itiney
 
 GENERALIZED PAIN
 
 CLINICAL 
 
 SYMPTOMATOLOGY 
 
 OF 
 
 INTERNAL DISEASES 
 
 PART II 
 
 GENERALIZED PAIN 1 
 
 I 
 
 PROF. DR. NORBERT ORTNER 
 
 VIENNA 
 
 Only Authorized Translation Into the English LanguagQ 
 of the 2nd German Edition 
 
 BY 
 FRANCIS J. REBMAN 
 
 WITH AN INTRODUCTION BY THOMAS WEBSTER EDGAR, M.D., 
 
 NEW YORK 
 
 NEW YORK 
 MEDICAL ART AGENCY
 
 COPTBIGHT, 1922 
 
 BY FRANCIS J. REBMAN 
 NEW YOBK 
 
 Printed in America
 
 AUTHOR'S PREFACE 
 
 THE favorable reviews of my book on "Ab- 
 dominal Pain" which have appeared in the medi- 
 cal journals have encouraged me to write this 
 Second Part, dealing with "Generalized Pain." 
 In these two volumes I have carefully and clearly 
 discussed all the salient features and symptoms 
 of painful internal diseases, and I sincerely 
 trust that the reader will derive that benefit 
 which it was my intention to convey. 
 
 NOEBEET OETNEE. 
 
 Vienna.
 
 INTRODUCTION 
 
 "GENERALIZED PAIN/' Part II of Clinical 
 Symptomatology of Internal Diseases, as trans- 
 lated from the original German, represents a 
 complete symptomatology of all the painful sen- 
 sations experjenced by the human organism, with 
 the exception of the abdominal region, which is 
 discussed in a separate volume. 
 
 Prof. Dr. Ortner has made it possible by this 
 book for the physician to appreciate the selective- 
 ness of the symptom pain, and the text may be 
 used as a guidance in the differential diagnosis 
 of many pathological conditions that heretofore 
 have been clouded by a multiplicity of vague un- 
 charted painful sensations. 
 
 This book "analyzes pain," and may be used 
 to great advantage by the physician when ques- 
 tioning his patient. 
 
 The more than kind reception accorded Part 
 I, "Abdominal Pain," undoubtedly will serve as 
 a fitting introduction to Part II. 
 
 Prof. Dr. Ortner has made the subject of gen- 
 eralized pain preeminently his own. 
 
 The translator has chosen clear and simple 
 English, making the book easier to digest and 
 
 vii
 
 Vlll INTRODUCTION 
 
 more readily assimilated. The long, interwoven 
 sentences of the original German have been 
 rendered short, presenting to the reader, however, 
 the original text in all its exactness. 
 
 THOMAS W. EDGAB, M.D. 
 New York City.
 
 TRANSLATOR'S PREFACE 
 
 DR. ORTNER divides his book on Clinical Symp- 
 tomatology into two parts, viz.: "Abdominal 
 Pain" and "Generalized Pain." The first part 
 deals entirely with pain which manifests itself in 
 the abdominal region of the human body and all 
 the subdiaphragmatic organs contained therein. 
 This volume was published in the early part of 
 1922 and has established itself firmly in the 
 medical book market. 
 
 The second part is now ready for distribution. 
 It deals with pain felt by the patient in those parts 
 of the anatomy which are not included in the first 
 volume, and the author very appropriately gives 
 it the title of "Generalized Pain." 
 
 The language employed is simple and not too 
 technical, a quality which will readily appeal to 
 the profession. The forthstanding features of 
 the book are the marvelous clinical experience 
 of the author, which he gives unstintingly to the 
 reader, and the clever way in which he weaves 
 the localized manifestations of pain and their 
 irradiations into adjacent and remote parts to- 
 gether into a solid unit. The two volumes com- 
 bined form a perfectly balanced whole which 
 
 be
 
 X TRANSLATOR'S PREFACE 
 
 can be conscientiously recommended to those who 
 seek reliable information on the subject. 
 
 I sincerely hope that the book will meet with 
 the approval of the medical men of this country, 
 and that my labors as translator will reap a well- 
 earned appreciation by the thoughtful student of 
 symptomotology. The book is devoid of pad- 
 ding and redundancies. Every sentence is care- 
 fully weighed and a necessity in its place, so that 
 without it the totality of the subject would be 
 disturbed, if not seriously injured. I think that 
 both "Generalized Pain" as well as "Abdominal 
 Pain" possess the inherent centrifugal power of 
 success. 
 
 I also take this opportunity to thank Dr. 
 Thomas Webster Edgar for his great kindness 
 and exceeding patience in looking over the proof- 
 sheets. 
 
 THE TRANSLATOR. 
 New York.
 
 TABLE OF CONTENTS 
 
 PAGE 
 
 PAIN IN THE HEART AND IN THE CARDIAC REGION . . 1 
 
 Pain in the Thoracic Wall 1 
 
 Moderate Cardiac Pain 2 
 
 Anginoid Pain 10 
 
 Angina Pectoris (Stenocardia) 26 
 
 Painful Attacks Resembling Angina Pectoris. . 47 
 
 Status Anginosus 71 
 
 PAINS IN THE SACRUM 73 
 
 PAINS IN THE COCCYGEAL. REGION (Coccygodynia) . . 103 
 
 PAINS IN THE SHOULDER 105 
 
 Pains in the Region of the Shoulder-Joint .... 105 
 
 Pains in the Region of the Shoulder-Blade 119 
 
 Pains* between the Shoulder-Blades 122 
 
 Pains in the Fossa Supraclavicularis and Su- 
 
 praspinata 138 
 
 PAINS IN THE BACK 146 
 
 PAINS IN THE NECK 169 
 
 Feeling of Constriction in the Neck 185 
 
 PAINS IN THE NAPE OP TJEE NECK 189 
 
 PAINS IN THE CHEST 195 
 
 Girdle Sense 204 
 
 Pains in the Region of the Ensiform Appendix 218 
 
 Retrosternal Pain and Feeling of Pressure. . . . 222 
 
 Laterosternal Pain 232 
 
 Pleurodynia 234 
 
 Sudden Violent Pain in the Chest 250 
 
 Pressure, Oppression in the Chest 255 
 
 PAINS IN THE EXTREMITIES 257 
 
 Paresthesia of the Extremities 266 
 
 Cold Hands and Feet 295 
 
 xi
 
 Xll TABLE OF CONTENTS 
 
 MM 
 
 Dead Fingers 296 
 
 Pains in the Bloodvessels 297 
 
 Dyspragia, Intermittent Angiosclerotic 298 
 
 Lancinating Pains in the Extremities 349 
 
 Painful Muscular Cramps 355 
 
 Painful Cramps in the Calves 355 
 
 Pain in the Foot or Hand . . 359 
 
 Pain in the Axilla and Groin 360 
 
 MUSCULAR PAIN 362 
 
 Trismus 382 
 
 Tetanic Muscular Cramps 387 
 
 PAINS IN THE BONES 395 
 
 So-called Rheumatoid Pains 431 
 
 Brittleness of Bones 432 
 
 Swellings in the Bones 433 
 
 Drumstick Fingers and Osteoarthropathie Hy- 
 
 pertrophiante * 435 
 
 ARTICULAR PAINS 446 
 
 I. Acute Articular Pains 446 
 
 Swelling of the Lymphatic Glands in Acute 
 
 Articular Diseases 455 
 
 Articular Diseases Not Metastatic 468 
 
 II. Chronic Articular Pains 478 
 
 Heberden's Nodes 501 
 
 HEADACHE 509 
 
 Headache of Cranial Origin 509 
 
 Nocturnal Headache 514 
 
 Posttraumatic Headache 515 
 
 Headache of Endocranial Origin 516 
 
 Headache and Increased Cerebral Pressure. . . . 530 
 
 Headache Due to Remote Causes 536 
 
 Migraine 559 
 
 Diagnostic Value of Localizing Headaches 568 
 
 INDEX . 571
 
 GENERALIZED PAIN 
 
 Pain in the Heart and the Cardiac Region 
 
 Pains in the Thoracic Watt. If a patient 
 complains about pain in the cardiac region, we 
 should first of all ascertain whether this pain is 
 really located in the heart itself, or its muscular 
 system, or is erroneously claimed by the patient 
 to emanate from these organs. 
 
 In this respect the existence of a pain-pro- 
 voking disease in the soft or bony coverings 
 over the heart, or in the skin, the mamma, the 
 muscles, the intercostal nerves, the ribs or even 
 the sternum, may be excluded. A careful ex- 
 amination and a proper knowledge of the symp- 
 tomatology in such cases will quickly solve the 
 problem. The reader is here referred for par- 
 ticulars to the chapters on "Pain in the Chest" 
 and "Pain in the Bones." 
 
 What I wish to emphasize at once is the fact 
 that women who have abnormally large breasts, 
 with the left mamma still more developed, com- 
 monly complain of pain in the cardiac region 
 or in the heart itself which is of a pressing or 
 
 i
 
 2 GENERALIZED PAIN 
 
 oppressive nature. These patients are, as a 
 rule, rather stout in general, and suffer from 
 difficulty in breathing, especially when making 
 any kind of bodily effort, conditions which 
 often lead to a mistaken diagnosis of an affec- 
 tion of the cardiac muscles, or an anatomical 
 defect of the heart proper. I have come across 
 such errors repeatedly. 
 
 The suspicion that the pain is caused by the 
 over-heavy mammary glands may be based on 
 the following facts: (1) an abnormal develop- 
 ment of the mamma; (2) the patients often 
 admit, without being asked, that the pain is 
 relieved as soon as they raise the mamma with 
 the hand; (3) when the patient is lying on her 
 back the pain continues, but disappears when 
 the mamma is raised with a suspensory. 
 
 Pain in the cardiac region may also be caused 
 through mechanical friction of the dress on the 
 nipple. As soon as the cause is removed, the 
 pain vanishes. 
 
 Moderate Heart Pain. If we are satisfied 
 that the affection is not located in the thoracic 
 frame, we have ground to believe that the seat 
 of pain is to be found in the heart itself, or in 
 its large blood vessels. But we should also think 
 of a reflex action arising from a disease in some 
 neighboring or even distant organ. 
 
 The pain varies in intensity. Sometimes it 
 consists only of a slight sensation of incon-
 
 HEAET 3 
 
 venience, sometimes it is moderate (subacute), 
 while at other times it is violent (acute). 
 
 Acute Pericarditis. Most likely we are deal- 
 ing with an acute involvement of the heart, 
 generally of the pericardium, but it may also 
 be myocardiac or endocardiac in its nature. In 
 acute pericarditis the patient complains of stab- 
 bing pains, and pressure in the region of the 
 heart. In some rare cases the pains assume a 
 very intense and troublesome character. But 
 more about this in another place. The pains 
 just described may also be present in subacute 
 and chronic pericarditis. In the majority of 
 cases, however, they seem to be absent even 
 where a chronic, chiefly tuberculous inflamma- 
 tion of the pericardium exists. But nearly every 
 kind of tuberculous serositis (pleuritis, perito- 
 nitis) runs a painless course. A pneumoperi- 
 cardium or a hematopericardium, it is needless 
 to say, will also produce pain in the region of 
 the heart. 
 
 Acute Myocarditis. Similar pains, generally 
 accompanied by slight fever, may be observed 
 in every case of myocarditis acuta, when an 
 abscess formation in the myocardium is present, 
 coupled with or following an ulcerous septic 
 endocarditis. 
 
 Overexertion. Paroxysmal Tachycardia. 
 Slight pain in the cardiac region, generally de- 
 scribed as stabbing, piercing, painful pressure
 
 4 GENERALIZED PAIN 
 
 at times follows in the wake of an acute over- 
 exertion, i.e., an acute straining of the heart due 
 to sport or gymnastic exercises, intense psychic 
 excitement (increase in blood pressure), or 
 after an attack of tachycardia. These troubles, 
 especially oppression in the chest, manifest them- 
 selves naturally only when a constitutionally 
 weak, untrained heart is suddenly subjected to 
 unusual exertion: shortness of breath, inability 
 to draw a long breath, dryness in the mouth, 
 constant irritation to clear the throat with 
 shreds of blood in the mucus, abnormally large 
 content of urates in the urine. 
 
 Similar conditions prevail when the heart is 
 afflicted with a pre-existing anatomical defect 
 and is suddenly subjected to unusual, severe 
 demands; but they may also be due to an acute 
 loss of tonus in an otherwise normal heart. A 
 thin, scarcely palpable pulse, cold sweats, pal- 
 lor of the face, coldness of the point of the 
 nose, cold and clammy hands and feet, short 
 breath, angina, oppression in the region of the 
 heart, vertigo, dizziness, eventually acute dilata- 
 tion of the heart, systolic murmurs, high blood 
 pressure, all these may be added to the afore- 
 said symptoms. 
 
