Chapter XII. 
 
 Thus, an inquiry is made into the condition of the 
 heart and circulation by asking if the breathing in 
 response to effort is good, or if he has palpitation or 
 breathlessness on running up stairs, beyond that 
 which one would expect from his age and habits ; 
 into the lung condition by the presence of a cough, or 
 of trouble in the breathing ; into the digestive 
 system by the presence of discomfort at any time 
 before or after meals, and by the movement of the 
 bowel ; into the urinary system by the frequency of 
 micturition, and particularly as to whether the patient 
 has to get up in the night to pass urine. By following 
 such lines as these, being often guided by some 
 incident in the patient's history or appearance, it will 
 usually be found that no essential sign is overlooked. 
 In all cases the patient's rephes must be as direct and 
 to the point as the question asked. The tendency to 
 prolixity, which many patients shoA\% must be firmly 
 repressed ; a clear reply should be obtained to each 
 question, and no question allowed to pass until the 
 answer is obtained. The patient may be so full of 
 his own view as to his condition that there may be 
 some difficulty in restricting him to the subject the 
 physician has in his mind, but if the physician will 
 but be persistent in his method — having a clear 
 conception in his own mind as to what he requires — 
 the patient can usualty be induced to give clear and 
 coherent replies. According to tiie tenor of the 
 replies the subsequent physical examination will be 
 guided. In drawing conclusions from the results of 
 the examination it is necessary to consider the 
 bearing of any abnormality, or supposed abnor- 
 mality, on the sufferings of the patient. It often 
 
Preliminary Excwiination of the Patient. 113 
 
 liappens that the complaint from which the patient 
 suffers is obscure, and the cause difficult or impos- 
 sible to determine. Should some other abnormalit}^ 
 be present, which is easily recognisable, then there 
 is a great tendenc}^ to attribute the sj'mptoms to this 
 demonstrable abnormality. 
 
 A patient of mine, suffering from some obscure 
 abdominal complaint, consulted a gynecologist, who, 
 finding an ovary which he considered too large, put 
 all the trouble and suffering down to this, and 
 removed it. Obtaining no rehef, the patient sought 
 the opinion of a surgeon, who, finding a slight dila- 
 tation of the stomach, put all the symptoms down 
 to that, and performed a gastro- enter otom}^ also 
 without rehef to the patient. In youth and in old 
 age certain forms of irregularity of the heart are 
 present in so many people that they may almost be 
 looked upon as normal, and have no important bear- 
 ing upon the patient's condition, yet when these 
 patients are found suffering from any obscure 
 condition, as weakness, fainting, or even epilepsy, 
 the diagnosis is often based upon this irregularity, 
 though its nature is not understood. To many 
 minds it is satisfying to detect an abnormal sign, 
 even though it has no connection with the complaint 
 from which the patient suffers. This tendency to be 
 misled by the detection of an abnormal sign is seen 
 very frequently in patients who ma}^ have a cardiac 
 murmur. All sorts of symptoms can be referred 
 back to this, and treatment for an innocent murmur 
 is often undertaken with unnecessary energy to the 
 neglect of the essential cause of the patient's 
 suffering. 
 
( 114 ) 
 
 CHAPTER XIIT. 
 AFFECTIONS OF THE DIGESTIVE ORGANS. 
 
 65. 
 
 The Nerve Supply of the Digestive Tract. 
 
 66. 
 
 Distribution of Sensory Symptoms in 
 
 
 affections of the Digestive Tract. 
 
 67. 
 
 Appetite. 
 
 68. 
 
 Hunger. 
 
 69. 
 
 Nausea. 
 
 70. 
 
 Mouth and Fauces. 
 
 71. 
 
 Tongue. 
 
 72. 
 
 Swallowing. 
 
 73. 
 
 (Esophagus. 
 
 65. The Nerve Supply of the Digestive Tract. — 
 
 The nerve supply of the digestive tract is derived 
 partly from the autonomic and partly from the 
 cerebro-sx^inal system. If one glances at Langley's 
 diagram (page 59) it will be seen that the autonomic 
 supply is derived from three regions: (1) from the 
 bulbar autonomic division by the vagus, distributed 
 to the walls of the gut from mouth to descending 
 colon ; (2) from the sympathetic division by the 
 splanchnics, which supply the stomach, small intes- 
 tine, and greater part of the great intestine ; and 
 (3) fromx the sacral autonomic division, which sup- 
 plies the descending colon and rectum. 
 
Affections of the Digestive Organs. 115 
 
 The cerebro-spinal nerve supply is limited to 
 tlie oral and anal orifices. The sensations at the 
 oral end are divided into those of common and 
 special sensations. The sensor}^ nerves are derived 
 from the fifth cranial and giosso-pharyngeal, and 
 supply the mouth, fauces, and a small portion of 
 the upper end of the oesophagus ; the exact extent 
 has not been accuratel}-^ defined. The mouth differs 
 from the skin in sensibilitj', touch being less acute 
 and less perfectly localised, though temperature 
 and pain senses are well developed. The nerves of 
 special sensibility (taste) in the tongue are derived 
 from the giosso-pharyngeal, fifth, and chorda tj^m- 
 pani nerves. The olfactory nerve, too, must be con- 
 sidered as an accessory nerve of digestion, for it has 
 remarkable effects in stimulating reflexly the salivary 
 and gastric glands, and also in the appreciation of 
 flavour. It has also, at times, a powerful effect in 
 inducing attacks of vomiting. 
 
 The distribution of the cerebro-spinal system 
 of nerves to the anal end of the gut is of very 
 small extent, being limited to little more than the 
 inner side of the external sphincter. So far as I 
 have been able to make out, the mucous membrane 
 covering the internal sphincter is devoid of direct 
 sensation. 
 
 66. Distribution of Sensory Symptoms in 
 affections of the Digestive Tract. — The nature of 
 the nerve supply explains tlie character of the 
 sensory symptoms evoked by affections of the diges- 
 tive tract. Limiting the stud}^ at present to the 
 subject of pain, it will be found that from the top 
 of the oesophagus to the anus there is, in the great 
 
 I 2 
 
116 
 
 Chapter XIII. 
 
 Fig. 13. 
 
 The shaded parts show the areas in which pain is felt in affections 
 of the digestive tube. Peristalsis passing through the whole digestive 
 tube may give rise to pain felt descending in the shaded area. 
 
 A. Area in which pain is felt in affections of the oesophagus. 
 
 B. Area in which pain is felt in affections of the stomach. 
 
 C. Area in which pain is felt in affections of the small intestine. 
 
 D. Area in which pain is felt in affections of the large intestine. 
 
Affections of the Digestive Organs. 117 
 
 majority of instances, a limitation of the distribution 
 of the pain to an area extending down the centre of 
 the body from about the middle of the sternum to 
 the symphysis pubis (shaded area in Fig. 13). 
 
 If pain be produced by stimulating the 
 oesophagus, as, for instance, by a hot drink, the pain 
 is always referred to the region over the lower part 
 of the sternum. Usually this pain is supposed to 
 be perceived " in the oesophagus," but if this sensa- 
 tion were in the oesophagus there is no reason why it 
 should not be felt better in the back, for the oeso- 
 phagus is nearer the posterior cutaneous surface 
 than the anterior. Pain arising from the stomach 
 is limited, in the vast majority of cases, to the 
 epigastrium. The best idea of intestinal pain is 
 found in watching a case of peristalsis of the bowel. 
 A painful peristalsis may start with pain referred 
 to the lower part of the epigastric region, then 
 it slowly descends with a grinding intermitting 
 severity until it reaches above the pubes, when the 
 call to defecate becomes urgent, and relief is at once 
 found mtli the expulsion of a loose motion. In such 
 an instance the movement has affected the whole 
 intestinal tract, and the peristaltic waves have 
 passed into aU quarters of the abdominal cavity, yet 
 the pain has descended in an even and unvarying 
 direction down the centre of the abdominal wall. 
 
 It is well to remember this feature of pain due 
 to peristaltic contraction of the gut, for it will be 
 found of frequent diagnostic importance in solving 
 the source of severe colic-like pains. As already 
 remarked, contraction of non-striped muscles is the 
 most frequent cause of violent visceral pain, and, as 
 
118 Chapter XIII. 
 
 a rule, when the pain is violent, it can be very 
 accurately localised. This limitation of the pain to 
 the middle line of the body is characteristic also of 
 the pain of other hollow viscera, as the gall-ducts, 
 uterus, and bladder, while the pain of renal colic 
 (contraction of the ureter and pelvis of the kidney) 
 is distinctly unilateral. 
 
 67. Appetite. — All actions that are performed 
 periodical!}^ or intermittently, in which volition par- 
 ticipates, are accompanied by sensations which make 
 known the time when the act has to be performed. 
 These sensations are in themselves not unpleasant 
 at first, but are accompanied by a desire to perform 
 voluntarity an act which will gratify that desire. 
 Thus, if the breath be held the desire to breathe is 
 not painful, but there is a longing for the sensation 
 of full inspiration. So, in regard to the call for 
 micturition and defecation, the sensation is one call- 
 ing for the gratification of a sense of relief. To 
 this categor}^ belongs the desire for nourishment, 
 liquid or solid — the appetite. 
 
 Appetite itself is a sensation so vague that no 
 definite description of its mechanism can be given, 
 though it is probably dependent on the digestive 
 glands in the mouth and the stomach. The con- 
 sciousness of appetite is accompanied hy increased 
 secretion of these glands — so much so, that even the 
 contemplation of a satisfying meal may cause the 
 " mouth to water." The aj^petite or desire for food 
 may be increased by the sight or odour of tempting 
 viands, or even by the mental contemplation of them, 
 and an abundant flow of the gastric juices may 
 result from such stimulation. 
 
Affections of the Digestire Organs, 119 
 
 The appearance of a normal appetite follows 
 the efficient absorption of food and its expenditure 
 in the production of energy. Thus it is seen at its 
 best in those who work in the open air. The 
 gratification of an appetite being amongst the most 
 elemental of pleasures, the presence of appetite is 
 a rough indication of health. Man's environment 
 so often prevents its display that means are taken 
 to excite an appetite by providing food in a manner 
 that will supph^ the craving. 
 
 These artificial aids, used to create appetite, 
 diminish the value of this sensation as a diagnostic 
 aid. The loss of appetite, as seen in animals 
 (horses, cattle), is the most important sign of im- 
 paired health, and its return is an indication of 
 restoration to health. In man also it has signifi- 
 cance, but, as man resorts to all sorts of artificial 
 aids, this significance is often diminished. Still the 
 question of loss and return of appetite affords 
 valuable aid in diagnosis. When an individual 
 loses his appetite it may be taken as an indication 
 that all is not well. The loss of appetite may, with 
 reasonable probability, be referred to a diminished 
 excitability of the secretory glands or their nerves. 
 The secretory reflexes which are associated with 
 appetite may be played upon in a great variety of 
 ways, as by mental excitement, impaired metabolism 
 (as in enforced rest), increased temperature and the 
 agents inducing it, affections of the digestive tube 
 and other organs. The symptom of anorexia, loss 
 of appetite, merely indicates, therefore, that there 
 is something wrong in the economy. Further ex- 
 amination mav reveal the cause, and the behaviour 
 
120 Chapter XI II. 
 
 of the appetite may often prove a safe guide as to 
 the progress or retrogression of the ailment. 
 
 Certain results follow the loss of appetite ; the 
 tongue becomes furred, the mouth unpleasant from 
 the lack of the mechanical friction of the tongue 
 against the palate and the absence of juices from 
 the inactive glands, abdominal discomfort arises 
 from the accumulation of flatus, and the bowels are 
 inactive from absence of stimulus. 
 
 An increased desire or craving for food (bouli- 
 mia) may arise during convalescence from a long 
 illness, such as typhoid fever. The craving is 
 probably due to the tissues losing the poisoned fluids, 
 returning to their normal state, and requiring 
 suitable nourishment of which they were deprived 
 during the illness. An abnormal appetite may be 
 one of a group of sjmiptoms, referable either to the 
 nervous system, as in hj^steria, or to conditions in 
 which there is no sign of mental defect, as in chloro- 
 sis, diabetes mellitus, intestinal worms. Enormous 
 quantities of food may be taken by those who are 
 thus affected. 
 
 Craving for certain forms of food is a frequent 
 sign, but there is often a craving for things that are 
 not food, and that are not digestible. This per- 
 verted appetite may arise as a matter of habit, for 
 the custom of eating earth (geophagy) is prevalent 
 among natives of widely separated countries. In 
 some cases the earth may contain nutritious proper- 
 ties, but in many cases it is used, not for its nutritive 
 value, but merely for the gratification of a perverted 
 taste, or to satisfy the craving in the absence of 
 proper food. Perversion of appetite is common 
 
Ajjections of the Digestive Organs. 121 
 
 amongst the insane, but it is also present as a 
 bad habit amongst others, as children, chlorotic 
 females, pregnant \\omcn, and others who have no 
 particular ailment. The objects eaten or swallowed 
 are of the greatest variety, as chalk, coal, earth, 
 plaster, ashes, pebbles, etc. 
 
 68. Hunger. — While the anticipation preceding 
 the performance of a periodic act may be pleasant 
 from the prospect of gratification, the undue delay 
 of performance results invariably in the sensation 
 becoming one of distress. Abstinence from food 
 may convert the sensation of appetite into one of 
 hunger, and hunger implies distress, and when 
 pushed to extreme is probably the most clamant of 
 all desires. Hunger becomes more than a mere 
 excess of appetite, xippetite is probably, as already 
 stated, the outcome of the active stimulation of 
 certain digestive glands, while hunger is the craving 
 of the whole body for nourishment, and the digestive 
 tract, Avith its limited sensations, is the vehicle for 
 the sustenance of the w^hole econom}^ This is seen 
 by the fact that hunger may exist when the stomach 
 is full, the appetite gratified, but the food prevented 
 from reaching the tissues in consequence of an intes- 
 tinal fistula. Apart from hunger due to starvation, 
 an increased craving can be induced b}' measures 
 taken to stimulate the appetite, by cooking, and the 
 various means of providing " tempting bits," and 
 this may be carried so far as to become a perverted 
 habit. Perverted tastes may arise, however, from 
 custom, or as a symptom of disease. 
 
 69. Nausea. — TJie unpleasant sensation, nausea, 
 is often associated with loss of appetite and certain 
 
122 Chapter XI 1 1. 
 
 affections of the stomach. Thougli it often comes 
 on at an early stage in the act of vomiting, it may 
 arise without vomiting, just as vomiting may 
 occur without any previous feeling of nausea. It 
 is associated with the digestive function, and its 
 appearance is accompanied by a stimulation of some 
 digestive glands, as shown by profuse flow of saliva. 
 In certain affections of the stomach, as in the gastric 
 catarrh of alcohohcs, it is the most distressful 
 symptom, occurring usually after a long fast, as in 
 the morning before food is taken. It may arise 
 suddenly from some reflex cause, as from a bad 
 odour, an offensive sight, or the appearance of 
 unattractive food. In addition to the disagreeable 
 sensation there is often some spasmodic contraction 
 of certain muscles, as the diaplu-agm with closure of 
 the glottis, as in the prehminary stage of vomiting. 
 Accompanying the nausea there is often a feehng 
 of faintness, the pulse becomes soft, weak, and rapid, 
 and the face blanched, due in all probability to the 
 action of the vagus diminishing the force of the 
 heart beat, and producing a vaso- motor depression. 
 
 70. Mouth and Fauces. — The pain complained 
 of in affections of the mouth and fauces may be local 
 or referred, or both. Local pain in the mouth may 
 be present in inflammatory affections of the mucous 
 membrane. In toothache it may be felt not only in 
 the affected tooth, but in neighbouring teeth, and the 
 jaw may become painful and tender (Fig. 4, page 
 54). The pain may be felt so severely in places 
 apart from the offending tooth that it requires some 
 care to detect which tooth is at fault. The pain 
 may be referred to parts outside the mouth, in the 
 
Affections of the Digestive Organs. 123 
 
 cheek, or in some portion of the head, and the skin 
 may become very hyperalgesic. It is necessary in 
 an}^ case of " neuralgia " of the face and the head 
 to carefully examine the condition of every tooth. 
 
 The fifth cranial nerve is particularly liable to 
 stimulation from affections other than those arising 
 from the mouth, and the presence of pain in the dis- 
 tribution of the fifth nerve may be due to a variety 
 of causes. The most striking of these conditions is 
 when there is some distinct affection of the nerve 
 itself or the nerve ganglion, in the disease called 
 trigeminal neuralgia or tic douloureux. Before the 
 full character of this complaint is revealed in all its 
 terrible characteristics, there is a period in which it 
 resembles so closely the characters of a toothache 
 that at first it is almost invariably mistaken for this 
 complaint, and one decayed tooth after another is 
 removed. The pain continuing to recur, the dentist 
 next attacks the sound teeth, and not infrequently 
 every tooth is removed, yet pain continues to recur in 
 the edentulous jaw. Relief may be found after the 
 removal of one or more teeth, but, as with the opera- 
 tion for nerve stretching, it is but temporary. It is 
 not possible in the early stages to distinguish between 
 a case of true tic and a toothache. In both the pains 
 may recur at intervals, and, when there is hyperal- 
 gesia of the skin of the cheek in toothache, the resem- 
 blance between the two conditions is very complete. 
 Thus, stroking of the hair may be exquisitely pain- 
 ful, and may bring on a spasm of pain. When one 
 decayed tooth after another is removed with no last- 
 ing benefit, then the true nature of the complaint 
 may be suspected, but as one is loth to come to the 
 
124 Chapter XIII. 
 
 conclusion that the case is one of true tic douloureux, 
 the teeth extraction continues. 
 
 Another instructive form of pain occurs in cer- 
 tain forms of angina pectoris, where the pain is not 
 only present in the chest and arms, but may be felt 
 in the lower jaw and tlu:oat. The pain of angina 
 pectoris may even start here, and be limited almost 
 entirely to this region. The feeling is described as a 
 sense of intense soreness along the lower jaw, akin to 
 what is felt in some forms of toothache. The nerves 
 supplying the fauces, and the voluntary muscles en- 
 gaged in swallowing, may also be hypersensitive, so 
 that the patient has a good deal of pain in swallow- 
 ing. In rare cases, after a severe attack of angina 
 pectoris, the patient may complain of pain in 
 swallowing for weeks after the attack has passed off. 
 Doubtless, in such cases, the violent stimulation has 
 reached the medulla and upper part of the cord by 
 the vagus, and the stimulation has affected the 
 sensory cells in the neighbourhood and left an 
 irritable focus, as witnessed by the hyperalgesia of 
 the muscles and mucous membrane shown in the 
 act of swallowing. 
 
 Inflammatory affections in the fauces often 
 cause great pain in the act of swallowing. When the 
 tonsils are acutety inflamed the increased secretion 
 of mucus continuously excites the act of swallowing 
 and causes great distress. The pain is felt not only 
 in the inflamed parts, but extends into the sides of 
 the neck, and up into the ear. The skin of the neck 
 behind the jaw may become hyperalgesic, and 
 frequently there can be detected enlarged and 
 tender glands behind the jaw. 
 
Affections of the Digestive Organs. 125 
 
 A number of patients ma}^ complain of pain on 
 swallowdng, and when careful investigation is made 
 it will be found to be due to a form of infection very 
 common amongst those who use false teeth where the 
 utmost cleanHness is not observed. The patient fre- 
 quently complains of a sore throat, and if the fauces 
 be inspected a slight redness of the pillars can be 
 detected. It the patient wears a plate on the roof of 
 the mouth, and this be removed, the undertying 
 mucous membrane will be found swollen and red, and 
 from tliis place to the fauces there can be detected an 
 extension of the inflammation in the form of small 
 red dots. Sometimes the surface of the mucous 
 membrane, under the plate, may be covered with 
 patches of tln:ush, and an infective process may 
 extend to the parotid and sub-lingual glands, causing 
 severe inflammation and swelling of these glands. 
 Inspection of the mouth may reveal other abnor- 
 mahties, as ulcers. 
 
 A very interesting instance of referred sensation 
 is seen in passing a bougie into the eustachian tube. 
 When a catheter is passed into the eustachian tube 
 for the purpose of insuflation, the sensation pro- 
 duced by the catheter is referred to the back of the 
 nose. If a bougie be passed along the catheter into 
 the eustachian tube, the sensation is at first referred 
 to some place between the back of the nose and the 
 ear. If the bougie be pushed further in, a part is 
 reached where the sensation is suddenly referred to 
 the neck behind the jau-. This transference of the 
 sensation is doubtless due to the parts being supplied 
 by nerve fibres from different sources — the exact 
 nature of the supply I am unable to determine. 
 
126 Chapter XIII. 
 
 71. Tongue. — In health the tongue should be 
 evenly and steadity protruded, moist, and of a 
 slightly translucent pale red colour. A tremulous 
 tongue should lead to an inquiry into the alcoholic 
 habits, and an unevenly protruded tongue to the 
 question of paratysis. 
 
 The principal cause of a fm-red tongue is 
 absence of friction, usually due to deficiency of 
 saliva and insufficient mastication. Too much stress 
 has been laid upon the supposed association of the 
 fiu-red tongue with certain " catarrhal " conditions 
 of the stomach and bowels. A person with no 
 appetite has a furred tongue because he does not 
 masticate. A person who bolts his food, or who 
 washes his food into his stomach by drinking while 
 eating, or who lives on " slops," has a furred tongue 
 from the same cause. The posterior third of the 
 tongue in some is always furred, and in these it will be 
 found that the palate is high and arched, so tliat the 
 tongue does not come into contact with the roof of 
 the mouth. Mouth breathers also have a tendency to 
 a furred tongue, for the playing backwards and 
 forwards of the air over the tongue dries it, and 
 favours the formation of the fur. This is especially 
 the case in fevers where the hot air passing over the 
 tongue dries it. This tendency is further increased 
 by the absence of mastication — the patient being so 
 often fed on slops. In fever a fur may appear 
 in spite of all precautions. A very striking 
 prognostic sign may be found in carefully watching 
 the tongue in febrile states, for the earliest symp- 
 tom that the fever is about to yield may be the 
 appearance of a small clean spot on the tongue. 
 
Affection,':; of the Digest ire Organs. 127 
 
 72. Swallowing. — The act of swallowing, so far 
 as it is carried out within the region of distribution 
 of cerebro-spinal nerves, is a voluntar}' and conscious 
 act ; but as soon as the bolus passes be3'ond into the 
 region supplied by the autonomic nervous system, it 
 becomes involuntary and unconscious. During the 
 act the respiration is inhibited and the levator palati 
 raises the palate and shuts off the nasal cavities. 
 Bilateral paralysis of this muscle, as after diph- 
 theria, leads to fluids regiu'gitating down the nose 
 during the act of swallowing. 
 
 Pain accompanying the act of sw allowing is due 
 most frequently to some inflammatory infection of 
 the tonsils or fauces. It is generally referred to the 
 neck behind the jaw, or up into the ear. Inspection 
 of the fauces wdll generally reveal the cause. In 
 rare cases, as alread}' cited, there may be a hyperal- 
 gesia of the mucous membrane and of the muscles 
 with a good deal of pain on swallowing. 
 
 There is sometimes shown a ciu-ious relationship 
 between the tonsils and the nerve supply of the 
 external ear. In a number of cases I have found 
 during a tonsilitis an attack of herpes zoster occur, 
 the eruption appearing on the lobe and pinna of the 
 ear. This has occurred so frequently that the asso- 
 ciation is more than casual, and I suspect some 
 intimate central relationship between the nerve 
 supph^ of these parts. Herpes zoster has been shown 
 by Head and Campbell to be due to a destructive 
 inflammation of the ganglia of the sensory root, and 
 it is difficult to explain the definite relationship of 
 the tonsilitis and the herpes on the ear, but the fact 
 is one w^orth}' of consideration in the investigation of 
 
128 Chapter XIII. 
 
 the relationship of the viscera to tlie cerebro- spinal 
 nerves. 
 
 73. (Esophagus. — The nerve supply of the 
 oesophagus being derived entirely from the autonomic 
 system, we get no direct response to stimulation. Pain 
 arises rather easily from stimulation, especially, as 
 everyone has experienced, on the drinking of hot 
 fluids. The pain thus excited is referred distinctly 
 to the front of the chest, and although the heart and 
 lungs are interposed between the site of pain 
 and the oesophagus, and although the oesophagus 
 itself is nearer the back of the chest than the 
 front, everyone unhesitatingly refers the pain as 
 being felt in the oesophagus. Nevertheless, after a 
 good many observations, I have come to the conclu- 
 sion that the laws governing the sensibility of the 
 oesophagus are the same as those governing the 
 sensibility of the other portions of the digestive tube, 
 and that the oesophageal pain is a referred pain and 
 not direct. That its sensibility is different from that 
 of the stomach is, I think, undoubted. The pain in 
 swallowing hot fluids, for instance, is more readily 
 induced by the oesophagus than by the stomach. 
 Also the stomach contents, though giving rise to no 
 sensation when in the stomach, may cause great 
 discomfort when they regurgitate into the oesophagus, 
 and it is for this reason that I assign the disagreeable 
 sensation of heart-burn to the acrid stomach contents 
 escaping into the oesophagus. (See page 140.) 
 
 Some recent observations by Hurst, Cook and 
 Schlesinger lead them to the conclusion that the 
 sensation of heat and cold on swallowing fluids is 
 actually felt at the lower end of the oesophagus, but 
 
Affections of the Digestive Organs. 129 
 
 their observations do not disprove, as they seem to 
 think, the referred character of the sensation. The 
 view I hold that the sensations of heat and cold are 
 really due to a reflex stimulation of the peripheral 
 vaso-motor nerves is not disproved because in some 
 cases the sensation is felt ' ' deeper ' ' than the skin ; and, 
 although I am far from asserting that the hypothesis I 
 put forward is absolutel}^ correct, the matter is not 
 the simple one these observers seem to imagine. 
 
 In some cases, particularly in females of a 
 neurotic habit, the moment a hard piece of food, as 
 a small crust of bread, or even a soft bolus or fluid, 
 touches the upper part of the oesophagus, the 
 oesophagus at once contracts with such violence and 
 persistence that no food can be taken for some time. 
 Sometimes a small portion of food may be grasped 
 in the spasm, when the spasm may last for hours, and 
 the patient be in great suffering on account of the 
 difficulty in breathing and the excessive flow of saliva 
 that cannot be swallowed. The forcible passage of 
 a bougie or probang at once gives relief. In a large 
 number of cases I have found the sj^stematic passage 
 of a bougie the best means of treatment. In some rare 
 cases the seat of the spasm may be lower down. 
 
 In stricture of the oesophagus, if the stricture 
 be high up the food is rejected at once, if low down 
 it may be delayed for some time. Sometimes the 
 oesophagus wall contracts strongl}^ and, as in 
 obstruction of the bowel, pain may arise from the 
 peristalsis, and is alwa3^s referred to the front of 
 the chest, at a level near that of the stricture. Great 
 care should be taken in all cases in the passage of an 
 exploratory bougie, lest injury be done to the walls. 
 
( 130 ) 
 
 Chapter XIV. 
 
 AFFECTIONS OF THE DIGESTIVE ORGANS 
 
 {co^itinued). 
 THE STOMACH. 
 
 74. The Nature of the Symptoms. 
 
 15. The Nerve Sii/pply of the Stomacli. 
 
 76. The Site of Pain in Affections of the Stomach. 
 
 77. The Character of the Pain. 
 
 78. Hyperalgesia. 
 
 79. Superficial Reflexes. 
 
 80. Viscero-motor Reflexes. 
 
 81. Vomiting. 
 
 82. Pyrosis ajicl Heart-hur72. 
 
 83. Air Suction. 
 
 84. Functional Sy7nptoms. 
 
 85. Structural Sy7nptoms. 
 
 86. The Diagnosis of Stomacli Affections. 
 
 87. Pain in Gastric Ulcer. 
 
 74. The Nature of the Symptoms. — The 
 
 stomach being an organ that daily makes itself 
 known by sensations of pleasure or discomfort, forces 
 its symptoms upon all. Considering its highly com- 
 plex organisation it is a wonderfully long-suffering 
 organ, for it not only digests food suitable for the 
 whole organism, but it has to submit to improper 
 
The Stomach, 131 
 
 food, to the gratification of gluttonous desires, and 
 to the caprices of perverted tastes. It cannot be 
 wondered at that it should so often become deranged 
 in structure and function, and that these derange- 
 ments should be of various kinds. 
 
 Its accessibility has permitted mam^ observa- 
 tions to be made on its functions in health and 
 disease, and has afforded scope for the ingenuitj^ of 
 the physiologist, the chemist, and the clinician. 
 Although continual progress is being made in the 
 discovery of its properties, it must be admitted that 
 httle of practical importance has been evolved for 
 the purpose of diagnosis and treatment of the great 
 majority of patients. So far as the physiologist is 
 concerned he cannot acquire the necessary informa- 
 tion, because symptoms of disordered digestion are 
 usually the outcome of years of improper feeding. 
 Food unsuitable for the digestive powers of the 
 •stomach deranges the functions of its secretory 
 glands and the structures of its walls, and it must be 
 confessed, we are ignorant of the nature of these 
 changes. It is for this reason that so little advance 
 has been made in diagnosis and treatment, apart 
 from the progress of surgical methods, and of the 
 ■examination of the stomach contents. Some light 
 may be thrown on obscure diseases by the observation 
 •of the progress through the alimentary canal of a 
 bismuth meal by the X-rays. These methods, how- 
 ever, are applicable to but a YQvy small proportion 
 of sufferers from stomach affections. 
 
 Attempts are continually being made to classify 
 affections of the stomach, and the lack of agreement 
 in these classifications is merely due to the fact that 
 
132 Chapter X I V. 
 
 attempts are made to differentiate what cannot be 
 differentiated. This will be realised when the nature 
 of stomach symptoms is considered. Apart from 
 some characteristic vomits (blood, mucus), and cer- 
 tain changes indicated in the position of the organ 
 (and these refer only to a very small proportion of the 
 cases), all the symptoms are of a reflex nature, pain, 
 cutaneous and muscular hyperalgesia, muscular con- 
 traction, vomiting, air suction. As any adequate 
 stimulus ma}^ suffice to produce these symptoms, and 
 as this adequate stimulus may arise from the most 
 varied causes, trivial or severe, it follows that there 
 is a great similarity in the symptoms in diseases of 
 the most varied kinds. Hence it is impossible in 
 many cases to tell the nature of the affection ; for 
 instance, a passing simple " indigestion " arising 
 from one indiscreet meal may present the symptoms 
 of " gastritis " or ulceration. For this reason it often 
 happens that no satisfactory^ diagnosis can be made 
 in the early stages of a chronic stomach complaint. 
 To ascertain the true nature of many stomach affec- 
 tions it is necessary to wait and observe the results 
 of treatment and the progress of the disease. When 
 patients come in a late stage of the complaint the 
 peculiar features of any given disease may have 
 become so evident that an accurate diagnosis can be 
 made ; but these form but a small proportion of the 
 chronic cases that the practitioner has to treat. 
 
 I have already pointed out that in visceral 
 disease certain areas in the spinal cord may become 
 for a time so irritable that stimuli from the peri- 
 phery give rise to an exaggerated response, as when 
 the skin becomes hyperalgesic and the recti muscles 
 
The Stomach, 133 
 
 contracted. This irritable focus in the cord is of 
 great frequency in stomach affections. Not only does 
 slight stimulation of the skin produce pain, but a 
 stimulus reaching the irritable focus from any 
 source may produce pain, and it is for this reason 
 that the ingestion of food is so frequently accom- 
 panied by pain. When pain occurs after food it 
 must not be assumed that there is an inflammation 
 of the mucous membrane, or that the stomach is itself 
 hypersensitive. The ingestion of food under normal 
 circumstances is accompanied by reflex processes 
 which are not perceived, and pain merely indicates 
 that there is an irritable focus in the cord through 
 which these reflex processes pass. The lesion in- 
 ducing the irritable focus in the cord may not 
 necessarily be a stomach lesion at aU, but may arise 
 from a neighbouring organ whose reflex centre in 
 the spinal cord is in close proximity to that of the 
 stomach. In gall-stone colic the pain may be so 
 violent as to invade the stomach area in the cord, 
 and the pain arising on the ingestion of food in a 
 case of hyperalgesia due to gall-stone disease may 
 persist for days after gall-stone has been passed per 
 rectum. 
 
 In true lesions of the stomach this irritable 
 focus in the cord is readily produced, and its presence 
 is demonstrated by the ease with which pain is in- 
 duced in certain stages of digestion by the hyperal- 
 gesia of the skin and muscles of the epigastrium, and 
 by the hardened epigastric muscles. 
 
 75. The Nerve Supply of the Stomach. — The 
 stomach is supplied by nerves from the dorsal sym- 
 pathetic and from the vagus. The origin of the 
 
134 Chapter XIV. 
 
 sympathetic has not been exactly determined, as the 
 experimental attempts to find the efferent fibres that 
 supply the stomach have not been very successful, so 
 that the place of origin in the spinal cord is best 
 inferred from clinical observations of the area in 
 which the pain and hyperalgesia arise. 
 
 The epigastric region is essentially the place to 
 which the sensor}^ symptoms are referred, and it is 
 the upper part of the left rectus muscle which con- 
 tracts first in response to stimulation from the 
 stomach. The nerve supply to the skin of this region 
 comes from the sixth and seventh thoracic nerves,. 
 and the upper portion of the rectus is supplied by 
 the sixth. Wlien the pain is severe, and tends to 
 radiate, it generally goes to the left of the epigas- 
 trium, but may invade the regions of the front of 
 the chest supplied by the fifth and fourth thoracic 
 nerves. I have seen the symptoms in rare cases 
 resemble attacks of angina pectoris, and it has 
 seemed to me that the cause of the pain in such cases 
 was violent peristalsis of the cardiac end of the 
 stomach. 
 
 The burning pain of heart-burn is generally felt 
 over the lower part of the sternum, in the region of 
 distribution of the fifth thoracic nerve in the chest. 
 It has seemed to me that the immediate cause of this 
 pain is the regurgitation into the oesophagus of the 
 acrid contents of the stomach. The frequency with 
 which in these cases some of the stomach contents 
 regurgitate into the mouth confirms this view. 
 
 The result of vagus stimulation is difficult to 
 determine in stomach cases. Pain may be felt in the 
 neck and jaw in severe gastric colic, very like that 
 
The Stomach. 135 
 
 felt in some cases of angina pectoris, and this, I can 
 only conclude, is a stimulus reaching the fifth cranial 
 and upper cervical nerve centres, by means of the 
 vagus. The brow pain felt in swallowing ice is 
 often spoken of as a vagal reflex, but this pain arises 
 not from the stomach, but from the back of the 
 mouth. This can be demonstrated, in suitable cases, 
 by keeping the ice against the soft palate, when the 
 pain will be evoked. The same peculiar pain can also 
 be evoked b}^ immersing the scalp in cold water. 
 
 In rare cases vagal stimulation, excited by 
 swallowing or by the ingestion of food into the 
 stomach, can produce irregular action of the heart, 
 of the nature of heart-block, or of extra-systoles. 
 
 76. The Site of Pain in Affections of the 
 Stomach. — In 1892 I pubhshed a papel-, in which I 
 gave the results of a careful inquiry into the site of 
 pain in 320 cases of affections of the stomach. In 
 the analysis I found that 95 per cent, referred their 
 pain to the epigastrium. Since that time I have kept 
 records of some thousands of cases, with the same 
 results. Whatever the nature of the lesion the pain 
 is referred with great certainty to the epigastrium 
 (B,Fig. 13, page 116). It may radiate from here up 
 into the chest, or to the left. It is not infrequenth^ 
 accompanied by a pain in the back, and the patient 
 sometimes states that the pain strikes from the front 
 through to the back. It might be inferred from the 
 situation of the pain that the pain itself was actually 
 in the stomach, but one can demonstrate that it is 
 really referred to the peripheral distribution of the 
 cerebro- spinal nerves in the abdominal walls. Thus, 
 in many cases, the skin and muscles in the area in 
 
136 Chapter XIV. 
 
 which the pam is felt are hyperalgesic, and it is but 
 reasonable to infer that the pain felt by the patient 
 is referred to a region where the sensory nerves are 
 so demonstrably affected. The movements of the 
 stomach do not cause a displacement of the pain, 
 and when the stomach itseh is shifted, as by deep 
 inspiration and expiration, there is no accompan}'- 
 ing shifting of the pain. In localised affections 
 of the stomach (as ulcer), however varied the 
 situation may be from cardiac to pyloric end, the 
 pain in the great majority of cases is referred 
 by the patient to some part of the epigastric 
 region. 
 
 ?7. The Character of the Pain. — Although the 
 stomach is a hollow muscular viscus, severe cramp- 
 like pain from violent peristalsis is of rare occur- 
 rence. It will usually be found, in the long run, 
 that the so-called " cranip of the stomach," in which 
 there is pain of great severity referred to the 
 epigastrium, is due to gall-stone colic. I have 
 watched many patients for years who suffered from 
 these severe attacks, and found that they all turned 
 out to be cases of gall-stone disease. In later years 
 I have had little difficult}' in recognising their 
 origin, because of the peculiar distribution of the 
 reflex phenomena in gall-stone disease {see page 156). 
 Violent cramp-like pain may rarely arise in stomach 
 affections, but the pain tends to radiate higher into 
 the chest, and, ma}^ be, into the jaw (vagus 
 stimulation). I\Iore frequently the pain of stomach 
 affections is of a dull prolonged boring character. 
 Its position being so definitely situated in a region 
 remote from the seat of the lesion (as in gastric 
 
The Stomach. 137 
 
 ulcer) shows that it is the outcome of a stimukitioii 
 of an irritable focus in the spinal cord. The pain 
 is therefore more prolonged, and varies little in in- 
 tensity. Such a distinction of the character of the 
 pain can usually be made, and seems to account for 
 the persistent boring pains in gastric ulcer and in 
 other conditions. 
 
 The relation of the pain to the ingestion of food 
 is ver}^ variable. In some the introduction of food 
 into the stomach causes immediate pain, or the pain 
 may come on at variable intervals after food. When 
 it comes on two or three hours after food, relief 
 ma}' sometimes be obtained from taking more food. 
 No very certain conclusions can be drawn from this 
 relation of pain to the ingestion of food. Attempts 
 have been made to diagnose the position of an ulcer 
 from this relationship, but there is no ground for 
 such a deduction. As a matter of experience the 
 pain in gastric ulcer may come on at any period 
 w^hatever its situation. This will be appreciated 
 when it is recognised that the ingestion of food or 
 some stage of its digestion acts as a stimulant 
 to an irritable focus in the spinal cord. The 
 occurrence of the pain one or two hours after the 
 food, wdth symptoms of peristalsis (as recognised 
 by the Avav}" character of the pain) and with acrid 
 regurgitations into the oesophagus, is fairly charac- 
 teristic of one form of d3^spepsia, sometimes spoken 
 of as " hyperchlorhydria," in which the trouble is 
 supposed to be due to an excessive secretion of 
 hydrochloric acid. This form of indigestion often 
 jdelds readily to suitable treatment, but it is 
 not infrequently associated with gastric ulcer and 
 
138 Chapter XIV. 
 
 gall-stone disease, and this association should be 
 kept in mind. 
 
 78. Hyperalgesia. — In addition to the pain other 
 sensory phenomena may arise, the chief of which is 
 hyperalgesia of the skin and deeper structures. The 
 area which becomes hyperalgesic is the epigastric. 
 It may be limited to a small area in the middle, but 
 it is usually diffused with indefinite borders, extend- 
 ing sometimes as an irregular band round the left 
 side to the spine. 
 