 Acute Insufficiency of the Suprarenal Cap- 
 sules. I refer here to that fierce pain which is 
 described by some authors as a sign of insuffi-
 
 HEART O 
 
 ciency of the suprarenal capsules in Addison's 
 disease. Personally, I have never observed it. 
 
 But an abnormally irritable heart may, even 
 without previous overexertion, give rise to anal- 
 ogous complaints of pain or palpitation, espe- 
 cially if hypoplasia be present. Such an over- 
 excitable heart may easily be traced by a pro- 
 nounced and spreading apex beat (in cardiac 
 hypoplasia even by a normal or also abnormally 
 weak apex beat), by an abnormally loud second 
 aorta tonus, often by a temporary systolic sound 
 over the apex or the pulmonary artery, by in- 
 clination to tachycardia, by a choppy, peripheral 
 pulse, or by other vasomotoric symptoms. 
 
 A pain which is strictly confined to the apex 
 and rendered more acute by external pressure 
 may also be the symptom of a chronic affection 
 of the cardiac muscle, in fact a definite sign of 
 a cardiac aneurysm. 
 
 Of high diagnostic interest are those cases in 
 which after a pronounced stenocardiac attack 
 pressure, oppression and moderate pain in the 
 cardiac region irregularly persist. In most cases 
 a slight rise in the temperature will be observed, 
 the objective examination shows pericarditic 
 friction, eventually the formation of a fluid exu- 
 date of the pericardium, i.e., a clear case of 
 epistenocardiac pericarditis, caused either by an 
 embolism of the branches of the coronary artery 
 due to a pericardial infarct, or by a partial
 
 6 GENERALIZED PAIN 
 
 chronic aneurysm of the heart. In the absence 
 of pericarditis a similar symptom complex, i.e., 
 pressure, oppression, slight pain, may endure 
 after an anginotic attack. The cause for this 
 will be found in an epistenocardiac myocarditis 
 (myomalacia) coupled with dilatation of the 
 heart. Its presence is indicated by a slight rise 
 in the temperature. In some rare cases these 
 pains assume an intensely bothersome character. 
 
 I wish to emphasize a fact which seemingly 
 has not as yet been properly appreciated, i.e., 
 if a patient complains of a sudden, solitary or 
 irregularly recurring pressure or stitch in the 
 cardiac region or behind the sternum, the possi- 
 bility of extrasystolic contractions must not be 
 overlooked as the probable cause of such solitary 
 sensations. According to my own experience, 
 the so-called frustaneous contractions are the 
 primary exciting factors in these sensations, in 
 conjunction with all the other extrasystolic con- 
 ditions. This seems to me an indirect proof 
 that cardiac pain may be the result of an ische- 
 mia of the myocardium. The same may be said 
 about the presence of cardiac pain in hemorrha- 
 gic anemia. 
 
 A stitch in the region of the heart may, how- 
 ever, be a purely nervous symptom, recognizable 
 when it is located to the left above, but without, 
 the absolute heart-dulness, or at the point of the 
 apex, where it is joined by a localized sensible
 
 HEART 7 
 
 pressure, i.e., an hyperesthesia of the membrane 
 over the heart-dulness. 
 
 It is a well-known fact that pain in the car- 
 diac region of a convulsive, oppressing character 
 is often the sequel of some violent psycluc emo- 
 tion. But it is well to remember that such 
 emotions may lead to real anatomical pain, e.g., 
 angina pectoris. 
 
 These stabbing pains cannot, however, always 
 and definitely be ascribed to nervous conditions; 
 they may just as well be the accompanying 
 symptom of a chronic anatomical disease, such 
 as chronic myocarditis, myofibrosis, myodegen- 
 eration of the heart, arteriosclerosis, renal heart 
 with increased blood pressure, affections of the 
 mitral or aortic ostium (the latter, however, 
 produce pain rather behind the sternum), a 
 total pericardial concretion with the heart (only 
 in exceptional cases), fatty heart (polysarcia 
 cordis et myodegeneratio adiposa), the beery 
 heart, cardiac syphilis, affection of the heart due 
 to growing, dropping heart, also every relatively 
 weak heart, in fact all morbid processes which 
 are connected with the left ventricle. They all 
 lead to pains in the region of the heart, and 
 behind the sternum, to a retrosternal sensation 
 of pain, eventually to a painful dyspnea. 
 
 Enteroptosis, above all sclerosis of the coro- 
 nary artery, frequently produce similar sensa- 
 tions of pain. Sclerosis of the coronary arteries
 
 8 GENERALIZED PAIN 
 
 causes pain in successive attacks, whilst the 
 other affections mentioned above produce a more 
 or less enduring pain of varying degree and 
 recurrent after bodily motion or exertion. Many 
 patients who complain about recurrent pains in 
 a certain localized point of the cardiac region 
 will be found to have suffered a short time ago 
 from an attack of pericarditis. In such cases I 
 have ventured upon a diagnosis of localized 
 pericarditic adhesion. Whether I was right I 
 will not presume to say. But I know for a 
 certainty that in other cases of definite (proved 
 by post mortem) such like adhesions no traces 
 of pain could be established. It is also certain 
 that contractures of the pericardium with the 
 diaphragm may be responsible for palpitation, 
 dyspnea, and sudden stabbing pains in the car- 
 diac region frequently accentuated by increased 
 diaphragmatic excursions (deep breathing, 
 sneezing, coughing, when ascending stairs). 
 The diagnosis must lean on the anamnesis (pre- 
 vious pleuritis, inflammatory pleural affection 
 in the subphrenic cavity, especially on the left 
 side), and eventually on the Roentgenogram. 
 Analogous manifestations may be provoked by 
 contractures of the diaphragm with parietal 
 pleura (pleuritis adhesiva). 
 
 In enteroptosis, particularly after cardiopto- 
 sis, we hear complaints about heart pain, palpi- 
 tation, anguish, chiefly when in left situ owing
 
 HEART 9 
 
 to increased displacement of the heart. Similar 
 painful sensations are experienced in every other 
 abnormal lateral displacement of the heart, in 
 sclerosis of the aorta, cachexia, neurasthenia, 
 but in the latter also without abnormal lateral 
 displacement because neurasthenics ars as a rule 
 supersensitive ; likewise in many other diseases 
 of the heart, even by persons in apparently good 
 health, probably when extraordinary demands 
 are made on the cardiac organs, when the heart 
 is pushed against the thoracic wall, and when 
 the diaphragm is raised above its normal level 
 by any cause whatever in the healthy as well as 
 in the afflicted. Palpitation, oppression, anguish 
 are the usual accompanying symptoms. 
 
 Arteriosclerosis is associated with pain in the 
 region of the heart because it increases cardiac 
 labor and raises the blood pressure. Of greater 
 moment still seems to me the fact that these 
 self-same pains with palpitation, early fatigue, 
 headache, and dizziness are often enough experi- 
 enced in the presclerotic stadium, and that at a 
 time when we find a more or less distinct ac- 
 centuation of the second aorta tonus with a 
 ringing sound and of a vacillating intensity, 
 likewise a moderate rise in the blood pressure 
 subject to constant changes, and eventually a 
 slightly elevated apex beat. All these mani- 
 festations may completely, or at any rate par- 
 tially, disappear after a few months when the
 
 10 GENERALIZED PAIN 
 
 causating factors (bodily overexertion, pre-emi- 
 nently mental excitement, also chronic nicotin- 
 ism) have been eliminated. 
 
 Retrosternal pains, chiefly above or behind 
 the sternum, deserve special mention. They 
 manifest themselves in the sense of oppression, 
 pressure, constant or convulsive sensations, at 
 times coupled with irradiation towards both sides 
 of the chest or of the shoulders, rarely in the 
 left arm under bodily exertion or mental ex- 
 citement, caused by sclerosis or lues of the aorta 
 (aortalgia). 
 
 They approximate anginoid pains with this 
 difference, that they are devoid of the feeling of 
 anguish and the fear of a recurrence of the 
 trouble, that they radiate chiefly into the arms, 
 preferably the left one, and assume the form of 
 spontaneous attacks. But they frequently lead to 
 anginoid or anginose attacks, because their basic 
 affection of the aortic wall easily leads to a 
 contraction or distortion of the ostia of the coro- 
 nary arteries, or similar diseases. A distinguish- 
 ing feature of these "aortal" pains may be found 
 in their rapid disappearance upon the removal 
 of the causative element (exertion, excitement). 
 What they have in common with angina pectoris 
 is Head's cutaneous hyperesthesia of the chest 
 and the left arm. As in genuine angina pectoris, 
 so here also moderate exercise in the open air
 
 HEART 11 
 
 but not in a closed room will banish the pain 
 promptly. 
 
 Continuous pains in the cardiac region may 
 be due to affections which superinduce spatial 
 contractions of the heart from without. The 
 patient complains of pressure, oppression and at 
 times of moderately intensive pain in the region 
 of the heart. There we are confronted by three 
 possibilities: (1) the formation of solid masses 
 in the anterior mediastinum (neoplasms, cysts, 
 gummata or any kind of inflammatory process). 
 The same may happen in the posterior sternum. 
 (2) Mediastinal pleuritis (diagnosis in detail is 
 given elsewhere). (3) An accumulation of gas 
 in the cellular tissue of the posterior mediasti- 
 num, the sequel of an interstitial emphysema 
 which is easily recognized by a tympanitic (ab- 
 normally sonorous and deep) percussion sound 
 in compensation of heart-dulness, or in other 
 words by a deficient apex beat, dulness of the 
 heart sounds despite an otherwise regular pulse 
 rhythm, even without taking into consideration 
 the symptoms of an interstitial emphysema over 
 the lungs, in the clavicle and the supraclavicular 
 fossa. But then every subdiaphragmatic disease 
 which produces an elevation of the diaphragm 
 either on both sides or on the left side only will 
 also cause a spatial contraction in the region of 
 the heart. I remind the reader here of abnormal 
 accumulations of gas in the stomach or in the
 
 12 GENERALIZED PAIN 
 
 intestinal canal corresponding with a flexura 
 coli lienalis, conditions which, indeed, often 
 enough, give rise to the afore-mentioned sub- 
 jective disturbances. Yet it strikes me that 
 this diagnosis is often made rashly at the bed- 
 side only to make room soon afterwards for a 
 recognition of a lethal sclerosis of the coronary 
 arteries. 
 
 Hernia and diaphragmatic eventration may 
 also show the same effects. (See chapter on 
 "Pain in the Chest.") 
 
 Aneurysms of the aorta claim here especial 
 attention even though arrosion of the anterior 
 bony thoracic wall should not as yet be in evi- 
 dence. Now to the left, or to the right, side of 
 and also behind the sternum a dull, at times also 
 violent, continuous "hammering" pain will be- 
 come noticeable. It is more or less frequently 
 interrupted by painful paroxysms of an inten- 
 sive character making excursions into one 
 (right) or both arms, or in the shoulders, or in 
 the back, either of spontaneous origin or due 
 (chiefly) to bodily exertion. 
 
 In aneurysms of the pectoral aorta the pa- 
 tient does not so much complain of pain, but 
 rather of a bothersome sensation of coldness in 
 the cardiac region. 
 
 Aneurysms of the innominate artery will 
 cause the same kind of pains which radiate into 
 the right arm or to the right shoulder.
 
 HEART 13 
 
 The diagnosis should be guided in these cases 
 by the fierce intensity of the irradiating pains, 
 the abnormal smallness of the pulse in the arte- 
 ries of the right arm and of the right carotid, 
 eventually also by paresis resp, paralysis of 
 the right recurrent nerve, acceleration of the 
 pulse in the right carotid and the subclavia (and 
 their branches) only, and by the Roentgeno- 
 gram. Pulsation behind the right sternoclavicu- 
 lar articulation or immediately above or below 
 it, a dulness above it or a pulsating protuber- 
 ance or tumor may not yet be noticeable in the 
 earlier stages. 
 
 Another source of pain may be found in the 
 irritation (no matter what its origin may be, 
 neuralgia, neuritis) of the left phrenic nerve, 
 f.i., due to diaphragmatic pleuritis, imagination 
 of the pleural membrane, compression of the 
 mediastinal glands, etc. The typical pressure 
 points, eventually singultus and a conspicuous 
 bradypnea lead the way to a proper diagnosis. 
 
 Piercing or pulling pain in the region of the 
 heart (often radiating into the back) is a regular 
 companion of tetanic convulsions, at any rate 
 when they are of a pronounced character. Te- 
 tanic contractions are here the probable under- 
 lying cause. 
 
 Persons suffering from poisoning with per- 
 chloride of mercury often complain of severe, 
 continuous pains in the heart region. Stomatitis
 
 14 GENERALIZED PAIN 
 
 and mercurial enteritis coupled with intense 
 pains in the extremities give expression to this 
 toxic neuromyositis. A patient of mine who 
 was so afflicted died, and the post mortem re- 
 vealed a high grade degeneration of the muscu- 
 lature of the heart. 
 
 A dull pain in the heart will often constitute 
 the most prominent, if not the only, symptom 
 of chronic tobacco heart. Anamnesis should here 
 be decisive. 
 
 In the aforementioned ailments we can speak 
 principally of continuous pains in the cardiac 
 region, but in sclerosis or syphilis of the coronary 
 arteries (aorta) they assume the character of 
 intermittent attacks due either to bodily exercise 
 or mental excitement, or also to spontaneous 
 causes. In their milder form they are known 
 as anginoid attacks. The diagnosis will rest on 
 the sensation of oppression and anguish which 
 accompanies the pain. 
 
 The kind of painful sensation experienced by 
 the patient should strongly appeal to the medi- 
 tation of the diagnostician. The patient says 
 that he feels a tense pressure back of the ster- 
 num, or a pressing, burning pain, a feeling as 
 if a specially hot or rather large morsel of food 
 had slipped down the esophagus. If we find 
 this in company with a well-pronounced sensa- 
 tion of anguish, we are pretty safe in deciding 
 on an arteriosclerosis of the heart or of the
 
 HEART 15 
 
 aorta or of the peripheral vessels. But if in 
 the absence of anguish we are dealing with pains 
 of a milder nature, the suggestion of neuritis or 
 hysteria lies closer. Angina pectoris is not al- 
 ways associated with very intense pains. (See 
 section dealing with "Angina Pectoris.") 
 
 Localization of the pains is here the important 
 factor for the differential diagnosis. As a rule 
 they point rather in the direction back of the 
 sternum, not to the region of the heart, as is the 
 case in typical angina pectoris. In other cases 
 the dragging pain is not located in the median 
 line behind the sternum, but on the outer edge 
 of the superior sternum, mainly to the left, some- 
 times travelling to the shoulder and the arm. 
 
 The neurotic, hysterical, anginoid heart pain 
 seeks with predilection the region of the apex, 
 frequently somewhat without and below it, or 
 the 2. or 4. left intercostal space. It flares up 
 under pressure of the finger unless the focus of 
 the pain is centered in the nipple (hyperesthetic 
 point). It would be a mistake to reduce this 
 kind of pain to a functional disorder of the 
 heart, especially so if we take into consideration 
 that nervous concomitant manifestations are not 
 infrequently associated with anatomical impair- 
 ment of the circulatory apparatus. 
 
 Sensations of anguish and oppression in the 
 region of the heart occurring chiefly in the night 
 time (over-early awakening), sometimes also in
 
 16 GENERALIZED PAIN 
 
 the daytime, even continuous, point rather to 
 an inferior form of angina pectoris (anginoid 
 conditions). But they may also constitute (even 
 if only in exceptional cases) symptoms of a 
 cerebral arteriosclerosis. We must consider here 
 the age of the patient (beyond the 40th year) 
 and the other symptoms of cerebral arterio- 
 sclerosis, viz., headache, vertigo, combined with 
 nausea or vomiting, impairment of memory, es- 
 pecially for events of a recent date, changes of 
 character such as abnormal irritability, depress- 
 ing moods, intolerance of alcohol, etc. 
 
 In the differential diagnosis we encounter 
 here a difficult question. Do anginoid condi- 
 tions in the sense of painful attacks in the 
 cardiac region coupled with sensations of an- 
 guish point to an incipient arteriosclerosis, or are 
 they a symptom of climacteric neurosis? We 
 meet them in both instances. The answer will 
 be found in the proper consideration of the other 
 classical signs of the latter, viz., congestion, par- 
 esthesia, attacks of tachycardia, Heberdens no- 
 dules, accumulation of adipose tissue, absence of 
 motoric pain, but improvement under bodily 
 exercise, success or failure of therapeutic meas- 
 ures (nitroglycerin, erythrotetranitrate show no 
 results). 
 
 Basedow's disease (hyperthyreoidism) is also 
 accompanied by anginoid attacks. Diagnosis is 
 assisted here by the findings of cardinal symp-
 
 HEAET 17 
 
 toms of this disease, struma, exophthalmos, 
 tachycardia, tremor, abnormally increased meta- 
 bolism, i.e., progressive emaciation in spite of 
 abundant food consumption. 
 
 Paroxysmal tachycardia may also evince an- 
 ginoid attacks coupled at times even with an- 
 ginose pains, owing to ischemia of the cardiac 
 muscles. 
 
 In some cases of psychopathia of a depressive 
 character which has so many points in common 
 with neurasthenia, e.g., melancholia, anginoid 
 troubles may also appear, especially in the sense 
 of precordial anguish. An analysis of the psy- 
 chic, likewise of the somatic, condition of the 
 patient sustains the diagnosis 
 
 In epilepsy these anginoid attacks bear a 
 double significance. They serve as a sensible 
 aura which is easily recognized because the sub- 
 sequent epileptic attacks sharply clear up the 
 situation. On the other hand, they represent an 
 epileptic equivalent: pre- and post-existence of 
 typical convulsions furnish the proof. In cases 
 devoid of these attacks the diagnosis is rather 
 difficult. As leading points may be mentioned: 
 youthfulness of the patient, consciousness tem- 
 porarily clouded during the attacks, unusual ac- 
 companying symptoms, complete physical ability 
 of subject during the free intervals in contra- 
 distinction to psychical changes in the inter- 
 paroxysmal stadium.
 
 18 GENERALIZED PAIN 
 
 Anginoid conditions often serve as concomi- 
 tant symptoms in the following diseases: the 
 so-called anatomical or functional affections of 
 the heart, acute peri- or myocarditis, acute over- 
 straining of the heart, chronic syphilitic myocar- 
 ditis, defects in cardiac stimulation, in general 
 in every initial myocardial weakness, especially 
 in the dropping heart, mitral heart, myocardial 
 tuberculosis, or in chronic pulmonary affections, 
 contraction of the heart with the pericardium, 
 arteriosclerosis, syphilis and aneurysm of the 
 aorta, and also in kyphoscoliosis. Irregularity, 
 retardation or acceleration of the heart beats, 
 dulness of sound, etc., will complete the diagno- 
 sis. Often when special demands are made on 
 the heart's action, for instance, in exceptional 
 cases of sudden increase in the blood pressure 
 (vesicular crises) we may hear of complaints 
 about pressure, pain and oppression in the re- 
 gion of the heart, extending to the nape of the 
 neck, by choice in the left arm. 
 
 In insufficiency of the left ventricle, nephritis, 
 arteriosclerosis and chronic myocarditis, these an- 
 ginoids come to the foreground in the shape of 
 sensations of anguish and dyspnea, culminating 
 eventually in severe attacks of cardiac asthma. 
 They rarely fail to make their appearance in 
 essential arterial, hypertension. 
 
 Sometimes they follow in the wake of pilocar- 
 pin injections, presumably by effects on the
 
 HEART 19 
 
 vagus branches of the coronary artery. They 
 are generally found also as partial symptoms in 
 vagotony. 
 
 At times it will be necessary to decide whether 
 we are dealing with a bronchial pain in an ar- 
 teriosclerotic patient or an anginoid condition 
 due to sclerosis of the aorta. 
 
 Anginoid pains, even anginose attacks, are 
 often coupled with other cardiac affections, such 
 as palpitation (cf. under that heading), skipping 
 pulse, precordial anguish, oppression due to a 
 postcecal pneumatosis of the stomach, or to 
 swallowing air or to abnormal gas formation in 
 the canal. These processes, no doubt, are gen- 
 erally formed in nervous people, whose heart 
 action as a rule is quite faultless, yet they al- 
 ways give rise to doubts about arteriosclerosis 
 or adiposity being present. I can never shake 
 off these doubts until I find definite proof of 
 an unmistakable elevation of the diaphragm, 
 succeed in removing the pain by evacuation of 
 the gas, and am convinced that motoric dyspnea 
 is not present. 
 
 If the elevation of the diaphragm is due to a 
 direct attack on the diaphragmatic muscles, or 
 to a lesion of the phrenic nerve, or if a basal 
 adhesive pleuritis has impaired the motility of 
 the diaphragm, the diagnosis will be much easier. 
 The clinical and radiologic examinations are the 
 directing guides.
 
 20 GENERALIZED PAIN 
 
 Anginoid conditions in the sense of pains in 
 the region of the heart, sensations of anguish, 
 palpitation, shortness of breath, may also point 
 to a dry pleuritis in the precordial region. More 
 about this anon. 
 
 A final diagnosis may meet with almost in- 
 superable difficulties in the following conditions: 
 fatty degeneration of the heart, in the beery 
 heart, sclerosis of the coronary arteries. Do the 
 anginoid conditions point to these affections or 
 to primary myocardiac troubles? In how far 
 and how often does nicotinism play here a role? 
 Does the bedside examination reveal these con- 
 ditions? 
 
 If we deal with a very sudden and highly in- 
 tensive pain in the cardiac region we may be 
 pretty sure that we are confronted by an ana- 
 tomical disorder of the heart or its larger vessels 
 or of other organs located close by, or also some 
 distance removed from the heart itself. Func- 
 tional disease is in such cases rather remote. 
 Particulars about this will be found under "An- 
 gina Pectoris." 
 
 Leaving this affection for the present out of 
 consideration, I wish to say that intensive pains 
 in the region of the heart caused by acute dis- 
 orders are proportionately of rare occurrence. 
 They come under our notice perhaps more in 
 the shape of an overstretching of the myocar- 
 dium in cases of paroxysmal tachycardia.
 
 HEART 21 
 
 Very sudden, fiercely stabbing pains point 
 to acute pericarditis coupled with a very pro- 
 nounced dyspnea. The pericarditis may be the 
 result of articular rheumatism or some other 
 acute infection (sepsis, pneumonia) or it may 
 be the forerunner of a rheumatic fever (acute) 
 or a partial manifestation of polyserositis. A 
 diagnosis of pericarditis under these conditions 
 is open to error. In my earlier years, when I 
 was a young assistant, I fell into this error. 
 It was really a case of pleuro-pericarditis, i.e., 
 pericarditis externa. Most of these cases are 
 due to some hemorrhagic infarct, but sometimes 
 also to pneumonia in the upper lobe or to an 
 independent pleuritis mediastinalis ant. sin. A 
 careful study of the friction fremitus will be 
 a decided adjuvant in the diagnosis. 
 
 These sudden pains do not often make their 
 appearance in cases of internal pericarditis, and 
 are therefore a fairly safe guide in diagnosing 
 for external pericarditis. 
 
 In internal pericarditis I have observed a cer- 
 tain particular kind of pain: In a case of fibrin- 
 ous pericarditis the patient complained of an in- 
 tensive, piercing pain in the cardiac region which 
 set in with every heart beat. It was so distinct 
 that temporary irregularities of the heart action 
 were marked by a simultaneous arhythmia of 
 the pain. In other cases of rare occurrence 
 so far as my own experience is concerned the
 
 22 GENERALIZED PAIN 
 
 patient complains of a violent, continuous pain 
 in the region of the heart, with excursions into 
 the left shoulder, of painful, superficial breath- 
 ing, often connected with singultus and vomit- 
 ing. The cause for these phenomena may, per- 
 haps, be found in a prominent mitral affection 
 of the pericardial branch of the phrenic nerve 
 or in the latter itself. 
 
 Acute affections of the aorta are apt to give 
 rise to complaints of sudden, at times very in- 
 tensive, pains in the region of the heart. I 
 have seen only two cases of acute infectious 
 (not syphilitic) aortitis so far in my practice 
 (more cases are reported in French literature). 
 In one case the patient complained of violent 
 continuous pains behind the superior sternum, 
 with increasing demarcation and a ringing qual- 
 ity of the second aorta tonus. It was a case of 
 florid acute articular rheumatism. The second 
 case was that of a convalescent from abdominal 
 typhoid. The patient, otherwise in good health 
 and able to do hard work, complained of pains 
 behind the sternum. When walking they in- 
 creased in violence and forced him to stand still 
 for a while. He had no fever, but a protracted 
 dicrotia, strongly accentuated, ringing quality 
 of the second aorta tonus, especially in the first 
 intercostal space to the right of the sternum. 
 
 Rare cases of aortic aneurysm, due to acute 
 infections (syphilis, tuberculosis, acute articular
 
 HEART 23 
 
 rheumatism), belong in this category. But it 
 seems to me that they develop rather on the 
 ground of mycotic embolism as spurious aneu- 
 rysms in the wall of an aorta that has already 
 deteriorated through the loss of the inner layer. 
 As a rule they are recognized only when the 
 aneurysm has run its full course. 
 