 The hyperalgesia may not be present in the 
 skin, but in the muscles, or in the sensitive layer 
 outside the peritoneum. This can be shown by first 
 testing the skin and finding the sensibility normal, 
 then pressing so tliat the muscle is stimulated ; or 
 by pushing the finger between the recti when the 
 peritoneal layer may be found sensitive. Of course, 
 in the latter case, one cannot assert that the pain is 
 elicited from this layer alone, for the pressure may 
 affect other structures. 
 
 79. Superficial Reflexes. — Associated with this 
 hyperalgesia there is invariably an increase of the 
 reflexes, superficial and viscero-motor. The super- 
 ficial is demonstrated by the liveliness of the response 
 when the skin is stimulated, the upper part of the 
 right rectus contracting rapidly and powerfullj^ Not 
 only is the increased reflex activity shown in the 
 response to the stimulation of the skin in the epigas- 
 trium, but it is also shown by the greatly extended 
 cutaneous field from which it can be elicited. Nor- 
 mally the reflex of the upper portion of the rectus 
 muscle is obtained from an area limited to the epi- 
 gastrium, but with an irritable focus in the cord the 
 
The Stomach. 139 
 
 cutaneous area, stimulation of \^hicli will cause a 
 reflex contraction of the upper portion of the rectus, 
 may extend as high as the axilla. The extension of 
 this area foUoAvs some peculiar law, as responses 
 cannot be elicited from the whole of the left chest, 
 but only from an area extending in an irregularly 
 shaped band up the side to the axilla. 
 
 80. Viscero-motor Reflexes. — The viscero- 
 motor reflex is recognised by a permanent rigidity 
 of the upper division of the left rectus muscle. This 
 may be so slight as to be evident as an increase in the 
 tone of the muscle and detected only on comparison 
 with the other parts of the muscular wall of the 
 abdomen, or it may be hard and resistant. In seek- 
 ing for this reflex gentle exploration is needed to 
 avoid the production of the superficial reflex. 
 
 81. Vomiting. — Vomiting as a symptom of 
 stomach affection is somewhat infrequent and of verj' 
 variable significance, and the most persistent vomit- 
 ing may arise reflexly from other organs, as in the 
 persistent vomiting of catarrhal jaundice, preg- 
 nane}^ and brain affections. As a symptom of stomach 
 affections the frequency of the vomiting and the 
 nature of the material vomited constitute the best 
 evidence. An occasional attack of vomiting may 
 arise from a great many causes. In persistent vomit- 
 ing, if reflex vomiting from other organs can be 
 excluded, some inflammatory affection may be recog- 
 nised, and the possibility of gastric ulcer considered. 
 The response to treatment is an important factor in 
 chagnosis. 
 
 Certain characteristics at the time of voniiting 
 give information. The morning sickness of pregnancy 
 
140 • Chapter XIV. 
 
 and of the alcoholic is very characteristic. The 
 vomiting, once a day, or every day or two, of large 
 quantities is suggestive of the dilated stomach 
 secondarj^ to p^doric stenosis. The character of the 
 material vomited is also of importance. If the con- 
 tents of the stomach contain the food that has been 
 taken many hours before, some obstruction to its 
 passage is suggested. The thick viscid mucus 
 vomited is characteristic of a somcAvhat violent 
 gastritis. The presence of blood (coffee-ground 
 vomit) is characteristic of ulceration. Inquiries 
 should always be made for the presence of " tarry " 
 stools. The vomiting of large quantities, sometimes 
 with brown froth, is characteristic of dilatation of 
 the stomach. Vomiting with a faecal odour usually 
 indicates obstruction of the bowel. The absence of 
 hydrochloric acid in the vomit suggests the possi- 
 bility of cancer. 
 
 82. Pyrosis and Heart-burn. — The food may 
 regurgitate back into the oesophagus. Sometimes 
 this is normal (merycism), and is of the nature of the 
 return of the cud in ruminants. In certain cases, 
 when the stomach contents become abnormally sour 
 and acrid, strong peristalsis may produce pain Avith 
 regurgitation of some of the contents into the 
 oesophagus, and thus give rise to the painful burning 
 sensation described as " heart-burn." This may be 
 accompanied by the return into the mouth of some 
 of the contents of the stomach, sometimes insipid to 
 the taste, sometimes sour and acrid (pyrosis, water- 
 brash). One form of this condition has received the 
 name of hyperchlorhydria, because an excess of 
 hydrochloric acid is present in the stomach contents, 
 
The Stomach. • 141 
 
 and because it can be relieved by alkalies. But this 
 increase in h3^drochloric acid is but one of the 
 abnormal manifestations, and excess in its secretion 
 is not necessarily the disease, nor the cause of the 
 S3"mptoms, for the administration of hydrochloric 
 acid relieves the sjanptoms, and the presence of 
 hydrochloric acid in the oesophagus does not cause 
 heart-burn. There are other acrid substances of 
 unknown nature present which evidenth^ excite the 
 peristalsis of the stomach. 
 
 83. Air Suction. — Flatulence is a common com- 
 plaint with d^^speptics, but true flatulence, i.e., 
 flatulence due to evolution of gases in the stomach, 
 is relatively rare. The vast number of people who 
 suffer from " attacks of wind," and who appear to 
 expel large quantities with a loud noise, owe their 
 attacks to air spasmodically sucked into the oesopha- 
 gus or into the stomach. These maj^ start with a 
 shght feeling of distension after meals, when the 
 patient endeavours to obtain relief by expelling 
 wind. In this attempt air is unconsciouslj^ sucked 
 into the oesophagus, and its noisy expulsion is sup- 
 posed to be an evidence of air being expelled from 
 the stomach. Sometimes the air is sucked into the 
 stomach, and its expulsion is accompanied by some 
 flatulence that was present in the stomach, and in 
 consequence considerable relief is obtained. Some 
 people when suffering from pain get a measure of 
 relief by sucking air voluntarily into the stomach 
 and then expelling it. 
 
 This air suction occurs most frequently in 
 people of a neurotic temperament, and the attacks 
 may come on when they are put out, worried, or 
 
142 ChaiJter X I V. 
 
 suffering frona affections of other organs. When a 
 patient complains of attacks of flatulence coming on 
 suddenly as during sleep, it will often be found that 
 the patient is an air-sucker. It might seem that an 
 uncontrollable reflex would cause the air suction, for 
 patients during an attack of angina pectoris may 
 hold themselves in such a manner that air is uncon- 
 sciously sucked in, and its expulsion is often accom- 
 panied by such relief that the origin of the suffering 
 is put down to a stomach affection. Attacks of 
 air suction may be stopped at once by the mouth 
 being kept wide open b}^ a gag. Wyllie's article in 
 the Edinburgh Hospital Reports (Vol. I.) throws a 
 great deal of light on the subject. 
 
 84. Functional Symptoms. — The symptoms 
 that arise from changes in function are available in 
 relatively few cases. Those clue to alteration in the 
 secretion are mainty limited to the recognition of an 
 excess of mucus, or an increase or diminution of the 
 amount of free hydrocliloric acid in tlie stomach 
 contents, obtained either from the vomit or by the 
 stomach tube. There are so many individual varia- 
 tions in the amount of gastric juice secreted and in 
 the relative proportion of hydrochloric acid present, 
 that deductions drawn from an examination of the 
 stomach contents must be applied with the greatest 
 caution. 
 
 Increase in the amount of hydrochloric acid is 
 indicative of no definite lesion, and the absence of 
 free hydrochloric acid, though suggesting the possi- 
 bility of cancer, is by no means diagnostic, as it may 
 be absent in a variety of conditions. Save that its 
 absence necessitates the consideration of the question 
 
The Stomach. 143 
 
 of cancer, it is doubtful if the symptom is of any 
 special importance. Functional derangement of the 
 digestive fluid may be detected by the delay of 
 digestion. This dela}' is recognised by the retention 
 by the stomach of portions of undigested food, and 
 by observing the time taken to digest a test meal, 
 and by the observation of the passage of a bismuth 
 meal through the stomach b}^ the X-rays. 
 
 Dilatation of the stomach is an evidence of a 
 loss of the function of tonicit}^ in the muscular A^'all, 
 and can be detected by careful percussion, or bj- the 
 presence of splashing when the stomach is shaken by 
 succussion, or by tapping over the stomach. The 
 extent of the dilatation can often be made out by 
 distending the stomach with carbonic acid gas. The 
 simplest method is to give the acid part of a seidlitz 
 powder in solution first, followed b}' the alkaline. 
 The evolution of the carbonic acid gas causes a 
 visible swelling in tlio abdomen due to the distension 
 of the stomach. 
 
 The use of the X-rays in the examination of the 
 digestive tract has been of the greatest service. B}^ 
 giving a meal containing a large quantity of bismuth 
 the movements of the food can be detected. Obser- 
 vation by this means has shed an unexpected light 
 upon the position and shape of the normal stomach, 
 and shows that the description usually given is quite 
 wrong. In quite healthy people the stomach may 
 be as low as the umbilicus. In fact so variable is 
 the shape and position of the stomach in presumably 
 health}^ people that no certain standard is yet 
 recognised. In consequence of this the recognition 
 of abnormal conditions of the stomach by the X-rays 
 
144 Chapter XIV. 
 
 is mostly limited to cases of very great increase in 
 size. 
 
 The retention of portions of food in the stomach 
 for a considerable time affords evidence of the 
 inefficiency of the peristaltic contractions to empty 
 the stomach of its contents. x\lthough dilatation is 
 seen in its most characteristic form in emaciated 
 people with pyloric stenosis, yet it may be of con- 
 siderable extent v/here there is no obstruction ; and 
 there may be difficulty in deciding whether the 
 dilatation is secondary to the pyloric stenosis. A 
 long history of stomach trouble with pain, particu- 
 larly if referred to the lower part of the epigastrium, 
 f suggests pyloric stenosis. In rare cases a history of 
 vomiting blood, or of huge hquid vomits at intervals, 
 is also suggestive of pyloric stenosis. Apart from 
 pyloric stenosis dilatation of the stomach is a very 
 common condition, and may be present when there 
 is no symptom pointing to digestive insufficiency. 
 At other times dilatation may be found associated 
 with all kinds of symptoms. 
 
 The cause of dilatation is, as I haA'e said, a lack 
 of tonicity in the muscular wall. It is impossible to 
 account for its appearance, and although it may 
 be spoken of as a symptom of " atonic dyspepsia " 
 yet it may be present with no dyspepsia. 
 
 85. Structural Symptoms.— Apart from the 
 evidences of dilatation which have been alluded to, 
 the symptoms produced by changes in the organ itself 
 are hmited to the detection of tumours in the stomach 
 wall. In the early stages they are impossible to 
 recognise, partly because of the manner in which 
 they occur as a somewhat diffuse thickening of the 
 
The Stomach. 145 
 
 stomach wall, and partly because of the unyielding- 
 contraction of the overlying muscles. It is only when 
 the tumour is in the anterior wall, or has increased 
 to a considerable size, that it can be detected. By 
 that time the patient's condition^ if the tumour is 
 malignant, will have suggested the serious nature of 
 the complaint. 
 
 Constriction of the stomach, however, may arise 
 as a result of contraction of gastric ulcers (hour- 
 glass contraction). The detection of this condition 
 is a matter of some difficulty, but it may be suspected 
 when in washing out the stomach a portion of the 
 fluid poured in cannot be drawn off. 
 
 86. The Diagnosis of Stomach Afiections. — 
 From the foregoing discussion it will be seen that 
 in the vast majority of stomach affections there are 
 few signs that may be considered distinctive of any 
 one complaint. When a diagnosis can at once be 
 made in any given case, the patient has been suffering 
 for a considerable time. As the general practitioner 
 is usually consulted long before a definite ph^^sical 
 sign, as a tumour, blood- vomit, or dilatation, is 
 apparent, and as the symptoms of ailments from 
 the simplest to the most serious are at first identical, 
 it is necessary to adopt other methods in order to 
 arrive at a diagnosis, such as watching the progress 
 of the affection, its response to treatment, and the 
 general condition of the patient. 
 
 As diets are so varied, the personal predilection 
 of the doctor may lead him to assume that the 
 patient's trouble at first is due to some dietetic error. 
 In this he may be right, and it is always best in any 
 given case to start the observation by ordering the 
 
146 Chapter X I V. 
 
 patient the simplest and most easily digested form 
 of food. My own practice, in all doubtful cases, is to 
 attend to decayed and deficient teeth, to prescribe a 
 diet in which the food is given in small amounts, the 
 solids dry so as to ensure efficient and thorough 
 mastication, and the fluid mostly in the form of milk, 
 also small in quantity. With people Avho have to 
 follow their daily work (which is the case with the 
 majority of patients who consult the general prac- 
 titioner), the food should be taken every two liours. 
 When at work this may be limited to a dry crust, to 
 be thoroughly and slowly masticated. At other 
 times meat or fish with dry bread or toast may be 
 given, if the patient is able to digest it with comfort. 
 The quantity must be regulated at all times by the 
 suffering of the patient. By this simple process the 
 majority of cases of indigestion due to error in diet 
 will be relieved. Speedy relief after such a change 
 of diet, or from some simple remedy, must not be 
 taken as an evidence that the stomach is free from 
 any serious lesion — all that has been done has been 
 to remove the stimulus that was adequate to produce 
 the reflex symptom (pain, hyperalgesia). This is a 
 point on which it is necessary to insist, for many 
 cases of severe stomach disease may be thus tem- 
 porarily relieved. In such cases the history must be 
 inquired into, and the presence of other symptoms 
 sought for. Persistence of suffering and of hyperal- 
 gesia of the epigastric skin and muscle, with con- 
 tracted recti, are signs usually indicative of ulcera- 
 tion. When these dietetic changes are followed by 
 no improvement, rest in bed is the next step, and the 
 patient may have to lie many months before improve- 
 
The Stomach. 147 
 
 ment sets in. When there is dilatation, washing out 
 the stomach and examination of the contents is of use. 
 
 The appearance of symptoms of indigestion in 
 persons over the age of forty j^ears, with wasting, 
 should at once arouse the suspicion of malignant 
 disease. In all cases the appearance of the patient 
 should be studied, and in case of blanching the ques- 
 tion of haemorrhage should be carefully inquired into. 
 
 The possibility of gall-stone disease should 
 always be borne in mind in chronic forms of indi- 
 gestion. In severe suffering the temperament of 
 the patient may aggravate the symptoms, for the 
 reaction of a shght stomach lesion in a neurotic 
 subject may cause widespread sensory phenomena. 
 
 87. Pain in Gastric Ulcer. — As gastric ulcer can 
 frequently be definitely localised, the comparison of 
 the site of the ulcer with the site of pain sheds a 
 light upon the mechanism of visceral pain, and 
 illustrates the practical value of the method of 
 examination where the reflex symptoms are care- 
 fully observed. I have watched patients with gastric 
 ulcer continuously for a great number of years, and 
 have had the opportunity of verifying the diagnosis 
 post-mortem, or at operation, in a good number. The 
 result of these observations has been to show that, 
 though the actual site of the ulcer had no direct 
 relation to the place where the pain was felt, there 
 was a fairly definite relation explicable by the 
 nervous connection of the parts. In many cases the 
 patient can locahse the pain with great definiteness 
 in some limited region, and the skin and deeper 
 tissues may there be hyperalgesic. In such cases I 
 have found that when the ulcer was situated near the 
 
 L 2 
 
148 Chapter XIV. 
 
 cardiac end of the stomach the site of pain and 
 hyperalgesia was in the upper part of the epigas- 
 trium, when the ulcer was in the middle of the 
 stomach the site of pain and hyperalgesia was in 
 the mid-epigastrium, and when the ulcer was at the 
 pylorus the pain was felt at the lowest portion of 
 the epigastrium. 
 
 To illustrate, not only the justification of this 
 view, but, more important, its practical utihty, I will 
 cite some typical instances. I was called into con- 
 sultation to see a young woman twenty hours after 
 perforation of the stomach had taken place. The 
 patient had suffered for many months from pain 
 after food. She located the site of this pain with 
 great certainty in the upper part of the epigastrium, 
 over the xiphisternum. I reasoned from this that 
 the perforated ulcer would be near the cardiac end 
 of the stomach. The incision opening the abdominal 
 cavity was, therefore, made as far to the left as 
 possible. On opening the abdomen there was found 
 a large quantity of fluid, and a considerable quantity 
 of flaky lymph covered most of the exposed organs. 
 The stomach was carefully searched, and we found it 
 rather firmly adherent at the cardiac end to the 
 posterior wall of the abdomen. We inspected the 
 whole of the stomach except the adherent part, and 
 there can be no doubt that the adhesions surrounded 
 the ulcer. We resolved not to break down these 
 adhesions, as it would have been impossible to drag 
 this portion of the organ sufficiently far out to enable 
 us to stitch it. The abdomen was very efficiently 
 flushed, the wound stitched up, and the patient 
 made a good recovery. 
 
The Stomach. 
 
 149 
 
 Fig. 14. 
 
 The shaded area shows site of pain, X corresponds to the jjosition of the 
 ulcer in the stomach as found at the post-mortem examination. 
 
 Another patient I saw in consultation suffered 
 from peritonitis, resulting from perforation of a 
 gastric ulcer. She was a servant girl, twenty years 
 of age. For three years she had suffered at varying 
 times from severe indigestion, and, a year previous 
 to my examination of her, she had vomited a 
 quantity of blood. The pain from which she 
 suffered was situated in the upper part of the 
 
150 Chapter XIV. 
 
 epigastrium, just over the xiphoid cartilage (in the 
 shaded area of Fig. 14), and was felt through to the 
 back. When admitted to the hospital, the abdomen 
 was hard and tense, the pulse very soft and 160 per 
 minute. The abdomen was extremely tender to the 
 touch ; but on closer examination this tenderness 
 was found to be purely cutaneous, the hypersesthesia 
 extending beyond the limits of the abdomen — over 
 the lower part of the thorax and down over the 
 thighs. In a few daj^s the hypersesthesia disappeared 
 except in a diffuse, ill-defined area about the 
 epigastrium ; the greatest tenderness always being 
 over the upper part of the epigastrium. The patient 
 sunk and died. At the post-mortem examination 
 there was found much matting of the stomach, 
 bowels, and liver in the upper part of the abdomen 
 by recent soft peritonitic adhesions. The stomach 
 was found perforated by a large ulcer near the car- 
 diac end, its position i7i situ being nearly as far out 
 as the mid-axillary line (indicated by x, Fig. 14). 
 There were two other superficial ulcers in the imme- 
 diate neighbourhood, but they were nearer the 
 oesophageal opening than the perforation. 
 
 A girl, aged fourteen years, who had had pain 
 after food for many months, referred the situation 
 of the pain with great precision to a spot in the 
 middle of the epigastric region (Fig. 15). She was 
 suddenly seized with collapse and severe pain over 
 the upper part of the abdomen. There could be no 
 doubt that it was a case of perforation of the 
 stomach. Within eight hours we opened the abdo- 
 men, and as I had noted the situation of the pain 
 previous to the rupture, I suggested that the ulcer 
 
The Stomach. 
 
 151 
 
 The shaded area shows the site of pain, and the + the position of the 
 gastric ulcer as found at the operation. 
 
 would probabty be found in the middle of the 
 stomach. The incision was therefore made well to 
 the left of the middle line. The perforation was 
 readily met with in the middle of the stomach on 
 the lesser curvature, in a position corresponding to 
 the + in Fig. 15. It was stitched up, and the patient 
 made an excellent recovery. 
 
152 Chapter X I V. 
 
 A female, aged thirty- two j^ears, for ten years had 
 frequently vomited large quantities of blood, and 
 suffered from severe pain in the epigastrium. The 
 pain was always felt with the greatest intensity at the 
 lower part of the epigastrium, corresponding to the 
 area shaded in Fig. 16. From this region the pain 
 would frequently strike round the left side, and be 
 felt severely over the sixth and seventh dorsal verte- 
 brae. The painful area in the epigastrium was often 
 extremely sensitive to the touch, and the cutaneous 
 hyperaesthesia sometimes extended as a broad band 
 round the left side. The last note I made about the 
 patient was on 1st April, 1897, to the effect that the 
 patient " vomited a large quantity of blood yester- 
 day. The pain is felt very severely midway between 
 the xiphoid sternum and the umbihcus, striking 
 round towards the left side " ; and then follows a 
 diagram noting the area, as marked in Fig. 16. 
 
 In treating this patient, at an early date, a 
 blister the size of a florin had been applied over the 
 painful area in the epigastrium. So much rehef 
 was obtained when the cutaneous surface was raw, 
 that savin ointment was used to keep the wound 
 from heahng, until all symptoms of pain had dis- 
 appeared. During the last five years of her life (she 
 died of phthisis) the patient had been in the habit, 
 from time to time, of applying the blister herself 
 whenever there was a recurrence of the pain. At 
 the post-mortem examination the effects of a 
 recent blister were still evident, as a superficial 
 erosion, occupying the lower part of the epigas- 
 trium, corresponding exactly with the area shaded 
 in Fig. 16. 
 
The. Stomach. 
 
 153 
 
 Fig. 1G. 
 
 The shaded area shows the site of pain, X the site occupied by the 
 ulcer at the pyloric orifice of the stomach as found at the post-mortem 
 examination. 
 
 The patient died suddenly on 7th July. At the 
 post-mortem examination held next day, an ulcer, 
 1 in. in diameter, with slightly thickened edges, was 
 found situated partly in the stomach and partly in 
 the p\dorus. I requested my colleague. Dr. Brown, 
 to note exactly what position the ulcer occupied in 
 relation to the external body wall, and he, carefully 
 noting the situation, indicated an area corresponding 
 to X in Fig. 16. 
 
154 Chapter XIV. 
 
 Another case had been under my care for ten 
 years for repeated attacks of epigastric pain. The 
 pain in this case was very constant, unless during 
 three pregnancies when she was quite free. She con- 
 sulted an eminent surgeon who wrote to me stating 
 that the patient had an ulcer in the middle of the 
 stomach and on the posterior wall, and he recom- 
 mended an operation for her rehef. I re-examined 
 the patient and made the following note in my diary : 
 " That, inasmuch as the pain is situated at the lowest 
 part of the epigastric region, and as there is also 
 here a Umited area of tenderness of the skin, the 
 ulcer should be found at the pyloric orifice." This 
 latter view was verified at the operation subsequently 
 performed. 
 
 A patient whom I had attended for twelve 
 years with m.itral stenosis, and wlio died in 1907, 
 aged thirty-six, suffered severely from gastric ulcer 
 in 1899, so that she had to be kept in bed for two 
 months, and be fed with the greatest care. The pain 
 gradually abated, but kept recurring at intervals. 
 It was always referred to the epigastrium, but 
 radiated widely. Thus I made this note on May 
 13th, 1903 : " Has severe pain starting at the shaded 
 area (as in Fig. 16) and passes round to the left side. 
 There is no tenderness of the skin or muscles, and 
 no vomiting. Stomach resonance as low as the 
 umbilicus." She died in February, 1907, from her 
 heart affection, and at the post-mortem examination 
 an ulcer was found at the pyloric end of the stomach 
 — at some distance from the epigastrium. The 
 relative positions of the site of pain and of the ulcer 
 were the same as shown in Fi^^. 16. 
 
( 155 ) 
 
 Chapter XV. 
 
 THE LIVER, GALL-BLADDER AND DUCTS. 
 
 88. Nerve Supply. 
 
 89. Reflex Symptoms in Gall-stone Disease. 
 
 90. Gastric Symptoms in Gall-stone Disease. 
 
 91. The Result of Reflex Symptoms. 
 
 92. Functional Symptoms in Gall-stone Disease. 
 
 93. Structural Symptoms in Gall-stone Disease. 
 
 94. Fever in Gall-stone Disease. 
 
 95. Nature of Reflex Symptoms in Affections of 
 
 the Liver. 
 
 96. Functional Symptoms in Affections of the Liver. 
 
 97. Structural Symptoms in Affections of the Liver. 
 
 88. Nerve Supply. — The symptoms associated 
 with the Uver, gall-bladder, and ducts, in many cases 
 resemble those of the stomach so closely that there 
 is often a difficulty in differentiating the one from 
 the other. This will be understood when it is borne 
 in mind that developmentally the Hver and its 
 appendages are an outgrowth of the digestive tube 
 immediately below the stomach. The region in the 
 cord from which the nerve supply passes is at, and 
 immediately below, the region of the stomach supply, 
 from the seventh to the ninth thoracic ; so that with 
 severe stimulation the irritable focus in the cord in- 
 vades the nerve supply of the stomach. As in stomach 
 
156 Chapter X F. 
 
 affections, the reflex phenomena appear in the epigas- 
 trium, but in gall-bladder affections the hyperalgesia 
 is most common on the right side, and the upper part 
 of the right rectus muscle becomes contracted. The 
 symptoms also tend to spread to the right side and 
 lower down in the abdominal wall. In addition to 
 the thoracic nerve supply the liver and gall-bladder 
 and ducts are also supplied by the phrenic nerve 
 (third, fourth and fifth cervical) and by the vagus. 
 
 89. Reflex Symptoms in Gall-stone Disease.— 
 The reflex symptoms in affections of the liver itself 
 are often not very distinctive, while those of the gall- 
 bladder and ducts are frequently violent and very 
 characteristic. This difference is due to the fact 
 that the former is a glandular structure, while the 
 latter contain non-striped muscular fibres which, we 
 have seen, may provoke the most violent sensor}^ 
 phenomena. 
 
 The pain in gall-stone disease varies much in 
 severity. It may begin with a sense of uneasiness in 
 the epigastrium, or over the lower ribs on the right 
 side. A small area of cutaneous or muscular hyper- 
 algesia may be detected somewhere in the region in 
 which the pain is felt, and also in the upper portion 
 of the right rectus. This muscle may be more or less 
 contracted. These symptoms may be slight and 
 variable, and continue for months or years, or the 
 patient may be seized suddenly with violent pain, 
 mth or without these preliminary symptoms. The 
 pain in the majority of cases of gall-stone colic is 
 situated in the middle line, about the lower part of 
 the epigastrium. It may come on gradually and 
 remain for an indefinite period, sometimes varying 
 
The Liver, Gall- Bladder and Ducts. 
 
 157 
 
 Fig. 17. 
 
 The shaded area shows the region of cutaneous hyperalgesia after an 
 attack of gall-stone colic. The + is the position of a tender point in 
 many cases in gall-stone disease, and is over the place where a twig of the 
 ninth thoracic nerve passes out of the rectus abdominis muscle. 
 
 slightly in intensity. From this place it tends to 
 spread to the right side, and may be felt with great 
 severity below the edges of the ribs. Sometimes it 
 may extend round to the back, and be felt most 
 severely over the ninth and tenth ribs. In rare cases 
 the pain may only be felt in the back. 
 
 The pain, intermitting shghtly, may remain for 
 many hours, unless relieved by a sedative. Frequently 
 after the subsidence of the pain the skin and muscles 
 
158 Chapter X V. 
 
 of the upper part of the right side of the abdomen 
 become very tender to touch, and the muscles hard 
 and contracted. In Fig. 17 the area of cutaneous 
 hyperalgesia is shown in the patient in whom I first 
 discovered the presence of hyperalgesia in 1891. 
 
 In a great many cases, after the subsidence of 
 the attack, the hyperalgesia may persist for several 
 weeks, and, during this period, severe attacks of 
 pain are very hable to be provoked, so that the 
 patient is scarcely able to move about. 
 
 In a small percentage of cases pain, sometimes 
 of great severity, is felt on the top of the right 
 shoulder, striking down the outside of the arm. It 
 is very necessary to recognise the relationship 
 between pain in this region and gall-stones. I have 
 known patients in whom there was this pain in the 
 shoulder and in the arm treated for years for 
 " neuritis," and the passage of a gall-stone has been 
 followed at once by relief. In many cases this 
 shoulder pain is not very severe, and the patient may 
 not refer to it. If, however, inquiry be made, the 
 patients frequently declare they have had pain 
 in the right shoulder, which they thought was 
 " rheumatic." When this shoulder pain is severe 
 and the chief complaint, if due to gall-stone disease a 
 careful search will reveal evidences in the upper part 
 of the abdomen, in the hyperalgesia of the sldn, in 
 the contraction of the muscles, and in the history of 
 the patient which leave little doubt as to the cause 
 of the shoulder pain. 
 
 90. Gastric Symptoms in Gall-stone Disease. — 
 In persistent " dyspepsia " and heart-burn, the 
 question of gaU-stones should always be considered. 
 
The Liver, Gall- Bladder and Ducts. 159 
 
 I have already referred to the association of pain on 
 the ingestion of food into the stomach with 
 gall-stone disease. One frequently sees patients with 
 a history of " acute gastritis " of which the sj^mptoms 
 are described as attacks of severe pain in " the pit 
 of the stomach," or " cramp of the stomach," fol- 
 lowed by a period when ingestion of food causes 
 pain. Such a history ^vill, in the majority of cases, 
 be found really to have been due to gall-stone coUc, 
 Avith the subsequent condition of hyperalgesia 
 associated with an irritable focus in the cord. 
 
 Nausea and vomiting are frequent accompani- 
 ments of gall-stone colic, and their occurrence with 
 the pain in the " pit of the stomach " might seem to 
 confirm the conclusion that the case is one of 
 " gastritis," or " cramp of the stomach." 
 
 91. The Result of Reflex Symptoms.— When 
 we come to consider the effect of this hyperalgesia, 
 contracted muscles and exalted reflexes, we get a 
 picture that is often very misleading. After the 
 attacks of severe pain have subsided the patient may 
 be unable to breathe freely, each inspiration being 
 checked, as it is in pleurisy, by spasm of the inter- 
 costal muscles, and severe pain may be felt over 
 the lower ribs on the right side. Such symptoms are 
 sometimes mistaken for pleurisy. If a careful ex- 
 amination be made, it can be demonstrated that 
 there is an extensive field of liyperalgesia, extending 
 up into the . chest and imphcating the intercostal 
 muscles. The exercise of hyperalgesic muscles is 
 always hmited on account of their increased tone, 
 and the tonic contraction tends to increase with their 
 continued action. It is for this reason that patients 
 
160 Chapter X V. 
 
 with gall-stone and persistent hyperalgesia of the 
 abdominal muscles are comparatively at ease when 
 at rest. On moving about there gradually comes on 
 a feeling of pain and dragging round the abdomen, 
 and the patient is unable to " stretch " himself freely. 
 This is simply due to the fact that the exercise of 
 the h^^eralgesic muscles has increased their tonic 
 contraction and their sensitiveness, so that their 
 exercise is painful and the extent of their movement 
 becomes greatly limited. 
 
 92. Functional Symptoms in Gall-stone 
 Disease. — It is in only a small proportion of cases 
 that jaundice is present in gall-stone disease. If 
 the stone is situated in the common duct, or can 
 cause pressure on the common duct, so as to obstruct 
 the channel, then jaundice arises. When the jaun- 
 dice is so slight that it is difficult to determine 
 whether it may not be due to a sallow complexion, a 
 careful inspection of the sclerotic may reveal a faint 
 tinge. It may be necessary in cases of doubt to 
 examine the urine or blood for minute traces of bile 
 pigment. 
 
 93. Structural Symptoms in Gall-stone 
 Disease. — It is only in very rare cases that gall- 
 stones can be detected in the gall-bladder. It can 
 only be done when the stones are so numerous as to 
 cause a tumour, or when the stones cause the gall- 
 bladder to become distended with fluid. This can 
 only happen at a late stage in the disease, and when 
 all the associated reflex phenomena have disappeared, 
 for the presence of hyperalgesia means also the 
 presence of a lively muscular reflex, which effectually 
 prevents the hand reaching the gall-bladder. When 
 
The Liver, Gall- Bladder and Ducts. 161 
 
 the abdominal muscles are lax the distended gall- 
 bladder may be felt as a tumour, and, in rare 
 instances, the stones have been palpated. The liver 
 is sometimes said to " enlarge and become tender." 
 As, however, the wi'iters who describe this have not 
 appreciated the association of this so-called " tender 
 liver " with contracted muscles, this observation 
 needs to be verified. For my part I have never been 
 able to satisfy myself as to a slight fiver enlargement 
 when there is hyj)eralgesia and contracted muscles. 
 The muscles are so tender on pressure and contract 
 so firmly that it is impossible to palpate the liver ; 
 the percussion note also becomes altered with a 
 contracted muscle. 
 
 94. Fever in Gall-stone Disease. — In the great 
 majority of cases of gaU-stone disease there is no 
 fever, except, it may be, a slight rise at the time of 
 an attack of colic. In some cases there is an asso- 
 ciated inflammation of the gall-ducts, and, as a 
 consequence, febrile attacks may occur of a very 
 characteristic type. These are generally very sudden 
 in their onset and in their subsidence. The patient 
 begins to feel chiUy and shivery, and when his tem- 
 perature is taken it wiU be found to be considerably 
 raised^l01-104°. He may have rigors. In the 
 course of one to three days the temperature returns 
 to normal. 
 
 In more advanced stages of cholangitis the tem- 
 perature may remain continuously above normal with 
 frequent exacerbations. With the formation of pus 
 the temperature usually remains continuously high. 
 
 In all obscure cases of intermittent temperature 
 the possibility of gaU-stones should be considered. 
 
162 Chapter X V. 
 
 Except malaria, there is no disease Avliich gives such 
 characteristic febrile attacks. In many cases a 
 slight jaimdice can be detected. 
 
 95. Nature of Reflex Symptoms in Affections 
 of the Liver. — I have dealt fully with the reflex 
 symptoms in gall-stone disease, because in this com- 
 plaint they are seen in their most striking form. In 
 disease of the Hver the same areas may be affected 
 though the s5''mptoms are less violent. As I have 
 pointed out, it is doubtful if the affections of the 
 parenchyma of an organ ever give rise to pain, unless 
 the fibrous covering is affected or stretched. As a 
 rule in liver affections there is Uttle pain, unless this 
 hyperalgesia of the external body wall and the tender 
 structures are stimulated, as in exercise of the 
 muscles, when pain will be felt in the muscles so 
 exercised. This is weU seen in cases of rapid in- 
 crease in the size of the Hver from heart failure, 
 when the capsule is stretched, and when, if the 
 patient moves about, there is considerable pain felt 
 in the muscles over the liver, in front and round to 
 the back. The enlargement of the liver due to heart 
 failure offers an excellent opportunity for the study 
 of the reflex symptoms of liver affections. These 
 symptoms are seen most strikingly when the heart 
 failure sets in with some rapidity, as in certain cases 
 of paroxysmal tachycardia, especially when the 
 tachycardia is due to auricular fibriUation, or where 
 heart failure sets in as a consequence of the perma- 
 nent establishment of auricular fibrillation. In cer- 
 tain cases this abnormal rhjrthm is suddeifly 
 developed, and in the course of a few hours the heart 
 dilates and the liver becomes very considerably 
 
The Liver, Gall- Bladder and Ducts. 163 
 
 enlarged. If the patient keeps at his work, feehng 
 weak and breathless, severe pain is suffered from 
 across the back and round in front over the hver. If 
 he be examined a patch of cutaneous hyperalgesia 
 may be found embracing a considerable portion of 
 the upper part of the right side of the abdomen. 
 The muscles below the ribs in front will be found 
 hyperalgesic and contracted, and the erector spinae 
 muscles at the level of the eighth to twelfth ribs will 
 also be found hyperalgesic. If the heart should 
 suddenly return to the normal, the hver enlarge- 
 ment subsides in a few hours, and the hyperalgesia 
 chsappears. If, however, the abnormal rhythm 
 persists, then with rest in bed the hyperalgesia 
 gradually diminishes until one can palpate the 
 liver through the abdominal wall, and even take 
 tracings from the enlarged and pulsating liver. 
 
 In enlargement of the liver due to other causes, 
 as hjrpertrophic cirrhosis, cancer, chronic and sub- 
 acute abscess, the reflex symptoms are of the same 
 nature but less acute. I have no experience of acute 
 inflammatory affections of the liver, so cannot tell 
 the nature of the symptoms present. 
 
 Severe and persistent vomiting may arise in 
 liver affections. In the early stages of " catarrhal 
 jaundice," before the jaundice appears, the patient 
 may suffer from the most violent and persistent 
 attacks of vomiting, and the cause may remain 
 unsuspected till the jaundice appears. 
 
 96. Functional Symptoms in Affections of the 
 Liver. — Jaundice is, of course, the most striking, 
 and needs no further description. In all cases of 
 sallow or dirty grey complexion, the liver should be 
 
 M 2 
 
164 Chapter X V. 
 
 carefully examined. When chronic liver affections 
 produce jaundice, or alter the complexion, there is 
 generally present also a considerable degree of wast- 
 ing. This wasting, with an enlarged hver and a faint 
 jaundice tinge, is very suggestive of malignancy. 
 In some cases of chronic heart failure there may 
 be wasting, enlarged Uver, jaundice, sUght or 
 severe, which simulate mahgnancy so closely that a 
 mistaken diagnosis is not uncommon. If the heart 
 be examined the evidences of heart disease are 
 always so marked that no difficulty should be met in 
 recognising the real nature of the liver trouble. 
 
 97. Structural Symptoms in Affections of the 
 Liver. — Normally the upper margin of the liver 
 dullness corresponds to a transverse line drawn at 
 the level of the junction of the sternum and the 
 xiphi-sternum. The lower edge corresponds in the 
 nipple line to the right costal margin. 
 
 Organic symptoms may be recognised as an 
 enlargement of the organ, or a diminution of its 
 size. When there is much muscular hyperalgesia it 
 is often difficult to define the limits of the organ. 
 In the absence of this, httle difficulty is found in 
 detecting the extent of the hver enlargement. This 
 is better done by palpation than by percussion, as a 
 distended bowel may communicate a resonant note, 
 particularly Avith enlargement of the left lobe. In 
 enlargement of the organ from heart failure the 
 organ can sometimes be felt to pulsate. This is per- 
 .ceived by putting the left hand belnnd and pressing 
 forward the hver, while the right hand is laid over 
 the liver, which will be found to heave gently wdth 
 each cardiac contraction. The extent to wliich the 
 
The Liver, Gall- Bladder and Ducts. 165 
 
 liver may enlarge is very great, and its lower margin 
 may extend as low as the brim of the pelvis. 
 
 The surface of the enlarged liver maj^ be nodu- 
 lar, as in cancer and cirrhosis. In the great majority 
 of cases the enlargement of the liver is downwards, 
 but in hydatids of the Hver, the cyst being on the 
 upper margin, the liver duUness may extend 
 upwards to the third rib. Percussion gives rise to 
 the characteristic thrill due to vibration set up in 
 the fluid contents of the cyst. 
 
 The hver may be pushed down by abnormal con- 
 ditions in the chest, as in emphysema or pleural 
 effusions, or it may be displaced downwards on 
 account of laxity of its Hgaments and of the abdo- 
 minal muscles (hepatoptosis). 
 
 It may be dragged up into the chest, as in the 
 retraction that follows the absorption of a long- 
 standing pleuritic effusion. 
 
 Diminution of the size of the Uver may occur, 
 as in atrophic cirrhosis, when it is the lower border 
 that recedes. 
 
( 166 
 
 Chapter XVI. 
 
 THE GREAT AND SMALL INTESTINE. 
 