 Sudden very violent pain in the region of the 
 heart accompanied by oppression, collapse and 
 vomiting may be the concomitant symptom of 
 a rupture of the heart with hemopericardium, 
 or of the ventricular septum due to anemic ne- 
 crosis, or of the rupture of a papillary muscle, 
 or of the aorta or of the coronary artery, or of 
 the rupture of a cardiac aneurysm, or of an 
 aortic valve or of an aortic valvular aneurysm, 
 or of the rupture of a pulmonary vein, the 
 bursting of an aortic aneurysm into an adja- 
 cent organ (pleura, bronchus, trachea, pericar- 
 dium, mediastinum, esophagus), or the bursting 
 of a bronchial gland into the aorta and thence 
 into the pericardium, or it may be the sudden 
 formation of a dessicating aneurysm of the 
 aorta. 
 
 The kind of pain of which the patient com- 
 plains, viz., the sensation as if something had 
 been torn in twain within the chest, and the 
 anamnesis are strong hints of the aforementioned 
 catastrophe. 
 
 The diagnosis of a rupture of the heart or
 
 24 GENEKALIZED PAIN 
 
 also of a cardiac aneurysm or of the aorta can 
 only be confirmed by the finding of an acute 
 hemopericardium. This would also establish the 
 diagnosis of the bursting of an aorta aneurysm 
 if such a diagnosis was already previously made. 
 Rupture of the aorta leads to death much 
 quicker than a rupture of the heart proper. 
 
 The diagnosis of a rupture of an aortic valve 
 depends upon the proof of an acute, i.e., sud- 
 denly arising, mostly incomplete insufficiency of 
 the valves themselves. In the spot where an 
 aortic aneurysm bursts into the mediastinum, or 
 into the upper vena cava or any other medias- 
 tinal organ, a painful sensation will be rarely 
 found, and we must look for other accompany- 
 ing symptoms for our diagnosis. But there are 
 cases in which severe pains in the chest with 
 vomiting are experienced. The pain is gener- 
 ally located to the right of the sternum, below 
 the right clavicle. 
 
 In the rupture of a papillary muscle the 
 diagnosis can never be definitely established 
 intra vitam; for besides the sudden, overwhelm- 
 ing pains, we find the symptoms of an acute 
 insufficiency of the heart which leads to death in 
 a few hours (galoping rhythm, embryocardia, 
 acute dilatation of the heart, absence of pulse 
 beats, dizziness, nausea, oppression). 
 
 The diagnosis of a desiccating aneurysm of 
 the aorta can only then be made with approach-
 
 HEART 25 
 
 ing certainty when we find an aortic aneurysm 
 in a patient who has suffered a trauma, but 
 previous to that was hearty and showed no signs 
 of an aortic aneurysm under medical examina- 
 tion, a person who never had syphilis, so that 
 the aneurysm came into evidence, so to speak, 
 as an acute process. 
 
 The stomach is frequently the source of sud- 
 den, vehement pains in the cardiac region. 
 There may be a perforation of a ventricular 
 ulcer into the peritoneal cavity, or an acute 
 peritonitis emanating from the stomach, or a 
 volvulus of the stomach or a gastritis. We 
 may be quite sure that no subjective pains will 
 arise from these conditions in the epigastrium 
 or in any other place in the abdomen, except 
 and exclusively in the region of the heart. A 
 definite diagnosis may be made if we have pre- 
 viously already examined the patient, and if 
 the anamnesis has informed us about the exist- 
 ence of a ventricular ulcer. Where this is not 
 the case and where we are confronted by a 
 suddenly arising volvulus of the stomach, only 
 the thought of the possibility of any one of these 
 affections of the stomach, together with a local 
 examination, can lead to a resulting diagnosis, 
 and even then the consideration of an angina 
 pectoris may offer complicating difficulties. This 
 latter point craves serious thought, because in
 
 26 GENERALIZED PAIN 
 
 many affections of the stomach the existing 
 pains are accompanied by sensations of anxiety. 
 
 Destructive affections of the gastric parietes, 
 foremost a ventricular carcinoma or ulcer, may 
 create sudden, most incisive pains in the region 
 of the heart, especially when they burst into the 
 pericardium. The acute formation of a hemo- 
 or hemopneumo-pericardium, aided by the pre- 
 ceding anamnesis and clinical examination, will 
 facilitate the diagnosis. 
 
 The sensation of anguish, principally the so- 
 called precordial anguish, i.e., oppression and 
 constriction in the cardiac region and behind the 
 sternum, often coupled with a choking sensation 
 in the throat culminating in real death agony, 
 constitutes one of the characteristic signs of 
 angina pectoris (stenocardia). There are cases 
 in which the sensation of anguish and oppression 
 in the chest is of such a high degree of intensity, 
 yet without pain, that the patient collapses and 
 death intervenes. But in the majority of cases 
 we come across a whole list of valuable symp- 
 toms: pain behind the median sternum following 
 the line of the heart, radiation into the left arm, 
 especially on the side of the little finger, like- 
 wise in the left side of the nape of the neck 
 itself, and also of the face, not always very 
 intense in its nature but rather secondary to the 
 sensation of anguish which becomes well nigh 
 unbearable; besides these there is pallor, the
 
 HEART 27 
 
 Hyppocratic fades, clammy cold sweat, absolute 
 rigidity of the body (the patient stands stock- 
 still, or if the attack comes in the nighttime he 
 sits up rigidly and immovable on the edge of 
 the bed), avoidance and fear of deep breathing 
 (in some cases, on the contrary, deep respira- 
 tion brings relief), accelerated, but sometimes 
 retarded, heart beats, overmastering the attack 
 by a special physical effort, sometimes by ab- 
 dominal straining during defecation, passage of 
 gas either through the mouth or per rectum. 
 Who has not observed these signs in his bedside 
 practice? 
 
 With the whole complex of these symptoms 
 before us, the diagnosis cannot go amiss. But 
 I wish to lay stress on the fact that in spite of 
 these symptoms angina pectoris is at times by 
 mistake diagnosed as an affection of the stom- 
 ach with gastralgia, because the attack may 
 yield either spontaneously or through the means 
 of a small dose of bicarbonate of soda to a 
 sudden act of belching or eructation. 
 
 If a stenocardia has been correctly diagnosed, 
 then we must inquire into the last cause of the 
 attack: an acute, or an acute infectious, peri- 
 carditis, or a chronic myocarditis may bring 
 about anginose attacks, or a concretion between 
 heart and pericardium, or a stenosis of the aortic 
 or mitral ostium, an embolism or thrombosis of 
 the coronary artery, or chronic nicotinism may
 
 28 GENERALIZED PAIN 
 
 be at the bottom of these attacks. Tabetic heart 
 crises or purely hysterical or vasomotoric con- 
 ditions may evince them. But the most fre- 
 quent cause will be found in a sclerosis of the 
 ascending portion of the thoracic aorta where 
 the coronary arteries branch off, or in a sclerosis 
 of these arteries themselves, i.e., endaortitis or 
 endarteritis of syphilitic origin. 
 
 Due consideration of age and anamnesis will 
 in all probability decide between syphilitic endar- 
 teritis, resp. endaortitis and arteriosclerosis as 
 underlying cause. Age below forty years points 
 to syphilitic endarteritis. But it is not an in- 
 fallible sign, for our present knowledge teaches 
 us that arteriosclerosis may also occur before 
 the fortieth year is reached; in fact, at almost 
 any time of life. Neither is the anamnesis a 
 definitely deciding factor, even in conjunction 
 with other coexisting metaluetic diseases, chiefly 
 of the central nervous system (tabes, taboparal- 
 ysis, cerebrospinal syphilis), because we should 
 bear in mind that arteriosclerosis has a basic 
 predilection for syphilitic affections. 
 
 The Wassermann reaction, although of great 
 significance, is not always an absolutely reliable 
 indication. It is true that in most cases this 
 disease points to syphilitic influences. But I am 
 not fully convinced that it may not be connected 
 also with a true arteriosclerosis of the aorta or 
 of the coronary arteries, and that, after all, an-
 
 HEART 29 
 
 gina pectoris may be the exciting factor of this 
 disease. In such cases of doubt we can only 
 find assistance in the resulting efficacy of anti- 
 syphilitic treatment. 
 
 Whether embolism of a coronary artery is the 
 cause of anginose affections can be easily de- 
 cided when the existence of an endocarditis of 
 the aortic valves has been definitely established 
 and when the patient, mainly of youthful age, 
 quickly succumbs under the anginose attack. 
 On the other hand, when the embolism originates 
 from an atheromatous ulcer at the root of the 
 aorta, the etiological diagnosis of the lethal an- 
 ginose attack will have no higher value than in 
 cases where a thrombosis in one (chiefly the 
 left) coronary artery was the basic cause. When 
 the outcome is not fatal a differential diagnosis 
 of an angina pectoris on the basis of an arterio- 
 sclerosis in one of the coronary arteries at the 
 time of the attack seems to me impossible. The 
 following conditions may point to thrombosis 
 as the exciting cause : unusually prolonged pains, 
 high degree of cardiac weakness, quick but thin 
 pulse, embryocardia, emaciated appearance, im- 
 paired diuresis, faint heart beats, splitting of the 
 first apex beat, acute dilatation of the heart and 
 acute vascular congestion. 
 
 If later on a partial cardiac aneurysm is rec- 
 ognized, the diagnosis of an acute thrombotic 
 or embolic occlusion of one of the branches of
 
 30 GENEBALIZED PAIN 
 
 the coronary artery may be regarded as cer- 
 tain. Furthermore, when a sudden anginose 
 attack is immediately followed by a feverish, at 
 times only fibrinose, but also exudative pericar- 
 ditis in some cases this manifests itself during 
 the first two or four days as a continuous sensa- 
 tion of pain or oppression in the region of the 
 heart it may be an indicator of an acute oc- 
 clusion of a coronary artery branch with a sub- 
 sequent necrotic infarct and the final formation 
 of a partial chronic cardiac aneurysm. Such 
 cases are by no means rare. But the diagnosis 
 is infallible. I remember just such a case. The 
 patient succumbed rapidly. The post mortem 
 did not show an "epistenocardiac pericarditis," 
 but a very pronounced sclerosis of the ascending 
 aorta and its arch, with a number of atheroma- 
 tous ulcers, one of which had burst through the 
 wall of the aorta. This produced a periaortitis 
 at the root of the aorta, followed by acute peri- 
 carditis. The anginose attacks were due to well- 
 marked changes in the switch of the coronary 
 artery. No traces of a sclerosis or occlusion 
 in the coronary artery or in its branches could 
 be discovered. Myomalacia of the heart was 
 absent. 
 
 Some authors claim that an acute infectious 
 aortitis may give rise to typical attacks of an- 
 gina pectoris, but I have never seen such a case. 
 
 In recurrent attacks of angina pectoris, espe-
 
 HEAET 31 
 
 cially when the anginose pains with irradiation 
 continue for several days, i.e., when a status 
 anginosus exists, it is well to think of an acute 
 pericarditis as the hearth from which the trouble 
 proceeds. It is claimed that even a dry pleuritis 
 in the precordium will induce typical anginose 
 pains, i.e., pains in the region of the heart with 
 excursions into the left arm, sensation of fear, 
 palpitation, excited heart action and dyspnea. 
 I have never had the privilege of seeing such a 
 case, although I have treated quite a number 
 of cases of extrapericardiac pleuritis with pains 
 in the region of the heart. 
 
 The problem offers greater difficulties when 
 angina pectoris is based upon a concretion be- 
 tween the heart and pericardium. In this con- 
 dition the coronary arteries are held in a vicelike 
 embrace, the circulation is impeded and anginose 
 pains are the result. 
 
 But such a diagnosis can only be established 
 when absolutely unmistakable symptoms of a 
 concretion are found. 
 
 In stenosis of the aortic or mitral ostium we 
 may observe angina pectoris either in a well 
 pronounced form, or in the shape of a mitigated 
 anginoid condition, probably as a symptom of 
 an insufficient blood supply in the myocardium 
 by increased activity. The diagnosis must rest 
 upon the finding of the exciting cause. But we 
 must not overlook the fact that painful attacks
 
 32 GENERALIZED PAIN 
 
 similar to a coronary angina in mitral stenosis 
 may also be the sequel of a consecutive sclerosis 
 of the pulmonary artery. I shall revert to this 
 later on. 
 
 Anginose attacks will also crop up in chronic 
 inflammatory or degenerating diseases of the 
 myocardium without affections of the coronary 
 artery. To distinguish these rare cases from 
 true sclerosis of the coronary arteries even with 
 approaching certainty intra vitam seems to me 
 impossible. 
 
 Chronic nicotine poisoning should be sus- 
 pected in all patients, especially in females, who 
 present one or more anginose attacks. We 
 should be guided here by the other coexistent 
 symptoms : palpitation, tachycardia, arythmia, es- 
 pecially in the sense of extrasystolic conditions, 
 cold sweats, tremor during the attack, retro- 
 bulbar neuritis, dyspeptic troubles, intermittent 
 distension of the thyroid glands, nocturnal 
 palpitation of the heart. And yet all these 
 symptoms may not constitute a definite proof 
 for the toxic genesis of the anginose attacks and 
 for a good prognosis. Nicotinism is a predis- 
 posing factor in arteriosclerosis, particularly 
 in the coronary arteries. A genuine angina 
 coronaria may already exist and the first visible 
 attack may be lethal although the patient has 
 experienced no previous inconvenience. 
 