 98. Difficulties in Diagnosis. 
 
 99. Pain. 
 
 100. Appendicitis. 
 
 101. Affections about the Anus aiid Perineum. 
 
 102. Perineal Reflex. 
 
 103. Functional Symptoms. 
 
 104. Structural Symptoms. 
 
 98. Difficulties in Diagnosis. — The difficulties 
 in diagnosis of affections of the bowels are very 
 great. The great length of the tube, with its coils 
 confusedly mixed so that there is no safe guide to 
 the locality of man}/ portions, the continual shifting 
 of each portion with the peristalsis of the gut, and 
 our very imperfect knowledge of many of its func- 
 tions, all combine to render diagnosis of bowel 
 affections a matter of great uncertainty. There is a 
 misconception, almost universal, as to the position 
 and form of the great intestine, many pictures of 
 this portion of the gut showing it as passing in 
 swelling folds up the right side, across the upper 
 part of the abdomen, and down the left side from 
 the splenic flexure to the rectum. It is further stated 
 
The Great and Synall Intestine. 167 
 
 that the position of this gut can be made out b}' per- 
 cussion. With the exception of the csecum, which 
 is more or less fixed in its place, and usualh^ dis- 
 tended with gas, no part of the gut can be accur- 
 ately mapped out. To begin with, it is doubtful if 
 the descending colon is ever distended in the manner 
 shown in the pictures. When empty of faeces it lies 
 behind coils of small intestine, a contracted narrow 
 tube. The study of the movements of the bowel 
 after bismuth meals shows that the transverse colon 
 varies extraordinarily in its position in different 
 people. The ready distension of any portion of the 
 small intestine renders attempts to differentiate the 
 particular portion distended a matter of the gxeatest 
 uncertainty. 
 
 A similar confusion exists in regard to the 
 locahsation of pain. The sensation of pain is fre- 
 quenth^ so diffuse that no clear indication of its 
 exact site can be obtained in many cases, W^hen 
 severe pain arises from peristalsis the situation 
 can often be localised with a certain amount 
 of precision, but here the recollections of the 
 patient are extremely unreliable. I have fre- 
 quently been struck by the discrepancy between 
 the patient's account of the position of the pain 
 described from memory, and the actual position to 
 which he refers the pain when asked to locate it while 
 suffering from an attack of pain. For this reason 
 the account given by the patient must be taken with 
 great reserve. 
 
 To a certain extent the confusion also depends 
 on the shifting of the site of pain. The cause of pain 
 in the intestine is often due to strong peristalsis. 
 
168 Chapter X V I. 
 
 and in disease the peristalsis often does not appear 
 at the site of the lesion, but at some distance above 
 it, whence it gradually descends, and as the wave 
 passes over coil after coil the position of the pain 
 shifts likewise. Peristalsis may be stimulated below 
 the disease, as, for instance, when the irritating 
 secretion from an inflamed portion of the gut causes 
 painful peristalsis as it is conveyed along the bowel. 
 
 On account of these and other reasons the 
 diagnosis of bowel conditions is often extremely 
 unsatisfactory, though the recognition of the difficul- 
 ties should lead to a more careful scrutiny of the 
 symptoms in each individual case. In the matter 
 of pain, the patient should, if possible, be interro- 
 gated at the time he is suffering, and the position of 
 the pain localised as he feels it. If this is impossible, 
 then he should be asked to pay strict attention when 
 it recurs to note the exact site of the onset and the 
 subsequent radiation of the pain. 
 
 99. Pain. — I have already pointed out that the 
 pain from peristalsis of the bowel is usually limited 
 to the central areas of the body. In order to recognise 
 the area in which the pain from any given portion 
 of the bowel may arise, I have taken careful observa- 
 tions in cases of obstruction of the bowel, as one was 
 frequentty able to demonstrate the site of the lesion 
 by operation or post-mortem examination. It is 
 well known that the bowel below the obstruction 
 ceases to contract and lies inert. On the other hand, 
 the bowel above the point of obstruction is usually 
 stimulated to violent peristalsis in the attempt to 
 overcome the obstruction. In consequence of this 
 violent peristalsis severe colic-like pains are set up. 
 
The Great and Small Intestine. 169 
 
 Careful observation of the patient during an attack 
 will reveal the fact that the pain starts high up in 
 the abdomen, passes gradually lower and lower, till 
 it reaches a climax at some definite part ; then it 
 ceases and does not descend lower. If when the pain 
 stops this part be noted, the situation of the ob- 
 struction can be localised within certain limits. 
 Unfortunately the limits are still wide ; nevertheless, 
 the information is extremely useful. If we take the 
 usual divisions of the areas of the abdomen as in 
 Fig. 13, page 116, it will be found that the peristalsis 
 of the small intestine gives rise to pain limited to 
 the umbilical region, ncA^er descending below that 
 area. The cases in which I have specially studied 
 the pains due to obstruction of the small intestine 
 have been strangulated hernias, and I have had 
 abundant opportunities in operating to verify the 
 situation of the obstruction. This localisation of 
 the pain in the umbilical region is supported by 
 the experience acquired in the case of peristalsis, 
 with the intestine exposed, already described. An 
 attempt has been made to find out whether the local- 
 isation might not be more exact, by noting the level 
 of the pain, but the sensation is evidently too diffuse 
 to permit of such exact localisation. One would 
 naturally expect to find a distinct relationship 
 between the level of the pain and the position of the 
 obstruction, but OAving to this diffusion I failed to 
 satisfy m3'self in any given case of the exact limits 
 of the pain. The pain, when very severe just at the 
 lowest limits, also extends widely across the abdomen 
 at the same level. In many cases a diffuse area of 
 hyperalgesia of the skin and muscles may be detected. 
 
170 Chapte?- XVI, 
 
 but it has been of such a vague character that I 
 have not found it of much value as an aid in 
 diagnosis. 
 
 In obstruction of the large intestine the pain 
 due to the peristalsis descends to the hypogastric 
 region (Fig. 13, page 116), and here certain limited 
 deductions can be drawn from the level at which 
 the pain stops. The cases I have studied have been 
 patients with obstruction at the splenic flexure, or 
 at the sigmoid flexure, and cases of hard masses of 
 faeces retained in the rectum. In the obstruction at 
 the splenic flexure the pain did not descend below 
 the middle of the hypogastric area, while the pain 
 due to peristalsis below the splenic flexure was felt 
 about, and below, the middle of the hypogastric area. 
 I have observed a number of cases with feecal masses 
 in the rectum, too large and hard for their expulsion 
 by the anus, the pain being felt above the pubis. In 
 these cases the situation of the pain and straining 
 efforts seemed identical with the pains and straining 
 during labour. This agrees with what has already 
 been said about the situation of pain in diarrhoea and 
 with distending enemata immediately before the 
 expulsion of the fluid contents of the rectum. 
 
 In many people scybalous masses may lie in 
 different parts of the bowel, and their presence may 
 set up, after a time, violent peristalsis, in some cases 
 accompanied by diarrhoea. Once the violent peri- 
 stalsis begins it does not subside until the scybalse 
 are shifted. The people in whom I have observed this 
 most frequently have been young women who have 
 neglected their bowels. The pains are very severe, 
 and the motions will often contain grejdsh hard 
 
The Great and Small Intestine. 171 
 
 lumps. After the bowels have been voided a large 
 area of hyperalgesia and muscular contraction over 
 the abdominal wall is left. This tenderness and 
 hardness and the history of colic-hke pains give rise 
 to many wrong diagnoses, the principal error being 
 to attribute the symptoms to peritonitis. \ 
 
 100. Appendicitis. — The nature of the symptoms 
 in appendicitis is illustrated in the following case : — 
 Female, aged 36. For a couple of years the patient 
 had suffered from violent attacks of abdominal pain. 
 I never saw her during an attack, but the following 
 was the condition found after a severe attack. The 
 abdominal wall over the right iliac fossa was hard 
 and rigid, due to the contraction of the muscles. 
 When the skin was lightly pinched there was no 
 increased tenderness but pressure on the rigid 
 muscle was very painful. The right thigh was 
 slightly bent upon the abdomen, and could be 
 extended only with difficult}^ owing to a tonic 
 contraction of the psoas muscle. On walking a short 
 distance the patient developed a stoop, due to the 
 increased contraction of this muscle. When the 
 erector spinse muscles on both sides were lightly 
 grasped in the lumbar region those of the right side 
 were found ver}^ painful. There were frequent calls 
 to micturition, the quantit}^ passed at each time 
 being small, and containing no abnormal constituents. 
 
 This description of the symptoms was confirmed 
 by Mr. Caird, who operated on the patient. The 
 following conditions were found at the operation : — 
 When the abdominal cavity was opened nothing 
 abnormal could be detected. The parietal peri- 
 toneum was perfectly healthy, and only healthy coils 
 
172 Chci'pter XVI. 
 
 of intestine were exposed to view. On separating 
 these coils the appendix was found red and inflamed, 
 adherent by soft red bands to the caecum, and 
 separated from the bladder by coils of uninflamed 
 intestine. The appendix was removed, and the patient 
 made a good recovery, though it was a couple of 
 months before all the symptoms quite disappeared — 
 the last symptom to go being the slight contraction 
 of the psoas muscle, which became more contracted 
 on walking a short distance. 
 
 Grouping the reflex phenomena in this case we 
 recognise (1) A viscero-motor reflex in the muscular 
 contraction of the transversalis abdominis, the 
 oblique and psoas muscles ; (2) a viscero-sensory 
 reflex in the increased sensitiveness of the sensory 
 nerves supplying the muscles over the right iliac 
 fossa and the erector spinse ; and (3) an irritability 
 of the bladder resulting in frequent micturition. 
 
 It is manifest from the condition found at the 
 operation that these very definite symptoms could not 
 have been caused by the imphcation of the structures 
 in the inflammation which affected the appendix. If, 
 on the other hand, we look into the origin of the 
 nerves, motor and sensory, that supply these muscles 
 and the sympathetic supplying the bladder, we find 
 that they all arise from a limited area in or near the 
 twelfth thoracic and first or second lumbar spinal 
 segments. It becomes, then, a justifiable inference 
 that the stimulus that produced these symptoms 
 arose in the appendix, and that this stimulus was 
 conveyed from the appendix by its sympathetic nerve 
 supply to the spinal cord, and therefore that the 
 appendix is supplied by a sj^mpathetic nerve that 
 
The Great and Synall Intestine. 173 
 
 joins the cord at the segments mentioned. In Fig. 5, 
 page 59, it is shown that the nerve to the bladder 
 leaves the cord at two places — with the sympathetic 
 nerves from the upper lumbar region, and Avith the 
 visceral sacral nerves. In the case just cited the 
 frequent micturition showed an increased sensitive- 
 ness of the bladder and so we can infer that the 
 afferent fibres of the bladder reach the spinal cord 
 at the upper lumbar region. 
 
 There are a few symptoms present in excep- 
 tional cases that need a passing notice. The nature 
 of the attacks of " appendicular colic " is to me very 
 obscure. In some cases the pains have been so dis- 
 tinctly referred to the umbilical region that I have 
 considered the question whether the intestine above 
 the inflamed appendix may not have been stimulated 
 to violent peristalsis. That the colic in appendicitis 
 may be due to violent peristalsis, at all events in 
 some cases, seems possible from the following experi- 
 ence. A man aged 40 years had suffered for four 
 years from violent attacks of colic and pain in the 
 abdomen. He had seen several physicians and sur- 
 geons and ultimately a diagnosis of gall-stones was 
 made, and he was operated upon. No gall-stones 
 were found and no relief was obtained from the 
 operation. I was asked to see him and I obtained, 
 with difficulty, a clear notion of the site of his 
 suffering and the spread of the pain. The pain 
 started always just at the low^er part of the epigastric 
 region and descended slowly in the middle, increas- 
 ing in severity to the lowest part of the umbilical 
 region (space c, Fig. 13, p. 1 16). It might stop in this 
 neighbourhood for some time, but did not descend 
 
174 Chapter X V I. 
 
 lower. From this account, it was reasoned that the 
 pain w^as due to some hollow viscus, that as it per- 
 sisted most severely in the central regions of the 
 abdomen, gall-stone colic and the coUc from a renal 
 calculus could be excluded. The only hollow viscus 
 that could cause pain in this region was the small 
 intestine, and the radiation of the pain indicated that 
 the peristalsis had started high up and stopped at the 
 end of the small intestine. A painful peristalsis 
 occurs onlj^ above the provoking cause, so that we 
 could infer the cause would be found at the lower end 
 of the small gut. Moreover, as in the great majority 
 of cases the appendix is the provoking agent at this 
 place, the probability was that the appendix was 
 affected. Acting on this diagnosis an operation was 
 performed. The small intestine was found deeply 
 injected, especially at its lower extremity, and the 
 appendix was found red, inflamed and adherent to the 
 neighbouring structures, the adhesions obstructing 
 the lumen of the lower part of the small intestine. 
 The removal of the appendix and adhesions was 
 followed by complete freedom from attacks of 
 colic. 
 
 The appendix wal] itself contains a muscle 
 coat, and the contents are frequently confined by 
 blocking of the passage, so it may perhaps be sur- 
 mised that the colic arises from a spasm of the 
 muscle coat. The reference of the pain to the middle 
 line would be in accordance with the experience that 
 peristalsis of any portion of the digestive tube causes 
 pain in the middle line, and parts that have 
 developed from the tube, as the gall-ducts and 
 appendix, follow the same law. 
 
The Great and Synall Intestine. 175 
 
 I cannot satisfactorily account for the predomi- 
 nant symptoms from the appendix being so distinctly 
 one-sided, seeing that it is developmentally a portion 
 of the digestive tube. But it is interesting to note 
 that, as in the case of the gall-bladder and ducts, and 
 even of the heart, though the most severe pains may 
 be situated across the middle line, the radiations and 
 persistence of the phenomena are one-sided. 
 
 In extension of the inflammation in appendicitis 
 other stuctures become involved, and these then 
 give rise to thq symptoms peculiar to themselves. 
 When the inflammation affects the parietal peri- 
 toneum, and adhesions form with it, these symptoms 
 will be found characteristic of peritoneal adhesions, 
 as pain and tenderness over the part {see page 203). 
 This fact may account for many of those aberrrant 
 symptoms in appendicitis, as when it is situated in 
 the pelvis and adherent to adjacent parts. 
 
 101. Affections about the Anus and Perineum. 
 — A somewhat compUcated series of symptoms 
 arise in affections about the anus, in consequence 
 of the nervous distribution passing from the 
 autonomic to the cerebro-spinal system. As at the 
 junction of other mucous and cutaneous surfaces the 
 sensibihty becomes profoundly modified, and there is 
 a transition area where certain forms of cutaneous 
 sensibility, such as pain, become more acute. This 
 difference in sensibility - is well seen in the case of 
 piles, for so long as the pile does not encroach upon 
 the tissues supplied by the cerebro-spinal nerves, no 
 direct pain is felt, whereas pain of the most distress- 
 ing character is felt when the pile encroaches on the 
 mucous membrane supplied by the cerebro-spinal 
 
176 Chapter X V I. 
 
 sensory nerves. Pain, however, may be felt from an 
 internal pile, and it is then referred to the back, over 
 the upper part of the sacrnm. I have seen much 
 relief afforded from this pain by free haemorrhage 
 from an internal pile. This referred pain is some- 
 times extremely distressing in cases of ulceration 
 within the rectum, especially after the bowels are 
 moved. When the ulceration or fissure involves the 
 sensitive marginal mucous membrane, the pain 
 becomes at times agonising and prolonged, and is 
 felt in an ill-defined area all around the anus and 
 over the sacrum. 
 
 There is an intimate relationship between this 
 region and the bladder, irritation at the anus i3ro- 
 ducing frequent micturition, and sometimes spasm 
 of the sphincter vesicae. This reflex is well seen in 
 women where the perineum has been torn at the birth 
 of a child and afterwards stitched up, retention of 
 urine being a frequent result. This reflex is prob- 
 ably limited to the skin of the perineum, as if care 
 be taken in stitching the perineum not to include 
 the skin in the stitches retention of urine is less 
 likely to occur. The skin supply for this region is 
 from the lower sacral nerves, and the nerve suppl}^ 
 for the sphincter vesicae is from the autonomic 
 sacral nerves — that is, from the same region of the 
 cord. 
 
 102. Perineal Reflex.— A curious connection 
 exists between the perineum and the respiratory and 
 other centres. This is seen particularly well in par- 
 turition, where, when the child's head presses on the 
 perineum, the contraction of the uterus is sometimes 
 greatly stimulated, and the mother is compelled to 
 
The Great and Small Intestine. 177 
 
 *' bear down " with uncontrollable energy. In 
 patients lightly under chloroform the traction made 
 by the forceps when the head reaches the perineum 
 somewhat causes the patient to breathe in a deep 
 and laboured fashion. Apart from its scientific 
 interest this latter reflex has to be borne in mind in 
 the administration of chloroform, as by the deep 
 respiratory movements a greater amount of chloro- 
 form may be taken than is desu'able. 
 
 103. Functional Symptoms.— Our knowledge of 
 the symptoms arising directly from abnormal func- 
 tions of the digestive tube is limited to the condition 
 of the faecal evacuations. These again must be 
 studied in association with other phenomena, as 
 pain, fever, distension of the abdomen. It is scarcely 
 necessary to insist on the systematic examination of 
 the faeces by the physician himself in all abdominal 
 oases, and the patient should be instructed to observe 
 for himself the character of the dejecta. The char- 
 acter of the normal stool is fairly constant, soft and 
 moulded, yellowish-brown in the adult, pale whitish 
 yellow in children and the milk-fed. The colour 
 may vary with the food and with drugs. The absence 
 of bile gives the characteristic pale drab-coloured 
 stools. There may be an admixture of the stoo] with 
 abnormal contents from the intestinal tract, as blood, 
 mucus and pus. Blood from near the anus, as in 
 piles, is usually unmixed mth the faeces, either free 
 or staining the faecal mass. When its origin is 
 higher up it becomes mixed with the food, and under- 
 going certain chemical changes, becomes black and 
 " tarry " looking. The character of the mucus in the 
 stools may give some idea as to its source ; small 
 
178 Chapter XV I. 
 
 jelly-like masses accompany the diarrhoea from an 
 inflamed swollen gut, shreds or membrane-like pieces 
 are seen in affections of the colon and rectum. Other 
 abnormal constituents may be present, as undigested 
 food, gall-stones, intestinal sand. 
 
 The character of certain stools is fairly typical, 
 as the diarrhoeic, with hard scybalous masses, 
 indicating that scybalse are lodged in some part of the 
 digestive tract, and setting up irritation ; the " pea- 
 soup " stools of typhoid fever and of pneumonia ; the 
 " rice water " stools of cholera ; the " frothy stools " 
 of infantile diarrhoea. The shape of the stool may 
 be modified by its passing through a constricted 
 passage near the anus. The recognition of ol)struc- 
 tion, partial or complete, need not be insisted upon. 
 
 Indirectly there are signs of functional dis- 
 turbance, as in the poor nutrition. Absorption of 
 toxic products may interfere with the functions of 
 other organs, particularly the heart, causing weak- 
 ness, irritability, and pain. The skin of the armpits 
 and of the abdomen may become of a dirty yellow 
 colour from the same cause. 
 
 104. Structural Symptoms. — Symptoms due to 
 changes in the bowels are very often difficult to make 
 out, owing to the mobility of these organs, and the 
 ease with which they can become distended with 
 flatus. Except the caecum and a small portion of 
 the ascending colon and the rectum, there is no part 
 in which changes can be with certainty located on 
 account of shifting and distension of the intestinal 
 coils. In addition to this, tumours and thickenings 
 in any part of the abdomen so readily convey the 
 tympanitic note from the bowel that percussion is 
 
The Great and Small Intestine. 179 
 
 seldom of much use in detecting these when they are 
 in the walls of the bowel. A further complication 
 arises when small portions of the muscles of the 
 abdominal wall become hard and contracted. 
 Manifest changes in the bowels should always be 
 considered with reference to the reflex phenomena 
 already described. 
 
( 180 ) 
 
 Chapter XVII. 
 
 AFFECTIONS OF THE URINARY SYSTEM. 
 
 105. Symptoms of Affections of the Kid7iey. 
 
 106. Symptoms of Affectio7is of the Pelvis of the 
 
 Kidney and Ureter. 
 
 107. Symptoms of Affections of the Bladder. 
 
 105. Symptoms of Affections of the Kidney. — 
 
 As in the affections of other glandular organs, 
 there are practical^ no sensory symptoms evoked 
 by disease of the kidney structure. Backache is 
 sometimes put down as present in inflammation of 
 the kidney, but considering how frequent backache 
 is, some doubt may be entertained whether the kidney 
 is the cause. For a great many years I have carefully 
 inquired into the S3^mptoms in aU sorts of cases of 
 albuminuria, acute and chronic, and I could find no 
 evidence of pain of anj^ form referable to the kidney 
 trouble All the symptoms of kidney disease (apart 
 from alteration in the size of the organ) are found 
 in the chemical examination of the urine, in the 
 frequent micturition, or as the result of its impaired 
 secretion on other organs and systems (vomiting, 
 headache, convulsions, changes in the cardio- vascular 
 system, dropsy). 
 
Affections of the Urinary System. 181 
 
 Functional Symj^tonis. — In the routine exam- 
 ination of all cases inquiry should be made into the 
 question whether the patient has to get up at night 
 to pass mine, and, if such is the case, the urine 
 should be examined for albumen or sugar. The 
 presence of albumen should lead to the careful exam- 
 ination of other systems, particularly the heart and 
 blood vessels, because it is the effect of the impaired 
 kidney function on these that offers the best guide 
 as to the importance of the albuminuria. It must be 
 borne in mind that the presence of albumen is not in 
 itself a matter of moment. It only indicates that 
 albumen is passing through the secretory cells, and 
 long experience has taught that when this happens 
 there is an injury to these cells which prevents the 
 elimination of other matters, which, being retained 
 in the blood, have a deteriorating influence on 
 other organs. It is for this reason that the 
 significance of the kidney affection is often deter- 
 mined by the symptoms in other organs and tissues. 
 
 Structural Symptoms. — It is only when there is 
 a considerable increase in the size of the kidney that 
 we can detect its presence cUnicalty with assurance. 
 And even then the subject has to be of a somewhat 
 spare habit. Normally we recognise a certain full- 
 ness under the lower ribs in either flank, which 
 rather indicates its presence than gives a clue to its 
 size. It is the relative greater fullness on one side 
 that leads to the recognition of the increase in the 
 size of this organ, and the absence of this fullness 
 which leads to the suspicion of a displaced kidney. 
 The nature of the enlargement in any given case is 
 surmised from the presence of other symptoms, as 
 
182 Chapter X V 1 1. 
 
 pus or tubercle bacilli in the urine, the cancerous 
 cachexia, etc. 
 
 Movable Kidney. — The careful palpation of the 
 abdominal cavity with the walls relaxed may reveal 
 a movable kidney. It is often present without symp- 
 toms, but its presence may be associated with a good 
 deal of vague, indefinite pain, dilatation of the 
 stomach, and more or less nervous disturbance of a 
 " neiu-asthenic " kind. Obscure attacks of vague 
 pains, nausea and collapse have been ascribed to a 
 movable kidney, and it is well to bear this in mind, 
 for such attacks may be attributed to appendicitis 
 or other intestinal lesion, or to renal colic. 
 
 106. Symptoms of Affections of the Pelvis of 
 the Kidney and Ureter. — Nerve Supply of the 
 Ureter. — ^The efferent nerves supplying the pelvis of 
 the kidney and the ureter come from the inferior 
 mesenteric, spermatic and hypogastric plexuses. The 
 level at which these nerves leave the cord can be 
 inferred from the study of the nerves implicated in 
 the reflex phenomena in cases of renal calculus. 
 From this study the nerves passing from the pelvis 
 of the kidney and the ureter can be inferred to 
 reach the spinal cord at the level of the lower 
 thoracic and upper lumbar nerves. The distribu- 
 tion of the pain and the stimulation of the 
 muscles to contraction, in the case of renal colic, 
 give a clue to the cerebro-spinal nerves reflexly 
 stimulated by the sympathetic nerves from the 
 pelvis of the kidney and the ureter. The pain 
 arising in the back above the crest of the 
 ilium, passing round the front and slanting down 
 
Affectio7is of the Ur'mary System. 183 
 
 into the testicle, as in the shaded area of Fig. 18, 
 page 185, traverses the fields of distribution of 
 several spinal nerves from the eleventh thoracic to 
 tlie second lumbar. In like manner the contraction 
 of the muscles that accompany the pain gives a clue 
 to tlie motor cerebro-spinal nerves that have been 
 stimulated. In many cases contraction of the 
 flat muscles over the ihac fossa (the external and 
 internal obliques, and the transversalis abdominis) 
 is produced, the lower portion of these muscles 
 being supplied by the lower thoracic nerves. 
 The contraction of the cremaster muscle, which is 
 often such a distinct feature in cases of renal colic, 
 implies a stimulation reaching the spinal cord at the 
 level of the first and second lumbar nerves. It is 
 interesting to note that a portion of the fibres of the 
 cremaster are continuous with the internal oblique 
 and both of these muscles contract in renal colic. 
 The genital branch of the genito-crural nerve con- 
 tains the motor nerve to the cremaster muscle, and 
 also the sensory nerve to the tunica vaginalis, which 
 latter becomes so hypersesthetic in renal colic when 
 the pain " shoots into the testicle," and it is manifest 
 that it is to the peripheral distribution of this nerve 
 that the pain is referred. It is to be remembered 
 that the scrotal covering of the testicle is supplied 
 by the sacral nerves, and the skin of the scrotum is 
 never affected in renal colic. 
 
 Non-striped muscle enters into the structure of 
 the pelvis of the kidney and of the ureter, and in 
 consequence we have the reflex symptoms developed 
 to a very marked and characteristic extent. While 
 any circumstances that can arouse the severe 
 
184 Chapter XVI I. 
 
 contraction of this muscle seem to provoke the pain 
 and attendant phenomena, the presence of a renal 
 calculus is, in the great majority of cases, the 
 immediate cause. The following description, while 
 referring to renal calculi, also applies to other 
 causes, as pus or tuberculous ulceration, which may 
 set up a painful contraction. 
 
 The position of the pain, its characteristic 
 radiation, and the attendant muscular contraction, 
 have been referred to. The place where the pain 
 starts is of very great importance as giving an idea 
 of the approximate site of the stone. It must be 
 remembered that the gradual shifting of the pain 
 from the back round to the front and down to the 
 groin is not an indication that the stone itself is 
 gradually being shifted and driven down the ureter. 
 Nor must it be imagined that because the distribu- 
 tion of the pain has a vague resemblance to our 
 notion of the position of the ureter that the pain is 
 felt " along the ureter." The pain in its radiation 
 is passing along some path in the spinal cord, and 
 thereby affects the cord centres of the nerves dis- 
 tributed to the body wall in the area shaded in 
 Fig. 18. Doubtless the peculiar path is directly 
 associated with the nerve supply of the pelvis of the 
 kidney and of the ureter, and as each part passes 
 into peristalsis a definite portion of the spinal cord 
 receives a corresponding stimulus, just as happens 
 in the case of the peristalsis of the bowel. 
 
 Bearing this in mind, it will be seen that when 
 the pain keeps recurring and starting from the 
 same place the stone is stationary, and its presence 
 
Affections of the Urinary System. 
 
 185 
 
 V 1 / 
 
 Fig. 18. 
 
 The shaded area shows the distribution of the cutaneous hyperalgesia 
 after an attack of renal colic. The band traverses portions of the fields 
 of distribution of the eleventh and twelfth thoracic nerves and of the first 
 lumbar. The tunica vagmalis and the lower portion of the left abdominal 
 muscles were also hyperalgesic. 
 
 stimulates a peristaltic contraction. Hence when we 
 find repeated attacks starting at the back we may 
 safely infer that the stone is lodged in or near the 
 pelvis of the kidne}^ There is some doubt whether a 
 stone in the kidney surrounded by glandular tissues 
 and not protruding into the pelvis can ever arouse 
 the pain characteristic of renal calculus, for it seems 
 that contraction of muscle is the cause of the pain, 
 and the calculus acts as a stimulus to the contraction. 
 
186 Chapter XV 11. 
 
 The explanation of the locahty of the pain is 
 that the spinal centres of some fibres of the eleventh 
 thoracic nerve wliich are distributed in the back 
 are first stimulated, that as the peristaltic wave 
 passes down it sends stimuli to other centres of 
 the eleventh and twelfth nerves whose fibres are 
 distributed in the area shaded in Fig. 18, and later to 
 the genital branch of the genito-crural nerve which 
 is distributed to the tunica vaginalis ; hence the pain 
 which shoots into the testicle and the tenderness of 
 the testicle, or rather of the tunica vaginaHs, after 
 an attack of renal colic. 
 
 In a number of cases the stone seems to stick on 
 its way down the ureter, and the pains then start at 
 a lower level. One may sometimes find a patient with 
 a history of attacks of pain starting in the back, 
 then after a time starting somewhere in the front of 
 the abdomen ; then they have ceased, and the symp- 
 toms of irritation of the bladder have appeared for 
 a period, followed by the expulsion of a calculus and 
 complete rehef. 
 
 I am disposed to think that in these cases the 
 stone is lodged at the entrance of the ureter into tlie 
 bladder. We know from observation on the bowel 
 that violent peristalsis takes place above the point 
 of obstruction, while the bowel below does not con- 
 tract, and it seems that the same is true of the ureter. 
 In these cases the pain passes down as low as the 
 testicle, and this would imply, if my reasoning is 
 right, that the peristalsis has extended to the lowest 
 portion of the tube. It is not likely if the stone were 
 lodged in the middle of the ureter, and completely 
 blocking the lumen, that a peristalsis would be set 
 
Affections of the Urinary System. 187 
 
 up in the part below. This is a point worth con- 
 sidering by those who have the opportunity of 
 locating the stone by operation, and seems to be 
 the explanation in the following case, 
 
 Male, aged 32, consulted me, with the following 
 history. He had emigrated to America two years 
 previously. For the first year he had enjoyed good 
 health, but during the past year he had been in such 
 constant suffering that his health was shattered, and 
 he had returned to his native country, in the hope 
 that the change might do him good. He was spare 
 and thin, walked with a slight stoop, and his face 
 was drawn and anxious. In conversation he was 
 nervous and irritable, and I had the greatest diffi- 
 culty in getting from him a distinct account of his 
 complaint, as he had become extremely neurotic, and 
 mixed his mental impressions and his digestive 
 troubles with the description of pains in various 
 parts of his body. With strict inquiry I found that 
 his illness began with severe attacks of pain in his 
 back, which he referred to the left lumbar region. 
 For three months these attacks continued until he 
 became weak and ill. After this the pain shifted, 
 starting over the iliac fossa and striking into the 
 testicle, and his testicle became tender, so that it hurt 
 him to wear his breeches. In the past few months 
 this pain had disappeared, and he was now suffering 
 from great perineal pain, especially at the end of 
 micturition. From the account given by the patient 
 the salient points have been selected, leaving out the 
 numerous other symptoms from which he suffered, 
 and which he had mixed up in almost inextric- 
 able confusion, besides giving his own irrelevant 
 
188 Chapter XVII. 
 
 views as he went along. It was evident that 
 the patient had had a renal calculus, which had 
 shifted its position and was now in his bladder, 
 and his long suffering had reacted on the 
 nervous system, producing very characteristic 
 neurotic or neurasthenic symptoms. I sounded his^ 
 bladder and could find no stone, but assured him 
 that there was a calculus in his bladder A few days 
 after he again called to see me, a totally different 
 man, erect and smiling, and held out to me, in the 
 palm of his hand, a calculus, the size of a small 
 bean, which he had passed the previous day. My 
 reading of the symptoms was, a renal calculus, at 
 first lodged in the pelvis of the kidney, then at the 
 lower part of the ureter, and finally in the bladder. 
 The suffering had weakened and exhausted the ner- 
 vous system and produced other widespread pheno- 
 mena. I have already drawn attention to the well- 
 known fact that prolonged suffering tends to produce 
 a hypersensitive nervous system, so that other affec- 
 tions, such as gastric flatulence, produce exaggerated 
 symptoms. 
 
 The reflex symptoms resulting from a renal 
 calculus may be much more extensive, and give rise 
 to symptoms indicative of other lesions, as shown by 
 the following case. 
 
 Renal Colic. — A man, aged 30, had suffered for 
 a year from occasional attacks of renal colic, and one 
 attack had been followed by hsematuria. He was a 
 very intelligent man, and I told him to note every 
 particular during an attack. The foUowing is a 
 summary of his statement — the original statement 
 being illustrated by the patient placing his hand 
 
Affections of the Urinary System. 189 
 
 over the regions mentioned : The pain suddenly 
 seizes him with great severity in the right lumbar 
 region, then after a few minutes it strikes into the 
 front of the abdomen over the iliac fossa. Then the 
 belly becomes hard and rigid. The pain then strikes 
 do^vn into the internal part of the groin, the testicle 
 is felt to be drawn up, and the pain then shoots 
 into the testicle. The facts here described were 
 corroborated by him in a few subsequent attacks, 
 each attack invariably pursuing the same sequence. 
 My notes made after an attack describe an indefinite 
 area of cutaneous hyperalgesia over the iliac fossa, 
 hardness and rigidity of the abdominal muscles over 
 the right iliac fossa, with great tenderness on 
 pressing over the muscles and on pressing the right 
 testicle and the right erector spinse muscles in the 
 lumbar region. Here the symptoms pointed to a 
 locahsed stimulation of the spinal cord at the origin 
 of the sensory nerves supplpng the skin over the 
 right iliac region, the testicle and the abdominal and 
 erector spinas muscles, and at the origin of the motor 
 nerves supplying these abdominal muscles and the 
 cremaster muscle. These nerves issue from the spinal 
 cord by the twelfth thoracic and first lumbar roots. 
 The area stimulated in the cord, it will be observed, 
 is not confined to one segment, but passes along a 
 path which affects only a hmited portion of several 
 segments — a curious feature with which I have 
 dealt in describing the radiation of pain. 
 
 In regard to the immediate cause of the symp- 
 toms, I reasoned that there was a calculus lodged 
 somewhere about the pelvis of the kidney, and that 
 its presence acted like a foreign body, sending a 
 
190 Chapter XVII. 
 
 wave of strong peristalsis down the ureter, the 
 gradual passage of the peristalsis sending strong 
 stimuli to a descending region of the spinal cord. 
 The fact that the pain always started at the same 
 place indicated that the stone remained fixed in its 
 position, a view confirmed by the fact that there was 
 never any evidence of the calculus having reached the 
 bladder. The reasons I had for the assumption that 
 the stone remained in the pelvis will be gathered as 
 I develop my argument. An X-ray photograph 
 failed to reveal the stone. Such being my opinion I 
 sent the patient to Mr. Wright, who, agreeing with 
 my diagnosis, operated in 1903, and found a small 
 calculus about the size of a pin's head adherent to 
 the apex of a calyx, opposite the junction of the 
 middle and lower third of the kidney. This was 
 removed, and the patient made a good recovery, and 
 has remained quite free from all symptoms. 
 
 The nerve supply of the viscera and their con- 
 nection with the cerebro-spinal nerves is fairly con- 
 stant. Sometimes it would seem as if the centres 
 in the cord were at a slightly different level, so that 
 the sensory symptoms were referred to regions 
 higher or lower than the usual level. Such is the 
 interpretation I give for the high situation of the 
 sensory symptoms in the following case. 
 
 Male, born 1864, consulted me in October, 1900, 
 complaining of severe spasms of pain from w^hich 
 he had been suffering five days. He had had 
 similar attacks twelve years before. He refeiTed 
 the pain with great definiteness to the area 
 shaded in Fig. 19, this area corresponding to 
 a region of deep cutaneous hyperalgesia — that 
 
Affections of the Urinary System. 
 
 191 
 
 Fig. 19. 
 
 The shaded area corresponds to the site of pain and cutaneous hyper- 
 algesia in a case of renal calculus after an attack of colic. 
 
 is to say, the skin here was very tender if 
 gently raised and gently pinched, but showed no 
 increased sensitivenesss to light scratching with a 
 pin-head. This area of tenderness extended round 
 to the spine. I was in doubt as to the cause of these 
 attacks of pain. The onset and character of the sen- 
 sation corresponded to an attack of renal colic, but I 
 had never seen a case with the pain and tenderness 
 so high. Under treatment (rest and opium) the 
 attacks subsided. He again consulted me for a 
 similar series of attacks in October, 1903. He had 
 
192 Chapter XVII. 
 
 had an occasional attack in the interval, but they 
 were becoming more frequent. There was still 
 present the characteristic area of deep cutaneous 
 hjrperalgesia, as in Fig. 19. During one of these 
 attacks the pain suddenly passed into the left lumbar 
 region, and then round to the front of the abdomen, 
 to the groin and into the left testicle. At the same 
 time he was conscious of the testicle being forcibly 
 drawn up. When I examined him there was much 
 tenderness on pressing the lumbar muscles and the 
 left testicle. Under rest and opium the pain sub- 
 sided, and two days later in voiding urine he passed 
 a small calculus. There was complete freedom from 
 pain until October, 1905, when he again had a few 
 attacks of pain referred to the area shaded in Fig. 
 19. The pain passed downwards to the groin and 
 testicle, and again he was conscious of the testicle 
 being firmly drawn up. He rested in bed four hours, 
 and upon micturating he passed another small 
 calculus. He has remained free from any further 
 attack. 
 
 107. Symptoms of Affections of the Bladder.— 
 The bladder in its development is derived from 
 two sources, the allantois and the cloaca. From the 
 former there comes the upper division, and from 
 the latter the fundus of the bladder (the trigone). 
 The nerve supply of the bladder is hkewise from 
 two sources, from the upper lumbar region and 
 from the sacral autonomic (second and third sacral) 
 {see Fig. 5, page 59). As a result of this nerve supply 
 the sensory symptoms are felt in two regions, in the 
 hypogastric region, where the upper lumbar nerves 
 are distributed, and in the perineum, and along the 
 
Affections of the Urinary Sy stein. 193 
 
 penis, where the sacral nerves are distributed. The 
 pain from an over- distended bladder, as in retention 
 of the urine, is felt mainly above the pubis, and 
 resembles in its situation and character the pain of 
 uterine contraction or the pain of peristalsis of the 
 lower end of the great gut. This pain is intermittent 
 in character, and is due to the passage of the waves of 
 contraction over the bladder. When there is much 
 irritation of the bladder, as in acute inflammation of 
 its mucous membrane, or in the presence of a stone, 
 the contraction of the bladder at the end of micturi- 
 tion is sometimes very severe, and the pain is then 
 felt both above the pubis and in the perineum, also 
 along the penis. In many cases of stone, the pain 
 from the perineum to the point of the penis is the 
 most distinct, being felt most severely at the end of 
 micturition, but severely also at other times, and 
 patricularly if the patient is jolted. The viscero- 
 motor-reflex is usually not well marked, but I have 
 noted contraction of the lowest division of the recti 
 in cases of stone in the bladder. 
 
 The act of micturition is a reflex that may be 
 stimulated into activity in a great many ways. Nor- 
 mally there is a distinct relationship between the 
 distension of the bladder and the act, fiUing of the 
 bladder setting up reflexly the contraction of the 
 muscular wall, which results in the expulsion of the 
 urine. In the child the act of micturition is purely 
 reflex, but with advancing age the individual 
 acquires more or less voluntary control of the act of 
 micturition. 
 