 On the other hand let us remember that
 
 HEABT 33 
 
 stenocardia in an inveterate smoker may also be 
 due to sclerosis or syphilis of the coronary 
 arteries not necessarily connected with anginose 
 attacks, but that the vascular cramps may be 
 superinduced by the immoderate use of tobacco. 
 If abstinence from smoking restores the heart 
 to normal activity we have a definite proof of 
 the toxic origin of the anginose attacks. 
 
 In rare cases of excessive use of coffee and 
 tea anginose attacks will appear. Palpitation 
 of the heart, tremor, and vasomotoric symptoms 
 differentiate them from genuine angina pectoris. 
 Even if these attacks are accompanied by brady- 
 cardia, the diagnosis for the aforesaid etiology is 
 contraindicated. A true angina pectoris exists 
 combined, like all other toxic anginas, with tachy- 
 cardia of a moderate degree, but in the severest 
 cases with bradycardia. 
 
 Among the toxic anginas we must count the 
 rare cases of anginose, or in most instances angi- 
 noid manifestations arising from chronic morphin- 
 ism or caused by inhalation of COz, e.g., after 
 carbonic acid baths or by tuberculin injections. 
 The diagnosis is governed by the anamnesis. 
 
 Toxic forms of stenocardia are also found by 
 some authors in lead poisoning, in gout and in 
 diabetes meUitus. I will not deny that such 
 toxic stenocardias exist in gout, for instance, as 
 vicarious attacks of an articular nature. But 
 so far as my own clinical experience goes, I
 
 34 GENERALIZED PAIN 
 
 speak with the utmost reserve. I remember two 
 cases of gout one a man, thirty-six years of 
 age in which I observed typical anginose at- 
 tacks. In the heart and vessels I could find 
 nothing abnormal. These conditions misled me 
 into a diagnosis of gouty, i.e., toxic angina 
 pectoris. But both patients soon succumbed to 
 a renewed attack of stenocardia. Clear cases 
 of sclerosis of the coronary arteries. In a third 
 case, I insisted on a diagnosis of angina coro- 
 naria. Three of my colleagues stuck to uratic 
 angina pectoris. The patient died of a classical 
 anginose attack in a tepid bath. 
 
 In tabes dor sails syphilis of the aorta or of 
 the coronary arteries may bring about anginose 
 attacks. Insufficiency of the aortic valves goes 
 together with tabes also. This last named com- 
 bination alone is often an indication that the 
 tabetic condition originates at the point of divi- 
 sion between the coronary artery and the aorta 
 which latter is either affected by syphilis or 
 arteriosclerosis. But this is a mere opinion, 
 because true angina pectoris is of rare occur- 
 rence despite the frequency of insufficiency of 
 the aorta in tabes. 
 
 On the other hand there are cases of tabes 
 dorsalis in which the anginose attacks assume 
 the full meaning of tabetic crises. The existing 
 causes, no doubt, will assist in distinguishing 
 between these two subdivisions.
 
 HEART 35 
 
 The true stenocardiac attack arising from an 
 affection of the coronary arteries is primarily 
 superinduced by some physical exertion (run- 
 ning for instance after a train or street car, 
 mounting steps, or a brisk walk after a heavy 
 meal) or by a sudden change in the temperature 
 (going from a warm room into the cold open 
 air), preceded by a faulty diet or a sumptuous 
 dinner or some psychic excitement. But the 
 tabetic crisis is independent of such causative 
 factors and comes into existence with a leap, 
 as it were, and without apparent reason. 
 
 Basedow's disease is likewise guilty of at 
 times most severe retrosternal pains shooting off 
 into both the upper extremities. These char- 
 acteristic and obvious symptoms should remove 
 all barriers for a proper diagnosis. 
 
 Nervous or hysterical angina pectoris is dis- 
 tinguished from a true coronary angina by the 
 peculiar behavior of the patient. Both, how- 
 ever, share that important symptom of centri- 
 fugal progression into one or the other arm, 
 likewise the sensation of oppression behind the 
 sternum and in the neck. In coronary angina 
 the patient remains perfectly still; in nervous 
 angina he groans and cries out with pain, is 
 extremely restless, and makes startling move- 
 ments. Still these distinguishing manifestations 
 do not always serve as deciding factors. I re- 
 member a case of lethal angina pectoris in which
 
 36 GENERALIZED PAIN 
 
 the patient rolled about the floor in most terrible 
 pains. Other patients, especially males, toss 
 about in bed in the most restless fashion, con- 
 stantly wailing and jabbering and gesticulating 
 until death puts an end to the agony. Rosen- 
 berg relates cases of lethal coronary angina in 
 which horrible contortions of the face and even 
 arc de cercle were observed. 
 
 The hysterical patient often describes the pain 
 as a sensation of stretching, a feeling of fullness 
 in the throat emanating from behind the lower 
 sternum. But in coronary angina the complaint 
 is more of the sensation of compression as if a 
 heavy weight were lying on the chest, as if the 
 breast were held in a vice, also the feeling of 
 intense burning especially in the region of the 
 manubrium of the sternum, due, at least in part, 
 to reflex contraction of the intercostal muscles. 
 
 Pain radiating into the region of the left ul- 
 nar nerve, even into the fingers, seems to point 
 more to anatomical than to nervous angina 
 pectoris. 
 
 The true anginose attack occurs, at any rate 
 in the beginning of the disease, generally at 
 intervals of weeks or months, preferably in the 
 night time. The individual attacks are of short 
 duration. In nervous pseudoangina we en- 
 counter again the noisy, theatrical element. The 
 attacks are more frequent, 30 to 40 follow each 
 other in rapid succession, mostly in the day-
 
 HEART 37 
 
 time and wind up in tears and sighs of a con- 
 vulsive character. The basic element will at 
 times assist us in arriving at a satisfactory con- 
 clusion. In nervous angina pectoris the attack 
 does not mature from a bodily movement, but 
 it comes on top of a psychical emotion in true 
 angina pectoris this may be even the exclusively 
 provoking element which is principally condi- 
 tioned by a special, definite external cause, e.g., 
 when entering a public place of meeting, a 
 church, a theatre, a hall filled with people or 
 when attending a social function. The object 
 of the patient is to have all eyes turned toward 
 her or himself. 
 
 The blood pressure during and between the 
 attacks, it seems to me, is a useful point of 
 differentiation. In true angina pectoris there is 
 generally a marked rise, but between the attacks 
 a depression. In the nervous attacks the press- 
 ure often rises considerably during the attacks, 
 but no marked hypotension is noticeable in the 
 intervals. 
 
 The presence of bradycardia during the attack 
 points strongly to a true angina pectoris. Ab- 
 normal difference between the rectal tempera- 
 ture and that in the armpits (0.6 to 1.0 and 
 above in favor of the former) speaks for true 
 and against neurotic angina pectoris. 
 
 Other conditions which are foreign to cases 
 of coronary angina, such as tachypnea, true
 
 38 GENERALIZED PAIN 
 
 hysterical or nervous stigmata, abnormal vita 
 sexualis point to hysterical or nervous angina. 
 To avoid dangerous errors it will be well to 
 remember that the so-called hysterical globus 
 is universally accepted as an important hysterical 
 stigma. But a similar sensation may also be 
 observed in true coronary angina. Some patients 
 complain that in stenocardiac attacks they ex- 
 perience the feeling of constriction in the fauces 
 resp. in the upper esophagus. This has been 
 erroneously accepted by some as a globus 
 hystericus, and in consequence a false diagnosis 
 of angina pectoris was made. 
 
 A special subdivision of nervous angina is 
 what might be called angino phobia, very preva- 
 lent among the members of the medical pro- 
 fession. There is pressure, pain, so to speak, 
 of a bursting character in the region of the 
 heart and behind the sternum, also irradiation, 
 oppression, palpitation, also vasomotoric mani- 
 festations, psychic affections, especially when 
 recalling the picture of certain morbid symp- 
 toms, but hardly ever after physical strenuous 
 efforts. 
 
 In this negative organic state, in this frequent 
 persistence of pressure sensation, in the recurrent 
 hyperesthesia in the region of the apex, in the 
 psychical provocation, in the fact that the patient 
 admits to be in the ban of a morbid conception 
 that forces him to anticipate a threatened attack
 
 HEART 39 
 
 when starting some physical movement, but 
 absent when his attention is averted elsewhere, 
 in pronounced psychic depression, or hypo- 
 chondriac moods, difficulty in breathing, also in 
 certain minute manifestations which are in abso- 
 lute contrast to those of a true angina pectoris, 
 there is a wealth of determining factors for a 
 correct diagnosis. 
 
 I would like to suggest here a classification 
 of dyspragia as it appears in different parts of 
 the body (extremities, heart, intestines, brain). 
 In the first place I would put the purely func- 
 tional form which is caused by absolute vaso- 
 constriction in which the walls of the vessels 
 remain perfectly intact (purely nervous or in 
 nicotinism), and in the third place the arterio- 
 sclerotic form without vascular contractions. In 
 the second place there would appear that form 
 in which the convulsive attacks based on vaso- 
 constriction are provoked by the arteriosclerosis 
 itself; I mean to say, the existence and recur- 
 rence of which is conditioned solely in the ana- 
 tomical defect of the vessels and the subsequent 
 paroxysmal vasoconstriction. Then there is a 
 fourth form also coupled with arteriosclerosis 
 with reflex actions on the vascular nerves by 
 way of abnormal stimulation, yet not to such 
 an extent that the morbid manifestations of 
 dyspragia are thereby produced. Only when an 
 additional extraneous agent which increases the
 
 40 GENERALIZED PAIN 
 
 stimulating action of the vasoconstrictors forms 
 a union with the arteriosclerosis are the mani- 
 festations of dyspragia elicited and maintained 
 until the aforesaid extraneous agency is re- 
 moved. So far as prognosis is concerned such 
 a classification should prove of importance. For 
 diagnostic purposes I think it would be a profit- 
 able graduation. Of course, in some cases only 
 the final outcome, i.e., the gradual disappearance 
 of the manifestations would bring the solution, 
 although the anatomical disease itself would 
 continue to exist. But we should bear in mind 
 that the retrogression of morbid symptoms may 
 be effected through collateral channels, especially 
 in those cases which originate exclusively from 
 anatomical affections. 
 
 In the differential diagnosis between angino- 
 phobia and a true coronary angina we may also 
 bring into service the observation that in the 
 former the sensation of fear consists rather of 
 the troublesome suspicion of a possible disease of 
 the heart and more so than of a real feeling of 
 oppression. This may also be the case in nervous 
 hysterical angina. It is a golden rule to be 
 exceedingly conservative when making a diag- 
 nosis of absolute nervous angina pectoris in 
 patients who have gone beyond the age of forty. 
 In most cases we are dealing with a combination 
 of a nervous component with an anatomical
 
 HEART 41 
 
 arteriosclerosis if not with an atypical angina 
 vera. 
 
 Attacks of nervous angina pectoris based on 
 sexual neurotic conditions and marked by op- 
 pression, pain in the cardiac region, anguish, 
 and even final collapse, can very often be re- 
 duced to excessive masturbation. Other points 
 that will assist in a correct judgment are palpi- 
 tation of the heart a symptom wholly foreign 
 to genuine angina also the localization of the 
 pain not behind the sternum, but rather in the 
 cardiac region proper where the skin especially 
 around the apex often has an hyperesthetic 
 appearance. 
 
 In vasomotoric angina pectoris it will be 
 noticed that the patient is extremely restless and 
 finds relief from the pain by constantly moving 
 about, as is the case in hysterical angina. The 
 painful attacks are frequently combined with 
 palpitation of the heart and are preceded by 
 the appearance of peripheral angiospasms, pal- 
 lor, feeling of cold or acrocyanosis of the extrem- 
 ities and of the face, paresthesia in the former, 
 giddiness, ague, syncope and collapse, generally 
 relieved by cooling applications. Careful obser- 
 vation of the blood pressure is a useful adjunct 
 in the differential diagnosis: in true sclerosis 
 of the coronary arteries a marked rise in the 
 blood pressure, rarely a depression; in the vaso-
 
 42 GENERALIZED PAIN 
 
 motoric form the blood pressure is but slightly 
 raised, if at all, but not over 20 mm. Hg. 
 
 Angina pectoris following in the wake of 
 acute, infectious, and also at times chronic 
 myocarditis without affections of the coronary 
 arteries may easily be recognized by its anginose 
 manifestations of a clinically inferior character. 
 It very likely arises from an irritation of the 
 cardiac nerves, by way of some myocardial 
 disorder, in the same manner in which the same 
 trouble springs in stenocardia from an acute 
 pericarditis. 
 