 In addition to the muscle waU of the bladder the 
 abdominal muscles may assist by compressing the 
 
194 Chapter XV II. 
 
 bladder, and in expelling the last drops the perineal 
 muscles (especially the levator ani and the accelera- 
 tor urinae) play an important part. The act of 
 micturition in the infant, or the calls to micturate 
 in the adult, may be so frequent as to raise the 
 question of some abnormal accentuation of the 
 stimulus. This may arise in a great many ways, as 
 in the excessive quantity of urine secreted (in 
 diabetes and certain forms of Bright' s disease), the 
 irritating nature of urine as in concentrated or very 
 acid urine, the presence of abnormal ingredients as 
 oxalates, pus, blood, calculi. The wall of the bladder 
 may be inflamed and irritated, so that a small quan- 
 tity of normal urine may serve as a stimulus. Stimuli 
 from other organs and tissues affecting the spinal 
 centres of the bladder may provoke frequent mic- 
 turition, as in affections of the kidney, ureter, anus, 
 and perineal region. Or there may be an irritable 
 focus in the cord, due to lesion of some other viscus, 
 which invades the bladder centre, so that impressions 
 from the healthy bladder have an exaggerated effect 
 and cause the frequent micturition seen in such cases 
 as renal calculus, appendicitis, affections of the 
 ovary and uterus, and piles. In these cases there 
 will always be found some region of hyperalgesia in 
 the external body wall characteristic of the particu- 
 lar organ at fault. A cause of frequent micturition 
 often overlooked is over-distension of the bladder 
 from some such obstruction as enlarged prostate in 
 the male, or pj-egnancy or pelvic tumour in the 
 female. Examination of the resonance above the 
 pubes may reveal the dullness due to a distended 
 bladder in the male, but when there is a pregnant 
 
Affections of the Urinary System. 195 
 
 uterus, or other tumour, it may not be possible to 
 recognise the distended bladder. The doctor, misled 
 by an account of frequent micturition, may fail to 
 detect the trouble, and very serious consequences may 
 result from this being overlooked. In pregnancy, 
 with retention of urine of this sort, the patient may 
 die if relief is not speedily obtained. 
 
 Functional Symptoms. — Although the chief 
 function of the bladder is to retain and expel the 
 kidney secretions, it, like other mucous membranes, 
 has a secretion of its own. The secretion is normally 
 only perceptible in very delicate analysis of the 
 urine. The contents of the bladder may irritate the 
 mucous membrane, so that its secretion may be more 
 a^bundant, and may become perceptible as a haze at 
 the bottom of the glass when the urine has cooled 
 and stood for some time. This mucous secretion may 
 increase in quantity with the irritation or inflam- 
 mation of the bladder wall, till the urine becomes 
 thick and viscid, and even blood-stained, according 
 to the degree of inflammation. Pus also may be 
 secreted from the inflamed mucous membrane, or 
 from an ulcer. These abnormalities, however, are to 
 be detected by following the usual routine of urine 
 examination, with which I do not propose to deal. 
 
 Structural Symptoms. — Changes of the organ 
 can only be detected by its increase in size above the 
 pubes, or by exploration with the finger in the rectum 
 or vagina. In either case, when abnormalities are 
 detected, additional evidence has to be sought by 
 examination of the bladder by the catheter, by 
 sounding, by X-rays, or by use of the cystoscopy 
 
 o 2 
 
( 196 ) 
 
 Chapter XVIII. 
 
 AFFECTIONS OF FEMALE PELVIC ORGANS. 
 
 108. The Uterus. 
 
 109. The Ovaries. 
 no. The Vagina. 
 
 I have been unable to satisfy myself as to the 
 sensibility of some parts of the female pelvic organs. 
 The uterus above the cervix is certainly insensitive 
 to ordinary stimuli, for I have many times tested 
 the interior, with my whole hand in the uterus, 
 during and after labour, and in scraping out the 
 contracted uterus. The pains during labour are 
 undoubtedly referred, as I shaU describe later. I 
 cannot form any definite opinion of the sensibihty of 
 the cervix, or for that matter of the vagina. In 
 regard to the cervix I have been able to pinch it and 
 to prick it, with no sensation, but on the other hand 
 great pain is often experienced when an attempt is 
 made to dilate it. But whether this is a direct or 
 a referred pain I could not decide. The patient is 
 so conscious of the stimulation of the external geni- 
 tals and to the discomfort in the sensitive parts, that 
 her statements become affected by suggestion, and 
 the reference is too confused to be of use. In th& 
 same way the extent of the supply of cerebro- spinal 
 nerves to the vagina is not understood, nor could I 
 
Affections of Female Pelvic Organs. 197 
 
 determine the limits by stimulation, for the sensory 
 nerves are modified for special sensations. The 
 tendency to exaggerated reflexes in most cases adds 
 to the confusion, for such patients will say they 
 experience a sensation before they are stimulated, 
 and in their apprehension they anticipate or 
 exaggerate the result. A further complication 
 results from the difficulty in diagnosis, it being very 
 rare to obtain a satisfactory proof of the nature of 
 the ailment in cases showing what seemed the most 
 typical evidence of referred symptoms. In the 
 following brief description the subject is dealt with 
 so far as reliable evidence could be obtained. 
 
 108. The Uterus. — The pain of uterine con- 
 traction is a distincly referred one, though this 
 seems scarcely probable on superficial observation. 
 In palpating the pregnant uterus during labour the 
 onset of the contraction and the pain are simul- 
 taneous and evidently so distinctly related that it 
 seems improbable that the pain is not a direct one, 
 especially when the pain is so often described as 
 being felt across the abdomen in the region where the 
 uterus is felt contracting. But if the matter be in- 
 quired into more carefully it will be found that the 
 pain is frequently not felt across the abdomen, but 
 across the back at the level of the top of the sacrum. 
 Here again the hasty observer has attributed the 
 pain to the child's head " distending the cer\4x," or 
 " pressing on the lumbar plexus " ; but this pain is 
 referred here before the cervix is distended, and also 
 after the child is expelled, during the " after-pains," 
 when the uterus can be found to contract, although 
 the patulous cer\ix is untouched. This pain in the 
 
198 Chapter XVIII. 
 
 back is found not only in labour at full term, but also 
 during a miscarriage. The pain referred to the 
 front of the belly, between the umbilicus and pubes, 
 is also present when the iiterus is not an abdominal 
 organ but a pelvic one, as in miscarriage, after- 
 pains, and other causes that induce uterine contrac- 
 tion. It is well seen in the severe spasms of pain 
 that occasionally occur when some fluid from a 
 vaginal douche escapes into the uterus and sets up 
 uterine spasm. 
 
 In rare cases we may find the pains due to the 
 contraction of the pregnant uterus referred to a 
 distinctly lower level, and in one case the pains were 
 all felt across the upper front portion of the thighs. 
 
 Very exact delimitation of the area of pain is 
 not possible, but the region in which uterine pain 
 may occur extends from the tenth thoracic to the 
 third lumbar nerves, though in any individual case it 
 is restricted to a limited portion of that distribution. 
 
 109. The Ovaries. — The nerve supply of the 
 ovary is not exactly known, but, like the testicle, its 
 develoj)ment starts higher up in the abdomen than 
 the position it occupies in adult life. The testicle 
 has been shown to be developed between the tenth 
 and twelfth dorsal vertebrae, and the nerve supply 
 presumabty comes from the same region. So far as 
 I have been able to make out, the pain felt in ovarian 
 trouble is referred to the lowest part of the abdomen 
 of one side, and over the groin in the position in 
 which the testicular pain is felt. The lowest portion 
 of the abdominal muscles in this situation readily 
 becomes hyperalgesic and contracted. This charac- 
 teristic region of tenderness has often misled 
 
Affections of Female Pelvic Organs. 199 
 
 observers into tlie belief that tlie pain evoked by 
 pressure in this region was due to a " tender ovary," 
 a statement with some truth in it, but not in the 
 sense intended, for the ovary itself in such eases is 
 not affected by the pressure, the pain of the pressure 
 arising from the stimulation of the hyperalgesic 
 skin or muscle. 
 
 Beyond an indefinite patch of hj^peralgesia of 
 the skin in the region of the groin, extending some- 
 times for a variable distance down the thigh, I have 
 not been able to make out much that is reliable in 
 regard to the hyperalgesic area of ovarian disease. 
 It is in these cases we often find such widespread 
 areas that it is doubtful how much is due to the 
 actual ovarian lesion. 
 
 Associated with all forms of pelvic trouble are 
 a number of other reflexes. Thus the breasts fre- 
 quently become tender, especiall}" at the menstrual 
 period. A cough is sometimes spoken of as being 
 " uterine," or of ovarian origin, but I have not been 
 able to convince myself of such a thing. Vomiting 
 is a frequent reflex symptom, particularly in preg- 
 nancy, but here it is probabh^ not of a reflex nature, 
 but toxaemic. As I have already remarked, it is 
 sometimes a pure reflex, as in the vomiting associated 
 with the uterine pains. The effects of stimulation of 
 the ovary have not led to a very definite result, partly 
 because of the difficulty in doing this without stimu- 
 lating the sensitive orifice (anal and vaginal). The 
 ovary, like the testicle, is partly covered b}'' germinal 
 epithelium, and this may modify the sensitivity. 
 
 110. The Vagina. — The character of the pain 
 in vaginal affections is so ill- defined that it is difficult 
 
200 Chapter XV III. 
 
 to say whether it is direct or referred. This is seen 
 in the cases of urethral caruncle, where the pain 
 may be of a very severe form and the localisation so 
 vague that the detection of the cause is often a 
 matter of some difficult} . It resembles in some 
 respects the severe vague pain of an anal fissure. 
 A powerful reflex contraction of the muscles that act 
 as sphincter of the vagina, on certain conditions of 
 irritation of the vaginal mucous membrane, may 
 produce vaginismus. 
 
( 201 ) 
 
 Chapter XIX. 
 
 PERITONITIS AND PERITONEAL 
 ADHESIONS. 
 
 111. Insensitiveness of the Peritoneum. 
 
 112. Symptoms in Peritonitis. 
 
 113. Symptoms in Peritoneal Adhesions {Parietal). 
 
 114. Sijmptoms in Peritoneal Adhesions ( Visceral). 
 
 111. Insensitiveness of the Peritoneum. — I 
 
 have already referred to the fact that the serous 
 surface of the peritoneum is insensitive to any form 
 of stimulation, but that the external layer of 
 the parietal peritoneum is an extremely sensitive 
 structure, stimulation of which produces the 
 sensation of pain. It is commonly assumed that 
 the peritoneum is an extremely sensitive structure, 
 liarticularly when inflamed. I must say, however, 
 that I have found no evidence of any increase in the 
 sensibility of the inflamed serous surface when I 
 have stimulated it directly, and I have done 
 this repeatedly in patients free from any form 
 of analgesia. To a certain extent the popular 
 misconception of the sensibility of the peritoneum 
 has arisen from the fact that no attention has been 
 paid to the hyperalgesia of the structures of the 
 external body wall, including the external layer of 
 the parietal peritoneum. The result has been that 
 
202 Chapter X I X. 
 
 the evidence of peritonitis is almost invariably based 
 on the pain and tenderness on pressure — evidence 
 which, as I have endeavoured to demonstrate, is not 
 due to peritonitis, but to the hyperalgesia of the 
 structures of the external wall. That peritonitis 
 may produce these symptoms is true, but it does so in 
 the same way as the viscera produce them — i.e., by 
 reflex stimulation. The reason of the insensibility 
 of the peritoneum is the same as that for the insen- 
 sibility of the viscera, namely, that the nerve supply 
 of the peritoneum arises from the sj^mpathetic, with 
 the exception of the external layer of the parietal 
 peritoneum, where the nerve supply is from the 
 cerebro-spinal nerves. 
 
 112. Symptoms in Peritonitis. — If we take a 
 case of acute peritonitis a careful analysis of the 
 symptoms reveals their true nature. Thus, in a case 
 of ruptured gastric ulcer, where there was an exten- 
 sive peritonitis limited to the upper part of the 
 abdomen as shown b}" post-mortem examination, the 
 patient lay on her back with the knees drawn up, 
 partly to relax the abdominal muscles, and partly to 
 avoid the pressure of the bed-clothes on the abdo- 
 minal wall. She shrank at the first attempts to pal- 
 pate the abdomen, and when the skin was tested it 
 was found extremely hyperalgesic, the lightest touch 
 producing the sensation of pain. The area over 
 which this hyperalgesia extended had no definite 
 relation to the extent of the peritoneal inflammation. 
 Thus, for instance, in marking out the linits of the 
 cutaneous hyperalgesia I found it extended for a few 
 inches up over the chest and down over the thighs, 
 the margin fading away indefinitely. The sensibility 
 
Peritonitis and Peritoneal Adhesions. 203 
 
 of the muscles of the abdominal wall could not be 
 tested on account of the hyperalgesia of the skin over 
 them. They were, however, partially contracted, 
 and the lightest palpation produced a rapid and 
 strong reflex contraction. 
 
 In less extensive peritonitis these symptoms 
 may be limited to a small portion of the abdominal 
 wall, and when they are present it is impossible to 
 distinguish them from the hyperalgesia and muscular 
 contraction due to some visceral affection. The 
 hyperalgesia following an attack of gall-stone colic, 
 or due to a gastric ulcer, is almost invariably attri- 
 buted to a " peritonitis," and this view is supposed 
 to be proved when, during operation for gall-stones, 
 a certain number of peritonitic adhesions are found. 
 While peritonitis can produce hyperalgesia of the 
 external body wall it should always be borne in 
 mind that the viscera can also do this, and when 
 hyperalgesia is found in gastric ulcer, after gall- 
 stone, renal or bowel cohc, the cause of the hyper- 
 algesia is in all likelihood not peritonitis, but the 
 presence of an irritable focus in the spinal cord, the 
 outcome of the violent visceral stimulation. 
 
 113. Symptoms in Peritoneal Adhesions 
 (Parietal). — I have broken down adhesions and 
 found them insensitive, but when they are attached 
 to the parietal peritoneum, cbagging on them may 
 produce severe pain. Ramstrom also describes the 
 serous surface of the parietal peritoneum as insen- 
 sitive, but that pulling on the adhesions attached to 
 the parietal la3^er causes pain, thus agreeing with my 
 own observations. I attribute this to the fact that 
 the inflammation that resulted in the production of 
 
204 Chapter XIX, 
 
 the adhesions had extended to the peritoneal layer 
 supplied by the cerebro-spinal sensory nerves. The 
 difficulty in distinguishing between visceral pain 
 and the pain due to the invasion of the external 
 bod}^ wall is very great. In many visceral ailments 
 the inflammatory affection extends and involves the 
 sensitive structures of the abdominal wall, and with 
 this extension a new train of symptoms arises which 
 may lead to wrong inferences if these differences in 
 the sensibihty of the structures are not clearly kept 
 in view. One can easily see how appendicitis may 
 give rise to symptoms which are entirely confined to 
 the reflex group, until the inflammation extends to 
 the abdominal wall, when another series of symp- 
 toms may arise which are produced by a different 
 mechanism, and are detected in the immediate region 
 of the inflammation. 
 
 For the study of the symptoms of adhesions 
 those formed after operation offer the best oppor- 
 tunity, inasmuch as their presence can be inferred 
 and the operation has determined the condition of 
 the viscera. Maylard says : " It is doubtful whether 
 any opening of the general peritoneal cavity ever 
 takes place without the subsequent formation of 
 adhesions, for no tissues of the body seem so ready 
 to exude a plastic cementing material, which glues 
 almost at once any structure lying in contact with 
 it." It is probably due to these adhesions that so 
 much pain and tenderness is felt after some simple 
 abdominal operation, even when the operation is 
 purely exploratory, and no injury has been done 
 to any viscus. The hyperalgesia in such cases is 
 often muscular, and associated with a lively reflex of 
 
Peritonitis and Peritoneal Adhesions. 205 
 
 the hyperalgesic muscles, so much so that tlieir exer- 
 cise, as in walking, may result in their shortening, 
 from an increase of their tonic contraction, for a 
 longer or shorter time. Small portions of these 
 muscles may remain firmly contracted for long 
 periods, and sometimes they so closely resemble a 
 tumour in the abdomen that it is impossible to 
 tell whether the hardness is a contracted muscle 
 or not. 
 
 Tn a case of pyloric stenosis, in which gastro- 
 enterostomy had been performed, muscle pain and 
 tenderness persisted in the left rectus muscle. As 
 the patient experienced no relief, she again con- 
 sulted the surgeon who had performed the operation. 
 He detected a small tumour in the abdomen, and 
 insisted on an operation for its removal. I thought 
 the tumour was a contraction of a portion of the 
 fibres of the left rectus muscle at the upper portion 
 of the second interseptal division. As, however, the 
 surgeon was very confident of his opinion, and I was 
 less sure of mine, the abdomen was opened. No 
 tumour was detected, but there Avere numerous fine 
 adhesions attached to the parietal peritoneum, 
 stomach, and bowel. It was manifest that the 
 apparent tumour had been entirely muscular, this 
 contraction being in the nature of a reflex, for there 
 was no extension of the inflammation from the 
 adhesions to the muscles. 
 
 114. Symptoms in Peritoneal Adhesions 
 (Visceral). — Adhesions limited to the visceral peri- 
 toneum may produce no symptoms, or they may 
 produce very well-marked reflex contraction of the 
 muscles, Avith more or less hyperalgesia of the skin or 
 
206 Chapter XIX. 
 
 muscles. This subject has not been worked out, and 
 I have only been able to investigate it to a limited 
 extent. It seems, however, one worthy of attention, 
 and there are plent}^ of opportunities for its study, 
 if careful notes of the condition be made before 
 operation. For many j^ears I applied it in the diag- 
 nosis of ovarian tumours to ascertain whether there 
 were likely to be adhesions or not. Then I found 
 that when the muscles of the belh-wall were not 
 contracted and not tender there were no adhesions 
 between the ovarian cyst and surrounding structures. 
 When, however, there was much muscular contrac- 
 tion and hyperalgesia, adhesions were alwaj- s found 
 between the tumour and the surrounding organs. 
 As, however, these observations were made and veri- 
 fied in only some tAventy cases, they are manifestly 
 insufficient for a definite statement, but I put forth 
 this suggestion as a line of observation well worth 
 consideration. 
 
( 207 ) 
 
 CFI AFTER XX. 
 
 AFFECTIONS OF THE LUNGS AND PLEURA. 
 
 115. Nature of the Subjective Sensations. 
 
 116. The Respiration. 
 
 117. Reflex Symptoms. 
 
 118. Functional Symptoms. 
 
 119. Structural Symptoms. 
 
 120. Affections of the Pleura. 
 
 121. Nature of the Pain in Pleurisy. 
 
 115. Nature of the Subjective Sensations.— 
 
 Owing to the constitution and the accessible situation 
 of the organs, the physical signs of affections of the 
 lungs are readily ascertained, and have been so well 
 explored that I shall do little more than touch upon 
 some of the reflex phenomena. Even though these 
 phenomena can be so readily recognised, their 
 mechanism is far from clear. The chief reflex which 
 presides over the movements of respiration involves 
 the employment of the muscles of the body-wall over 
 such a large area that the symptoms often become 
 very complicated. The subjective sensations of the 
 patient arise also from such a number of causes that 
 it is often impossible to understand how they are 
 produced. As in other parenchymatous organs, no 
 
208 Chapter XX. 
 
 form of stimulation of the lung tissue seems to be 
 capable of producing sensation directly or reflexly. 
 Below the epiglottis there is no sensation ehcited 
 from stimulating the air passages, though coughing 
 is readily induced in certain regions. The lung 
 itself is insensitive to stimulation when healthy (as 
 is seen when an exploring needle penetrates the 
 lungs) or when diseased. It is well known that the 
 lung may be acutely inflamed, torn by an apoplexy, 
 ulcerated and scooped out by a tuberculous process, 
 and no sensation be felt by the patient. When pain 
 arises in connection with affections of the lung, it 
 is from the implication of the pleura in the disease 
 process, or from the muscles of respiration becoming 
 sore and tender from excessive exercise. 
 
 Although no pain arises in connection with 
 lung affections, other sensations appear, as the sense 
 of breathlessness, " air hunger," and a sense of suffo- 
 cation. These sensations may be the occasion 
 of acute distress, and provoke attempts at deep 
 inspiration. 
 
 Dr. Haldane considers it " probable that ' air 
 hunger ' is always due to excitation of the respira- 
 tory centre in consequence of an abnormal condi- 
 tion of the blood. Nothing else is known to produce 
 ' air-hunger.' The excitation may be due to (1) excess 
 of COo. This is the normal excitant. The excess of 
 CO2 may be due to hindrance to entry or exit of air 
 (asthma, bronchitis, etc.), or to hindered penetration 
 of COo from the blood to the alveolar air (pneumonic 
 or dropsical conditions in the lung). A second cause 
 is diminished alkalinity of the blood. This acts just 
 like CO., on the centre. A typical example is the 
 
Affections of the Liings and Pleura. 209 
 
 liyperpnoea of diabetic coma (oxy butyric acid in the 
 blood). If want of Oo arises in the tissues from liin- 
 dered absorption of O., by the lungs, from defective 
 circulation (as in certain forms of heart failure) 
 or other cause (Co^ poisoning, poisoning by nitrites, 
 or other substances, which disable the haemoglobin, 
 etc.), the blood also becomes less alkaline from lactic 
 acid formation, or lactic acid is formed in the centre 
 itself. The centre is thus stimulated, and hyperpnoea, 
 as a secondary result of want of Oo, results. Want 
 of O2 does not seem to be a direct stimulus to the 
 centre. It is only in a limited number of cases that 
 pure 0-2 can relieve dyspnoea." 
 
 116. The Respiration. — The movements of 
 respiration consist in the contraction of certain 
 muscles, increasing the size of the chest cavity, and 
 producing the inspiratory act. The muscles em- 
 ployed in the act of respiration are the diaphragm, 
 the external intercostal muscles, the levatores cos- 
 tarum, and serratus posticus superior. As these 
 muscles in their contraction enlarge the cavity of the 
 chest by raising the thorax and twisting the costal 
 cartilages, and thus stretch the elastic tissue of the 
 lungs, so when they cease to act the thorax falls by 
 its o^\^l weight, assisted by the recoil of the costal 
 cartilages and of the elastic tissues of the lungs. The 
 thoracic cavity is thus reduced, and the air is ex- 
 pelled. It is possible that the internal intercostal 
 muscles contract with each expiration. In both forced 
 inspiration and expiration a large number of acces- 
 sory muscles may take part in the respiratory 
 movements. 
 
 Although the nerve supply of these muscles 
 
210 Chxpter XX. 
 
 involved in respiration come from widely separated 
 portions of the cord, they are all under the dominance 
 of one centre in the medulla oblongata — the 
 respiratory centre — the noBtid vital of Flourens, 
 situated in close proximity to the nuclei of the 
 vagus nerves. 
 
 The normal rate of respiration is from fourteen 
 to sixteen per minute, when the body is at rest. 
 Abnormalities are usually considered from the stand- 
 point of increase in rate and violence of the act of 
 respiration. There are, however, conditions of slow 
 respiration, apart from mechanical obstruction, 
 which are of some interest as they are associated 
 with certain neurotic conditions, and the slow re- 
 spiration jitroduces a form of heart irregularity {sinus 
 arrhythmia). However variable the rate. Dr. Haldane 
 points out that the alveolar ventilation mil be the 
 same— the frequent breathing being shallow, and the 
 slow breathing deep. 
 
 Although the physiology of respiration so 
 clearly defines the method b}^ which respiration is 
 regulated, yet there is nothing so perplexing to 
 explain as the influences that operate in producing 
 abnormal forms of respiration. In any given case 
 of increased frequency of respkation it is difficult or 
 impossible to say whether the condition is the result 
 of imperfect aeration or reflex stimulation. The 
 presence of non-striped muscle fibres in the smaller 
 bronchi leads to the surmise that these may become 
 tonically contracted, and therefore prevent the 
 emtrance of air to the alveoli. 
 
 This action seems all the more probable when 
 we reflect that asthma is so often the outcome of a 
 
Affections of the Lungs and Pleura. 211 
 
 remote stimulation, as from the nasal cavity, and 
 that muscular contraction is very susceptible to 
 reflex stimulation. Dyspnoea of a very severe form 
 may arise from peripheral stimulation, as is seen in 
 pneumonia, or pulmonary apoplexy, when tlie 
 breathing may be greatly increased in frequency 
 and in violence. The alteration in the breathing is 
 not the outcome of a diminution of the breathing 
 space by the inflammatory exudation, or apoplexy, 
 for the rate of breathing may suddenly return to 
 the normal, with no diminution in the extent of the 
 affection of the lung. Presumably here the increased 
 respiration is the outcome of a reflex, but whether 
 the stimulation played directly upon the respiratory 
 centre, or whether it caused a reflex spasm of the 
 bronchial muscles, we cannot tell. The dyspnoea 
 arising from other sources is equally obscure. Dr. 
 Haldane considers " the respiratory trouble in heart 
 failure to be due (at least mainly) to the slowed cir- 
 culation, and consequent imperfect aeration of the 
 tissues. The deficiency of O.. in the tissues will cause 
 increased formation of lactic acid, and consequent 
 diminished alkalinity of the blood, and consequent 
 necessity for an abnormally great removal of CO.^ 
 from the blood. The increased respirations may also 
 materially assist the circulation by aspirating more 
 venous blood towards the heart. The breathless 
 healthy person is breathless from excess of COo in 
 the arterial blood. In heart disease there is no ex- 
 cess of CO.;, or deficiency of O.. in the arterial blood, 
 but this condition exists in the tissues owing to the 
 slow circulation. Slight hyperpnoea will diminish 
 the CO.. in the arterial blood, and thus compensate 
 
212 Chapter X X. 
 
 for excess of CO.^ ; but hyperpnoea cannot appreci- 
 ably increase the oxygen in the arterial blood, and 
 therefore cannot compensate for the want of Oo in 
 the tissues. The patient is therefore blue, although 
 his breathmg may not be noticeably increased. 
 Exertion during any condition where the circulation 
 (particularly in the coronary vessels) is defective, and 
 cannot be increased in response to the increased need 
 for blood, will lead to a fall of blood pressure, the 
 heart being incapable of supplying enough blood to 
 correspond to the increased flow (vaso-dilatation) in 
 the worldng muscles. Fainting will thus be caused. 
 The same effect is seen in CO., poisoning, where even 
 a sUght exertion produces fainting with absolute 
 certainty, and may be fatal." 
 
 117. Reflex Symptoms.— Co?!^//^. — Coughing is 
 essentially a reflex phenomenon, the centre for which 
 is one of the numerous areas associated with the 
 main respiratory one in the bulb. The stimulus is 
 conveyed from the periphery by some branch of the 
 vasfus. The result of the stimulus is to cause first a 
 deep inspiration, which is followed by a closure of 
 the glottis, then by a sudden and powerful contrac- 
 tion of the muscles of expiration which forces the air 
 through the resisting glottis. By this process the air 
 drawn into the lungs by the prehminary inspiration 
 is driven out with such force that all movable matter 
 in the larger tubes is swept out. The area that most 
 readily excites the cough reflex is the mucous mem- 
 brane of the larynx, the nerve supply being from 
 the superior lar3rngeal nerve, a branch of the vagus. 
 The respiratory tract below the larynx and the 
 lung tissue seem to be incapable of originating the 
 
Affections of the Lungs and Pleura, 213 
 
 stimulus. The cough in affections of the lung arises 
 only when the secretion has been carried by the con- 
 tractions of the bronchial muscles, and by the cilia of 
 the respiratory tract so far upward as to reach the 
 sensitive region about the larynx. Thus it is that in 
 pneumonia the cough may be only shght, and only 
 provoked ^\'hen the secretion has passed up the 
 respiratory tube. In phthisis and abscess, and all 
 cases where there is abundant expectoration, it is to 
 be noted that the starting of a cough after a period 
 of quiescence is followed by a persistence until the 
 accumulated matter is expelled. The first cough 
 is initiated by the gradual conveyance of the phlegm 
 to the sensitive area, while afterwards the cough for- 
 cibly expels the contained matter, and so keeps up 
 the irritation until there ceases to be forced out any 
 more secretion. This sensitive region may be stimu- 
 lated by the inhalation of cold air, and it seems to 
 be the starting place of the spasm of uncontrollable 
 coughing in whooping-cough. While this is prob- 
 ably the true explanation of the great majority of 
 cases, coughing can also be excited by stimulation by 
 other means. When a pleuritic effusion is aspirated, 
 scratching the visceral pleura mil often produce a 
 cough, or irritation of the branches of the vagus that 
 go to the stomach or ear may produce coughing. It 
 is always well to exclude the possibility of irritation 
 in the larynx, before assuming the presence of the 
 more remote stimulation. A very curious cough 
 reflex is sometimes present in persons who have an 
 occasionarextra-systole. This is usually due to the 
 ventricle contracting prematurely before the auricle, 
 and the individual may be conscious of this, and may 
 
214 Chapter X X. 
 
 give at the same time a short cough — without the 
 prehminary inspiration. In hysteria violent and 
 persistent coughing may occur either from a trivial 
 laryngeal irritation, or it may be in consequence of 
 some other reflex irritation. 
 
 Sneezing. — A reflex of a somewhat similar 
 nature to that of coughing arises from stimulation 
 of the mucous membrane of the nose. It differs from 
 a cough, inasmuch as there is no closure of the glottis, 
 and the blast of air is sent through the nose as well 
 as the mouth. It also differs from the act of cough- 
 ing in always being a pure reflex. Coughing can be 
 done voluntarily, but sneezing cannot. Sneezing can 
 be inhibited by biting the upper lip, or pinching the 
 edge of the nasal bones, even after the preliminary 
 inspiration, and by a mental reaction, as when 
 another person is observed to imitate the act. 
 
 Persistent attacks of sneezing are common^ 
 associated with a swelling of the erectile tissue over 
 the turbinate bones in the nose, and a free secretion 
 from the mucous membrane of the nose and eyes. 
 
 118. Functional Symptoms. — Aeration of the 
 blood. — Impaired function is seen in the degree of 
 aeration of the blood, and in the character of the 
 expectoration. Aeration of the blood is the main 
 function of the lungs, and imperfect aeration is 
 manifested in the production of the reflex phenomena 
 (air-hunger, increased respiratory movements) and 
 in the colour of the blood. The former of these 
 symptoms has already been discussed ; the latter is 
 observed mainly in an abnormal colour of the 
 external tissues, as in the lips, cheeks, or skin 
 generally. 
 
Affections of the Lungs and Pleura. 215 
 
 As vaih all other respiratory symptoms, the pro- 
 duction of the signs of imperfectly aerated blood is 
 obscure and complicated. The face may show a 
 slight degree of duskiness, the redness be a little 
 darker than that of health, or the redness of the lips 
 a little deeper in cases, say, of mitral stenosis. Blue- 
 ness of the lips may be due to imperfect aeration of 
 the blood in the lungs, but it also may be due to 
 slowing of the circulation. It is remarkable how 
 much darker the venous blood becomes if the rate 
 of flow through the capillaries be diminished. This 
 is probably the cause of the cyanosis in congenital 
 heart disease. In some cases there has been found 
 a great increase in the number of red blood cor- 
 puscles, and a certain degree of duskiness is found 
 in cases of polycythemia. Where there is a duskiness 
 due to some permanent condition as polycythemia, or 
 the cyanosis of congenital heart disease, exertion 
 often increases the depth of the cyanosis. 
 
 In failing hearts, with embarrassment of the 
 pulmonary circulation, a very considerable duskiness 
 may be evident, as also in cases where there is ob- 
 struction to the entrance of air into the lungs. As 
 the heart is exceedingly susceptible to oxygen, 
 imperfect aeration of the blood has a very marked 
 effect upon it, a diminished supply of oxygen acting 
 speedily in stopping its action, and in the ad- 
 ministration of chloroform this is one of the most 
 important facts to be borne in mind. 
 
 Expectoration. — Expectoration is the product 
 of perverted function, and may be due to a secretion 
 of the respiratory tract or lungs. It may also come 
 from regions outside the lungs, as when an abscess 
 
216 Chapter X X. 
 
 or ])leural effusion bursts into the lungs, or bronchi. 
 It is the most frequent cause of cough, and coughing 
 is due to the attempt to get rid of the secretion. The 
 expectoration is conveyed in the first place by the 
 contraction of the bronchial muscles, and by the cilia 
 of the respiratory tract to the bronchial tubes, tiU 
 an excitable part is reached, when coughing is in- 
 duced, and the blast of air expels the accumulated 
 secretion. The force exercised in compressing the 
 chest helps to expel secretion accumulated in any 
 part of the respiratory tract, or in the lungs and 
 pleural ca^dty, so long as there is an exit. 
 
 The character of the expectoration indicates its 
 source, a transparent and frothy expectoration com- 
 ing from the upper air passage, while the more viscid 
 comes from the lower, or from near the alveoh, as in 
 the early stages of pneumonia, when it is usually 
 stained more or less deeply with blood. A clear 
 pink-stained mucus may result from a pulmonary 
 apoplexy. A purulent sputum is due to a lesion of 
 some standing. In bronchitis the sputum gradually 
 changes from a mucous to a muco-purulent character. 
 An abundant muco-purulent sputum is found in 
 chronic bronchitis and old standing catarrhal pneu- 
 monia. With an excess of fever, the latter condition 
 may resemble an attack of acute croupous pneu- 
 monia, but the abundant purulent secretion serves 
 to indicate the nature of the ilhiess. The secretion 
 from phthisical cavities is also purulent. When 
 large quantities of pus are expectorated, the source 
 is a cavity in the lungs or pleura, or a subphrenic 
 abscess, as a suppurating hydatid cyst of the liver. 
 
 The microscopic examination for bacilli and 
 elastic fibres is fully detailed in text-books. 
 
Affections of the Lungs and Pleura. 217 
 
 119. Structural Symptoms. — Structural symp- 
 toms are recognised b}^ changes in the consistence of 
 the lung tissue, in the invasion of the normal 
 resonant area by structures of more solid consistence, 
 changes in the shape of the chest wall, and the 
 presence of accessory sounds or the modification of 
 the normal respiratory sounds in auscultation. It 
 is not my purpose to enter into the details of these 
 changes, and I merely point out here that the exist- 
 ence of any abnormal state can only be ascertained 
 by thorough knowledge of the normal condition of 
 the lungs. The position of the lungs in relation to 
 other organs, the modification of the signs of the 
 lung in the different regions of the chest, should all 
 be familiar through the systematic examination of 
 a great number of healthy people. In all these ob- 
 servations, and more particularly in the examination 
 of abnormal or diseased lungs, the recognition of the 
 abnormal signs depends on the comparison of the 
 signs in one individual with anothei, or in the com- 
 parison of the signs on opposite sides in the indi- 
 vidual examined. As there are infinite gradations, 
 it requires careful training to recognise many of the 
 more deHcate but none the less very impprtant 
 phenomena. 
 
 120. Affections of the Pleura. — Insensitiveness 
 of the Pleura. — If the affection of the lung gives 
 rise to no sensation of pain, the same cannot be said 
 of the pleura, for the pains associated with pleiu-isy 
 may be of the most violent kind. In consequence of 
 this well-recognised fact, the pleura is supposed to 
 be an extremely sensitive structure, though, as a 
 matter of fact, it is as insensitive as the peritoneum 
 
218 Chapter X X. 
 
 to ordinary stimulation. In a great number of cases, 
 when the ribs have been resected, I have repeatedly 
 explored the pleural cavity for any evidence of sen- 
 sation, and I could employ no form of stimulation 
 capable of producing pain. When I probed the vis- 
 ceral pleura, even to penetrating the lung, no sensa- 
 tion was produced ; when I scraped the surface of 
 the parietal pleura no sensation was produced, unless 
 I pressed with some force, when a vague sensation 
 was experienced, due probably to the pressure being 
 exercised on the structures of the external body wall. 
 
 121. Nature of the Pain in Pleurisy. — From 
 the result of such experience one is forced to con- 
 sider carefully how the great pain felt in pleurisy is 
 produced. Inquiry into the nerve supply of the 
 pleura is fruitless, for there is practically no in- 
 formation about the matter in either anatomical or 
 physiological text-books. Although I carried out a 
 series of careful dissections of intercostal nerves to 
 their finest branches, I could detect none entering the 
 pleura. Whether there is a layer containing fine 
 nerve endings outside the pleura similar to that 
 described by Eamstrom lying outside the peritoneum, 
 I do not know. A careful study of all the phenomena 
 connected with a painful pleurisy reveals the 
 mechanism by which it is produced, and gives some 
 indication of its nerve supply. The most severe pain 
 occurs in the movements of respiration, and is due to 
 the painful contraction of the intercostal muscles. In 
 the abdominal muscles the muscular hyperalgesia 
 and tonic contraction can be demonstrated. It is not 
 so easy to do this in the case of the intercostal 
 muscles, but there is good reason for inferring that 
 
Affectio7is of the Lungs and Pleura. 219 
 
 Fio. 20. 
 
 Areas in which pain and hyperalgesia were present in a case of 
 diaphragmatic pleurisy. The shaded area on the left shoulder is in the 
 cutaneous distribution of the fourth cervical nerve, and is an evidence 
 of the conduction of a stintiiilus from the diaphragm by the phrenic nerve, 
 which leaves the spinal cord with the fourth cervical narve. The phrenic 
 nerve contains afferent fibres as well as efferent (motor), and it is m all 
 probability by the former that the stimulus is conveyed to the centre of 
 the fourth cervical nerve in the cord. The shaded area in the abdomen 
 is in the region of distribution of the 8th and 9th thoracic nerves. 
 
220 Chapter X X. 
 
 the viscero-motor reflex is as definite in pleuritis 
 as in peritonitis. The muscles are often tender on 
 pressure, and their contraction is not only painful but 
 ends in a spasm which restrains the movements of 
 the chest. The symptoms of pain and violent con- 
 traction are identical with those that occur when 
 the muscle is hyperalgesic, apart from a pleurisy, as 
 in the painful contraction of the intercostal muscles 
 in " muscular rheumatism," and in those cases where 
 the hyperalgesia extends into the chest wall from 
 affections of other viscera, as in gall-stone disease 
 {see page 159). 
 
 The mechanism of the pain can also be inferred 
 from those cases in which it is felt at a distance 
 from the inflamed pleura. When the diaphragm- 
 atic pleura is inflamed the pain may be felt in two 
 regions very widely separated, namely, in the abdo- 
 men below the ribs and on the top of the shoulder. 
 (Fig. 20.) 
 
 It not infrequently happens that the onset of 
 pneumonia is accompanied by a severe pain in the 
 abdomen, and the skin in the region where the pain 
 is felt may be found extremely hyperalgesic. (Not 
 infrequently, and particularly in the young, this pain 
 misleads in the diagnosis, giving the impression that 
 some abdominal viscus is at fault.) The area in 
 wliich this hyperalgesia is found is within the peri- 
 pheral distribution of the eighth and ninth thoracic 
 nerves. I have no distinct proof that in such cases 
 the pain and hjrperalgesia are due to pleurisy, and 
 not to the lung affection, except for the very common 
 experience that the inflammation of the lung is pain- 
 less, while inflammation of the pleura is usually 
 
Affections of the Lungs and Pleura. 221 
 
 associated with pain, and the hyperalgesia'^may be 
 detected in basal pleurisies without pneumonia. It 
 is evident that there must be some correlation 
 between the lesion and the area of hyperalgesia, and 
 as no nerve from the region of the eighth or ninth 
 thoracic nerves supplies the lungs, it is reasonable 
 to conclude that the nerve supply from the inflamed 
 pleura must be from tliis region. The pain felt in 
 the shoulder is more instructive. It is, however, a 
 somewhat rare phenomenon, but in the few cases I 
 have seen in which there has been cutaneous hjrperal- 
 gesia, the area could be marked out very distinctly, 
 and was found to be within the distribution of the 
 fourth cervical nerve. I have already dealt some- 
 what fuUy with the distribution of the phrenic nerve 
 and its relation to the fourth and fifth cervical nerve. 
 Its distribution being to the diaphragm, and not to 
 the lungs, permits of the reasonable inference that 
 the pain and hyperalgesia in the shoulder found 
 associated with pneumonia are due to the pleurisy 
 and not to the pneumonia. 
 