 Mild attacks of angina pectoris in which the 
 patient complains only of pressure in the cardiac 
 region and behind the sternum when engaged 
 in bodily movements or in mental action may 
 be observed in myodegeneration of the heart 
 without giving rise to a notable sclerosis of the 
 aorta or the coronary arteries. At any rate we 
 have no clinical proof of it. What arrests the 
 attention is rather the obvious dullness of the 
 heart sounds even when the patient is leaning 
 over in the front, the smallness of the peripheral 
 pulse and a splitting of the heart sounds. The 
 prognosis is much more possible for a long life 
 if good care is taken of the heart. In these 
 cases the thought always lies near that we are 
 rather dealing with an overstretching of the 
 heart during some physical exertion. 
 
 In some cases of paroxysmal tachycardia the
 
 HEART 43 
 
 patient ocmplains of severe pains behind the 
 sternum with extensions into the arm, obviously 
 anginose attacks reduceable to an ischemia of the 
 myocardium. Although we find acceleration of 
 the pulse as an accompanying symptom in pain- 
 ful attacks of true angina pectoris, this should 
 not be a disturbing element in making a proper 
 diagnosis of paroxysmal tachycardia in which 
 the pulse rate is much higher (160 the minimum, 
 a rate never obtained in coronary sclerosis). 
 
 It is worth the while to emphasize here the 
 fact that attacks of coronary angina are some- 
 times accompanied by symptoms which are apt 
 to lead to errors of a serious character for the 
 patient as well as the attending physician. 
 
 There are cases of true angina pectoris of the 
 severest type in which the sensation of anguish 
 is totally wanting. But it would also be an 
 error to infer from the presence of this sensation 
 that the attack rests upon an anatomical basis. 
 
 It cannot be disputed that the true steno- 
 cardiac attack is elicited by some physical move- 
 ment. On the other hand there are cases of 
 true angina pectoris in which the attack does 
 not follow a bodily motion, not even a physical 
 overexertion, but in which, the same as in nerv- 
 ous or hysterical angina the spell comes only 
 during the night abruptly shaking the patient 
 out of his sleep. Other patients suffer from the
 
 44 GENERALIZED PAIN 
 
 evil turn by day as well as in the night, the 
 nocturnal attacks generally being of a longer 
 duration. These latter cases bear unmistakable 
 signs of coronary sclerosis. 
 
 Furthermore, there are cases in which no 
 palpable reason for the occurrence of nocturnal 
 anginose attacks can be discovered, e.g., a late, 
 unusually heavy dinner. They come spontane- 
 ously without any recognizable provocation, and 
 physical exercise seems to have a beneficent 
 effect on the patient. And yet the disease is a 
 true coronary sclerosis beyond a doubt. Two 
 of my patients died during such a nocturnal 
 attack. The same observation has been made by 
 others (Cushman, sen.) 
 
 If the attacks are of a milder type it might 
 be proper, from the therapeutic as well as from 
 the diagnostic standpoint, to advise the patient 
 to take some food during the night which might 
 forestall a possible attack. If the result is 
 favorable, as no doubt it will be, it would be a 
 proof that the nocturnal attacks coming on 
 during the resting period are due to ischemia of 
 the heart derived from lessened irrigation, whilst 
 bodily effort stimulates the circulation in the 
 cardiac muscles and thus aborts the attacks. 
 
 The reverse is the case in dyspeptogenoiis 
 angina pectoris, in which the intake of certain 
 food stuffs, or of any kind of food, is the signal 
 for the attack, and bodily exercise is neutral
 
 HEAKT 45 
 
 in its reaction. In this peculiar etiologic factor 
 the clinician may find a hint for the diagnosis; 
 likewise, according to French authors, in the 
 milder character of the attack, its longer dura- 
 tion and less dangerous moment; also in the 
 undisputed dilation of the heart during the at- 
 tack and in the accentuation of the second 
 pulmonary sound. But I share with Krehl his 
 doubts on the subject. What I have seen my- 
 self were true cases of arteriosclerosis in which 
 acute dyspepsia was the provocative cause. 
 Krehl attributes the attacks to nervous super- 
 sensitiveness of the heart. As a rule I scent 
 especially in older patients a coronary sclerosis 
 as the exciting focus. 
 
 The diagnosis of an hysterical angina pectoris 
 due to psychical conditions is sometimes used as 
 a factor in the differential diagnosis of a steno- 
 cardia arising from a sclerotic affection of the 
 coronary arteries. But I hesitate to subscribe 
 to such an opinion, because I have seen cases of 
 true stenocardia which beyond a doubt originated 
 from psychic emotions rather than from any 
 bodily exertion. 
 
 Accompanying polyuria, urina spastica, is 
 frequently considered an important symptom of 
 nervous, hysterical angina pectoris. But this 
 may also be misleading. I remember one of 
 the gravest cases of coronary angina with poly- 
 uria immediately after the stenocardiac attack.
 
 46 GENERALIZED PAIN 
 
 Polyuria parallel with salivation is not an in- 
 frequent obvious reflex action of a stenocardiac 
 attack. 
 
 The influence of cold and palpable vaso- 
 motoric disturbances preceding the attack, par- 
 esthesia, shivering, pallor of the face and of the 
 extremities may be looked upon as decisive 
 symptoms in vasomotoric angina pectoris. But 
 even here the utmost precaution must be exer- 
 cised. Cold, to be sure, is one of the principal 
 causes. A sudden change from the atmosphere 
 of a well heated room into the cold temperature 
 out-of-doors, or the cold clammy sheets of the 
 bed may provoke an attack. But what seems 
 to me of still greater import is the fact that 
 vasomotoric phenomena may also come before 
 an attack of true coronary angina. Not long 
 ago I saw a patient with the whole characteristic 
 symptom complex of stenocardia. The post 
 mortem showed the presence of a grave mes- 
 aortitis and mesarteritis. 
 
 Vasomotoric symptoms may also be observed 
 in both the upper extremities, or perhaps only 
 on one side of the body, or in everyone of the 
 four extremities; and again there may be a 
 periodic constriction of a bronchial artery as 
 against the contralateral, even a local asphyxia, 
 eventually confined to one side only. And yet 
 there is a true angina pectoris. 
 
 Vertigo or intermittent unilateral blindness
 
 HEART 47 
 
 when associated with stenocardiac attacks, are 
 accompanying vasomotoric symptoms. 
 
 It seems to follow that at the very best only 
 the whole complex of vasoconstringent symp- 
 toms in its entirety, and then only with prudent 
 reserve, may be considered as indicating vaso- 
 motoric angina, but when it is confined to, the 
 narrow limits of certain corporeal regions 
 mainly the left upper extremity it cannot serve 
 as a criterion against a serious coronary angina. 
 
 Certain morbid manifestations which suddenly 
 make their appearance during violent weather 
 disturbances, tornadoes, simooms, severe thunder- 
 storms, are frequently looked upon as mere 
 nervous or vasomotoric disorders. But my own 
 experience has led me to the firm conviction that 
 they are occasioned by these disturbances them- 
 selves. 
 
 There is a series of painful attacks which 
 present themselves in a manner similar to those 
 connected with angina pectoris. In the front 
 rank are the diseases of the circulatory appar- 
 atus as well as of more distant organs. I refer 
 here first to those diseases which have already 
 been mentioned as the source of very intensive 
 pains in the region of the heart. In a rupture 
 of the organs referred to in that chapter the lo- 
 cation of the pain is often falsely placed in the 
 precordial region, sometimes in the epigastrium 
 or the abdomen. In consequence it is errone-
 
 48 GENERALIZED PAIN 
 
 ously taken for a lethal angina pectoris. Only 
 the proof of an existing hemopericardium or an 
 acute insufficiency of the aorta can protect us 
 against such an error when the pain is properly 
 localized as existing in the precordium and not 
 behind the sternum. 
 
 Attacks similar to those in true angina pec- 
 toris mostly of a recurrent nature are also 
 produced by other diseases, especially by sclerosis 
 of the pulmonary artery. But then the patient 
 complains of, besides anguish and oppression, 
 pain in the cardiac region with a feeling as if 
 this pain were penetrating away down into the 
 chest, yet without irradiation into the periphery 
 which is so charactertistic of coronary sclerosis. 
 There is but little shortness of breath or none 
 at all, but a high grade cyanosis, in contradis- 
 tinction to pallor in angina, or to the slighter 
 degree of cyanosis in stenocardia springing from 
 mitral stenosis. The differential diagnosis must 
 be determined by the remaining symptoms, viz: 
 generally existing abnormally large dilatation 
 of the right ventricle with simultaneous primary 
 stenosis of the mitral ostium, the unusual reson- 
 nance of the second pulmonary sound, dilata- 
 tion of the pulmonary artery, and eventually a 
 relative insufficiency of the pulmonary valves. 
 
 The same conditions exist in those isolated 
 cases of pseudoanginose attacks which arise from 
 thrombosis of the pulmonary artery or of the
 
 HEART 49 
 
 right ventricle. Notice the solitary deepseated 
 pain associated with the feeling of anguish, 
 uyanosis, rapid asphyxia, all of which affect the 
 differentiation of coronary angina. But when 
 the beginning and the progress of such a throm- 
 bosis is only gradual we may observe repetitions 
 of the pseudoanginose attacks coupled with 
 cyanosis and dyspnea and even with distinct 
 dilatation of the right ventricle. The accompany- 
 ing cyanosis and dyspnea, the deepseated pain 
 devoid of peripheral radiation, and regular dila- 
 tation in the right region of the heart are, indeed, 
 the guiding points in the differential diagnosis. 
 
 Embolism of the trunk of the aorta leads to 
 pain in the cardiac sector. Accompanying 
 dyspnea and cyanosis, deepseated pain, the 
 missing participation of the affected side of the 
 thorax in the breathing rhythm, bloody sputum, 
 and above all the conspicuous frequency and 
 smallness of the arterial pulse are signs full of 
 meaning for the diagnosis. 
 
 Painful attacks have repeatedly been ob- 
 served in innate pulmonary stenosis. The de- 
 termining factors in the diagnosis of this disease 
 are: systolic crepitus of a whirring character in 
 the second intercostal space to the left of the ster- 
 num, in the left interscapular fossa and possibly 
 in the left carotid, peripheral cyanosis, even- 
 tually hypertrophy of the left ventricle, tuber- 
 culous lesions in the lungs, and pre-senility age.
 
 50 GENERALIZED PAIN 
 
 Tumors in the right ventricle or the left 
 auricle deserve mention here. But I will say 
 at once that the diagnosis in these cases will 
 always be more or less guesswork. Perhaps, the 
 most distinguishing feature in this connection is 
 hemorrhagic pericarditis which so frequently 
 and rapidly accumulates again after a paracen- 
 tesis. In addition there are spasmodic attacks 
 of suffocation when changing the posture of the 
 body, metastasis of Troissier's ganglion, inex- 
 plicable embolism, pronounced cyanosis mostly 
 without dyspnea when the tumor is in the right, 
 but bloody sputum if in the left auricle. 
 
 Indurated mediastinitis may in my opinion 
 occasion similar painful attacks. Pains behind 
 the sternum may appear during a walk, only 
 to disappear again when the patient sits down 
 to rest, likewise painful dysphagia. The most 
 prominent adjuvants in the diagnosis are a 
 strongly marked Oliver-Car 'darelli sign and the 
 Roentgenogram. 
 
 Mediastinal neoplasms, e.g., a lymphocarci- 
 noma may at times simulate an angina pectoris, 
 for in this state the patient also complains of 
 retrosternal pain experienced during walking or 
 accentuated by more lively physical exercise. 
 This pain is undoubtedly due to the dragging 
 of the mediastinal tumor in the more vigorous 
 respiratory movements of the chest. 
 
 Pseudoangina with cyanosis of the higher type
 
 HEART 51 
 
 may also be found in thrombosis of the superior 
 vena cava. 
 
 Perforation of an adjacent organ into the 
 pericardium will induce sudden, very violent 
 painful attacks. Sensation of anguish and col- 
 lapse with lethal results often follow. If the 
 perforated organ is cavernous (pulmonary cav- 
 ity, neoplasm of the lung, carcinoma of the 
 esophagus) we have before us a pneumoperi- 
 cardium, with classical symptoms, especially in 
 auscultation; otherwise it is pericarditis which 
 in connection with the initial pains should facili- 
 tate a definite diagnosis unless the basic disease 
 *is never fully recognized. 
 Among the diseases of distant organs I re- 
 mind my readers here of the perforation of an 
 ulcus ventriculi, or an acute peritonitis originat- 
 ing from the stomach, i.e., gastric volvulus. In 
 these cases we may even come across a very 
 intensive sensation of anguish coupled with 
 acute overwhelming pains in the region of the 
 heart resembling in every detail a typical attack 
 of coronary angina. But when we consider that 
 in angina pectoris the pain is localized rather 
 behind the sternum and less in the cardiac region, 
 and concentrate our attention on the pressure 
 and hammering sensation, the tension in the 
 epigastric abdominal wall, occult hemorrhages in 
 the stools, etc., we shall be able with the aid of 
 the anamnesis to arrive at a definite diagnosis.
 
 52 GENERALIZED PAIN 
 
 If the attack is accompanied by vomiting, once 
 only or repeatedly, I would look upon this 
 symptom as an indication against rather than 
 for angina pectoris, unless the patient has 
 shown signs of cerebral or syncopic complica- 
 tions. In such cases vomiting is often enough a 
 concomitant symptom in angina pectoris and of 
 no further value so far as the differential diag- 
 nosis is concerned. Furthermore, if vomiting 
 occurs in the intervals between the attacks as 
 well as at the time of the attacks themselves, this 
 would likewise render the symptom worthless 
 for differential diagnostic purposes, for it would 
 at the utmost only indicate a catarrhal gastric 
 congestion arising from the steadily increasing 
 insufficiency of the heart in stenocardia. Of 
 course, in such a case there would be other 
 admonitory symptoms of cardiac insufficiency 
 present such as tachycardia, abnormal weak- 
 ness of the heart beats and of the pulse, embryo- 
 cardia, eventually also dilatation of the heart 
 and additional manifestations of congestion. 
 Blood pressure, if observed, will also be a guid- 
 ing symptom. In angina pectoris it is generally 
 higher, in peritonitis it shows a downward 
 tendency. 
 
 If a patient comes to you complaining of a 
 sudden, perhaps, recurrent pain of a spasm-like, 
 crushing pain in the region of the heart and 
 behind the sternum, sometimes even, it is said,
 
 HEART 53 
 
 with a radiation in the left arm and in the left 
 trigeminal region associated with feelings of 
 anguish, then think of the possibility of an 
 existing cholelithiasis. The pains sink deep into 
 the epigastrium and into the right hypochon- 
 drium with excursions into the dorsal region. 
 There is also distension of the liver, tenderness 
 in the notch of the gallbladder, febrile attacks 
 with periodical enlargement of the cystic bile 
 ducts. When such conditions come under our 
 observation it is wise to follow this procedure: 
 if there is cardiac pain resembling stenocardia 
 make a thorough examination of the liver, 
 especially for engorgement under palpation and 
 percussion, sensitiveness to pressure in the region 
 of the notch at the acme of the inspiratory act 
 and other signs of a gallbladder colic; do not 
 overlook an approaching chill, a rise in the body 
 temperature, irradiation into the dorsal region, 
 hepatic zones of the skin, and urobilinuria. If 
 you do, you will avoid missing the correct diag- 
 nosis of an angina pectoris situated ad portam 
 hepatis, and in error bring in a verdict for 
 anginose or pseudoanginose attacks when it is 
 a case of hepatic colic. 
 
 It would likewise be an error to look upon 
 a lesser and brief rise in the temperature ob- 
 taining during an attack as a contraindication 
 in the diagnosis of an angina pectoris, for it is 
 not an impossible factor in these affections.
 
 54 GENERALIZED PAIN 
 
 Myocarditis and myomalacia are by no means 
 exceptional offsprings of a diseased heart, not 
 to speak of epistenocardiac pericarditis. 
 
 The diagnostic situation may become more 
 complicated when we have to deal with a patient 
 who complains of periodical very severe pains 
 behind the sternum and who upon examination 
 shows an insufficiency of the aorta. Here we 
 are apt to find a slight dilatation of the left 
 ventricle, a sudden nocturnal attack of very 
 violent pains behind the right hypochondrium, 
 thence ascending behind the sternum to the level 
 of the right mamilla. The pains may settle in 
 this region and persist with the utmost intensity; 
 they may become intermittent or remain for 
 hours in the retrosternal circumference. I have 
 such a case in mind. One of the attending 
 physicians diagnosed gastric colic; another, vas- 
 cular pains; a third, achylia of the stomach; and 
 a fourth, chronic nicotinism. But suddenly one 
 of the attacks was followed by an attack 
 of icterus with pronounced bilirubinuria which 
 lasted four days. This led to a final diagnosis 
 of liver colic. The patient had incomplete in- 
 sufficiency of the aorta, a positive Wassermann 
 he once had a chancre , the liver was dispro- 
 portionately enlarged and the spleen was dis- 
 tended. I attributed the nightly attacks of pain 
 to syphilis of the liver. The absence of motoric 
 pain, the long intervals between the attacks for
 
 HEART 55 
 
 months at a time, the statement made by the 
 patient that flatus per anum always relieved the 
 distress, the fact that the attacks often lasted for 
 hours and were without the sensation of anguish, 
 the engorgement of the liver and of the spleen 
 and the almost exclusive arrival of the attacks 
 in the night time, should have been sufficient in- 
 dications for correcting the diagnosis of "liver 
 colic." 
 
 There is another situation in which errone- 
 ously a false diagnosis of an impending abdomi- 
 nal angina pectoris may creep in. A patient, 
 seventy years of age, came to me complaining of 
 sudden sharp pains in the epigastrium diagonally 
 across the abdomen, travelling quickly up behind 
 the superior region of the sternum, followed by 
 oppression and dyspnea accompanied by rasp- 
 ing sounds in the chest and expectoration of a 
 watery, frothy sputum. My first thought was 
 of angina pectoris with cardiac asthma, resp. 
 pulmonary edema, especially so as the patient 
 bore every evidence of a severe arteriosclerosis 
 and very strong dilatation in the left ventricle, 
 besides a muscular mitral insufficiency. But a 
 more mature analysis of the symptoms brought 
 me to the conclusion that the pains did not 
 originate from an angina pectoris at all, but 
 rather from a peracute congestion of the liver, 
 for the liver appeared to be enlarged and the 
 pain in it on pressure resembled in localization
 
 56 GENERALIZED PAIN 
 
 and character in every detail that pain which 
 always sets in with the attack. Of course, the 
 diagnosis is much easier if one has the oppor- 
 tunity to watch the patient during the attacks as 
 well as in the intervals and observe the rapid 
 fluctuations in the size of the liver and all the 
 other symptoms in this congested organ (also 
 urobilinuria). I have seen three such cases in 
 which there were, however, also pains in the left 
 epigastrium and behind the sternum as symp- 
 toms of the peracute engorgement caused by pre- 
 ceding physical overexertion. I was enabled to 
 make a correct diagnosis only by a close study 
 of the patient during the whole time that the 
 pain lasted. It is of interest to know that in 
 all these cases they were men over fifty years of 
 age with moderate arteriosclerotic myocarditis 
 the pains never set in except immediately after 
 brisk bodily movements. With rest in bed they 
 disappeared again within three or four days, as 
 did also the engorgement of the liver. 
 
 A similar localization of the "liver pain"- 
 frequently it is rather of a mild and not colicky 
 character seems to occur in the morbid affec- 
 tion of the left lobe of the liver, be this condition 
 of a concomitant or independent nature. It has 
 been recently described in a case of acute en- 
 gorgement due to an acute spinllosis of the 
 liver (Plaut-Vincent) , a concomitant symptom 
 of Plant-Vincent's angina.
 
 HEART 57 
 
 But not only a hepatic colic but a painful 
 attack provoked by an acute necrosis of the 
 pancreas or else by an acute pancreatitis may 
 be localized by the patient in the cardiac region 
 and in consequence erroneously attributed by the 
 attending physician to angina pectoris. But in 
 such a case the diagnosis of an acute affection 
 of the pancreas should be made without diffi- 
 culty on the ground of rise in the temperature 
 during the attack, pressure and throbbing sensa- 
 tion in the epigastrium, nausea, vomiting, bulg- 
 ing of the epigastrium and possibly in the region 
 of the cecum and ascending colon while the rest 
 of the abdomen shows no signs of distention but 
 is rather sunk in, and finally and especially the 
 acute collapse. 
 
 Among the chronic affections of the pancreas 
 it is principally carcinoma which gives rise to 
 violent crises of pain. These may very well 
 wear the guise of an angina pectoris when reach- 
 ing up into the cardiac territory, which, however, 
 is a rather unusual coincidence. But the absence 
 of irradiation in the arm, that fan-like extension 
 of the pain over the entire abdomen and even 
 into the sacrum, together with the other typical 
 symptoms of a pancreatic disease should proffer 
 the key to the solution. 
 
 We have already mentioned perforation of 
 a tumor into an adjacent sphere and also vol- 
 vulus ventriculi as causes of very intense pain.
 
 58 GENERALIZED PAIN 
 
 It is meet to add here that other diseases of the 
 stomach may elicit pain in the cardiac and in 
 the retrosternal region, with irradiation into both 
 arms, and that this pain may be easily mistaken 
 for an anginose attack. 
 
 I have in mind here that form of angina 
 pectoris which is looked upon by some authors 
 as a reflex action of the stomach. I have never 
 seen such a case myself. The cases of purely 
 nervous dyspepsia with secondary nervous an- 
 gina pectoris cannot belong here. Neither can 
 those of purely secondary cardiac neurosis in 
 which strong palpitation, arythmia, oppression 
 and the feeling of anguish are the prominent 
 symptoms, whilst pain is of subordinate import. 
 Of course, there are other points to be taken 
 into consideration, such as anginoid, similar to 
 those in stenocardia, also with irradiation in the 
 left arm, in company with the rest of the symp- 
 toms already enumerated. These manifestations 
 may show up after a heavy meal and disappear 
 again with a proper regulation of the digestive 
 apparatus by the aid of an emetic or the stomach 
 pump. Ravenous eating, insufficient mastica- 
 tion, overloading of the stomach seem to be the 
 essential causative factors for these anginose 
 attacks. But in my opinion they do not seem 
 to bear the convincing stamp of an existing re- 
 flex angina. I am inclined to attribute them to 
 a preexisting weakness of the heart or to an
 
 HEART 59 
 
 affection of the aorta or of the coronary vessels, 
 conditions which may easily give rise to painful 
 manifestations when spurred by an acute dis- 
 turbance in the digestive organs. 
 
 But I admit the possibility that in ulcus ven- 
 triculi even without perforation pain may rise 
 from the epigastrium upwards behind the ster- 
 num with excursions into the left or into both 
 shoulders or also into the left arm. The pain 
 may be the product of bodily exertion, especially 
 when an adhesive perigastritis is present, the 
 same as happens in a true angina pectoris. 
 Bicarbonate of soda and subsequent belching 
 promptly relieve the situation. Our decision 
 will be supported by the proper consideration 
 of local muscular tension, sensitiveness to pres- 
 sure in the epigastrium in ulcus ventriculi, local 
 hyperesthesia of the skin, Boas's pressure point, 
 vomiting in stenocardia only under certain 
 conditions , examinations for occult hemor- 
 rhages and the Roentgenogram. The objective 
 finding of an arteriosclerosis should be used with 
 the utmost discretion, because this condition ma- 
 terially advances the formation of a round tumor 
 in the stomach. 
 
 Similar conditions prevail in rare cases of 
 carcinoma of the stomach. There also the 
 patient complains of pains behind the upper 
 sternum aggravated by walking or physical 
 exertion almost exclusively. If however, an
 
 60 GENERALIZED PAIN 
 
 arteriosclerosis, especially of the aorta is also 
 present, the difficulties will be considerably in- 
 creased and only the most careful examination 
 of the gastrointestinal tract together with the 
 anamnesis proffer the desired help. 
 
 Ulcus and carcinoma ventriculi lead to angina- 
 like pains much sooner when they are associated 
 with pylorostenosis. Pylorostenosis may at any 
 time resemble stenocardia on account of its pain- 
 ful attacks. In these colicky affections the 
 patient is apt to complain of pressure behind 
 the sternum, of pains coming on in the night 
 time coupled with feelings of anguish, oppression 
 in the chest. Ructus brings relief. The latter 
 after H2S, the colicky character of the pains, 
 copious vomiting, sarcinae in the vomitus and 
 stools and the X-ray are the typical guides. 
 A combination of angina pectoris and pyloro- 
 stenosis is not an uncommon phenomenon. 
 