 From the consideration of these facts we can 
 draw the inference that the pain in pleurisy is due 
 to a reflex stimulation (viscero-sensory reflex), and 
 that as there arises also a hyperalgesia of the inter- 
 costal muscles, their contraction is not only painful, 
 but their continued exercise increases the violence 
 and painfulness of their contraction. As happens in 
 all muscles affected by a visceral stimulus (viscero- 
 motor reflex), there is a great tendency with exercise 
 for the muscle to be tonicaUy contracted, and hence 
 the constrained and limited movements of the chest 
 wall present in pleurisy. 
 
( 222 ) 
 
 Chapter XXI. 
 
 AFFECTIONS OF THE CIRCULATORY 
 SYSTEM. 
 
 122. Heart Faihire. 
 
 123. The Nature of the Symptoms in Heart Failure. 
 
 124. Consciousness of the Heart's Action. 
 
 125. Breathlessness. 
 
 126. Viscerosensory and Viscero-motor Reflexes. 
 
 127. The Viscerosensory Reflexes in Dilatation 
 
 of the Heart and Liver. 
 
 128. The Pain of Angina Pectoris is a Viscero- 
 
 sensory Reflex. 
 
 129. Evidences of the Viscero-motor Reflex. 
 
 130. Organic Reflexes. 
 
 131. Summation of Stimuli the cause of Angiyia 
 
 Pectoris. 
 
 There is no s^^stem in the bodj^ whose function 
 can be so well observed, and whose size and position 
 can be better made out, than that of the circulatory 
 system. As a consequence of this accessibility the 
 circulatory apparatus has received a great deal of 
 attention, and innumerable methods are employed 
 in the investigation of its action. The value of many 
 of these methods is unquestioned, but unfortunately 
 the tendency has been to place undue reliance on 
 
Affections of the Circulatory System.. 223 
 
 the results obtained by mere pli^^sical examination, 
 and to neglect the more important indications to be 
 derived from the reflex phenomena, chieflj^ expressed 
 in the sensations felt by the patient. 
 
 122. Heart Failure. — In order to realise fully 
 the meaning of cardiac symptoms, it is necessary 
 to appreciate the mechanism of heart failure. By 
 heart failure is meant the inability of the heart to 
 maintain the circulation efficiently. The lack of 
 efficiency may be made evident in extreme cases by 
 such signs as orthopnoea, dropsy, unconsciousness. On 
 the other hand, the failure of the heart to maintain 
 an efficient circulation may be manifest long before 
 these extreme symptoms appear. The first sign is 
 a feeling of distress when the patient makes an 
 effort. This may vary within very wide limits ; for 
 instance, turning o>ver in bed may exhaust the 
 heart's strength, or the patient may be unable to 
 walk across the room, or up a flight of stairs, 
 without some form of discomfort checking him. 
 The exhaustion of the patient's strength in 
 such circumstances is seen simply as a limita^tion 
 of the heart's power to respond to effort. Each 
 individual has become accustomed to what he 
 can do with comfort, and he recognises his heart 
 failure by not being able to exert himself with com- 
 fort to the extent he had formerly done. The 
 symptoms produced in health by over-exertion are 
 frequently identical with those produced by slight 
 exertion when the heart has become weakened and 
 where this slight exertion is more than can be done 
 with comfort. It will thus be seen that the symptoms 
 of heart failure are really recognised by a limitation 
 
224 Chapter XXI. 
 
 of the field of cardiac response, that is, the patient 
 finds he is stopped, on a sHght exertion, by the 
 symptoms which, when in health, only stopped him 
 after a prolonged, exhausting exertion. 
 
 This weakness of the heart can be expressed in 
 another way, namely, the premature exhaustion of 
 reserve force. It is because the heart possesses the 
 power to lay up a reserve of force that it is able to 
 respond to calls on its energy, so that it can accom- 
 modate itself to the varying activities of the body. 
 When the body is at rest the heart not only over- 
 comes the resistances opposed to its work with ease, 
 employing only a portion of its power, but it is at 
 the same time building up a store of energy ready 
 to be liberated when the next call is made by the body 
 for more work. After severe bodily labour the store 
 of reserve forces become exhausted, and if the 
 labom- be persisted in, there arises a feeling of dis- 
 tress, which expresses the exhaustion of the heart's 
 reserve force. It is this faculty of building up a 
 sufficient reserve store that distinguishes a healthy 
 heart from a weakened heart, and the first evidence 
 of weakness is shown by a too speedy exhaustion of 
 the reserve. This is made evident by distress being 
 aroused when the individual undertakes some form 
 of exertion he had been wont to do with ease — that 
 is, by a limitation of the field of cardiac response. 
 
 It will thus be seen that the symptoms of heart 
 failure in the first instance are personal, due to the 
 patient' s recognition of his limitations. The estimate 
 is therefore a very variable one, and depends on each 
 individual recognising his own limitations, and 
 detecting Avhen these limitations become narrowed. 
 
Affections of the Circulatory System. 225 
 
 Each individual obtains a fair estimate of his power 
 of exertion, and this is his measure of health. A 
 limitation of these powers in an intelligent patient 
 calls attention to his condition. It will further 
 be observed that the main s^'mptoms of exhaustion 
 of reserve force are the same when a healthy heart 
 exhausts its store after a prolonged effort as when 
 an enfeebled or diseased heart exhausts its limited 
 store by a slight effort. These s^^mptoms are in 
 the main subjective and reflex, though certain 
 changes may also be made out in the size of the heart 
 and its rate and rhythm. It is, however, the sub- 
 jective and reflex symptoms that are of the greatest 
 importance, whatever may be the nature of the 
 functional disorder or structural lesion. 
 
 It wiU frequently be found that patients whose 
 hearts show many forms of functional and structural 
 abnormalities (valvular murmurs, cardiac enlarge- 
 ment, irregular action) have such a store of reserve 
 force that they can pursue laborious occupation 
 Avith ease and comfort, and live to a good age. On 
 the other hand, patients may show no physical sign 
 of abnormality ; the heart may be normal in size 
 and in rate, and regular in rhythm, and the sounds 
 be clear and free from murmur ; but the reserve force 
 be so small that the slightest exertion entails at once 
 distressful sj^mptoms of heart exhaustion, and the 
 lives of these persons may be Yery precarious. 
 
 123. The Nature of the Symptoms in Heart 
 Failure. — The value of s^maptoms thus depends upon 
 the estimation of the amount of reserve force stored 
 up in the heart muscle. An imperfect valvular appar- 
 atus is but an embarrassment to the heart muscle in 
 
226 Chapter XXI. 
 
 its work. We can detect that valvular imperfection 
 by the presence of a murmur, but we can only draw a 
 very limited conclusion as to its bearing on the heart's 
 work. This is really obtained by considering the 
 amount of reserve force, and the estimation of the 
 reserve is made by observing how the patient's heart 
 responds to effort. The same rule applies to other 
 forms of circulatory changes, as affections of the 
 myocardium and of the arterial system. When, 
 therefore, we detect what we consider to be an 
 abnormal sign, we must not draw our conclusions 
 from that sign alone, but must consider how far its 
 cause has proved an impediment to the heart's action, 
 and this is done by estimating the amount of reserve 
 force. In doing this a wise discretion must be 
 exercised, for other factors may have precipitated 
 the exhaustion. An individual may have an organic 
 lesion, as a valvular defect, but in addition may 
 have been subjected to a life that predisposes to 
 exhaustion, as excessive labour, improper or insuffi- 
 cient food, mental anxiety, sleeplessness, infections, 
 diseases of other organs ; and such factors, rather 
 than the mere valvular flaw, may be the actual cause 
 of the exhaustion of the reserve force. Or the 
 individual may have a sedentary occupation, wherein, 
 owing to lack of judicious exercise, his reserve force 
 has gradually diminished, until some unaccustomed 
 but not excessive effort calls attention to the limited 
 field of cardiac response. 
 
 Not only must a careful calculation be made of 
 these accessory, and it may be all- important, factors, 
 but there must be a recognition of the significance 
 of the cardiac abnormalities or supposed abnor- 
 
Ajjections of the Circulatory System. 227 
 
 malities. I do not enter here on the points which 
 indicate the nature and seriousness of such abnor- 
 mahties, as, for instance, murmurs and heart 
 irregularities, but I wish to insist upon the fact that 
 the chnician should familiarise himself with such 
 points. For instance, a young person may have 
 a fainting attack, and when lying quietly in bed 
 the pulse is found very irregular. This sign, which 
 is a perfectly normal one, though rarely recognised 
 as such, is not infrequently linked up with the 
 fainting attack, with which, as a matter of fact, it 
 has no connection, and the patient is subjected to 
 unnecessary treatment and restriction, and he 
 becomes alarmed by the idea that he has 
 a weak or diseased heart. In advanced life 
 another form of irregularity is of extreme 
 frequency (the extra-systole), and the recogni- 
 tion of its presence, with some limitation of 
 the field of cardiac response, often leads to the 
 conclusion that the irregularit}^ is in some way 
 responsible for the other cardiac signs, and energetic 
 but futile means are taken in the attempt to cure 
 the irregularity. In the same way this morbid 
 dread of the unknown leads to the idea that certain 
 cardiac symptoms as pain, especially when dignified 
 by the term of angina pectoris, is of very grave 
 significance. If it be once realised that pain is as 
 constant a symptom in affections of the heart as in 
 other hollow muscular organs, and that the pain is 
 as readil}" induced by adequate causes in the heart 
 as in the stomach, a truer perception will be obtained 
 of the symptoms of many obscure heart affections. 
 I shall show later that pain is one of the expressions 
 
 Q 2 
 
228 Chapter XXI. 
 
 of an exhausted heart muscle, and in order to 
 appreciate its significance the conditions that have 
 led up to the exhaustion of the heart muscle should 
 be ascertained — a matter usually of no great 
 difficulty — and these conditions will guide us to a 
 safe conclusion. 
 
 If the idea be followed up that the earliest of 
 heart S3'mptoms are simply due to an exhaustion of 
 the store of reserve force, it will be found that there 
 is a great resemblance in the reflex symptoms 
 among all forms of heart affections — functional and 
 structmal. The most important symptoms are 
 confined mainly to the patient's sensations, and 
 demand careful consideration. The mechanism by 
 which they are produced is not at all times clear, 
 and some of them are undoubtedly reflex ; although 
 I cannot give a full explanation of their production,, 
 I attempt here a brief description of the most im- 
 portant of the subjective symptoms and some of 
 the phenomena associated with them. 
 
 124. Consciousness of the Heart's Action. — 
 Under normal circumstances the movements of 
 the heart and circulation are carried on without 
 the individual being conscious of their action 
 unless he voluntarily directs his attention to the 
 subject. When the heart is over-stimulated it may 
 contract with such force that the individual 
 becomes conscious of its action. The stimula- 
 tion may arise from a great many circumstances, 
 as, for instance, from heat, either by a rise 
 in the patient's temperature or from a hot bath. 
 It may arise from nerve stimulation, as from mental 
 excitement, or from some peripheral irritation in 
 
Affections of the Circulatory System. 229 
 
 the viscera. Its significance is greatest when it 
 arises in consequence of exhaustion of the heart ; 
 coming on in consequence of bodil}^ exertion, it 
 is often the first sign of exhaustion of the reserve 
 force. When it is thus produced, it forms a valuable 
 sign for estimating the amount of reserve force 
 present in the heart-muscle. It gives no indication 
 of the conditions that have led to this exhaustion, 
 for it may occur in a healthy heart after prolonged 
 exertion, as well as in a diseased heart after a very 
 slight exertion. Under these circumstances the 
 heart's action is usually rapid as well as forcible, 
 but in some cases there is not much increase in 
 rate. The consciousness of the heart's action is 
 often spoken of as palpitation. While it may not 
 occasion much suffering, there are individuals of a 
 neurotic type in whom this consciousness of the 
 heart's action causes much distress. In these 
 patients the heart may be quite healthy, and the 
 palpitation is then the action of an undue excita- 
 bility of the sympathetic nerve supply of the heart. 
 As other portions of the nervous system are abnor- 
 mally excitable the heart's action may cause con- 
 siderable distress bodily and mentally. In patients 
 with this neurotic temperament, where there is real 
 heart trouble, as in mitral stenosis, palpitation on 
 exertion may be so readily induced that it acts as a 
 protection from over- exertion, because, in order to 
 avoid its occurrence, the patient is perforce kept 
 quiet. 
 
 The occmrence of palpitation should always 
 lead to an examinaton of the nervous system as well 
 as of the heart's condition. 
 
230 Chapter XXI. 
 
 Other sensations of the heart's abnormal action 
 may be felt by the patient. A gentle fluttering 
 maj^ be felt within the chest during a period of 
 irregular action. This may be brief and transient, 
 or, as in certain cases of paroxysmal tachycardia, it 
 may continue during an attack of many hours. 
 Accompanying the latter condition there is often a 
 feeling of exhaustion which leads the patient to 
 rest, or to go about carefully and quietly. When 
 the heart resumes its normal action the patient is 
 at once conscious of a change and of a sense of 
 relief. A more common sensation is that when 
 the heart is felt to stand still, in what is called 
 intermittent action of the heart. This sensation is 
 usuall}^ felt in cases of extra-systole, which is so 
 frequent in advanced life though occasionally 
 present in the young. Here the ventricle con- 
 tracts prematureh", and often before the auricle ; 
 the individual is not conscious of this prematiure 
 beat or extra-systole which is followed by a long 
 pause, and it is this pause which often alarms the 
 patient. After the long pause the next beat is 
 frequently big and powerful, and the patient 
 may be conscious of the shock due to this. In 
 nervous people this big beat often causes much 
 mental anxietj^ 
 
 Another curious reflex is sometimes met with 
 in these extra- systoles, the patient giving a little 
 gasp or cough when the extra-systole occurs. 
 
 125. Breathlessness. — Breathlessness is so fre- 
 quently associated with affections of the heart that 
 its occurrence under any circumstances necessitates 
 a consideration of the heart's condition. It is so 
 
Affections of the Circulator y System. 231 
 
 common a sign of exhaustion of the reserve force 
 that in an inquiry into a patient's cardiac symptoms 
 the amount of exertion that can be undertaken 
 before breathlessness occurs should be carefully 
 inquired into. In many cases the breathlessness 
 may occur independently of any bodily exertion, 
 coming on when the patient is in bed, and persisting 
 till the patient has to sit up and breathe in a 
 laboured fashion (orthopiioea). 
 
 The mechanism by which breathlessness is 
 brought about in heart affections is far from 
 clear, and so many factors are concerned in respira- 
 tion that 2i\\Y endeavour to explain its cause would 
 lead to such vague and indeterminate speculation 
 that, in the present state of our knowledge, little 
 good would result. The great point is to observe 
 the fact, to exclude other possible causes of 
 breathlessness (as affections of the lungs, mechanical 
 obstructions to the breathing, anaemia, and other 
 blood affections), and then from a study of the 
 cardiac conditions to determine the nature of the 
 exhaustion that has been produced. This is seldom 
 a matter of much difficulty when a sufficient experi- 
 ence of the various forms of heart disease has been 
 acquired. The presence of a demonstrable lesion in 
 the heart may be a guide, as shown by modification 
 of the heart sounds, or changes in the size, rate and 
 rhythm of the heart. In the absence of these the 
 age of the patient may be suggestive — if old, 
 degenerative changes in the myocardium ; if young, 
 the probabilit}^ of some general infection, as tuber- 
 culosis ; if middle-aged, the possibility of exhaus- 
 tion of the reserve force from over-work, worry, bad 
 
232 Chapter X X I. 
 
 nourishment — in fact, the consideration of the 
 factors that tend to exhaust the reserve force of 
 the heart, breathlessness being often the first sign 
 of such exhaustion. 
 
 Apart from breathlessness brought on by 
 exertion there are some definite forms of breathless- 
 ness whijch are recognised as especial^ associated 
 with heart affection. The best known of these is 
 the Cheyne-Stokes respiration, where periods of 
 apnoea alternate with periods of laboured 
 breathing. Another characteristic form is that in 
 which patients are seized in the night with attacks 
 of breathlessness, and have to sit up and breathe 
 in laboured fashion for periods of varying, duration, 
 from half-an-hour to several hours. This form of 
 laboured breathing is sometimes spoken of as 
 cardiac asthma, and its onset is often mistaken for 
 the more common form of asthma. When asthma 
 is found to occur in people of middle or advanced age 
 for the first time, the possibilit}^ of its cardiac origin 
 should always be borne in mind. 
 
 In many cases the patient breathes quietly 
 though hurriedly, with no distress, and the respira- 
 tory condition may, in consequence, be overlooked, 
 though the rate of respiration may be from twenty 
 to thirty times per minute. With failing hearts 
 (as in typhoid fever, in conditions in which elderly 
 people are forced to lie in bed, or in valvular disease) 
 this rate tends to increase, and on examination 
 respiration is found to be shallow and limited to the 
 upper portion of the chest. In such cases there will 
 almost always be found evidence of stasis or oedema 
 at the bases of the lunss. The first si^n of this 
 
Affections of the Circulatory System. 233 
 
 condition, apart from the increased rapidity of the 
 respiratory movement, is the detection of fine crepi- 
 tations on deep inspiration heard over the base of the 
 lung, on that side towards which the patient habitu- 
 ally lies. My usual method of detecting this is to 
 ask the patient on which side he has lain, and then to 
 ask him to sit up and to auscultate the base of the 
 lung on the side on which he has lain. This is the 
 first step in the physical examination of the patient. 
 If done at a later stage the movements may have 
 deepened the respiration, so that the crepitations 
 have disappeared. One usually detects the fine 
 crepitations on the first full and deep nspiration. 
 In the early stages of pulmonary stasis, after this 
 thorough ventilation of the bases of the lungs, the 
 crepitations disappear. If measures are not taken 
 to stop this tendency to oedema, or if in spite of all 
 endeavours the oedema increases, the crex)itations 
 become more numerous and persistent, and the 
 lung resonance may become impaired. In fatal 
 cases the bases of the lungs become dull, there 
 is an absence of the respiratory sounds, and post- 
 mortem the lungs are found sodden and airless. In 
 suitable cases there can be detected coincident with 
 these lung s^anptoms evidences of the dilatation of 
 the right heart, as epigastric pulsation due to the 
 filling and emptying of the dilated right ventricle. 
 
 A sense of suffocation is an occasional symptom 
 in heart affections. It may be the first sign of 
 exhaustion of the reserve force, coming on when the 
 patient exerts himself. It may suddenly seize a 
 patient when he is lying in bed. Its mechanism is 
 obscure. The sensation is usually referred to the 
 upper part of the chest and throat. 
 
234 Chapter XXI. 
 
 126. Viscero-sensory and Viscero - motor 
 Reflexes. — Under these terms I include such sen- 
 sory phenomena as pain and hyperalgesia of the skin, 
 muscles, mammary glands, and the contraction of the 
 muscles, which gives rise to a sensation described 
 " as if the breast - bone were breaking." After 
 obtaining a full account of the patient's sensations 
 and experiences, if careful inquiry be made in regard 
 to a number of sjmiptoms, as pain, constriction of 
 the chest, soreness of the chest or arms, frequent 
 micturition, increased flow of saliva, bad dreams, 
 there will be found a number of phenomena which 
 the patient does not include in his description, 
 because his mind is occupied with the sensations 
 which cause him suffering and discomfort. The 
 accurate noting of these less obtrusive phenomena 
 will often tlirow^ a flood of light on many an obscure 
 process and' reveal the mechanism by which the 
 more obtrusive phenomena are produced. 
 
 In the physical examination careful testing for 
 hyx3eralgesia should fu-st be made. The skin of the 
 left chest should be lightly pinched and compared 
 with that of the right. The breasts should be 
 lightly compressed and the resultant sensations 
 compared. The tenderness to pressure of the 
 pectoralis major where it forms the anterior wall of 
 the left axilla should be tested. In the same way the 
 skin of the neck and the sterno-mastoid should be 
 tested. The upper edge of the trapezius muscle 
 where it passes from the scapula to the neck should 
 be lightty compressed along its whole border, and it 
 will sometimes happen that certain areas will be 
 found very tender. These are places where a small 
 
Affections of the Circulatory System. 235 
 
 nerve trunk is pressed upon. Special areas of 
 tenderness may sometimes be found, as under the 
 left breast, and over the second and third ribs in the 
 nipple line. In one patient, where this latter ten- 
 derness was very marked, I found, at the post-mortem 
 examination, on dissection, a small nerve trunk (the 
 internal anterior thoracic nerve). 
 
 Angina pectoris affords an excellent illustration 
 of the application of the principles I have en- 
 deavoured to enunciate, as the symptoms can be 
 with certainty referred to the organ at fault, and 
 because the complex of symptoms that are included 
 in an attack of angina pectoris are capable of being 
 analysed with great precision. This is, in a great 
 measure, due to the peculiar distribution of the 
 sensory nerves in whose peripheral distribution the 
 characteristic phenomena are shown, and whose 
 centres in the spinal cord and medulla are in close 
 relationship to the centres of the autonomic nerves 
 of the heart (sympathetic and vagus). The cases I 
 cite demonstrate that the term " angina pectoris " 
 includes a number of reflexes, and I give in detail 
 the more conspicuous of these, namely, sensory 
 reflexes, where the pain and hyperalgesia affect the 
 chest, arm, head, and neck ; motor reflexes, resulting 
 in spasm of the intercostal muscles ; secretory 
 reflexes, shown by profuse secretion of saliva and 
 urine. Some cases show other reflexes, as the 
 respiratory, but the discussion of these would lead 
 me beyond the object I had in writing this book. 
 
 Notwithstanding the numerous papers devoted 
 to the consideration of angina pectoris, practically 
 none have dealt adequately with the analysis of the 
 
236 Chapter XXI. 
 
 symptoms present dm^ing an attack. Angina 
 pectoris is often surrounded by such tragic circum- 
 stances that it forms a suitable theme for disquisition, 
 and on that account we too often get the lurid 
 description of an impressionist artist instead of 
 the plain, matter-of-fact description of an accurate 
 observer. A careful sifting of all the details brings 
 out the fact that the essential principles underlying 
 the pains associated with affections of the heart 
 differ in no way from those of any other hollow 
 muscular organ. So terrifying is the attack to the 
 patient that his perceptions of the details of his 
 suffering are generalh^ confused, so that often no 
 clear account can be obtained from his description ; 
 but if he is intelligent and is asked to note particu- 
 lars in subsequent attacks, he may be able to throw 
 a very valuable light on the onset and character 
 of the sensations he experiences. The observations 
 made by the physician of patients during an attack 
 also afford great help in this respect. 
 
 127. The Viscero-sensory Reflexes in Dilata- 
 tion of the Heart and Liver.— Before dealing with 
 the more characteristic attacks of heart pain 
 which go by the name of angina pectoris, I wish 
 first to draw attention to the very distinct sensory 
 evidences that arise from -the dilatation of the 
 heart. These sensory symptoms are practically 
 identical with those that arise in cases of distension 
 of any other viscus, as the stomach, bladder or liver. 
 To illustrate this I select cases where the dilatation 
 of the heart occurs rapidly, and is followed by a 
 rapid distension of the liver, such as we find 
 in certain forms of paroxysmal tachycardia. In 
 
Affections of the Cirmdatory System. 237 
 
 certain of these cases the rhythm of the heart starts 
 suddenly at some abnormal place in the auricle or 
 ventricle, or at the fibres joining auricle and ven- 
 tricle. The heart at once beats with great rapidity, 
 but fails to maintain the circulation, and in conse- 
 quence we have very rapidly developed great dila- 
 tation of the heart, fullness of the veins, enlargement 
 of the liver, and dropsy. I have seen a number of 
 these cases, and in two particularly I have observed 
 some fifteen to twenty attacks, of which the following 
 is a typical description. 
 
 The patient may be in good health and no 
 abnormality be detected save, in some cases, the 
 occurrence of an extra- systole. Suddenly the 
 heart's rate becomes greatly accelerated, to 150 beats 
 and more per minute. In a few hours the patient's 
 face becomes dusky, the lips swollen and livid, and 
 there appears great shortness of breath on exertion, 
 marked increase in the size of the heart, distension 
 and pulsation of the veins of the neck, and enlarge 
 ment and pulsation of the liver. The jugular and liver 
 pulsation are of the ventricular type. Pain and 
 oppression may be felt over the chest. The skin and 
 deeper tissues of the left chest become extremely 
 tender on pressure in the area shaded in Fig. 21. If 
 the left pectoralis major muscle be grasped where it 
 forms the axillary fold it wiU be found extremely 
 tender. The skin of the left side of the neck may 
 also be tender, and if the left sterno-mastoid muscle 
 and the left trapezius muscle, above the middle of 
 the scapula, are lightly grasped they may be found 
 exquisitely sensitive. The skin and muscles over 
 the liver will also be found extremely sensitive to 
 
238 
 
 Chapter XXI. 
 
 The areas shaded in the neck, chest and upper part of the abdomen 
 represent the distribution of cutaneous hyperalgesia in a patient suffering 
 from acute dilatation of the heart and liver. 
 
 pressure, and the parts hyperalgesic extend over a 
 much larger area than the enlarged liver. If the 
 heart's rate revert to the normal the patient at once 
 experiences great relief, and in a few hours all signs of 
 the circulatory disturbances disappear. The hyper- 
 algesia may last with diminishing severity for a few 
 days. The tenderness of the skin and muscles in 
 the regions described above may be found in patients 
 during the early stages of dilatation of the heart 
 from any cause, ctnd is very common in heart failure 
 
Affections of the Circulatory System. 239 
 
 following the onset of auricular fibrillation. In 
 some cases one can tell when improvement is taking 
 place by noting the diminution of this tenderness. 
 
 There can be little doubt as to the mechanism 
 by which the hyperalgesia of the tissues in the 
 three regions is brought about. The relation of the 
 dilatation of the heart and liver with these sensorj^ 
 phenomena is undoubtedly that of cause and effect. 
 The tenderness to pressure of the tissues in the 
 left chest is due to stimulation of the afferent 
 sympathetic nerves by the dilated heart. These 
 nerves stimulate the sensor}^ centres of the third and 
 fourth thoracic nerves in the spinal cord, so that a 
 stimulus reaching them from their peripheral dis- 
 tribution gives rise to a painful impression. The 
 tenderness of the left sterno-mastoid and trapezius 
 muscle, and of the skin of the neck, is due to the 
 afferent fibres of the " bulbar autonomic " system — 
 that is the vagus, conveying a stimulus to the sensor}' 
 roots of the second and third cervical nerves. The 
 hyperalgesia of the tissues covering the liver is 
 due to stimulation of the sensory centres in the 
 spinal cord by the afferent sympathetic fibres from 
 the engorged liver. 
 
 128. The Pain of Angina Pectoris is a 
 Viscero-sensory Reflex. — The usual description given 
 of the pain in angina pectoris is that it is felt in 
 the heart and shoots into the arm, or that there 
 are two pains, a local pain in the heart and a referred 
 pain in the arm. If, however, a careful analysis 
 be made of all the symptoms present, facts will 
 be found that practically demonstrate that in 
 angina pectoris there is but one knid of pain, and 
 
240 
 
 Chapter XXI. 
 
 Fig. 22. 
 
 The shaded area shows the distribution of the pain and cutaneous 
 hyperalgesia in a typical case of angina pectoris. The roman numbers 
 refer to the nerves implicated, viz., I, II, III and IV, thoracic ner^^es 
 and VIII cervical nerve. 
 
 that its production is in accordance with the law I 
 have attempted to estabhsh, namely, that it is a 
 viscero-sensory reflex. One is not able in every case 
 to demonstrate the proofs of this hypothesis, but 
 facts derived from suitable cases afford legitimate 
 conclusions applicable to all cases. Shortty, these 
 facts are, that the pain in the very gravest cases 
 may be felt in regions distant from the heart ; that 
 
Affections of the Circulatory System. 241 
 
 Fig. 23. 
 
 The shaded areas show the distribution of the eruption in a case of 
 herpes zoster affecting the upper thoracic nerves. 
 
 this pain is identical in character with that felt over 
 the heart ; that the pain may originally start in parts 
 distant from the heart, and gradually approach and 
 settle over the heart ; and, lastly, that the tissues 
 of the external body wall, in the exact region in 
 which the pain was felt, may be found extremely 
 hyperalgesic after the pain has passed away. From 
 this last fact it is inferred that, inasmuch as the seat 
 
242 Chapter X X I. 
 
 of pain corresponds to the region of hyperalgesia, 
 therefore the pain was due to stimulation of the 
 hyperalgesia nerves. To assume otherwise would be 
 to ignore a principle that explains satisfactorily the 
 sensation of pain wherever arising. 
 
 Another fact tends to support this view, namely 
 that the eruption of herpes zoster affecting the arms 
 may occupy a situation similar to that in which 
 pain is felt in angina pectoris. Herpes zoster is due 
 to an inflammation of the ganglia on the posterior 
 roots of spinal nerves. Compare Figs. 22 and 23. 
 
 The following observations illustrate this point. 
 They are examples chosen from a large number of 
 cases that demonstrate the same feature. For the 
 sake of brevity only those points bearing upon this 
 argument are referred to. 
 
 Female, aged 30, suffering from stenosis of the 
 aortic, mitral and tricuspid valves, was seized 
 with a violent pain, referred to the outer part of the 
 left side of the chest wall. The pain passed off, but a 
 sense of soreness and smarting remained over the 
 part in which the pain v/as felt. On examining her 
 I foimd a portion of the sldn of the chest extremely 
 tender to touch, corresponding to the area shaded in 
 Fig. 24. 
 
 A few days later she began to suffer from 
 attacks of pain in the left breast and down the 
 inside of the left arm, and on examination I found 
 that the hyperalgesia had extended and occupied an 
 area similar to that shaded in Fig. 25. 
 
 These attacks of pain became so severe on the 
 shghtest exertion that she was obUged to keep to 
 her bed. She partially recovered from these attacks. 
 
Affections of the Circulatory System. 243 
 
 Fig. 24. 
 
 The shaded area shows the distribu- 
 tion of the cutaneous hyperalgesia after 
 the first attack of angina pectoris (com- 
 pare with Fig. 25). 
 
 FiCx. 25. 
 
 After repeated attacks of angina 
 pectoris the pain and hyperalgesia ex- 
 tended to the regions shaded here. 
 Note the areas in the neck and inner side 
 of right elbow (compare with Figs. 22 
 and 23). 
 
244 Chapter X X I. 
 
 but they recurred with increased severity. When 
 suffering the most severe attacks the hyperalgesia 
 embraced nearly the whole of the left chest and 
 inside of the left arm, and also a portion of the right 
 chest. The left sterno-mastoid muscle and trapezius 
 also became very tender, and the patient would 
 sometimes complain of pain on the inner surface of 
 the right arm, at the elbow, where also I found a 
 patch of cutaneous hyperalgesia. Two years and a 
 half after the first attack of pain she was recovering 
 from a series of violent attacks, when, on getting out 
 of bed, she fell forward and died immediately. 
 
 The fact that in this case the attacks of pain 
 were followed by a hyperalgesia of the sldn in the 
 region where the pain was felt, and the further fact 
 that the pain started at a distance from the cardiac 
 region, and was often felt most severely at a distance 
 from the heart, proves that the cardiac pain in this 
 case was a viscero-sensory reflex, and that the pain 
 felt over the precordia was presumably of the same 
 nature. 
 
 Female, aged 56, with high blood pressure,, 
 suffers from pain in the foot (gout), and has had 
 several severe attacks of true angina pectoris, in 
 which the pain is referred over the left chest and 
 through to the shoulder. After the attack she passes 
 a large quantity of clear urine, and the skin and 
 deeper tissues of the left breast and the left sterno- 
 mastoid and trapezius muscles become very tender 
 on pressure. In one attack the pain was felt in a 
 limited area over the second left interspace, and 
 next morning I found the skin and deeper tissues at 
 this place extremely tender to the slightest pressure. 
 
Affections of the Circulatory System. 245 
 
 In tills instance, also, the hyperalgesia of the 
 skin corresponded to the region where pain was 
 felt, and is presumptive evidence in favour of the 
 view that the pain as well as the hyperalgesia is the 
 result of the viscero-sensory reflex. 
 
 Male, aged 42, consulted me on October 18th, 
 1905, complaining of pain in the left little finger and 
 ulnar border of the left arm and forearm, coming 
 on when he exerted himself at his work and on going 
 up hill. For some months he suffered from a dull 
 aching pain at the back over his shoulder blades. 
 I found dilatation of the aorta, slight incompetence 
 of the aortic valves, and sHght enlargement of the 
 heart (verified at the subsequent post-mortem 
 examination). The blood pressure was 150 mm. Hg. 
 During the following week§ the pain in the left arm 
 increased in severity, gradually extended up the 
 arm till it was felt in the axilla, and finally invaded 
 the left chest. At first the pain was wont to start 
 at the little finger and to pass rapidly up the arm, 
 but latterly it seized him with such severity and 
 suddenness that he could not tell where it began. 
 It usually held him with the greatest severity either 
 over the heart or in the inner surface of the left arm 
 immediately above the internal condyle. I par- 
 ticularly asked him to note in his frequent attacks 
 if there was a difference between the arm pain and 
 the chest pain, and his reply was that there was no 
 difference in the character of the pain, but, if any- 
 thing, the arm pain was the worse. Sometimes the 
 pain was very severe up the left side of the neck and 
 behind the left ear. Under treatment he seemed to 
 make considerable improvement. During January, 
 
246 Chapter XXI. 
 
 1906, these attacks recurred. During some of them 
 the pain was so agonising that he felt he was dying, 
 and wished to die. The pain was equally severe in 
 chest and arm, and saUva sometimes dribbled 
 from his mouth. On February 12th the least 
 exertion was sufficient to induce a severe attack of 
 pain ; from three p.m. to seven p.m. he was 
 scarcely free from pain, and ultimately became 
 unconscious. When I saw him next day he was 
 having another series of attacks. He was keeping 
 his left arm very still, and helping himself to food 
 entirely with his right hand. He told me he dare not 
 move his left arm, as even the act of lifting the left 
 hand to his mouth was sufficient to induce an 
 attack. His pulse was extremely soft and weak. 
 His blood pressure had fallen to 95 mm. Hg. 
 During the following night he had another series of 
 attacks, became unconscious and expired. 
 
 1 omit many details in this case on purpose to 
 emphasise the regions in which the pain was felt in 
 a case of the most severe form of angina pectoris. 
 It seems to me that no other explanation save 
 that of the viscero-sensory reflex can satisfactorily 
 account for the pains in this case, and to attempt 
 to distinguish the chest pain as a heart pain and 
 the pain in the arm as a referred pain would be 
 arbitrary, illogical, and opposed to the e\ddence. 
 The radiation of the pain from the hand to the 
 chest was practically of the same nature as the 
 more common radiation of the pain from the chest 
 to the hand. The pain in the neck and behind the 
 ear, on the same hypothesis, would be induced by 
 the stimulus passing from the heart by the vagus. 
 
Affections of the Circulatory System. 247 
 
 a view that would also explain the increased flow of 
 saliva during some of the attacks, points to whicli 
 I shall afterwards revert. 
 
 It is interesting to note here that the movement 
 of the left arm would induce an attack of angina 
 pectoris. I have already pointed out that a 
 stimulus from any source reaching an irritable 
 focus in the cord will cause the characteristic pain 
 to arise. In the next observation the stimulus 
 reached the cord from the skin of the chest. 
 
 The two following observations of attacks of 
 angina pectoris which I witnessed illustrate true 
 heart pain of the most severe type at places remote 
 from the heart. 
 
 Male, aged 14, suffering from adhesive medias- 
 tinitis, with enormous enlargement of the heart. 
 The patient lay propped up in bed. As I was gently 
 testing the sensibility of the skin outside and under 
 the left nipple the patient was suddenly attacked 
 with severe pain. He gave a great sob, and leant 
 forward with his left upper arm across his chest, 
 and his right hand pressing it gently. He rocked 
 backwards and forwards with deep sobs, while tears 
 streamed down his cheeks. His pulse became very 
 soft and his face pale, with beads of perspiration 
 on his forehead. In a few minutes the pain sub- 
 sided and he lay back exhausted. Afterwards he 
 said that, on my touching a certain spot, a pain shot 
 from his chest to his arm, and during the whole 
 time the awful pain remained in his arm, and he put 
 his hand over the fleshy part of the upper arm. His 
 doctor told me he had given up examining him by 
 auscultation, because on a few occasions, on applying 
 
248 Chapter X X I. 
 
 the stethoscope, attacks similar to those I had 
 witnessed were induced. 
 
 Female, aged 60, complained of pain of agon- 
 ising severity limited to the ulnar border of the 
 left forearm. Coming to see me one day she hiurried 
 to catch the train, and when she reached my con- 
 sulting room she sat down. In a few minutes the 
 pain seized her, and she took up her left arm and 
 nursed it across her breast with evidences of 
 great suffering. The pain subsided in a few moments. 
 and she said she felt as if she would have died. 
 The pain was felt nowhere but in the left forearm. 
 Three months afterwards the patient died from 
 heart failure. At the post-mortem examination 
 there was found marked atheroma, calcification of 
 the coronary arteries and extensive chronic fibrous 
 myocarditis. 
 
 In this last case the pain was doubtless limited 
 to the highest sensory nerve centre (first thoracic), 
 whose fibres are associated with the sympathetic 
 supply of the heart. 
 
 129. Evidences of the Viscero-motor Reflex. — 
 So far I have dealt with the viscero-sensory reflex, 
 and e\ddence no less striking can be found of the 
 viscero-motor reflex among the group of symp- 
 toms included in the term " angina pectoris." Some 
 would limit the term " angina pectoris " to that class 
 of cases where, in addition to the pain, there is a 
 sense of constriction in the chest, amounting at times 
 to a sensation as if the chest were gripped in a 
 \ace, or as if the breast-bone would break. I am 
 convinced that these sensations arise from spasm 
 of the intercostal muscles, and correspond to tlie 
 
Affections of the Circulatory System. 249 
 
 hard contraction of the flat abdominal muscles in 
 affections of the abdominal viscera. If one watches 
 a case of what is called " muscular rheumatism " 
 where the intercostal muscles are affected, and 
 where these muscles are stimulated by the shghtest 
 movement to violent cramp-like contractions, one 
 cannot but be struck by the resemblance to the 
 description given of the " gripping " sensation 
 experienced by patients suffering from certain 
 affections of the heart. I have watched the attacks 
 in such cases and could find no difference between 
 them and those where the sense of constriction was 
 the chief symptom in heart disease. The 
 viscero-motor reflex may be present alone, or, as is 
 more commonly the case, it may be associated with 
 pain. The purely viscero-motor reflex is seen best 
 in the elderly, where it may be considered as a 
 symptom of one form of the terminal affections of 
 the heart due to arterio-sclerosis or old age. I have 
 found it a precursor of steadily advancing cardiac 
 weakness, and although for a time considerable 
 relief may be afforded, the changes in the heart are so 
 advanced that, in the nature of things, only one end' 
 can be looked for. The three foUowing observations 
 illustrate these views. 
 
 Male, aged 82, with large tortuous arteries, 
 was seized while Avalldng with a sense of constriction 
 across the chest that compelled him to stand still. 
 These attacks became so frequent and so severe 
 that he could scarcely walk fifty yards before he had 
 to stop and lean against the wall. He described 
 the sensation as one not of pain, but as if somebody 
 gripped the upper part of the chest with a strong 
 
250 Chapter XXI. 
 
 hand. With rest and suitable treatment these 
 attacks gradually disappeared. Three months later 
 the heart suddenly became irregular (auricular 
 fibrillation), dropsy set in, and he died seven weeks 
 later from heart failure. 
 
 Male, aged 56, was seized with a spasm which 
 held his chest as in a vice when he walked up a hill. 
 There was no pain but the sense of constriction and a 
 sense of suffocation produced such discomfort that he 
 was forced to stand still. Within a few minutes tlie 
 chest would feel free, but the sensation would at once 
 recur if he attempted further effort of the same 
 kind. Thus, in going to business, he had to go up 
 a steep hill, but frequently found it impossible to do 
 so, and then had to go downhill and reach his 
 destination by another and less steep road. 
 
 Female, aged 78. Two years before her death 
 she experienced attacks of breathlessness with a 
 sensation of constriction across the chest. This 
 feeling of tightness was so readily set up that she 
 was obUged to stay in bed. The attacks dis- 
 appeared, but recurred again shortly before her 
 death. These latter attacks were accompanied by 
 slight precordial pain. She became gradually weaker 
 and died. At the post-mortem examination the 
 coronary arteries were found markedly thickened, 
 with calcareous patches in their walls. 
 
 The following experience illustrates the fact 
 that the viscero-motor reflex is a symptom distinct 
 from the pain. 
 
 Male, aged 48, consulted me on November 25th, 
 1905, for a pain he felt across the middle of his 
 chest. He had felt a slight pain here for some 
 
Affections of the Circulatory System. 251 
 
 months on walldng up a hill. He was a master-buMer, 
 and on this day, while watching his men at work, 
 feeUng cold, he began to help them to dig up some 
 earth, to warm himself. He did tliis for a quarter of 
 an hour with a good deal of energy. He then 
 examined a few partially built houses, running up 
 and down a great many steps. On his way home he 
 became conscious of pain in his chest, and as it con- 
 tinued to increase in severity he called on me. I 
 examined him carefully, and found a slight dilata- 
 tion of the heart with an impure first sound. The 
 blood pressure was 130 mm. Hg. On his way home 
 the pain increased in severity, and after he reached 
 home it became very violent. A colleague saw him 
 and prescribed opium, which relieved him. When I 
 saw him next morning he gave a graphic account of 
 his sufferings. He said : " In the tram coming home 
 the pain got worse, and after getting home it became 
 so severe that I felt I was going to die. The pain 
 spread from my chest down my left arm to my little 
 finger. You asked me, when I saw you yesterday, if 
 I felt any gripping sensation, and I did not know 
 what you meant ; but, by George ! I Imow now. When 
 the pain was at its worst, I felt my chest suddenly 
 seized as in a vice, and I rolled on the floor in agony. 
 The pain and the gripping eased off for a time and 
 then came on again. This continued tiU I got the 
 opium. This morning I awoke all right, but at 10.30 
 that gripping sensation came on and held me tight 
 for ten minutes. I dare not move for fear the 
 awful pain should come on, and I felt every moment 
 it was about to come, and I was in such terror of it 
 that the sweat poured off me." 
 
252 Chapter X X I. 
 
 With rest and treatment these attacks grew less,tiU 
 he only felt a sUght pain when he over-exerted himself. 
 So far the symptoms I have dealt mth have 
 been mainly concerned with the reflexes connected 
 with the sympathetic nerve supply. Equalh^ 
 instructive symptoms, though less frequent, can be 
 shown to arise from stimulation of the vagus. At 
 its centre in the medulla this nerve is in near rela- 
 tionship to the upper cervical nerves, and, it would 
 seem, more particularly the sensory nerves supplying 
 the sterno-mastoid and trapezius muscles. Not only 
 may these muscles become extremely tender in 
 various heart affections, but the pain from heart 
 affections may be felt in the region of distribution 
 of the cervical nerves as already noted. The 
 following observations also show the same thing. 
 
 Male, aged 62, complained of great pain striking 
 into his chest and behind Ms ears when walking. Thus, 
 in going to his work, he allowed seven or eight minutes 
 to walk to the station, but nov,^ it took liim over half 
 an hour, as he had to stop on account of the pain 
 every fifty yards. After accurately noting the pain he 
 described it as arising in the left breast, extending 
 across to the right breast, seizing him in the neck, and 
 extending up beliind the ears, where it held him. \^'ith 
 great severity. In showing me the situation, he laid 
 the fingers of both hands over the insertion of the 
 sterno-mastoid muscle into the mastoid process. On 
 one occasion the pain extended from the breasts to the 
 armpits, and down the side of each arm to the elbow. 
 
 This patient dropped dead while at his work, 
 and on post-mortem, examination T found extreme 
 calcareous degeneration of the coronary arteries. 
 
uiffedions of the Circulatory System. 253 
 
 130. Organic Reflexes. — Other very striking 
 phenomena are sometimes met with during an 
 attack of angina pectoris. During or after an 
 attack an abundant flow of sahva and the secretion 
 of large quantities of pale urine may occur ; both 
 symptoms I suggest are due to reflex stimulation of 
 nuclei in the floor of the fourth ventricle. Possibly 
 the polyuria may be of the same character as that 
 in diabetes insipidus, which, as is well known, may 
 be induced in animals by puncture of the floor of 
 the fourth ventricle. 
 
 Male, aged 58, of gouty diathesis, complained 
 of pain, induced by the slightest exertion, which 
 arose in the left breast, passed up the armpit, and 
 extended down the inner surface of the left arm to 
 the Uttle finger. During an attack an abundant flow 
 of sahva took place into the left side of the mouth. 
 These attacks became so frequent that he could only 
 walk a very short distance without inducing an 
 attack. He died while sitting at his desk, and at 
 the post-mortem examination I found that the heart 
 had ruptured, and the coronary artery was very 
 atheromatous. Where the rupture had taken place 
 the m.yocardivmi had nearly disappeared. 
 
 Male, aged 46, whose work entailed periods 
 of great muscular exertion, complained of pain 
 striking into the chest when walking up a hill. 
 If he stopped as soon as he felt the pain coming on, 
 it passed off, but if he persisted the pain increased 
 to an agonising severity and radiated into both 
 arms, but worse into the left, as far down as the 
 httle finger. At the same time the chest was gripped, 
 
254 Chapter XXI. 
 
 so that he was forced to straighten himself and to 
 breathe deeply, and at the same time his mouth filled 
 with saliva, and an aching pain was felt in the 
 throat. A few minutes after each attack he had to 
 pass urine, which was always abundant and very 
 clear. These details I had from him after he had 
 carefully noted a number of attacks. 
 
 131. Summation of Stimuli the Cause of 
 Angina Pectoris. — The fundamental functions of 
 the heart muscle correspond to those of other in- 
 voluntary muscles that form the walls of holloAv 
 organs ; these functions being modified to suit its 
 special work. Like the other viscera the heart is 
 insensitive when stimulated in a manner that pro- 
 vokes pain when apphed to the tissues of the exter- 
 nal body wall. I have pointed out that a long strong 
 contraction of a hollow organ can produce pain, and 
 that this is undoubtedly the cause of the severe pain 
 associated with renal calculus, gaU-stones, spasm of 
 the bowel, and uterine contractions. Can the heart 
 give rise to pain in a similar manner ? On account 
 of the modification of its functions, the heart cannot 
 pass into a prolonged state of contraction. Imme- 
 diately it contracts, the function of contractility is 
 abolished and the muscle passes at once into a state 
 of relaxation, and for this reason the pain cannot be 
 produced by a " spasm of the heart." But I suggest 
 that the heart muscle may produce pain when it is 
 confronted with work greater than it can readily 
 overcome, a condition which produces strong peri- 
 stalsis and pain in other hollow viscera. But the pain 
 in the heart arises by a slightly different mechanism. 
 A skeletal muscle wiVL contract in obedience to 
 
Affections of the Circulatory System. 255 
 
 stimulation of a sensory nerve going to the spinal 
 centre of its nerve, if a stimulus of sufficient strength 
 be appUed. If the stimulus be too weak, no contrac- 
 tion follows, but if this weak stimulus be frequently 
 and rapidly repeated, then the muscle contracts in 
 accordance with the law of the summation of stimuli. 
 I suggest that the heart muscle induces pain on the 
 principle of summation of stimuH. If we minutely 
 study our cases we shall find that the pain rarely 
 arises at the fii'st exposure of the heart to the effort 
 that induces the pain. Sometimes effort has been 
 undertaken a few minutes before the pain comes on, 
 and in certain cases it may not come on for hours 
 after the casual exertion has ceased. 
 
 From such observations we can infer that the 
 heart muscle was exhausted by the exertion, and so 
 ofreat was the exhaustion of the reserve force that 
 it was unable to regain its reserve on cessation 
 of effort ; thus the exhaustion persisted till it 
 culminated in an attack of angina pectoris. 
 
( 256 ) 
 
 CHAPTER XXIT. 
 
 ESTIMATION OF THE VALUE OF 
 SYMPTOMS. 
 
 132. The Relation of the Symptoms to the General 
 
 State. 
 
 133. Remote Effects of the Lesion. 
 
 134. Relation of Symptoms arising from different 
 
 Causes. 
 
 135. The Bearing of Symptoms on Progiiosis. 
 
 136. The Bearing of Symptoms on Treatment. 
 
 In this chapter I endeavour to sum up the 
 general principles which have been applied in more 
 detail in the earlier chapters. That the interpre- 
 tation of symptoms should be imperfect can readily 
 be recognised, for not only is the subject too vast 
 to be dealt with in a few pages, but the knowledge 
 to deal with it efficiently is lacking. I confine myself, 
 therefore, to a few general principles that have 
 been of service to me in my endeavours to estimate 
 the value of symptoms in individual cases. 
 
 132. The Relation of the Symptoms to the 
 General State.— Before a final opinion is formed 
 of the value of any symptom, the physician must 
 consider the patient as a whole, and the relation 
 
Estimation of the Value of Sipnptoms. 257 
 
 of aiw abnormal sign to the general health. The 
 patient's complaint may be of a trivial nature, and 
 the examination of the different organs may reveal 
 no abnormality^ ; nevertheless the contemplation 
 of the patient's whole economy may help one not 
 to dismiss the symptoms too hastily because of their 
 seeming triviality. Malignant disease of the stomach 
 may cause the symptoms of a simple indigestion, but 
 a slight loss in weight and a slight change in the 
 patient's colour ma^^ ultimately be found to indicate 
 the grave nature of the illness. The description of 
 the patient's complaint maj^ be given in such terms 
 that the physician may fanc}^ it is exaggerated and 
 due to the patient being of a neurotic habit. This 
 may be true, yet the complaint from which the 
 patient suffers may have so undermined his strength 
 that the neurotic habit has been induced by his 
 prolonged suffering. It is necessary to state this 
 because the presence of many reflex phenomena is 
 apt to be pooh-poohed, because of the manifest 
 hypersensitiveness of the patient's nervous system. 
 There is no doubt that in people of a neurotic habit 
 there is a greater tendency for reflex phenomena to 
 be readily produced, yet the phenomena should not 
 on that account be ignored, but should be utilised for 
 the purpose of discovering the lesion if possible, and 
 the neurotic tendency being duly discounted, their 
 true value should be estimated. However widespread 
 such symptoms as pain and hyperalgesia may be, 
 there is always some irritation in the cord, induced, 
 as a rule, bj^ some trouble in the viscera or external 
 bod}^ wall. This was well illustrated in the following 
 case, which was under nw observation for many 
 
258 Chapter XXII. 
 
 years. I attended the patient during several attacks 
 of rheumatic fever from 1880 to 1884. She 
 developed well-marked symptoms of aortic, mitral 
 and tricuspid valvular disease, and was for years 
 very short of breath occasionally, but had no pain 
 or hyperalgesia. In 1895 she began to complain of 
 pain, particular^ after meals, referred to the lower 
 part of the epigastric region, with a limited area of 
 hyperalgesia. The pain became very severe, so that 
 I came to the opinion that she had a gastric ulcer 
 near the pyloric orifice. The hyperalgesia spread 
 widely round to the left chest. She kept in bed for 
 a few weeks, but began to go about her household 
 duties before the pain and hyperalgesia had dis- 
 appeared. She then began to have attacks of pain 
 in the chest on exertion, slight at first, but gradually 
 becoming more severe, until they resembled in every 
 respect attacks of angina pectoris. Coincident with 
 the pain, hyperalgesia appeared in the chest and 
 arm. The distribution of this hyperalgesia, due 
 manifestly to the heart lesion, coalesced with that 
 due to the gastric ulcer, so that there was an exten- 
 sive field of hyperalgesia embracing the left chest 
 and abdomen, from the level of the second rib to 
 below the umbilicus. At the patient's death there 
 were found the lesions of the three valves mentioned, 
 and an ulcer at the pyloric orifice. Anyone seeing 
 the patient after the development of tlie extreme 
 field of hyperalgesia might have attributed the whole 
 condition to some such vague complaint as " neuras- 
 thenia," particularly if the nature of the cardiac 
 lesions were not detected. I have seen another case 
 with very severe attacks of angina pectoris and wide- 
 
Estimation of the Value of Symjitoms. 259 
 
 spread liyi^eralgesia where no cardiac abnormality 
 could be detected. The extraordinary acuteness and 
 extent of the sensory phenomena might have led to 
 the surmise that there was only a neurasthenic con- 
 dition, yet at the post-mortem examination the 
 coronary artery was found almost impermeable, and 
 the muscle of the heart greatly degenerated. The 
 rule I make in these cases is to recognise the fact 
 that, however exaggerated the reflex symptoms, and 
 however neurotic the patient may be, the symptoms 
 are nevertheless due to actual affection of some 
 viscus, and a careful consideration of all the other 
 features of the case will lead one to an approximately 
 correct estimation of the value of the symptoms. 
 
 133. Remote Effects of the Lesion.— Not 
 only may the continuance of a visceral lesion and 
 prolongation of suffering lead to the exhaustion of 
 the patient's nervous system (which is probably the 
 reason for the ease with which the reflex phenomena 
 are produced in many people), but the original 
 ailment, in consequence of persistent suffering, may 
 alter the vvhole mental balance of the patient. 
 Previous to an illness he may be sensible, unselfish, 
 and considerate of his relatives and dependents, 
 but during illness he may become utterly selfish, 
 wear out the patience of his children and dependents 
 with his peevishness and want of consideration, 
 in order that his own requirements and comforts may 
 be satisfied. Patients in this condition are extreme^ 
 difficult subjects for diagnosis, for it is to their 
 interest to magnify their complaints, and it is 
 difficult to estimate the value of their symptoms. 
 This is particularly the case if one searches for 
 
260 Chapter XXII. 
 
 hyperalgesia of skin or muscle, for they readily 
 complain of pain and tenderness. To discriminate 
 the symptoms in such people the distribution of the 
 sensory phenomena (pain and hyperalgesia) affords a 
 .very good guide. Thus if one tests for hyperalgesia 
 of a heart affection, and the symptoms are found to 
 extend up the chest and over the clavicle, one 
 might reject the symptoms, for the skin over the 
 clavicle as low as the second rib is supplied by the 
 fourth cervical nerve, while below it is supplied 
 by the second thoracic, so that the extension of 
 the hyperalgesia from the second thoracic to the 
 fourth cervical is not conceivable. So it is in 
 other complaints ; the peculiar distribution of the 
 sensory phenomena in affections of any given 
 organ being unknown to the patient, one can test 
 his reliability by noting the distribution of his 
 pain and hyperalgesia. 
 
 This method of discrimination is also to be used 
 in distinguishing true visceral sensory phenomena 
 in cases of suspected hj^steria and malingering. If 
 the symptoms are found to follow the distribution 
 peculiar to one organ, even if the patient be evidently 
 hysterical, then it may be concluded that there is an 
 affection of the viscus, and it remains to make care- 
 ful consideration of the other factors in the diagnosis 
 in order to estimate what value the symptoms 
 possess. 
 
 The intensification of reflex phenomena is par- 
 ticularly noticeable where the conditions of living 
 have reduced the bodily strength, through worry, 
 sleeplessness, or improper nourishment. I have been 
 particular^ struck, for instance, with the s^^mptoms 
 
Estimation of the Value of Symptoms. 261 
 
 of angina pectoris that ma}^ be induced in young 
 people who have had a long and trying period of 
 strain. Women who work hard for their living, or 
 who look after household duties during the day, and 
 have to attend an invalid parent or ailing child 
 during the night, who are frequently disturbed in 
 sleep, or who pass the greater part of the night in 
 constant attendance, become gradually exhausted, 
 and the struggle may go on until an attack of pain 
 in the chest imperatively calls attention to the 
 exhausted heart. In such people the attacks of 
 angina pectoris may be extremeh^ severe, and the 
 hyperalgesia may be widespread, affecting both 
 sides of the chest (the left breast particularly often 
 becoming extremely tender), and, it may be, the 
 neck, particularly the left sterno-mastoid and 
 trapezius muscles. 
 
 In estimating the value of the symptoms in such 
 cases the history of the patient's life gives an 
 indication, and one can then recognise, with assur- 
 ance, the condition of the heart that has provoked 
 these manifestations. 
 
 Similar exaggerated sjanptoms, having a 
 peculiar distribution, may arise should any other 
 organ be affected ; as in stomach affections, a slight 
 indigestion may give rise to such s^'mptoms as to 
 make it difficult to tell whether som.e more serious 
 condition, as gastric ulcer, may not be present. 
 
 In doubtful cases one feature when present 
 ma}^ be taken as a rule to distinguish an 
 affection of an organ from some general nervous 
 manifestation, that is, the viscero-motor reflex. Un- 
 fortunately, this symptom is practically limited to 
 
262 Chapter XXII. 
 
 affections of the abdominal organs, and needs to be 
 sought for with care, lest a too susceptible super- 
 ficial reflex be started. But when detected it ma}^ 
 be looked upon as demonstrating the presence of 
 some visceral trouble. 
 
 134. Relation of Symptoms arising from 
 different Causes. — When a patient presents him- 
 self one may be able, on physical examination, to 
 detect some abnormal condition to which one can 
 refer with certainty the cause of the patient's 
 suffering. It may happen, however, that we detect 
 an abnormality having no direct bearing upon the 
 complaint of the pa,tient, and in the absence of one 
 having such a direct bearing, there is too often a 
 tendency to refer the patient's complaint to the pres- 
 ence of the recognisable abnormality. There is no 
 doubt that symptoms may be provoked by lesions 
 remote from the place where they are ex- 
 perienced, as in referred pain, and there is no doubt 
 that many other symptoms may be produced by 
 lesions of remote organs, as in the widespread effects 
 of kidne}^ disease. But keeping all this in view, there 
 is still need of a wise discretion in estimating the 
 influence of lesions in which there is no recognisable 
 connection with the symptoms. Thus epileptic 
 attacks may be brought on b}^ affections of the heart 
 as in heart-block (Adams-Stokes S3aidrome), where 
 the left ventricle becomes so slow in its action that 
 the brain does not receive a sufficient supply of blood. 
 In consequence of this anaemia the patient may faint 
 or have an epileptic seizure. The weU-recognised 
 connection between a heart abnormality and an 
 epileptic attack in this particular instance has led 
 
Estimation of the Value of Symptoms. 263 
 
 to the assumption that, if a patient has epilepsy 
 and at the same time has some affection of the heart 
 such as irregular action, there is a connection 
 between the two. Under such circumstances it is 
 necessar}^ to recognise the nature of the irregularity, 
 and as it is now possible to demonstrate with pre- 
 cision the different forms of heart irregularity, 
 the recognition of the particular form of irregular 
 heart action at once permits of determining the 
 probabilities of the heart being the cause of the 
 epileptic attack in any given condition. Irregular 
 action of the heart being so common, the occiurence 
 of epilepsy is in the majorit}^ of cases due to an 
 independent affection, and there is no casual relation 
 necessarily present between the two conditions. 
 
 I have already referred to errors arising from 
 attributing the cause of symptoms to some demon- 
 strable structural affection which may be merely 
 coincident or independent. 
 
 It is impossible to lay down rules applicable to 
 all cases, and I write this in order that the subject 
 should in every case receive consideration, since the 
 recognition of the possibility of error may prevent 
 the error being made. 
 
 135. The Bearing of Symptoms on Prognosis. — 
 Of all branches of medicine there is none which 
 has received so little real consideration as the matter 
 of prognosis. The subject itself is one which has to 
 be considered in nearly every case that comes under 
 the notice of a medical man. Its im.portance is 
 appreciated in all stages of life, and the just con- 
 sideration of the meaning of symptoms is of cardinal 
 importance in regard to the patient's future. 
 
264 Chapter XX 1 1. 
 
 In addition to recognising the meaning of any 
 abnormal sign or sj^mptom, we should endeavour to 
 acquire a knowledge of what bearing it has upon the 
 future history of the patient. This knowledge can 
 only be obtained by watching how patients exhibit- 
 ing the abnormality withstand the storm and stress 
 of life. This should be a special object of every 
 general practitioner, for it is he who has the oppor- 
 tunity of watching individual cases over a long 
 period of years, and of estimating the bearing of 
 any abnormality on the patient's future life. 
 
 I am afraid that our profession as a body does 
 not sufficiently recognise its responsibility in regard 
 to prognosis. When an individual submits himself for 
 an opinion, he does so with such implicit confidence 
 that the verdict given may alter the whole tenor of 
 his life. He may, for instance, be seeking to enter 
 some profession, when a preliminary medical exam- 
 ination reveals what the medical man takes to be an 
 abnormality. An imperfect knowledge of its nature 
 may, and unfortunately often does, lead to its being 
 regarded as presaging possibly grave consequences, 
 and the candidate is rejected. He is thus shut off 
 from the prospect of his chosen calling, and, know- 
 ing the reason of his rejection, passes through life 
 uneasily apprehensive of some impending disaster, 
 whilst all the time the supposed abnormality may be 
 a sign of little or no consequence. 
 
 If we look at an insurance form we realise the 
 hardships to which applicants are exposed. " Is the 
 pulse regular ? " " Are the sounds of the heart 
 pure ? " "Is the urine free from albumen ? " When 
 such questions are answered in the negative the 
 
Estimation of the Valve of Symptoms. 265 
 
 applicant may nevertheless be perfectly health}', yet 
 is either rejected or is penalised for life by having 
 to pay a higher preniium, and, in addition, he is 
 burdened with the consciousness of infirmity. 
 
 I dwell on this matter with some insistence, 
 because I have known of so many instances in 
 which gross injustice has been done to individuals 
 not onh' from a pecuniary aspect, but in having 
 imposed upon them great expense, unnecessary 
 treatment, and mental disquiet, because the meaning 
 and prognostic significance of some simple symptom 
 had not been recognised. 
 
 A serious responsibility is thrown upon every 
 practitioner at times in advising upon other ques- 
 tions. Should a man give up his business ? is a 
 question upon which advice is constantly sought ; and 
 whether the individual be a statesman or a labourer, 
 the greatest care is necessary in formulating the 
 answer. " Should a woman with some heart affection 
 marr}' ? " or, " If she be pregnant, should the preg- 
 nancy be allowed to proceed ? " are problems that 
 every general practitioner at one time or another will 
 have to meet ; and if he seeks for guidance in the 
 text-books he finds merely vague views which he 
 cannot apph^ to the individual case. This fact alone 
 should arrest the attention of the profession, and 
 make it conscious how insufficient are the indications 
 for an intelligent prognosis. 
 
 In estimating the value of an}^ abnormal sign, 
 or in determining the condition of the patient, a 
 clear idea must be obtained of the mechanism by 
 which any given symptom is produced, and of the 
 effects that the underlying lesion has upon the 
 
266 Chapter XXII. 
 
 economy. It is impossible to give here indications 
 that would be of value, partty because the subject 
 traverses the whole field of clinical medicine and 
 partly because I am not competent to deal with the 
 matter, being only impressed with the importance 
 of the subject and the necessit}^ for its further con- 
 sideration. So far as my experience goes, I can only 
 say that one should never base a prognosis upon the 
 presence of a single symptom, but should carefully 
 investigate the effect of any abnormal sign on the 
 functional efficiency of the organ and upon the 
 economy as a whole. Tlie presence of albumen in 
 the urine is often a sign of variable import. In 
 many cases it is a sign of great gravity, and this 
 being recognised, it is too often regarded as being 
 invariably a serious matter. It is now recognised 
 that its significance depends on the conditions induc- 
 ing it, and it may appear when there is no serious 
 affection of the kidney, or when the kidney affection 
 is of such a nature that it may have little effect 
 upon the system. Cases of albuminuria should not 
 therefore be hastily condemned until a complete 
 review of the whole circumstances of the case, such 
 as the history of the iUness, the condition of the other 
 constituents in the urine and their effect upon the cir- 
 culatory system, has been made. In the same way the 
 presence of a cardiac murmur or irregularity, or even 
 an attack of angina pectoris, should never be con- 
 sidered as aif ording grounds for a grave prognosis until 
 the whole circumstances of the case are taken into 
 consideration. I mention these instances merely as 
 indications as to what comse to pursue when doubts 
 arise as to the significance of any abnormal sign. 
 
Estimation of the Value of Symj)to7ns. 267 
 
 The syinptonis which arise reflexly in like 
 manner liave to be carefully weighed. Intensity of 
 suffering may have no relation to the gravity of the 
 complaint. Toothache causes no anxiety as to the 
 prognosis, though the immediate suffering is severe. 
 Were the cause of the pain not so easily recognised 
 the agonising distress would at times be viewed 
 with the gravest anxiety. Extreme suffering from 
 some trivial disease may be found among the 
 symptoms of many organs. When it is recognised 
 that the most agonising pains are associated with the 
 contraction of non-striped muscular fibres, it will 
 be realised that the cause inducing a contraction 
 capable of calling forth violent pain may be of the 
 most varied kinds, trivial as well as important. 
 Even in the matter of angina pectoris the violence 
 of the pain bears no necessary relation to the gravitj' 
 of the heart complaint. In many cases the onlj^ 
 sensation brought on by exhaustion of the heart 
 muscle may be limited to a mere sense of constriction, 
 and this, if properly appreciated, may indeed be 
 the one sign which calls attention to the serious 
 condition of the heart. I have repeatedly been con- 
 sulted by elderly people for this sense of constric- 
 tion across the chest when they exerted themselves, 
 and in many cases it was the earliest symptom that 
 heralded the termination of the patient's life. On 
 the other hand, some of the most violent attacks of 
 angina pectoris have occurred in people in whom the 
 exhaustion of the heart was but temporary, and the 
 restoration of reserve force resulted in a complete 
 cessation of pain and in permanent recovery. 
 Between these extremes there are many intermediate 
 
268 Chapter XXI I. 
 
 forms, and it needs a careful inquiry into all the 
 circumstances before a definite prognosis can be 
 given. 
 
 In regard to the reflex phenomena the tendency 
 to the exaggeration of s3'mptoms by people with a 
 hypersensitive nervous system must always be 
 borne in mind. 
 
 136. The Bearing of Symptoms on Treatment. — 
 The due appreciation of the mechanism by which 
 symptoms are produced has a profound influence on 
 treatment. It is often stated that treatment has to 
 be symptomatic, that is, the symptoms are to be 
 treated because the nature of the affection inducing 
 those symptoms cannot be detected. Whole systems 
 of treatment are based upon this idea, and though 
 at times we may be forced to accept this line, it 
 should always be done with regret at our incapacity 
 to recognise the underlying cause of the suffering. A 
 constant endeavour to make out the meaning of these 
 symptoms, which have perforce to be treated 
 without knoAvledge of their cause, will gradually 
 diminish the number of patients who have to be 
 treated symptomatically. 
 
 As pain is the most common complaint from 
 which so many suffer, its relief is an aim of our 
 treatment. But it should never be supposed that the 
 assuagement of pain is the only object. It has 
 become stereotyped to say " remove the cause," and 
 if this advice had not become so much of a platitude 
 more attention might be given to the " search for the 
 cause." The recognition of the cause can only be 
 attained in the majority of sufferers by a recognition 
 of the mechanism bv which the suffering is produced. 
 
Estimation of the Value of Symptoms. 269 
 
 Recognising, for instance, tliat contraction of non- 
 striped muscle produces a referred pain, the know- 
 ledge of liow the pain is produced leads to the recog- 
 nition of the hollow viscus producing it. There must 
 be an abnormal stimulus exciting the muscle to con- 
 traction, and experience leads us to conclude what 
 is the most common cause likely to produce the stimu- 
 lation in a particular viscus. A pain with accom- 
 pamdng phenomena located in a certain region in- 
 forms us that the stimulus arises from the gall- duct 
 or the ureter. Experience tells us that a gall-stone or 
 renal calculus is the most frequent caiuse. The 
 absence of s^aiiptoms indicative of smy other lesion 
 confirms this view. On recognising that this is the 
 cause, the question arises : Can we remove it ? In 
 the vast majority of cases this is only possible by 
 surgical operation, and the question of the propriety 
 of this procedure has to be considered. If, as is often 
 the case, this proves inadvisable, then the treatment 
 must proceed on other lines, and the recognition of 
 the mechanism by which the pain arises again gives 
 indications. As it is manifestly due to the strong 
 contraction of non- striped muscle, measures that will 
 relax the contraction of the muscle will naturally be 
 the remedy in this particular case for the time being. 
 On the other hand, if the pain be aroused by 
 some hollow muscular organ, where it is possible by 
 simple means to remove the cause that stimulates 
 the contraction, to this end treatment should 
 be primarily directed. If, for instance, the 
 indications point to the pain arising from painful 
 peristalsis of the boAvel, the inquiry wall proceed to 
 find out the probable nature of the stimulus. If 
 
270 CJiapter XXI I. 
 
 there has been a histor}- of constipation, or incom- 
 plete evacuation of the bowel, the retention of 
 scybalous masses is suggested as the cause of the 
 peristalsis, and the treatment will be guided to 
 measures that will lead to evacuation. So also with 
 regard to any other viscus that can be emptied, the 
 recognition of the nature of the symptoms affording 
 the best guide for a rational and effective treatment. 
 In an organ, such as the heart, that cannot have 
 the cause of the suffering removed by some mechani- 
 cal process, the consideration of the conditions that 
 induce the symptoms leads to a rational guide in 
 treatment. As I have pointed out, any symptom 
 of suffering points to an exhaustion of the reserve 
 force, whatever be the nature of the functional 
 exhaustion or structural lesion. The recognition of 
 this indicates that treatment in the first instance 
 must be directed to the restoration of this reserve 
 force, and this can be done when consideration of 
 the factors inducing the exhaustion are appreciated, 
 such as over- work, worry, sleeplessness, or the ham- 
 pering effect of some organic lesion. This demands 
 careful investigation into the special features of each 
 individual case. 
 
 These remarks may seem so evident as to be 
 altogether unnecessarj^, as everyone recognises them. 
 But though as a matter of theory they are the 
 commonest of platitudes, as a matter of practice 
 they are often neglected. If we consider the 
 matter in relation to the treatment of heart 
 affections, for instance, it would be found that, w^hat- 
 ever the nature of the heart failure, a routine method 
 of treatment is, with few exceptions, invariably 
 
Estimation of the Value of Symptoms. 271 
 
 adopted. Thus lieart failure is supposed to demand 
 ^\llat are called " heart tonics," and the usual 
 treatment is to prescribe the tonic which is dictated 
 by the fancy or the physician or by the fashion of 
 the day. In our inquiries into S3'stems of treatment, 
 sucli as are elaborated at places like Nauheim, it 
 will be found that routine methods are employed, 
 after few or no discriminating inquiries into the 
 peculiar features of each case. One could indefinitely 
 extend illustrations, drawn from other systems, where 
 rule of thumb treatment is followed, to the neglect 
 of the simple and obvious methods suggested by the 
 careful appreciation of the meaning of symptoms. 
 
 I have already pointed out that treatment may 
 be a factor in diagnosis — so-called diagnosis "ex 
 juvantibus " — the manner in which symptoms react 
 to treatment being often a useful help, as, for in- 
 stance, the use of mercury or iodide of potassium in 
 suspected cases of syphilis. But it is necessary also 
 to appreciate when possible the manner in which the 
 treatment acts. It must be the experience of every- 
 one who has seen a large number of cases of stomach 
 affections, that many cases of great suffering, where 
 there is manifest structural lesion, obtain relief by 
 some simple remedy or change in diet. Thus in 
 pyloric stenosis Avith dilatation of the stomach the 
 patient may have suffered for a long period, and 
 some simple remedy, as bicarbonate of soda, may 
 give instant relief and freedom from suffering for a 
 long time. So also a change in the diet may have 
 the same result. Too often such remarkable experi- 
 ences are mistaken by physician and patient as 
 evidences of the curative value and potency of the 
 
272 Chapter XXI I. 
 
 drug or system of diet, and so we get the exaggerated 
 praises of different drugs and systems so common 
 nowadays. If it be recognised that some constituent 
 was present in the stomach which occasioned the 
 sufferings of the patient, and that the drug had 
 neutraHsed its effects, or the change of diet had pre- 
 vented its formation, it would have led to a truer 
 appreciation of the benefits obtained by the 
 treatment. It cannot be too strongly insisted 
 upon that the reflex sj^mptoms, which are those that 
 are thus " cured," may arise, not from the actual 
 lesion, but from a susceptibility to stimulation, 
 or from some agent capable of inducing an adequate 
 stimulation, and that the symptoms give no clue 
 to the nature of the stimulation or to the agent 
 causing it. 
 
 The recognition of the meaning of the reflex 
 phenomena is of much use in so many ways that it 
 is scarcely possible to do more than indicate certain 
 phases of their value. The muscular contraction 
 and hyperalgesia are always indications that some 
 active process is going on. In cases of gastric ulcer, 
 for instance, the treatment may have been so success- 
 ful that the patient's sufferings are relieved and a 
 " cure " is said to have resulted. But a careful 
 examination of the left rectus muscle may reveal 
 tenderness of its upper division with increased tone ; 
 and these symptoms indicate that the stomach lesion 
 is still so active that it keeps up an irritable focus in 
 the cord, and give indication that the treatment 
 should be continued if a permanent recovery is to be 
 attained. Occasionally one meets with cases where 
 this viscero-motor reflex has been recognised and 
 
Estimation of the Value of Symptoms. 273 
 
 taken as the factor needing treatment. In gall-stone 
 disease, when there is present the tell-tale sign of 
 contracted muscles in the epigastrium, energetic 
 means, as baths, electricit}^ massage, are frequently 
 employed to reduce the " hardness " of the belly wall ! 
 The conception of the nature of the reflex 
 phenomena may give a more direct aim to our 
 therapeutic endeavours. I have already pointed 
 out how the suffering in stomach affections may be 
 due to the accidental presence of an agent that is 
 capable of producing pain, and that remedies may 
 neutralise the effect of the agent without modifying 
 the disease process. It is conceivable that an effect 
 ma}' be produced in other ways, whereby treatment 
 may influence the reflex symptoms at some portion 
 of the chain between the lesion and the mental 
 conception of the suffering. Thus a drug may act 
 upon the muscular spasm when it causes pain, or it 
 may act upon the spinal cord at the level where the 
 visceral nerve stimulates the sensory nerve. It is 
 just possible that it is here the relief is obtained in 
 certain forms of counter-irritation. Thus I have seen 
 a patient with a pyloric ulcer of the stomach obtain 
 relief b}' a blister on the epigastrium over the limited 
 area in which the pain was felt. This blister did not 
 directlv affect the ulcer, because the ulcer did not 
 lie at the same level [see Fig. 16). Nor could one 
 imagine that any reflex effect was produced in 
 the ulcer itself. It seems more probable that the 
 stimulus from the skin affecting directly the peri- 
 pheral distribution of the sensory nerve prevented 
 by some inhibiting process the stimulus from the 
 visGus passing to the sensory cells in the spinal cord. 
 
274 Cha^Jter XXII. 
 
 This seems the more reasonable, because it was 
 found that on the heahng of the bhster the old pain 
 from the ulcer returned, but if the blistered skin 
 were kept raw by the application of some ointment 
 the pain from the ulcer was subdued. This view 
 receives support from the result of the researches 
 of Sherrington, b}^ which it has been shown that 
 nerve paths may be stimulated from a variety of 
 sources, but that of several contemporaneous stimuli 
 one stimulus may be received and the others 
 inhibited. 
 
INDEX. 
 
INDEX 
 
 ABDOMINAL 
 
 tumour, 178, 205. 
 wall, 63, 203, 205, 273. 
 
 ABSCESS 
 
 in lung, 213. 
 subphrenic, 216. 
 
 ADAMS-STOKES 
 
 syndrome, 262. 
 
 ADHESIONS 
 
 after operation, 204. 
 peritoneal, 175, 203. 
 
 parietal, 203. 
 Adsceral, 205. 
 
 AERATION 
 
 of blood, 214 
 
 tissues in heart disease, 211. 
 
Index. 277 
 
 AFFECTIONS 
 
 of anus, 175. 
 bladder, 192. 
 circulatory systeiU; 222. 
 digestive organs, 114. 
 female pehac organs, 196. 
 intestines, 166. 
 kidney, 180, 266. 
 liver, etc., 155. 
 lungs, 207. 
 
 mouth and fauces, 122. 
 ovaries, 198. 
 pelvis of kidney, 182. 
 perineum, 175. 
 pleura, 207^ 217. 
 stomach, 130. 
 ureter, 182. 
 urinary system, 180. 
 uterus, 197. 
 vagina, 199. 
 
 AIR-HUNGER, 208. 
 
 AIR-SUCTION 
 
 in stomach, 1-11. 
 
 ALBUMINURIA, 180, 181, 266. 
 
 ALCOHOLIC 
 
 gastric catarrh, 122. 
 morning sickness, 140. 
 
 ANGINA PECTORIS, 88, 100, 124, 235, 239, 240 (fig), 
 243 (fig), 254, 261. 
 cause, 254. 
 
 ANOREXIA, 119. 
 
 ANUS 
 
 affections of, 175. 
 nerve-supply, 115. 
 
278 Index. 
 
 AORTIC 
 
 dilatation, case, 245. 
 disease, facial aspect, 107. 
 
 APPEARANCE OF PATIENTS, 104. 
 
 APPENDICITIS, .5, 100, 171, 204. 
 
 APPETITE, 118. 
 perverted, 120. 
 
 AREAS 
 
 of cutaneous hyperalgesia 
 
 in angina pectoris, 240, 243. 
 dilatation of heart and 
 
 liver, 67, 238. 
 diaphragmatic pleurisy, 219. 
 gall-stone colic, 157. 
 gastric ulcer, 75. 
 peritonitis, 202. 
 pneumonia, 220. 
 renal colic, 185, 191. 
 of eruption in herpes zoster, 241. 
 pain. See " Paix." 
 
 ARTERIO-SCLEROSIS, 249. 
 
 ASTHENIA, 
 
 neuro muscular, 90, 
 
 ASTHMA, 99, 210. 
 cardiac, 99, 232. 
 
 ATONIC DYSPEPSIA, 144. 
 
 AURICULAR FIBRILLATION, 162, 250 
 
 AUTONOMIC 
 
 nerves, diagram, 59. 
 nervous system. 5S, 114. 
 
Index. 279 
 
 B 
 
 BACKACHE, 180. 
 
 BISMUTH 
 
 in intestines, 167. 
 
 BLADDER 
 
 afiections of, 192. 
 calculus in, 186, 193. 
 development, 192. 
 functional symptoms, 195. 
 irritation of, 193. 
 nerve-supply, 192. 
 over-distension, 194. 
 pain in, 118. 
 secretion, 195. 
 structural symptoms, 196. 
 
 BLOOD 
 
 aeration of, 208, 214. 
 in f seces, 177. 
 
 heart disease, 211. 
 
 BOULIMIA, 120. 
 
 BOWELS. See " Intestines." 
 
 BREATHERS 
 
 mouth-, 126. 
 
 BREATHLESSNESS, 230. 
 
 BRONCHITIS, 
 
 expectoration in, 216 
 
280 Index. 
 
 CALCULUS 
 
 in bladder, 186, 193. 
 
 renal. See " Colic, Eexal." 
 
 ureteral, site of, 184, 186. 
 
 CAMPBELL 
 
 on herpes zoster, 127. 
 
 CANCER 
 
 of liver, 165. 
 
 stomach, 140, 142, 147, 257. 
 
 CARDIAC 
 
 asthma, 99, 232. 
 
 condition, facial aspect, 107. 
 
 irregularity, 263, 266 
 
 murmur, 6, 94, 113, 226, 266. 
 
 pain, 88. 
 
 reflexes, 100. 
 
 valvular imperfection, 94, 225, 242, 258. 
 
 CASE REPORTED 
 
 of adhesive mediastinitis, 247. 
 
 angina pectoris, 242, 244, 245, 247, 248, 250, 253. 
 
 aortic dilatation, 245. 
 
 appendicitis, 171. 
 
 atheroma, 248, 250, 252, 253. 
 
 auricular fibrillation, 250. 
 
 calculus, renal, 187, 188, 190. 
 
 cardiac rupture, 253. 
 
 cardiac valvular disease, 242, 258. 
 
 enlargement of heart, 247. 
 
 fibrous myocarditis, 248. 
 
 gastric ulcer, 148, 149, 150, 152, 154, 258. 
 
 mediastinitis. adhesive, 247. 
 
Index. 281 
 
 CASE REPORTED— co^^iimef/. 
 
 of perforation of gastric ulcer, 148, 149, 150, 152, 154, 202. 
 peritonitis, 202. 
 pyloric stenosis, 205. 
 renal calculus. 
 
 colic. See " Colic." 
 rupture of heart, 253. 
 stomach affections, series, 135. 
 ulcer, gastric. See " Gastric." 
 
 CEREBRO-SPINAL 
 
 nervous system, 58, 115. 
 
 CHEYNE-STOKES 
 respiration, 232. 
 
 CHLOROFORM 
 
 parturition, 177. 
 
 CHLOROSIS 
 
 facial aspect, 108. 
 
 CHOLANGITIS, 161. 
 
 CHOLERA 
 
 stools, 178. 
 
 CIRCULATION 
 
 afiections of, 222. 
 enquiry concerning, 112. 
 
 CIRRHOSIS 
 of liver, 165. 
 
 CLINICAL OBSERVATION, 22. 
 
 CLINICAL TRAINING, 25. 
 
282 Index. 
 
 CLASSIFICATION OF DISEASE, 
 anatomical, 40. 
 clinical, 42. 
 
 CLASSIFICATION OF SYMPTOMS, 40. 
 
 COLIC 
 
 appendicular, 173. 
 
 gall-stone, 133, 136, 156, 203. 
 
 intestinal, 117. 
 
 -like pains, 117. 
 
 renal, 82, 106, 118, 183, 185, 187, 188, 190. 
 
 COMPLEXION, 107. 163, 215. 
 
 CONDITION 
 
 of organs, 112. 
 
 patient, general, 109. 
 
 CONJUNCTIVITIS, 11. 
 
 CONSCIOUSNESS 
 
 of heart's action. 228. 
 
 CONTRACTION 
 
 of heart-muscle, 256. 
 muscles, 78. 
 
 non-striped muscle, 183, 267, 269. 
 stomach, hourglass, 145. 
 uterus, 197. 
 
 COOK 
 
 on swallowing fluids, 128. 
 
 COUGH, 212. 
 
Index. 283 
 
 CRAMP 
 
 of stoinach, 136, 159. 
 
 CREMASTER 
 muscle, 183. 
 
 CURES 
 
 value of, 272. 
 
 CUTANEOUS. ^ee"SKTN. 
 
 DEVELOPMENT 
 
 of appendix, 175. 
 bladder, 192. 
 liver, etc., 155. 
 tunica vaginalis, 70. 
 
 DIAGNOSIS, 2. 
 
 of intestinal affections, 166. 
 
 stomach afiections, 145. 
 treatment as a factor in, 271. 
 
 DIAPHRAGMATIC PLEURISY, 219 (fig.), 220. 
 
 DIARRH(EA 
 
 facial aspect, 108. 
 
 DIARRH(JiIC 
 
 stools, 178. 
 
 DIETS. 145. 
 
284 Index. 
 
 DIGESTIVE 
 
 organs, afiections of, 114. 
 system, inquiry into, 112. 
 tract, areas of pain, 116. 
 
 functional symptoms, 177. 
 
 nerve-supply, 114. 
 
 sensory symptoms, 115. 
 
 DIGITALIS, 8 
 
 DILATATION 
 
 of aorta, case, 245. 
 
 heart and liver, 236, 238 (fig.), 
 stomach, 113, 140, 143, 147. 
 
 DIPHTHERIA, 5. 
 
 DISEASE 
 
 classification of, anatomical, 40. 
 
 clinical; 42. 
 definition of, 11. 
 detection of, 13. 
 
 DEUGS, 7. 
 
 DUSKINESS 
 
 of skin, 107, 215. 
 
 DYSPEPSIA, 158. 
 atonic, 144. 
 
 DYSPNCEA, 98, 211. 
 
Index. 285 
 
 E 
 
 EAR 
 
 herpes zoster on, 127. 
 
 EFFORT SYNDROME, 90. 
 
 EMPHYSEMA 
 liver in, 165. 
 
 ENEMA 
 
 pain of, 71. 
 
 EPIGASTRIC 
 
 blister, 152, 273. 
 nerve supply, 134. 
 pain, 116, 135. 
 reflex, 138. 
 
 EPILEPSY, 262. 
 
 EUSTACHIAN TUBE 
 
 sensation in, 125. 
 
 EXAMINATION 
 
 of patient, 50, 101. 
 
 EXHAUSTION, 27, 82. 
 
 eSect on symptoms, 260. 
 
 of heart, 87, 90, 224, 229, 232, 267. 
 
 EXPECTORATION, 215. 
 
 EXTRA-SYSTOLE 
 
 of heart, 135, 227, 2.30, 237. 
 cough in, 213, 230. 
 
286 Index. 
 
 F 
 
 FACIAL ASPECT 
 
 in liver affections, 107, 163. 
 
 respiratory affections, 215. 
 of patients, 107, 215. 
 
 F.^CES 
 
 examination of, 177. 
 impacted, 170. 
 
 FAUCES 
 
 affections of, 122. 
 in swallowing, 127. 
 nerve supply, 115. 
 
 FEMALE 
 
 pelvic organs, 196. 
 
 FIBRILLATION, AURICULAR, 162, 250. 
 
 FEVER 
 
 in gall-stone disease, 161. 
 
 FISSURE 
 
 of anus, 176. 
 
 FLATULENCE, 141. 
 
 FOCI 
 
 in spinal cord, irritable, 132, 25' 
 
 FOOD 
 
 pain after, 133, 137. 
 retention in stomach. 144. 
 
Index. 287 
 
 FUNCTIONAL SYMPTOMS, 45. 
 
 of bladder, 195. 
 digestive tube, 177. 
 gall-stone disease, 160. 
 kidney, 181. 
 liver, 163. 
 
 respiratory affections, 214. 
 stomach, 142. 
 
 FUNCTIONS 
 
 of stomach, 131. 
 heart muscle, 254. 
 
 FURRED TONGUE, 126. 
 
 GALL-BLADDER, 155. 
 
 GALL-STONE 
 
 colic, 133, 136, 156. 
 pain, 106, 118, 156. 
 
 in shoulder, 106, 158. 
 
 GALL-STONE DISEASE, 147. 
 
 confused with appendicitis, 173. 
 facial aspect, 107. 
 fever in, 161. 
 
 functional symptoms, 160. 
 gastric symptoms, 136, 158. 
 reflex symptoms, 156, 273. 
 structural symptoms, 160. 
 taken for pleurisy, 159. 
 treatment, 273. 
 
 GASTRIC 
 
 catarrh of alcohoHcs, 122. 
 
 symptoms in gall-stone disease, 136, 158. 
 
288 Index. 
 
 GASTRIC— CO Jiiinue^. 
 
 ulcer, 132, 137, 145, 203, 258, 272. 
 perforation, US, 149, 202. 
 pain in, 74, 137, 147, et seq. 
 
 site of pain, 147, 149 (fig.), 151 (fig.). 153 (^%.). 202. 
 treatment, 273. 
 vomiting in, 139, 140. 
 
 GASTRITIS, 132. 140, 159. 
 
 GENERAL CONDITION 
 
 of patient, 109. 
 
 GEOPftAGY, 120. 
 GOOSE-SKIN, 102. 
 
 GRAVES' DISEASE 
 
 facial aspect, 108. 
 
 H 
 
 H./EMORRHOIDS, 175. 
 
 HALDANE 
 
 on air-hunger, 208. 
 
 respiratory trouble, 211. 
 
 HALLER 
 
 on insensitiveness of viscera, 65. 
 
 HEAD 
 
 on herpes zoster, 127. 
 
Index. 289 
 
 HEART 
 
 action, consciousness of, 228. 
 affections. 222. 
 
 auricular fibrillation. 150, 162. 
 -block, 135, 262. 
 dilatation, 236, 238 (fig.). 
 enlargement, 247. 
 
 exhaustion, 87, 90, 224, 229, 232, 267. 
 extra-systole, 135, 217, 230, 237. 
 failure, 223, 271. 
 
 facial aspect, 107. 
 enlarged liver, 162, 164. 
 inquiry into condition, 112. 
 irregularities, 113, 263. 
 -muscle, 254. 
 pain in, 254. 
 
 response to stimuli, 85, 87. 
 rupture, 253. 
 soldier's, 89. 
 spasm, 254. 
 treatment, 271. 
 valvular imperfection, 94, 225, 242, 258. 
 
 HEART-BURN, 128, 134, 140, 158. 
 HEPATOPTOSIS, 165. 
 
 HERNIA 
 
 mistaken tot hydrocele, 70. 
 strangulated, 169. 
 
 HERPES ZOSTER, 241, 242. 
 in tonsilitis, 127. 
 
 HIRST 
 
 on swallowing fluids, 128. 
 
 HUNGER, 121. 
 Air-, 208. 
 
290 Index. 
 
 HYDATIDS 
 
 of liver, 165, 216. 
 
 HYPERALGESIA, 257, 260. 
 cutaneous, 80. 
 
 areas of, 84. 
 
 (figs.) 67, 75, 157, 185, 191, 219, 238, 240, 
 243. 
 in affections of respiration, 218. 
 
 circulatory system, 234, 243, 258. 
 gall-bladder and duct, 157, 203. 
 intestines, 169. 
 liver, 67. 
 ovary, 199. 
 
 stomach, 75, 138, 202, 258. 
 angina pectoris, 239, 240, 243. 
 dilatation of heart, 238, 239. 
 obstruction of bowel, 170. 
 peritonitis, 202. 
 pleurisy, 218. 
 pneumonia, 220. 
 muscular, 63, 67 (fig.), 80, 160, 203, 218. 
 of testicle, 70. 
 
 HYPERCHLORHYDRIA, 137, 140. 
 HYSTERIA, 260. 
 
 ICE 
 
 pain of swallowing, 135. 
 
 INDIGESTION, 132, 257. 
 
 INFANTILE DIARRHOEA 
 
 stools, 178. 
 
Index. 291 
 
 INSENSITIVENESS 
 
 of viscera. See '" Sensibility or Sensitiveness." 
 
 INSURANCE 
 
 examination for, 264. 
 
 INTESTINES 
 
 affections of, 166. 
 
 obstruction, 140, 168, 180. 
 
 pain in, 117 (fig.), 168. 
 
 peristalsis of, 72, 117, 167, 168, 173. 
 
 IRREGULARITIES 
 
 of heart, 113, 263. 
 
 IRRITABLE FOCI 
 
 in spinal cord, 132, 257. 
 
 IRRITABLE HEART OF SOLDIERS, 89, 94. 
 
 JAUNDICE, 107, 160, 163. 
 
 K 
 
 KIDNEY 
 
 affections of, 180, 266. 
 calculus. See " Colic, Renal. 
 movable, 182. 
 
 nerve supply, 182, 186, 189. 
 -pelvis and ureter, 182. 
 
292 Index. 
 
 L 
 LABORATORY OBSERVATION, 22, 37. 
 
 LABOUR 
 
 uterus during, 197. 
 
 LANGLEY 
 
 on dilatation of pupil, 103. 
 
 's diagram of autonomic nerves, 59, 114. 
 
 LARYNX, 212. 
 
 LAW OF ASSOCIATED PHENOMENA, 36, 92. 
 
 LAW OF PROGRESSION, 35. 
 
 LIVER, 155. 
 
 area of pain in afiections of, 67 (fig.), 
 enlarged, 20, 161, 164. 
 
 in heart failure, 162, 164, 236, 238 (fig.). 
 facial aspect in afiections of, 107, 163. 
 nerve supply, 155. 
 painful, 20, 161. 
 symptoms, functional, 163. 
 
 reflex, 162. 
 
 structural, 164. 
 
 LOCALISATION 
 
 of pain, 75, 106, 135, 147, 167, 169, 184. 
 renal calculus, 184. 
 sensation, 51. 
 
 LUNG 
 
 affection of, 207. 
 condition, inquiry into, 112. 
 crepitations at base,, 232. 
 stasis or oedema, 232. 
 
Index. 293 
 
 M 
 
 MALARIAL CACHEXIA 
 
 facial aspect, 107. 
 
 MALIGNANT DISEASE 
 facial aspect, 107. 
 of stomach, 140, 142, 147, 257. 
 simulated by liver affections, 164. 
 
 MALINGERING, 260. 
 
 MARRIS 
 
 on toxins, 51. 
 
 MAYLARD 
 
 on peritoneal adhesion, 204. 
 
 MEDIASTINITIS 
 
 adhesive, 247. 
 
 MERYCISM, 140. 
 
 MICTURITION, 112, 171, 176, 180, 193. 
 
 MISCARRIAGE, 198. 
 
 MORNING SICKNESS, 139. 
 
 MOTOR REFLEX, 53. 
 
 MOUTH 
 
 affections of, 122. 
 -breathers, 126. 
 nerve-supply, 115. 
 
294 Index. 
 
 MURMUR, CARDIAC, 6, 94, 113. 
 
 MUSCLES 
 
 abdominal, hard contracted, 78, 203, 273. 
 
 simulating tumour, 205. 
 contraction of, 78. 
 creniaster, 183. 
 heart-, 254. 
 intercostal, 218, 248. 
 levator palati, 127. 
 non-striped, 183, 267, 269. 
 of respiration, 209. 
 rectus, 133, 139. 
 
 MUSCULAR 
 
 hyperalgesia, 63, 67 (fig.), 80, 110, 203, 218. 
 layer of body wall, sensitiveness of, 63, 203. 
 rheumatism, 220, 249. 
 
 N 
 NAUHEIM TREATMENT, 271. 
 
 NAUSEA, 121. 
 
 NERVES 
 
 cerebro-spinal, to digestive tract, 115. 
 chorda tympani, 115. 
 cranial, fifth, 115, 123. 
 genito-crural, 186. 
 glosso-pharyngeal, 115. 
 laryngeal, 212. 
 of taste, 115. 
 olfactory, 115. 
 phrenic, 156, 219 (fig.), 221. 
 stimulation of, 103, 274. 
 sympathetic to stomach, 133. 
 thoracic, 53, 134, 241 (fig.), 
 vagus, 133, 134, 156, 252. 
 
Index. 
 
 NERVE-SUPPLY 
 
 in appendicitis, 172. 
 of anus, 175. 
 
 bladder, 192. 
 
 digestive tract, 114. 
 
 epigastrium, 134. 
 
 gall-bladder, 155. 
 
 kidney, 182, 186, 189. 
 
 larynx, 212. 
 
 liver, etc., 155. 
 
 oral orifice, 115. 
 
 ovaries, 198. 
 
 perineum, 176. 
 
 pleura, 219. 
 
 respiratory muscles, 209. 
 
 stomach, 133. 
 
 ureter, 182, 186, 189, 
 
 vagina, 196. 
 
 NERVOUS SYSTEM, 
 
 autonomic, 58, 59 (fig.), 114. 
 cerebro-spinal, 58. 
 constitution, 58. 
 
 NEURALGIA, 12-: 
 
 NEURASTHENLA.. See " Neurotic." 
 
 NEURITIS, 158. 
 
 NEUROSIS, WAR, 91. 
 
 NEUROTIC 
 
 temperament, etc., 109, 141, 182, 229, 257, 258. 
 
 x2 
 
296 Index. 
 
 OBSERVATION 
 
 accuracy of, 20. 
 
 clinical and laboratory, 22. 
 
 OBSTRUCTION 
 
 of intestines, 140, 168. 
 pyloric, 140, 144, 205. 
 
 OEDEMA 
 
 pulmonary, 232. 
 
 (ESOPHAGEAL PAIN, 117. 
 area of, 116. 
 
 (ESOPHAGUS, 128. 
 nerve-supply, 115. 
 stricture of, 129. 
 
 ORAL ORIFICE 
 
 nerve-supply, 115. 
 
 ORGANIC REFLEXES, 97, 253. 
 
 ORGANS 
 
 digestive, aSections of, 114. 
 female pelvic, affections of, 196. 
 review of, 110. 
 sensibility of, 65. 
 
 ORTHOPNCEA, 231. 
 
 OVARIES, 198. 
 
 OVARIAN TUMOURS, 206. 
 
 OVARY 
 
 operation on, 113. 
 
Index. 291 
 
 PAIN, 27. 
 
 after food, 133, 137. 
 
 colic-like, 117. 
 
 definition of, 57 
 
 in angina pectoris, 239, 240, 243. 
 
 appendicitis, 171. 
 
 bladder, 118. 
 
 diaphragmatic pleurisv, 219. 
 
 digestive tract, 116 (fig.). 
 
 gall-stone disease, 118, 156. 
 
 gastric ulcer. See " GtASTric Ulcer." 
 
 heart affections, 254. 
 
 intestine, 117, 168. 
 
 liver, 66. 
 
 movable kidney, 182. 
 
 o?sophagus, 117, 128. 
 
 ovarian trouble, 198. 
 
 peristalsis of intestine, 72, 117, 168. 
 
 pleurisy, 208, 218, 219 (fig.). 
 
 pneumonia, 220. 
 
 renal colic. See " Colic, Renal." 
 
 shoulder, 106, 158, 219, 221. 
 
 stomach, 117, 134, 135, 137, 147. 
 
 testicle, 68, 82, 106, 183, 186. 
 
 tunica vaginalis, 69. 
 
 ureter, 184, 186. 
 
 uterine labour, 197. 
 
 uterus, 118. 
 
 vagina, 199. 
 localisation of, 75, 106, 135, 147, 167, 169, 184. 
 radiation of, 52, 55. 
 referred, 176, 182, 192, 197. 
 relief of, 268. 
 
 sensitiveness of tissues to, 61. 
 visceral, 15, 68, 118. 
 
 artificial production, 71. 
 mechanism, 74. 
 
298 Index. 
 
 PALATAL MUSCLES, 127. 
 
 PALLOR 
 
 of face, 108. 
 
 PALPITATION, 229. 
 
 PARTURITION 
 
 perineal reflex, 176. 
 
 PATIENT 
 
 appearance, 104. 
 examination, 104. 
 facial aspect, 107. 
 general condition, 109. 
 sensations, 105, 207. 
 
 PELVIC ORGANS 
 
 female, 196, 
 
 PELVIS OF KIDNEY 
 
 affections of, 182. 
 
 PERFORATION 
 
 of stonmch, 148, 149, 150, 152, 154, 202. 
 
 PERINEAL REFLEX, 176. 
 
 PERINEUM, 175. 
 torn, 176. 
 
 PERISTALSIS 
 
 of intestine, 72, 117, 167, 168, 173. 
 oesopliagus, 129. 
 stomach, 134, 137, 140. 
 ureter, 82, 184, 186. 
 
 PERITONEAL ADHESIONS, 175, 201. 
 parietal, 203. 
 visceral, 205. 
 
 PERITONEUM 
 
 sensitiveness of, 64, 201. 
 
Index. 299 
 
 PERITONITIS, 64,171,201. 
 
 PERNICIOUS AN.EMIA 
 
 facia] aspect, 107. 
 
 PHRENIC NERVE, 156,219,221. 
 
 PHTHISIS 
 
 cough, 213. 
 expectoration, 216. 
 
 PILES, 175. 
 
 PILOMOTOR REFLEX, 102. 
 
 PLEURA 
 
 affectionsof, 207, 217. 
 
 PLEURISY, 217. 
 
 and gall-stone disease, 159. 
 
 cough in, 213. 
 
 diaphragmatic, area of pain, 219 (fig.), 220. 
 
 effect on liver, 165. 
 
 PNEUMONIA 
 cough, 213. 
 expectoration, 216. 
 facial aspect, 108. 
 pain, 220. 
 stools, 178. 
 
 POLYURIA, 253. 
 
 PREGNANCY 
 
 vomitingin, 139, 199. 
 
 PREGNANT UTERUS, 197. 
 PROGNOSIS, 4, 37, 263. 
 
300 
 
 Index. 
 
 PULMONARY 
 
 apoplexy, expectoration, 216. 
 condition, facial aspect, 107, 215. 
 cEdema, 232. 
 stasis, 232. 
 
 PULSE 
 
 irregular, 227. 
 observation of, 25. 
 
 PYLORIC STENOSIS, 140, 144, 205. 
 PYROSIS, 140. 
 
 R 
 
 RADIATION IN DISEASE, 55. 
 
 RAMSTROM 
 
 on histology of abdominal wall, 64, 203. 
 
 RAYNAUD'S DISEASE, 102. 
 
 RECTUM 
 
 ulceration of, 176. 
 
 RECTUS MUSCLE, 133, 139. 
 
 REFLEX 
 
 cardiac, 100. 
 
 epigastric, 138. 
 
 motor, 53. 
 
 organic, 97, 253. 
 
 perineal, 176. 
 
 pilo-motor, 102. 
 
 secretory, 99. 
 
 skin or superficial, 138. 
 
 symptoms, 48, 132, 156, 159, 162, 172, 176, 19-3, 199, 212, 
 
 234, 257. 
 vaso-motor, 102. 
 viscero-motor, 77, 139, 234, 248. 
 viscero-sensory, 74, 234, 236, 239. 
 
Index. 301 
 
 EEFLEXES 
 
 in angina pectoris, 235. 
 appendicitis, 172. 
 gall-stone disease, 156. 
 kidney affections, 180. 
 liver affections, 162. 
 parturition, 176. 
 respiratory affections, 212. 
 stomach affections, 138. 
 visceral disease, 74, 81 (fig.)- 
 
 KEGURGITATION 
 
 from stomach, 128, 134, 140. 
 
 REMOTE EFFECTS 
 
 of lesion, 259. 
 
 RENAL 
 
 calculus 
 
 colic. See " Colic, Renal." 
 
 nerve-supply. See '" Nerve-Supply. 
 
 RESEARCH, 9, 17. 
 
 RESISTANCE TO STIMULATION, 84. 
 
 RESPIRATION, 209. 
 Cheyne-Stokes, 232. 
 with failing heart, 201, 232. 
 
 RETENTION 
 
 of food in stomach, 144. 
 urine, 176, 193. 
 
 RHEUMATISM, 158, 220, 249. 
 
 RIGIDITY 
 
 protective, 78. 
 
302 Index. 
 
 S 
 
 SALIVA 
 
 flow in angina pectoris, 253. 
 
 SCHLESINGER 
 
 on swallowing fluids, 128. 
 
 SECRETIONS 
 
 of bladder, 196. 
 respiratory tract, 213, 215. 
 stomach, 142. 
 
 SECRETORY REFLEXES, 99. 
 
 SENSATION 
 
 radiation of, 52, 54. 
 
 SENSATIONS 
 
 in afiections of lungs and pleura, 207. 
 of patient, 105. 
 
 SENSIBILITY OR SENSITIVENESS 
 of female pelvic organs, 196. 
 
 muscular layer of body-wall, 63. 
 
 organs, 65. 
 
 peritoneum, 64, 201. 
 
 pleura, 217. 
 
 tissues, 61. 
 
 viscera, 62. 
 
 SHERRINGTON, PROFESSOR 
 on radiation of pain, 52. 
 
 stimulation of nerves, 103, 274. 
 
 SHOULDER-PAIN, 106, 158, 210, 219 (fig.), 221, 
 
 SICKNESS 
 
 morning, alcobolic, 140. 
 
Index. 303- 
 
 SITE OF PAIN. See " Area," and " Localisation." 
 
 SKIN 
 
 duskiness, 107, 215. 
 
 goose-, 102. 
 
 hyperalgesia. See " Hyperalgesia." 
 
 -reflex, 138. 
 
 sensibility, in, 62. 
 
 SNEEZING, 2U. 
 
 SOLDIERS HEART, 89, 94. 
 
 SPASM 
 
 in swallowing, 129. 
 of tlie heart, 254. 
 
 intercostal nucleus, 248. 
 
 SPINAL 
 
 cord, irritable foci, 132, 257. 
 
 STASIS 
 
 pulmonary, 232, 
 
 STENOSIS 
 
 of cardiac valves, 242. 
 pyloric, 140, 144, 205. 
 
 STIMULATION 
 
 mechanism of, 51. 
 resistance to, 84. 
 sensitiveness to, 61. 
 threshold of, 85. 
 
 STIMULI 
 
 summation of, as cause of angina pectoris, 254. 
 
304 Index. 
 
 STOMACH 
 
 affections of, 130. 
 
 irritable focus in, 132. 
 
 reflexes in, 138. 
 cancer of, 140, 142, 147, 257. 
 constriction of, 145. 
 cramp, 136, 159. 
 diagnosis, 145. 
 
 dilatation of, 113, 140, 143, 147. 
 functions, 131. 
 functional symptoms, 142. 
 hyperalgesia from, 138. 
 malignant disease, 140, 142, 147, 257, 
 nerve-supply, 133. 
 pain, areas, 117, 134, 135, 137, 147. 
 pain with gall-stone colic, 106. 
 perforation, 148, 149, 150, 152, 154. 
 peristalsis, 134, 137, 140. 
 pyloric stenosis, 140, 144, 205. 
 regurgitation from, 128, 134, 137, 140. 
 retention of food, 144. 
 secretion, 142. 
 structural symptoms, 144. 
 treatment, 145, 271. 
 tumour, 144. 
 ulcer. See " Gastric Ulcer." 
 
 STONE 
 
 in bladder 
 kidney 
 
 See " Calculus. 
 
 STOOLS 
 
 character of, 178. 
 
 STEICTURE 
 
 of oesophagus, 129. 
 
lyidex 305 
 
 STRUCTURAL SYMPTOMS, 43. 
 
 of bladder, 196. 
 digestive tube, 178. 
 gall-stone disease, 160, 
 kidneys, 181. 
 liver affections, 164. 
 respiratory affections, 217. 
 stomach affections, 144. 
 
 SUFFOCATION 
 
 sense in heart affections, 233 
 
 SWALLOWING, 127. 
 
 hot and cold fluids, 128. 
 
 ice, pain in, 135. 
 
 in angina pectoris, 124. 
 
 painful, 125. 
 
 spasm in, 129. 
 
 SYMPATHETIC NERVES. See " Autonomic. 
 to stomach, 133. 
 
 SYMPTOMS 
 
 bearing on prognosis, 263. 
 treatment, 268. 
 classification of, 33. 
 definition of, 14. 
 differentiation of, 31. 
 functional, 20. See " Functional." 
 mechanism of, 92. 
 methods of investigation of, 14. 
 of affections of organs. See " Affections." 
 reflex. See " Reflex." 
 relation of, 256, 262. 
 sensory, in digestive tract, 115. 
 structural. See " Structural." 
 value of, 256. 
 
 SYSTEM, NERVOUS. See " Nervous." 
 
,306 Inder. 
 
 T 
 
 TACHYCARDIA, 162, 230, 236. 
 
 TEETH 
 
 false, inflammation from, 125. 
 
 TEMPERAMENTS, 109. 
 
 neurotic, 109, 141, 229, 257, 258. 
 
 TESTICULAR PAIN, 68. 
 
 in renal colic, 82, 106, 183, 186. 
 
 TIC DOULOUREUX, 123. 
 
 TONGUE, 126. 
 
 TONSILITIS, 127. 
 
 TONSILS 
 
 inflamed, 124. 
 
 in swallowing, 127. 
 
 TOOTHACHE, 55, 122, 267. 
 
 TREATMENT, 7. 
 
 as factor in diagnosis, 271. 
 bearing on symptoms on, 268. 
 of affections of heart, 271. 
 
 stomach, 145, 271. 
 
 TRIGEMINAL NEURALGIA, 123. 
 
 TUMOUR 
 
 abdominal, 178, 205. 
 in stomach, 144. 
 ovarian, 206. 
 
 TUNICA VAGINALIS, 69. 
 
 TYPHOID FEVER 
 
 facial aspect, 108. 
 stools, 178. 
 
Index. 307 
 
 U 
 
 ULCER 
 
 gastric. See '" Gastric." 
 
 ULCERATION 
 
 of pelvis of kidney, 184. 
 rectum, 176. 
 ureter, 184. 
 
 UMBILICAL FISTULA 
 
 pain in operation for. 72. 
 
 URETHRAL CARUNCLE, 200. 
 
 URETER 
 
 afEections of, 182. 
 nerve-supply, 182, 186, 189. 
 peristalsis, 184, 186. 
 site of stone in, 184, 186. 
 
 URINARY SYSTEM 
 
 affections of, 180. 
 inquiry into, 112. 
 
 URINE 
 
 albumen in, 180, 181, 266. 
 
 retention of, 193. 
 
 secretion, in angina pectoris, 253. 
 
 UTERUS, 197. 
 
 pain in, 118, 196, 197. 
 
 VAGINA, 199. 
 
 nerve-supply, 196. 
 
 VAGUS NERVE, 133, 134, 156, 252. 
 
 VALUE 
 
 of symptoms, 256. 
 
308 Index. 
 
 VALVULAE IMPEEFECTION 
 
 of heart, 94, 225, 242, 258. 
 
 VASO-MOTOR REFLEXES, 102. 
 
 VISCERA 
 
 hollow, pain in, 118. * 
 
 insensitiveness of, 65. 
 
 VISCERAL 
 
 disease, cutaneous hyperalgesia, 84. 
 
 pain in, 74. 
 pain, 15, 68, 118. 
 
 artificial production, 71. 
 
 mechanism of, 74. 
 
 reflexes, 74, 81 (fig.). 
 
 VISCERO-MOTOR REFLEX, 77, 139, 234, 248. 
 VISCERO-SENSORY REFLEX, 74, 234, 236, 239. 
 VOMITING, 82, 98, 139, 163, 199. 
 
 W 
 
 WAR NEUROSIS, 91. 
 
 WATER-BRASH, 140. 
 
 WILSON, R.M., 89 
 on toxins, 51. 
 
 X-RAYS 
 
 in examination of digestive tract, 143, 167. 
 
 London: Printed by Shaw and Sons, Fettek Lane, E.C.4. 
 
APPENDIX. 
 
 THE THEORY OF DISTURBED REFLEXES 
 
 IN THE PRODUCTION OF SYMPTOMS 
 
 OF DISEASE. 
 
 Sir JAMES MACKENZIE, M.D., F.R.S., etc., 
 
 DIEECTOR OF THE ST. ANDREWS CLINICAL INSTITUTE. 
 
 [Reprinted by land 'permission of the "British Medical Journal."] 
 
 Whex we started the Institute for Clinical Research in St. Andrews 
 we recognised that if success were to attend our efforts we must 
 have a clear comprehension of our object, and a definite idea how 
 that object should be attained. We define our object as the 
 
 Prevention of the Diseases that are Common amongst the People. 
 
 To understand how disease should be prevented it was 
 necessary to know what are the diseases which are common 
 among the people. On inquiry it was found that, except in a 
 small percentage of cases, this knowledge was nowhere to be 
 obtained. 
 
 Here, then, the first step to be taken was to know what the 
 diseases are which we wished to prevent. 
 
 The next question was how to proceed to get this knowledge. 
 The great majority of the sick suffered from complaints, and 
 showed signs of ill health, but the disease was unknown. In a 
 few cases the disease could be recognised, because medical know- 
 ledge had advanced so far as to detect certain signs and symptoms 
 which experience had shown to be due to definite causes. Seeing 
 that the diseases we wished to prevent were for the most part 
 unrecognisable, it would be futile to attempt to prevent them, 
 so that it was manifest an undertaking must start with preliminary 
 inquiry into the nature of the diseases. , 
 
310 
 
 Appendix. 
 
 Definition of Disease. 
 
 In order that our inquiry should be pursued in a logical and 
 systematic manner, we sought to get a clear grasjj of what we 
 meant by disease. The definition of an abstract term such as 
 disease would probably be given in different terms, according to 
 the standpoint of the definer. After much consideration and 
 discussion we analysed the phenomena in over 1,000 cases and 
 worked out the following scheme, which revealed the present state 
 of knowledge on the subject, and at the same time afforded a guide 
 for our inquiry. 
 
 If we take a simple disease like conjunctivitis, where the 
 cause can be ascertained, we find that the diseased state consists 
 of a foreign body which injuriously affects the tissues, causing 
 certain reactions or symptoms, as pain, lacrymation, redness, 
 blepharospasm. Such a condition may be considered a complete 
 diagnosis and can be represented by the diagram (Fig. 1), where a 
 is the injurious agent and the surrounding circles are the reactions 
 or symptoms. 
 
 Fig. 2. 
 
 Fig. 1 represents a disease completely diagnosed, where A is the agent 
 acting injuriously on the tissues and producing reactions or symptoms, 
 which are represented by the circles at the periphery— as tj-phoid fever, or 
 conjunctivitis due to a foreign body in the eye. 
 
 Fig. 2 represents a disease not fully diagnosed, where, while the 
 symptoms are recognised, the injurious agent a has not been reeogmsed, 
 though its nature can be inferred, as in measles. 
 
 We found in our inquiry that the complete diagnosis is 
 possible only in a relatively few cases— where the injurious agent 
 has been recognised as due to a foreign body or to a microbe, as m 
 typhoid fever, pneumonia, diphtheria. 
 
 In some cases the reactions occur in such definite groups that 
 they can be differentiated, and it can be assumed with reasonable 
 
Appendix. 311 
 
 certainty that the disease is caused also by a microbe which has 
 not yet been identified, as nieasles, small-pox, rabies, etc. These 
 are represented in Fig. 2, in which the injurious agent is represented 
 by a dotted ring. 
 
 There were other cases in which the group of symptoms were 
 also capable of differentiation, but in which the nature of the 
 injurious agent was unknown, or a matter of speculation, as in 
 migraine, epilepsy, diabetes, etc. This is represented in Fig. 3 
 where a point of interrogation represents the injurious agent. 
 
 The bulk of patients suffer from diseases in which, so far, it 
 has been found impossible either to recognise the agent or to 
 arrange the symptoms into groups that permit of their clear 
 differentiation from others that they resemble. The nomenclature 
 of such conditions is usually based on the presence of a dominant 
 symptom or of a number of symptoms associated with some organ, 
 auch as anaemia, neuralgia, neurasthenia, debility, disordered 
 action of the heart, indigestion. The knowledge of the disease in 
 those cases may be represented diagrammatically (Fig. 4) as a 
 confused heap of symptoms in which it is not possible to obtain a 
 suggestion as to their relation to a common cause. 
 
 ? 
 
 o 
 
 O 
 
 o 
 
 
 
 O 
 
 
 
 
 
 o 
 
 
 
 Fig. 4. 
 
 
 Fig. 3. 
 
 Fig. 3 represents a disease with a well-defined group of symptoms, 
 Ijut where tlie nature of the agent is not recognised — as migraine, con- 
 vulsions. 
 
 Fig. 4 represents the vast majority of diseases, where a number of 
 unco-ordinated symptoms are jiresent with no recognisable cause. 
 
 To the latter group belong probably all chronic diseases, 
 even though the ill health is definitely due to damaged organs 
 which can be recognised by physical signs — as arterio-sclerosis, 
 chronic heart disease, chronic kidney disease, and even consumption 
 and cancer. The reason for including these is that they are prob- 
 ably secondary diseases, the original cause not being capable 
 of recognition. 
 
312 Appendix. 
 
 The Relation of Symptoms to Disease. 
 
 This method of looking upon disease reveals not only the 
 state of our knowledge of diagnosis, but gives a guide in research. 
 It shows that disease is only revealed by the symptoms it produces, 
 and that even in the few diseases where the nature of the agent 
 is understood it can only be i'dentified in the human body by its 
 symptoms. 
 
 A consideration of the history of the recognisable diseases 
 shows that the first step in research is to recognise the symptoms. 
 The next step is to group them together, so that one group can be 
 clearly differentiated from those that resemble it. By this method 
 the clinical observer differentiates the disease, it may be, without 
 recognising the cause. Having reached this stage, he can present 
 a clear-cut problem to, for example, the bacteriologist, who may 
 complete the diagnosis by discovering the injurious agent. The 
 symptoms of the majority of diseases have not yet been clearly 
 difierentiated, and there is little prospect of progress being made 
 until this has been done. 
 
 This brief review of our present knowledge of disease shows 
 that the chief aim of medical science — the prevention of disease — 
 can never be achieved till we are able to recognise the diseases. 
 "Where success has been achieved and disease prevented, it was 
 due in the first instance to the recognition of the symptoms. The 
 clinical observer who obtained this knowledge succeeded because 
 the symptoms were striking in character and easily recognised — 
 as by the presence of a rash or eruption or other sign. It is 
 reasonable to conclude that if we had a better understanding of the 
 mechanism by which less obtrusive symptoms are produced we 
 would get nearer to the detection of the agent producing them. 
 When a person falls ill, the fact is made evident only by the 
 symptoms, so that the only way in which the disease can be 
 detected is by the recognition of symptoms. 
 
 The study of symptoms has been carried on since the dawn 
 of medicine, and from the early days additions have continually 
 been made to their numbers, until to-day the number is so great 
 that no one individual can recognise more than a fraction of them, 
 and methods are ever being invented for the discovery of 
 new symptoms. If our enterprise were but to seek for new 
 symptoms, it would be in vain, for the addition of new symptoms 
 would but add to the confusion of a subject already far too 
 chaotic. 
 
Appendix. 313 
 
 The Evolution of a Science, 
 
 All subjects that have attained the position of a science have 
 passed through stages of which the collection of facts was the 
 first. So long as these facts were unco-ordinated their accumulation 
 tended to confusion, and there came to be recognised the need 
 for an ordered arrangement based upon a law of nature. 
 
 The history of chemistry is an illustration. The appreciation 
 of Dalton's atomic theory gradually enabled the mass of detail 
 to be classified according to a law of nature. Not only this, but 
 it opened up possibilities and gave guidance to further re- 
 search, and so enabled the science of chemistry to make 
 remarkable progress. 
 
 Symptomatology is in the same confused state as chemistry 
 was before the recognition of the atomic theory ; and it calls as 
 urgently for a classification based upon some law of nature that 
 reveals the mechanism of the production of symptoms. 
 
 The Classification of Symptoms. 
 
 Hitherto there has been no clear conception of the nature of 
 symptoms, and the classifications that have been made have 
 hampered progress and misdirected the course of research. Thus 
 symptoms are usually described from the standpoint of the organ 
 giving rise to them, and specialists devote themselves to the study 
 of the symptoms of individual qrgans or systems. When a 
 person falls ill nearly every organ of the body may be disturbed, 
 and each specialist has no difficulty in detecting symptoms 
 belonging to his particular branch. In consequence of this we 
 find that confusion of diagnosis M^hich results when a patient 
 consults a number of specialists. 
 
 Another source of error arises from the fact that when one 
 organ is diseased its impaired function is revealed not by the organ 
 at fault but by its effects upon the other organs of the body. 
 
 It is now many years since I saw the need for a knowledge 
 of the mechanism by which symptoms were produced. I have 
 steadily pursued the subject, and several years ago I dimly 
 recognised that there was some definite law governing this 
 mechanism. I attempted a classification and I was able to group 
 a number of symptoms according to their mechanism, such as a 
 structural group, recognised by a physical sign, a functional group 
 due to interference with the functions of an organ, and a reflex 
 group, due to the peculiar stimulus setting up definite reactions. 
 But there remained a large group, which I recognised somehow or 
 other belonged to the last group, but their mechanism was not clear. 
 
314 Appendix. 
 
 This was the state of knowledge when we began our inquiry. 
 We recognised that it was useless to attempt a research into any 
 particular disease until we had acquired a knowledge of the laws 
 that underlay the production of symptoms, and to that end our 
 chief endeavour was given. We met twice a week ; at one meeting 
 we discussed the nature of one particular symptom, and sought for 
 an explanation in the daily routine of examining patients. At the 
 other weekly meeting we discussed in detail the symptoms of 
 individual patients. 
 
 The Law Governing the Prodaction of Symptoms. 
 
 As time went on we got a better insight into one»symptom 
 after another, and we felt we were getting nearer the law of which 
 we were in search, and gradually its recognition dawned upon us. 
 At first we scarcely recognised it when it was put before us because 
 of its extreme simplicity, for we found the law to be that the vast 
 majority of the symptoms of disease are distdirhances of normal 
 reflexes. 
 
 I know quite well that no one who reads this will accept at 
 present the view that this theory will do for clinical medicine what 
 the atomic theory did for chemistry, but I know equally well that 
 when the method of applying it is understood its significance will 
 be appreciated, and it will have a very far-reaching influence on 
 the progress of medicine. 
 
 How the Theory was Discovered. 
 
 The discovery of this law is the outcome of a long and pains- 
 taking search wdth a definite object in view. 
 
 Shortly after entering general practice, over forty years ago, 
 I was impressed with my ignorance of the diseases from which my 
 patients suffered. In the majority the evidence of ill health was 
 confined to the patient's sensations, which I could not interpret. 
 Eealising this, I resolved to see if I could not improve my know- 
 ledge, and began to pay more attention to such signs as I could 
 detect, and the principal sensations of w^hich the patient complained. 
 I had not gone far when I realised that these signs and symptoms 
 were so numerous that I could only hope to investigate a limited 
 number. But even when I had selected a few for particular 
 observation I did not know what method to pursue. On reflection 
 I decided upon concentrating my attention on two aspects : 
 (1) The mechanism by which a symptom ivas produced ; and (2) the 
 bearing the cause of the symptom had on the patient's future. 
 
 Of these aspects the latter is, of course, of the utmost practical 
 value to a doctor, and although under the term " prognosis " it 
 
Appendix. 315 
 
 has received perfunctory attention, I found that neither the 
 manner in which the subject should be studied nor the individual 
 whose opportunities fitted him for the task had been realised ; 
 but with that I do not deal here. 
 
 The study of the mechanism by which symptoms were 
 produced led me into several different fields. There was, for 
 instance, the pulsatile movements in the jugular veins and the 
 liver, the movements of the heart in health and disease, and the 
 mechanism of irregular heart action to be considered. I devoted 
 several years to finding out the mechanism of these signs, and the 
 results were an ample reward for the labour and time spent, and 
 helped to make that revolution which has made of human cardio- 
 logy a totally different subject from what it was when these 
 researches were begun. 
 
 The study of the sensations of the patient was much more 
 difficult. I began with the most clamant of all — pain. Hilton's 
 book on Rest and Pain was the furthest step that had been taken, 
 but valuable as it was it did not go to the root of the matter. 
 For some ypars I made little progress — collecting isolated facts 
 but unable to see any reasonable explanation for their causation. 
 In 1888 Dr. James Ross published his article on referred pain, and 
 I at once recognised that he had provided a hypothesis which not 
 only helped to explain much that was obscure but gave a guide 
 for carrying the subject further. In this paper he stated that pain, 
 when arising in an organ, was felt in two ways — first by a pain in 
 the organ itself, and second by the pain felt in the external body 
 wall at a place remote from the organ. The first of these he called 
 splanchnic and the second he called somatic. 
 
 I had already gone so far in my inquiry that I recognised the 
 significance of his somatic or referred pain, but I was doubtful 
 of his splanchnic, considering that it also was really referred. 
 He used as an illustration the pain of gastric ulcer when limited 
 to the epigastrium as being a splanchnic pain, but when I examined 
 a patient with a gastric ulcer I found that on a deep inspiration, 
 while the stomach descended, the pain remained fixed. 
 
 Though suggestive this was far from convincing, and I sought 
 diligently for other signs, and in 1891 I found a sign which threw 
 much light upon the matter. This was finding a large area of 
 hyperalgesia of the skin over the liver in a patient after an attack 
 of gall-stone colic. This led me to seek for cutaneous hyperalgesia 
 in other cases, and I soon found that it was of frequent occurrence, 
 particularly in affections of abdominal organs. It required, 
 however, a long training to acquire the skill to detect it in many 
 cases. 
 
316 Appendix. 
 
 Shortly after this another sign was recognised — namely, the 
 contraction of the muscles of the abdominal wall, due to disease 
 of an abdominal organ. It had been recognised before, and spoken 
 of as " protective rigidity," but its real nature and significance had 
 never been understood. I watched how portions of the muscle 
 wall of the abdomen would becone hard and resistant during the 
 course of a disease, such as gastric ulcer, apj)endicitis, gall-stone 
 disease, cholecystitis. I observed it disappear with imj^rovement, 
 until it was not evident, and I could recall it by gently rubbing 
 over it. I noted in patients the sudden contraction of muscle 
 that ensued under certain conditions. Thus, some of my patients 
 described that on the onset of an attack of renal colic the testicle 
 would be dragged up (by contraction of the cremaster muscle). 
 
 I described these * symptoms of pain and hyperalgesia in 
 consequence of disease of the viscera as a viscerosensory reflex, and 
 the contraction of the muscle as a viscero-motor reflex. 
 
 There was a large group of symptoms which occurred when 
 l^atients fell ill from some obscure cause (as infection), such as the 
 feeling of exhaustion, loss of appetite, breathlessness on exertion, 
 palpitation, vomiting, mental depression. These had been vaguely 
 described as toxic symptoms, and I had indeed described them 
 as due to a hypersensitiveness of certain parts of the central 
 nervous system, but I did not clearly realise the mechanism which 
 produced them ; this was the stage reached when we started the 
 Clinical Institute, and the matter was summarised in an address 
 I gave on the " Soldier's heart and war neurosis : a study in 
 symptomatology. ' " ' 
 
 The Application of the Theory. 
 
 In the description of the theory and its application which 
 follows, some simple observations are given to show the manner 
 in which certain reflexes are disturbed ; while we have found it 
 already of value in the interpretation of our patients' symptoms, 
 we recognise that there is required a much better knowledge of 
 reflexes before the theory can be used in a systematic manner. 
 The illustrations therefore are merely to indicate how it may 
 become of use. 
 
 While the stimulus and response parts of a reflex may often 
 be recognised, the mechanism of that part of the reflex in the 
 central nervous system is not yet quite clear. Consequently the 
 diagrams of this j)art of the reflex do not pretend to represent the 
 actual mechanism. 
 
 In attempting so to explain the theory that symptoms arise 
 from disturbed reflexes as to carry conviction we recognise that 
 we are handicapped in that what we take to be facts may not be 
 
Appendix. 317 
 
 accepted as facts by the reader, and it would take up too much 
 space and time to give our reasons. When, for instance, I state 
 that exhaustion of heart muscle produces pain and proceed to 
 develo]) the argument in which that statement is accepted as a 
 fact, the reader" may not accept the statement. The observations 
 on which that statement is based have been carried on for many 
 years, during which patients have been watched and the circum- 
 stances provoking the pain have been considered, the gradual 
 progress of the case observed, and the conditions at the posf- 
 mortem examination carefully noted. Another long series of 
 observations have been made to discover the laws that govern 
 the production of pain in all muscular organs — a research, indeed, in 
 which we are still engaged, and which every day tends to confirm 
 the view advanced here. In like manner, when I take it as a fact 
 that exhaustion is due to a disturbance of a vasomotor reflex, 
 it is not possible to give the long series of observations on which 
 the statement is based. 
 
 Until we are able to publish the researches into these and 
 other matters involved in this description, I would ask the reader 
 to assume that our facts are proven, so that the explanation of this 
 theorv mav be understood. 
 
 Fig. 5. — Diagram of a simple reflex arc. The stimulus affects the 
 receptor a, from which a nerve passes to a nerve cell at b, where it joins 
 another cell which sends an efferent fibre to c — the effector or structure 
 ivhich gives the response. 
 
 Description of a Reflex Arc. 
 
 In the reflex arc we recognise the following parts (Fig. 5). 
 j^. The receptor or place where the reflex is initiated. An afferent 
 nerve fibre conducts the stimulus to b, the nerve centre. Here the 
 -afferent nerve ends in a synapse with one or more nerve cells — 
 the actual number and relationship varying in complexity. The 
 nerve centre in turn sends an efferent fibre to c — the efiector or 
 structure, be it muscle or gland or centre of consciousness, which 
 .gives the ultimate response characteristic of the reflex. 
 
 The whole of this arc is necessary for the production of a 
 simple reflex. Symptoms, or, in other words, alterations in the 
 
318 Appendix. 
 
 reflex, may be referable to causes acting upon any part of the arc-, 
 but in practice they are found to be mainly confined to alteration; 
 in A; the receptor ; B.. the nerve centre ; or c, the effector. 
 
 The Part of the Reflex in Life. 
 
 The whole economy of the body is built up of a system of 
 organs whose activities dej^end on reflexes. A flood of stimuli is- 
 continually being poured into the system through the skin and 
 special senses, and each stimulus produces a definite reflex on 
 some part of the body. In the deeper tissues of the body stimuli 
 are continually arising and being sent to difierent- organs, which 
 respond by some modification of their activity. 
 
 The sources of stimulation, therefore, arise in every part of 
 the body. Organs that at one time are the source of stimulation 
 become at other times the effectors. Thus, when pain is felt, the- 
 source (a part of the reflex) may be the peripheral distribution 
 of any sensory nerve, while the brain is the organ which responds 
 (the c part of the reflex). The difierent organs of the body during 
 periods of activity and quiescence send out stimuli-producing 
 reflexes which modify the activities of other organs — as the heart 
 when it increases its activity in responding to a call for more 
 blood, or decreases its activity in a cessation of effort. 
 
 The interplay of these reflexes results in the harmonious action^ 
 of the organs of the body which we recognise as " health."' The 
 disturbance of one or more of these reflexes results in a disharmony 
 which we recognise as symptoms of disease. 
 
 Methods by which Disturbed Reflexes are Produced. 
 There are two ways in which reflexes may be disturbed : 
 
 1. By the nature of the stimulus acting on the a part 
 of the reflex arc, the impulse entering through the nervous 
 system. 
 
 2. By altering in a positive or negative sense the 
 receptivity of the B and c parts of the reflex, the agent, 
 (chemical or thermic) entering through the blood stream. 
 
 Disturbance of Reflexes due to the Stimulus Entering 
 through the Nervous System. 
 
 The following observations sufficiently illustrate the- 
 mechanism by which this kind of disturbed reflex is produced. 
 
Appendix. 319 
 
 Many years ago I had shown that the only serous membrane 
 in which a sensation of pain could be produced was the visceral 
 layer of the tunica vaginalis. 
 
 Observation 1. 
 Dr. Orr, in tapping a hydi-ocele, tested this statement and noted the 
 sensitiveness of the parietal and visceral layers of the tunica vaginalis. 
 He found he could scratch the parietal layer and the patient feel nothing, 
 but when he touched the visceral layer with the trocar the patient (1) 
 drew back, (2) felt severe pain, (3) became pale, (4) nauseated, and (5) 
 collapsed. 
 
 Observation 2. 
 A man was seized with an attack of renal colic and suffered violent 
 pain in the left side of the abdomen, with contraction of the muscles. 
 He became pale, and sweat poured out ; he vomited, and the pulse became 
 soft, and he felt faint. 
 
 In Observation 1 the touching of the visceral layer of the 
 tunica vaginalis was the stimulus at the receptive or a part of the 
 reflex. Then followed a variety of responses or effects on the c 
 part of the reflex : (1) A muscular response in the sudden drawing 
 back of the body ; (2) the sensation of pain — the centre of con- 
 sciousness being the response part of the reflex ; (3) pallor — a 
 cardiac reflex— due to a stimulation of the vagus, which also 
 probably caused (4) the nausea, and (5) collapse, due to a vaso- 
 motor reaction. In Observation 2 we have a similar series of 
 reflexes, these being in addition, the vasomotor reflex causing the 
 sweating, and the vomiting reflex. 
 
 Alteration of the Receptivity of the B and C Parts 
 of the Reflex Arc. 
 
 The other method, by altering the b and c portions of the 
 reflex arc, comes about through the circulation in the blood of 
 certain agents which affect parts of the arc in a negative or positive 
 way — that is, either increasing or diminishing the intensity of the 
 impulses during their passage from A to c. 
 
 The demonstration of the disturbance of the reflexes through 
 the nervous system is readily understood from such observations 
 as 1 and 2. The demonstration of the circulatory — chemical or 
 toxic — influences is not so easy. Perhaps the best way is to 
 consider the effects of certain drugs whose effects have been 
 sufficiently observed. 
 
 Observation 3. — The Effect of Atropine. 
 An individual who receives a certain quantity of atropine may 
 complain of impaired vision and palpitation. When examined he is found 
 to have a dilated pupil and an increased heart rate, which is abnormally 
 increased on effort. 
 
320 Appendix. 
 
 Each of these effects is due to the drug blocking the passage of 
 normal impulses at c. The pupil of the eye is maintained in an 
 ever- varying balance between dilatation and contraction, respond- 
 ing with great sensitiveness to the stimulus of light. This is 
 because of two reflexes, one presiding over the dilator muscles of 
 the pupil and the other over the sphincter muscles. The atropine 
 blocks the passage of the normal impulses to the sphincter at c 
 and the balance is upset. The heart's activity is regulated in 
 the same way by two sets of nerves, acceleration of rate by the 
 sympathetic, and slowing of rate by the vagus. The heart is like 
 the pupil, ever ready to respond to a demand for more or less 
 blood from the tissues, according to their ever-varying activity. 
 The atropine acts by paralysing the peripheral end of the vagus, 
 or by depressing the c end of the reflex arc, and the uncontrolled 
 sympathetic fibres cause the increased rate. 
 
 Fig. 0. — Diagram of a mviscular reflex. The stimulus from 
 to B, where it affects the nerve cells supj^lying the muscles c and c'. In 
 response to the stimulus the muscle at c contracts, while the muscle at 
 c' relaxes. The signs + and — indicate the different actions. 
 
 Observation 4. — The Action of Strychnine. 
 
 Tn the reflex action of muscles in causing the movement of a joint 
 there occvirs normally at the same time as the contraction of the muscles a 
 relaxation of the opposing muscles. Thus in Fig. 6 the stimulus arising 
 at A, is diverted at b to c, which causes a contraction of the muscle, and to 
 c', causing a relaxation of the muscle. These reactions are shown by -f 
 and — . The effect of strychnine in producing convulsions is by converting 
 the inhibition of the muscles which takes place in a reflex movement of a 
 joint into a contraction of these miiscles, as in Fig. 7, where both reactions 
 are seen, represented by + sign. 
 
 This observation shows the influence of an agent modifying 
 the reflex at the B portion of the arc, and explains the mechanism 
 of the convulsions in rabies as well as in strychnine poisoning. 
 It is to be noted that neither the strychnine nor the toxin in 
 rabies can by themselves initiate a stimulus for the production 
 of a reflex— this arises always from some part of the body through 
 the A portion of the reflex arc, as at the skin. This fact shows that 
 
Appendix. 321 
 
 the drug does not cause convulsions, but only modifies the reflex 
 in such a way that the stimulus from A produces the convulsions. 
 These methods of action probably explain the action of all 
 drugs or toxins which are supposed to act on centres. A great 
 number of drugs are credited with causing vomiting for instance, 
 but the manner in which they act is to render the B or c portion 
 of the arc more susceptible to a stimulus so that a normal stimulus 
 passing into the nervous system affects certain reflexes which have 
 been rendered unduly sensitive. 
 
 Fig. 7. — Diagram illustrating the effects of strychnine. The response 
 from the stimvilus arising at a affects the cells at b differently, so that while 
 the muscle at c contracts the muscle at c' does not relax, but also contracts. 
 This is shown by the — sign in Fig. 6 being now a + sign. 
 
 The following observation shows how a normal act can 
 affect the reflex at b when it is rendered hypersensitive by an agent 
 such as a drug. 
 
 Observation 5. 
 
 A man with a regular heart, after I had given digitalis, showed 
 irregularities which a graphic record demonstrated to be due to the 
 dropping out of ventricular systoles, the auricular rhythm being unaffected. 
 The digitalis was stopped, and in a few days the heart's rhythm became 
 quite regular, the ventricular systoles having ceased to drop out. Com- 
 menting on this fact to the patient, he said he could bring the irregularity^ 
 back, and I asked him how, and he replied, " By swallowing." I requested 
 him to swallow, which he did, and a ventricular systole dropped out. I 
 took a long tracing, and when he did not swallow the rhythm was regular, 
 but as soon as he swallowed a beat was missed. This was repeated a great 
 number of times. Four days later the heart was quite regular, and 
 swallowing had no effect ujjon the heart's rate. 
 
 Observation 6. 
 A woman, aged 52, experiences attacks in which she becomes 
 prostrated, suffers severe pain in the head, and vomits. If she lies quite 
 still she does not vomit, but if she is startled by a noise — such as the 
 banging of a door or ringing of a bell — or if she smells tobacco or cooking, 
 vomiting occurs. 
 
 In this condition there is manifestly a hypersensitive condition 
 of the B part of the reflex arc, but it is to be observed that vomiting 
 occurs from a stimulus from the periphery, just as the convulsion 
 in rabies and strychnine poisoning. 
 
322 Appendix. 
 
 The Added or Reinforced Stimulation. 
 
 In the production of reflexes in disease the reffex often takes 
 place with unusual ease or facility, a slight stimulus producing an 
 exaggerated reflex or calling into play an unusual reflex, as in 
 Observation 5. The reason for this is that the disease disturbs 
 some parts of the reflex arc rendering them more or less susceptible 
 to stimulation. This may happen in several ways. 
 
 In certain forms of visceral disease certain areas of the skin 
 or other tissues of the external body wall show an increased 
 susceptibility to stimulation. Thus, when pressure is applied to 
 the skin of such a strength that in the unaffected part it jiroduces 
 only the sensation of touch or pressure, it produces in these 
 hyperalgesic areas the sensation of pain. The explanation of this 
 disturbance of the normal reflex is that already a stimulus is 
 affecting the arc from the diseased organ a, and the added stimulus 
 of pressure a' is sufficient to produce pain (Fig. 8). 
 
 Fig. 8. — Diagram to illustrate an added or reinforced stimulus. The 
 presence of disease at a (say gastric ulcer, a diseased tooth) keeps up a 
 persistent irritation at B, so that a stimulus from a' (the skin or other 
 organ) not sufficient to cavise pain by itself, affects the irritated cells at 
 B and produces pain (see also Observations 5, 6, 7). 
 
 The contraction of the muscles of the abdominal wall in 
 disease of abdominal organs (the " viscero-motor reflex ") is but an 
 exaggeration of the normal reflex which maintains the tone of 
 these muscles. If the gradual disappearance of these contractions 
 be observed it will be found to merge into that state of resistance 
 which we recognise as tone in these muscles, so that the contraction 
 in visceral diseases is but an exaggeration of the normal tone. 
 
 The increased sensitiveness which is shown by hyperalgesia 
 of the tissues of the external body wall is capable of giving rise 
 to pain from a stimulus reaching the central parts of the arc. 
 
Appendix. 323 
 
 Observation 7. 
 
 A man with advanced aortic disease suffered from attacks of angina 
 pectoris. He liad a diseased tooth, which caused a slight degree of jiain. 
 During the attacl^s of angina pectoris, in addition to the pain in the chest 
 and left arm he had pain along the jaw, but the pain was always most 
 ■severe around the diseased tooth. 
 
 In this instance the diseased tooth kept up a continual 
 irritation of the A part of the sensory reflex, and the pain would 
 become more severe when pressure was made on it in chewing, 
 the reflex arc being disturbed by an increase of the stimuli at a. 
 During the attacks of angina pectoris pain was felt along the jaw — 
 where there was already a disturbed reflex — this additional 
 ■stimtilus reaching the arc at b produced an increase of the pain, or 
 in other words an increased response, at c. 
 
 Observation 8. 
 
 A man suffered from jaundice with severe attacks of gall-stone colic 
 ior several days. The skin of the upper part of the abdomen on the right 
 side was very tender on pressure (hyperalgesia). The pains suddenly 
 oeased and a gall stone the size of a bean was passed by the bowel. The 
 hyperalgesia of the skin persisted, but he sxif?ered pain over the hyperalgesia 
 region on taking food. ^Vllen the hyperalgesia disappeared he suffered 
 no pain on taking food. 
 
 Here, as in Observation 5, a normal stimulus (resulting from 
 the taking of food) on entrance into the central nervous system 
 afiected a hypersensitive part of a reflex. 
 
 Balanced Reflexes. 
 
 There are a great many different kinds of reflexes, some so 
 obscure that their mechanism is not clear. There is one form 
 which from its symplicity illustrates the theory of disturbed reflexes 
 as the basis of symptoms. This is the kind which might be called 
 balanced reflexes, where two systems of reflexes mutually react. 
 This was seen in the description of the reflex contraction of 
 muscles, when at the same time one set of muscles contracts 
 another set relaxes, where strychnine and the toxins of rabies and of 
 tetanus disturb this balance (Figs. 6 and 7). It is also shown in the 
 pupil, where normally the movements of the pupil are exquisitely 
 balanced by the nerves supplying the dilator and sphincter fibres, 
 and where atropine upsets this balance by jiaralysing the sphincter 
 fibres. It also occurs in the heart, where the play between the 
 accelerator and depressor nerves of the heart results in the delicate 
 regulation of the heart's activity in response to stimuli from the 
 other organs of the body. 
 
324 Appendix. 
 
 In many illnesses the balanced reflex is upset, so that we find 
 the pulse rate a valuable indication of the patient's state. In 
 most toxic cases the rate is increased, possibly by the excitation of 
 the accelerator (sympathetic) part of the reflex. In some cases 
 the toxin stimulates the depressor part, as in typhoid fever, and 
 the efiect upon this part of the balanced reflex is seen in certain 
 diseases where the heart's rate becomes very slow, as in the 
 following observation. 
 
 Observation 9. 
 
 A man 50 years of age began to suffer from sudden attacks of loss of 
 consciousness of brief duration. His pulse was found to be slow, and 
 records — graphic and electrographic — showed that his ventricle was 
 responding only to every second auricular beat. As this is typical of one 
 kind of an over-action of the vagus, an attempt was made to remove this 
 by atropine, which paralyses the peripheral end of the vagus. A hypo- 
 dermic injection of one-fiftieth of a grain of atropine was follo^yed in ten 
 mimites by the appearance of more beats, and in thirty-five minutes the 
 ventricle responded to every auricular systole. 
 
 In this instance the disturbed reflex was due to an over-action 
 of one part of the balanced reflex (the vagus) and the removal of 
 this over-activity at the c portion of the arc by the atropine 
 restored the heart to its normal rhythm. 
 
 An example of the disturbance of the balanced reflex, which 
 not only illustrates the mechanism but throws light on a matter 
 of real importance in practice, is afforded by the variation in the 
 heart rate occasioned by the act of respiration. In differentiating 
 the different forms of heart irregularity I recognised one form 
 common in the young, which I called the youthful type of irregu- 
 larity, and demonstrated that it was produced by the breathing ; 
 the heart increased in rate during inspiration and decreased during: 
 expiration. This variation was more marked if the individual 
 breathed slowly and deeply. 
 
 On inquiring into the significance of this form of irregularity 
 I found it present in young people in perfect health. I found it 
 disappeared when any febrile illness caused an increase in the 
 heart's rate, and it returned when the fever fell and the rate 
 returned to normal. I have used this irregularity for over twenty 
 years as a guide in doubtful cases after recovery from illness, 
 looking upon its presence as a proof that the disease had departed, 
 and that the heart was free from any active process. This view 
 is now justified. Under ordinary circumstances the balance 
 between the accelerator and depressor nerves is so even that a 
 
Appendix. 325 
 
 stimulus such as breathing disturbs the balance. The presence 
 of a toxic agent aSects the reflex, causing an increase in the rate, so 
 that the slight stimulation from the act of breathing no longer 
 has any effect, and hence the reappearance of the irregularity at 
 the termination of a febrile illness. 
 
 The Disturbed Fail of the Response. 
 
 The tendency to heart-block by stimulating the vagus (as 
 by the use of digitalis) is more apt to occur when the bundle 
 connecting the auricle and ventricle is damaged, and the question 
 arises, Is the effect at c which produces heart-block due to an 
 increase of the vagal activity or an increased susceptibility of the 
 responding organ — that is, the auriculo-ventricular bundle ? That 
 the reflex may be impaired by the diminished susceptibility of the 
 recipient organ at c can be inferred from the following observation : 
 
 Observation 10. 
 A man 68 years of age consulted me because he had found that on 
 making a considerable effort, as running upstairs, his pulse, in place of 
 increasing in rate, fell to nearly one-half its rate. I tested him, and found 
 that this was so ; I considered that the bundle which conveys the stimulus 
 from auricle to ventricle was damaged, so that while the damaged bimdle 
 could convey a stimulus at the rate of 60 or 70 times a minute, it failed to 
 do so when the rate became liigher. Subsequent records, graphic and 
 electrographic, confirmed this view. 
 
 In this instance the normal balance of the reflex between 
 the augmenting and inhibiting nerves to the heart is disturbed by 
 the damage to the recipient organ. 
 
 Multiple Stimuli and Multiple Responses. 
 
 The response at c may be due to stimuli originating at different 
 places and in different ways. Thus an abdominal muscle may 
 contract in response to a stimulus from the brain, or from the skin, 
 or from the movements of respiration, or from the movements of 
 the body, or from a visceral stimulus, as in Observation 2. 
 
 A single stimulus can give rise to a number of responses — 
 indeed, most stimuli do ; we have seen that a cutaneous reflex 
 giving rise to a movement of a joint does so by the contraction 
 of one group of muscles and the inhibition of another group, while 
 Observations 1 and 2 showed that in response to a stimulus a 
 number of reflexes followed. 
 
326 Appendix. 
 
 Multiple Reflexes. 
 
 During ill health the patient may complain of a number of 
 symptoms, and the doctor may detect a number of signs. This is 
 due to the fact that the agent which causes ill health disturbs 
 a great many reflexes. To look at these signs and symptoms, each 
 one recorded as an isolated fact, presents such a confused picture 
 that a coherent description of the patient's condition cannot be 
 given. When the individual reflexes are recognised, then the 
 symptoms can be grouped upon a rational principle. 
 
 This plan of analysis can be employed in studying the reflexes 
 produced by the impaired functions of organs, or by the specific 
 reaction to the toxins of disease, as well as to drugs, in the manner 
 already described. 
 
 The Disturbed Reflexes due to Organic Disease. 
 
 One essential question in cases of diseased organs is their 
 functional efficiency. When all the organs are functioning in a 
 normal manner the reflexes pass unnoticed by the individual. 
 When a failure of function takes place the reflexes are disturbed and 
 symptoms appear. It is difficult to recognise the real source of a 
 reflex, for many organs when they fail to function in a normal 
 fashion do not themselves show the signs of failure, but the signs 
 are shown by other organs that are deprived of the material the 
 erring organ contributes to the economy. 
 
 While the failure of each organ will give rise to different 
 reflexes the fundamental principles governing the production of 
 the symptom will be the same. 
 
 The Disturbed Reflexes due to Heart Failure. 
 
 The symptoms produced by heart failure offer a good illustra- 
 tion, as they have been worked out in some detail. 
 
 When a healthy individual engages in violent physical effort 
 he will in time produce exhaustion of the heart, so that it no longer 
 supplies sufficient blood to the organs and tissues, and the individual 
 suffers distress. The same thing happens when an individual with 
 a diseased heart undergoes an effort which leads to exhaustion, 
 only in the second instance the amount of effort is less. The signs 
 of heart failure are those of distress and are not to be found by the 
 examination of the heart but by effects of an insufficient supply 
 of blood to other organs. This is well recognised in advanced 
 heart failure when there are in addition to distress on effort, the 
 physical signs of dropsy and an enlarged liver. 
 
Ajypendix. 327 
 
 In the great majority of people who sufEer from heart failure 
 these physical signs never appear. In them the heart failure is 
 made manifest by a limitation in their response to efiort ; they are 
 pulled up by distress in some effort they were wont to perform in 
 comfort. This is because of certain reflexes that are set up by 
 organs which suffer from an insufficient supply of blood. The 
 reflexes are of a nature that produce distress of such a clamant 
 kind that cessation of effort is called for. They are mainly of two 
 kinds — the distress associated with (1) breathlessness and (2) pain 
 in a distinctive region. 
 
 In healthy people the most frequent evidence of heart 
 exhaustion (as in running) is breathlessness and the accompanying 
 sensation of tightness at the throat and a sense of suffocation. 
 Occasionally there is also a sensation of constriction of the chest 
 with pain across the chest. 
 
 What happens in a healthy person is also what happens in one 
 with a weak and diseased heart, one diSerence being that less efiort 
 produces the distress in the latter case and another that pain is a 
 fairly frequent cause of distress. 
 
 The mechanism of these two reflexes is quite distinct. 
 Respiratory distress is the outcome of a disturbance of the respira- 
 tory reflex on account of the heart being unable to supply purified 
 blood to some part of the respiratory system. I do not discuss 
 further this mechanism here, as it would lead us too far, but 
 everyone recognises that breathlessness is a sign of heart exhaustion 
 and that it is due to a disturbed reflex. 
 
 The other reflex, of which pain is the dominant feature, is a 
 reflex arising from exhaustion of the heart muscle itself. The 
 pain is often accompanied by other reflex signs, as contraction 
 of the intercostal muscles producing the constriction of the chest — 
 sometimes of such extreme violence as to be more dreaded than 
 the pain. Sometimes the mouth fills with saliva, and the pain 
 may be felt not only in the chest but in the arms and along the jaw 
 (Observation 7). These are multiple reflexes comparable with 
 that described in Observation 2. 
 
 Observation 11. 
 
 A man 68 years of age complains of breathlessness on going up a hill 
 or stairs. Also'^of pain across the chest, on effort vmder certain conditions, 
 such as walking out on a cold day or after a full meal. Tlie pain across 
 the chest is preceded by a sense of tightness, or constriction, such as used 
 to pull him vip when rvmning a race in boyhood. These signs of limitation 
 have come on gradually, and he noticed his limitation fifteen years ago. 
 There are no physical signs of disease, except some arterial degeneration 
 
3^8 Appendix. 
 
 This account is one common to a great many people, in whom 
 the coronary arteries become diseased so that the heart muscle 
 does not receive an adequate supply of blood. 
 
 In this case the heart in supplying the active muscles of the 
 legs fails to supply other parts with enough blood, and amongst 
 others the respiratory system is affected, and gives rise to the 
 complex reflex which is called breathlessness. At other times 
 the heart muscle does not receive a sufficient supply of blood, and 
 it gives rise to its peculiar reflex — pain and contraction of the 
 muscles of the chest wall. 
 
 In heart exhaustion, then, we have two prominent reflexes — 
 the one arising from a deficient supply of blood to the respiratory 
 organs, and the other arising from exhaustion of the heart muscle. 
 Which of these reflexes first appears on heart exhaustion depends 
 on whether the respiratory or cardiac reflex is first called into play. 
 In the case quoted, under certain circumstances it was the respira- 
 tory, and under others it was pain. Occasionally they may both 
 appear. 
 
 In certain cases the respiratory reflex is readily produced, 
 as in auricular fibrillation — a condition in which pain is infrequent 
 and rarely severe, while in diseases which limit the supply of 
 blood to the heart muscles pain is readily induced. In the following 
 instance the reaction of the reflex to the different heart states is 
 brought out. 
 
 Observation 12. 
 
 A man 66 years of age con-siilted me for pain on walking. The pain 
 at first was only produced by walking, and only on certain occasions — 
 mostly on walking after a meal. The pain was situated across the chest, 
 and was accompanied by a gripping sensation. As years passed the pain 
 became so easily provoked that walking under any circumstances would 
 cause it. Tlie heart was normal in size and the rhythm of the heart normal. 
 One day, when 72 years of age, he called to see me, and said that mitil 
 recently he could walk 200 yards before the pain compelled him to stop. 
 Now he can only walk 100 yards when he is pulled up, not by pain but by 
 breathlessness. Indeed, since this breathlessness occ\u-red he had not 
 suffered from pain. On examination I found the heart was irregular in 
 its action, the irregularity being characteristic of that due to auricular 
 fibrillation. 
 
 This is not an isolated instance, as I have had several cases 
 with a somewhat similar history, but explains an observation I 
 made many years ago, that people with auricular fibrillation do not 
 suffer from severe attacks of angina pectoris. 
 
Appendix. 
 
 329 
 
 The Effects of Drugs. 
 
 It has already been shown that drugs act by causing a 
 disturbance of reflexes. This way of looking at the action of drugs 
 explains much that is obscure in pharmacology, as the following 
 observation shows. 
 
 For a long time it was recognised that digitalis acted in a 
 remarkable manner in some cases of rapid pulse in reducing the 
 rate, while it had no effect in other cases. It was never understood 
 why there should be this difference. I found out about fifteen 
 years ago that in the cases in which it had this slowing effect the 
 heart was regulated by abnormal rhythms — mainly that abnormal 
 rhythm due to the condition now recognised as auricular fibrillation. 
 I have attempted many times to reduce the increased rate of the 
 heart when the rhythm was normal, and invariably failed. I 
 speculated for a long time as to the cause of this difference, but 
 never understood it till the theory of disturbed reflexes made the 
 matter plain. 
 
 In infectious diseases — as pneumonia, measles, etc. — the 
 balanced reflex that moderates the heart's action is disturbed by 
 the toxins of the casual agent of disease, so that the rate of the 
 whole heart is increased. 
 
 In auricular fibrillation this reflex is not disturbed. When the 
 rhythm is normal the ventricle contracts only to the stimulus that 
 arises from an auricular systole. In auricular fibrillation there is 
 no rhythmic contraction of the auricle, but a continuous fibrillary 
 twitching of the muscle, so that in place of the regular stimulus 
 from the contracting auricle there is a shower of weak stimuli 
 which assail the conducting system between auricle and ventricle, 
 and cause the rapid ventricular rate. Not only is there this 
 difference in the cause of the increased rate, but there is a difference 
 in the condition of the cardiac reflex. In rapid pulse with the 
 normal rhythm the reflex is disturbed by the toxins of the diseased 
 state, so that the digitalis can produce no effect. In auricular 
 fibrillation the reflex is unaffected, so that the digitalis can act 
 upon the vagus portion, and in doing so depresses the conducting 
 mechanism to the ventricle and renders it not so susceptible to the 
 numerous stimuli from the auricle. 
 
 The Analysis of Symptoms. 
 
 In many diseases all the symptoms on which a diagnosis is 
 based are reflex in origin — in some the reflexes are disturbed by 
 the entrance of the stimulus through the nervous system, and in 
 others the disturbance is through the circulation. To the former 
 
330 Appendix, 
 
 belong the symptoms of such diseases as gastric ulcer, renal 
 calculus, gall-stone disease, where the symptoms are of the type 
 described in Observation 2. The symptoms in infections are 
 due to the disturbance of the reflexes through the circulation, as 
 influenza, malaria, typhoid and typhus fevers, measles, and 
 abscess formation, apart from the swelling. 
 
 In some diseases we get a mixture of both kinds of reflexes, 
 as in appendicitis, where there is not only the local pain and 
 tenderness of the tissues of the external body wall, with contraction 
 of the muscles of the abdomen, but the feeling of exhaustion, rapid 
 pulse, tendency to vomit. In cholecystitis we get a similar 
 complex. 
 
 The need for the more accurate recognition of symptoms is 
 seen when it is considered how difficult it is to diagnose even such 
 seemingly simple affections as gastric ulcer and appendicitis. 
 Though surgeons have been operating for these complaints for 
 many years, the most experienced recognise that in many cases 
 they find they have been mistaken in their diagnosis. This is 
 due in a great measure to the fact that the nature and mechanism 
 of the symptoms of these diseases have never been understood, 
 and .the symptoms were never clearly differentiated from those 
 of other diseases which they resemble. 
 
 It will thus be seen that symptomatology is like chemistry, 
 where the combination of elements results in the production of a 
 great number of compounds bewildering in their variety. Never- 
 theless, as in chemistry, when they are subjected to strict analysis 
 they can be resolved into their component elements. When the 
 analysis of symptoms is studied as fully as the analysis of chemical 
 compounds have been studied, then it will be possible to group 
 the disturbed reflexes in an orderly manner. The next step then 
 will be to find out the agents capable of provoking the different 
 reflexes, so that we get nearer to the immediate cause of disease. 
 
 The employment of this method of investigation is but a 
 return to those methods of clinical research which were so fruitful 
 in their results in the past, especially during the early half of the 
 nineteenth century. To realise how great the progress was during 
 that period we have to consider the discoveries associated with 
 the names of Addison, Bright, Graves, Adams, Stokes, Cheyne, 
 Paget, Hodgkin, and Jenner. These observers employed the most 
 useful of all weapons in research — the trained senses. What we 
 aim at is to recognise the methods which these great observers 
 employed, and by improving and refining their methods restore 
 clinical medicine to the van of research. 
 
Appetviix. 331 
 
 Structural and Functional Symptoms. 
 
 A certain numbor of symptoms are due to structural changes 
 and functional derangements. These are generally shown by 
 physical signs, and are due to departures from the normal in 
 various ways, as in alteration in the size and shape and consistence 
 of organs, changes in the colour, as pallor, modification of the 
 sounds of the heart and lungs. These are not dealt with here, 
 but will have to be reconsidered in view of this theory of disturbed 
 reflexes, because many apparently structural and functional signs 
 are really disturbed reflexes, or are produced by disturbed reflexes. 
 
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