 Intestinal disturbances such as stubborn ob- 
 stipation and gastric dyspepsia may also pro- 
 voke troubles in the chest. They come in the 
 form of anginose attacks, oppressive pains be- 
 hind the sternum, sometimes with, at other times 
 without irradiations just as in true angina pec- 
 toris. The differential diagnosis between a re- 
 flex or toxic angina pectoris and a true steno- 
 cardia can only be decided when we have definite 
 proof that the anginose manifestations abso- 
 lutely coincided with the gastric disturbances
 
 HEART 61 
 
 and that the former disappeared with the cessa- 
 tion of the latter. It is well also to bear in 
 mind that there is a strong connection between 
 true anginose attacks and constipation and the 
 accompanying straining efforts to expel the 
 scybala. In some of these cases a possible weak- 
 ness in the cardiac vessels, that is a slight inclina- 
 tion to vasoconstriction might attract our atten- 
 tion. I have in mind here male patients who 
 have been treated properly or insufficiently, it 
 matters not for syphilis and in whom there 
 may be a suspicion of a syphilitic coronaritis. 
 When the patient tells us that brisk walking 
 causes a slight oppression, and we find a posi- 
 tive Wassermann reaction, especially in syphili- 
 tic suspects, we may gather valuable information 
 about such anatomical lesions in the vessels of 
 the heart. 
 
 The discharge of mucous masses from the 
 canal in colitis membranacea is also reputed to 
 bring about attacks of precordial pains of an 
 anginose type through a spastic reflex action on 
 the coronary arteries. I have never had the 
 opportunity of seeing such a case. 
 
 The differential diagnosis of true angina pec- 
 toris and certain neuralgias craves special atten- 
 tion in this place. I have previously mentioned 
 that angina pectoris very often sets in with vaso- 
 motoric manifestations in the left upper extrem- 
 ity. It may be added here that if it appears
 
 62 GENERALIZED PAIN 
 
 on the ulnar side of this extremity it may be 
 accepted as the first signal of an anginose at- 
 tack. This pain starts from its accustomed 
 irradiation field, ascends to the shoulder and then 
 settles behind the sternum resp. in the cardiac 
 region. In some cases it specializes only in the 
 upper, in others only in the fore-arm. There is 
 a certain resemblance to thoraco-brachial neural- 
 gia. This may become so accentuated that, as it 
 happens in true angina pectoris, paresthesias 
 and hyperesthetic zones continue to prevail, 
 especially in the ulnar region, for a considerable 
 time after the attack. The affected (nearly 
 always the left) arm becomes so sensitive that 
 even the slightest touch evokes intensive pain. 
 In these cases the evidence of typical pressure 
 points, the sensation of weight and stiffness, the 
 sensibility disturbances in the affected part, and 
 the accentuation of pain when moving the upper 
 extremity involved, are the deciding factors. 
 
 Of course, when the pain is entirely confined 
 to the chest and when irradiation does not exist, 
 the question will naturally arise: Is it angina 
 pectoris or intercostal neuralgia? The evidence 
 of typical pressure points will speak for the 
 latter. Additional proof for the differential 
 diagnosis will be found in the circumstance that 
 intercostal neuralgia does not show that axio- 
 matic dependence on bodily movement which is 
 so conspicuous in most cases of angina pecto.ris 4
 
 HEART 63 
 
 But there is another condition which may 
 intervene here as a disturbing element. There 
 are cases of true coronary sclerosis without aneu- 
 rysm of the aorta or even without a considerable 
 distension of the aorta itself in which anginose 
 pains are felt not only behind but simultaneously 
 also to the right and left of the sternum, gen- 
 erally in the second or third intercostal space; 
 likewise laterosternal pressure points on both 
 sides as well as in the second and third inter- 
 costal space on the level of the mamillary line. 
 The resemblance to intercostal neuralgia be- 
 comes thereby still more marked. 
 
 Although hyperalgesias of the skin over the 
 left breast in a more or less extended circum- 
 ference are often enough noticeable, it seems to 
 be rather difficult to demonstrate in most cases 
 the other lateral and retrosternal pressure points 
 of intercostal neuralgias. This fact alone, inde- 
 pendently of the other findings, the causative 
 agents of the attack and the remaining accom- 
 panying symptoms, appears to be the most reli- 
 able guide to a correct differential diagnosis. 
 
 Sometimes an angina pectoris is erroneously 
 diagnosed when it is in reality a neuritis of the 
 phrenic nerve. Here, too, the patient complains 
 of sudden severe pains in the chest with heavy 
 oppression. But the differences are consider- 
 ajble. Regardless of the basic disease (pleuritis, 
 pneumonia, pericarditis, subphrenic inflamma-
 
 64. GENERALIZED PAIN 
 
 tion, polyneuritis) of a neuritis of the phrenic 
 nerves and the incumbent rise in the tempera- 
 ture we find here generally very pronounced 
 dyspnea in superficial breathing, while in angina 
 pectoris the patient breathes without hindrance, 
 or, perhaps with reserve, i.e., as little and as 
 lightly as possible in order to forestall pain. 
 Cardiac asthma, however, may coexist, not neces- 
 sarily, but if it does it may be readily recognized 
 from the sputum and other pulmonary condi- 
 tions. Moreover, in neuritis of the phrenic nerve 
 the typical pressure points, singultus are in 
 evidence, whilst death-agony is absent, fear of 
 suffocation prevails. 
 
 Vagus neurosis of a purely functional nature 
 may also assume the appearance of angina 
 pectoris. Severe oppression in the chest arising 
 from the stomach, most intensive pains with 
 death-agony, a sensation as if the heart came 
 suddenly to a standstill, followed by an abnor- 
 mally quickened cardiac activity are among the 
 salient features. Negative organic conditions 
 carry no importance, but strongly symptomatic 
 are: high grade dyspnea, volumen pulmonum 
 auctum, a host of vasomotoric manifestations 
 such as chills, a general feeling of cold, pallor 
 of hands and feet signs, all of which fit in the 
 frame of vasomotoric angina pectoris. 
 
 Anginose attacks come to the surface not 
 only in functional disturbances of the vagus
 
 HEART 65 
 
 Gowers' so-called vasovasal affections but also 
 in anatomical lesions of the nerve itself. Physio- 
 logic observations show that the vagus nerves 
 carry vasoconstricting fibers to the coronary 
 vessels. It follows that an angina pectoris may 
 be the possible outcome of an irritation of this 
 nerve. Variot has observed a similar condition 
 in children suffering from tuberculosis of the 
 bronchial glands assumed to be due to vagus 
 compression. 
 
 Fusiform dilatation of the esophagus needs 
 to be mentioned here. Mechanically irritating 
 particles of food may cause the rise of gases or 
 the acid contents of the stomach, and the pas- 
 sage of a dilated piece of food may occasion a 
 sudden spasm in the muscles of the esophagus 
 and thus cause very intensive spastic pains be- 
 hind the sternum with a feeling of a heavy 
 weight on the chest and in the stomach, with 
 anguish and dyspnea. The pain may even sneak 
 along the ribs in the form of an intercostal 
 neuralgia, and also radiate to the shoulders and 
 arms. 
 
 The diagnosis should offer no difficulties if 
 we keep our eye fixed on the typical manifesta- 
 tions such as congestion of food, regurgitation, 
 fits of coughing and dysphagia, also a puriform 
 dilatation of the stomach due to a cavity above 
 the latter, stagnation of foodstuffs which may 
 easily be separated by physical and chemical
 
 66 GENERALIZED PAIN 
 
 examination from the stomach contents; and 
 the X-ray. The proof of a bipolar occlusion 
 of the cavity above the stomach can be estab- 
 lished when the flow of the water through the 
 stomach tube comes to a sudden stop. 
 
 Every form of esophageal spasm, no matter 
 of what origin, may resemble angina pectoris. 
 The main differential points are these: the vic- 
 tim of a stenocardial attack complains of a 
 painful feeling in the chest as if he had swal- 
 lowed too large or too hard a morsel, and of 
 spontaneous or forced belching. 
 
 Moreover, the pains in spasms of the esopha- 
 gus, generally located behind the lower sternum, 
 are frequently coupled with dyspnea, feeling of 
 anguish, palpitation of the heart, and fainting 
 spells not unknown in angina pectoris either. 
 The resemblance between the two diseases is 
 very strong. But the differentiation ought to 
 be assisted by the thought that the esophageal 
 attack is directly due to the act of deglutition 
 (the intake of food), a causal moment which in 
 the anginose attack is lacking. If in some cases 
 spastic attacks in the esophagus cannot directly 
 be attributed to the swallowing of food, yet the 
 cause will ever lie in the act of deglutition, i.e., 
 the swallowing of saliva dry gulping. Still 
 another cause may be found in a central or peri- 
 pheral lesion of the vagus. The stomach pump, 
 the X-ray and eventually esophagoscopy should
 
 HEART 67 
 
 remove any remaining doubts. It is noteworthy 
 also that at times solid food will pass, while 
 liquids provoke spasms. 
 
 Yet, there are cases in which, quite indepen- 
 dently of gulping, a feeling of spastic contrac- 
 tion rises from the region of the cardia to within 
 about the lower third of the sternum. It is an 
 undulating, cramp - like, ascending sensation 
 which after a few moments less than a minute 
 recedes, only to repeat again a second or a 
 third time and finish with a belch. No difficulty 
 in deglutition is experienced. In my opinion 
 we are dealing here with a sensibility neurosis 
 in the section of the cardia and the lower third 
 of the esophagus, an esophagalgia, a true car- 
 dialgia. To accept the term "cardialgia" as iden- 
 tical with gastric spasm I consider misleading, 
 "Gastralgia" is the proper name that should 
 attach to the latter complaint. It is not unlikely 
 that some forms of cardia esophagalgia, in- 
 clining to enteralgia, is connected with a concur- 
 rent motility neurosis of a lesser degree. I 
 look upon it as the expression of an anatomical 
 lesion of the esophagus, the accompanying mani- 
 festation of an esophageal diverticulum, a peptic 
 ulcer of the esophagus. This would, no doubt, 
 render the diagnosis much easier. 
 
 In some cases indubitably a true neurosis 
 exists, rarely idiopathic in its nature, but rather 
 a reflex-neurosis emanating from the gastro-
 
 68 GENERALIZED PAIN 
 
 intestinal canal an upshot of acute indigestion 
 with diarrhea a sign of habitual excess in smok- 
 ing, especially of cigarettes; perhaps, a func- 
 tional vascular pain in the affected region, an 
 intermittent esophageal dyspragia due to nico- 
 tinism. When the originating cause is not quite 
 so palpable, an error as to angina pectoris will 
 be obviated when we observe that the patient 
 seeks relief in walking about and shows no signs 
 of oppressing anguish. In cases of doubt the 
 following points will be of assistance: the pains 
 extend from the region of the xiphoid process 
 to about the lower third of the esophagus and 
 not, as in angina pectoris, higher up behind the 
 corpus sterni; the ascending, undulating move- 
 ment of the cramps, and the fact that the pain 
 is not due to physical exertion, but rather re- 
 lieved by it. I have come across several cases 
 of cardia-esophagalgia in sclerosis of the thor- 
 acic aorta. This might be a sympathetic or 
 causative reflex action of the vagosympathieus. 
 But why not the result of a minor constriction 
 at the portal end of the esophageal artery or 
 a sclerosis of the same? If that is so then these 
 pains which are so similar to anginose attacks 
 and frequently accompanied by difficulty in 
 deglutition would be nothing else than a true 
 dyspragia intermittens angiosclerotica esophagi 
 based on anatomical conditions. This conten- 
 tion, however, is open to discussion and further 

 
 HEART 69 
 
 research. Should it prove correct, another dif- 
 ficulty but not insuperable would be added 
 to the differential diagnosis. 
 
 For other affections of the esophagus the 
 reader is referred to the chapter on "Pains in 
 the Chest." 
 
 The fact that in angina pectoris the irradia- 
 tion sphere is so prominently localized in the 
 occipital region, or in the teeth or in the left 
 lower maxilla is frequently the cause for an 
 erroneous diagnosis of occipital or trigeminal 
 neuralgia, and that angina pectoris may also 
 give rise to pains in the epigastrium, in the porta 
 hepatis, in the lumbar region, and may even 
 reach out into the testicles, especially the left 
 one, and also into the lower extremities, should 
 not be left unnoticed. I refer the reader to my 
 book on "Abdominal Pain," Rebman Company, 
 New York. 
 
 I have repeatedly pointed out that dypnea 
 is not to be considered as an important factor 
 so far as angina pectoris is concerned, but that 
 it should rather lead us in the direction of a 
 vagus stenocardia no matter whether the affec- 
 tion of the vagus nerve is of an anatomical or 
 functional nature. The probability is that, when 
 stenocardia and dyspnea appear together, car- 
 diac asthma has associated itself with the angi- 
 nose attack. It is quite natural that in these 
 cases we witness a mixed, principally an expira-
 
 70 GENERALIZED PAIN 
 
 tory dyspnea, and that the stenocardiac pallor 
 is due to hepatic conditions. But even under 
 this assumption and also in the total absence 
 of cardial asthma and a cardiac pulmonary 
 edema arising therefrom, the diagnosis should 
 offer no difficulty. The periodicity of the mani- 
 festations must here be carefully studied in order 
 to understand the connection between the exist- 
 ing asthmatic and stenocardiac conditions, a 
 combination which prevails particularly also in 
 thrombosis or embolism of the coronary arteries. 
 In every case of angina pectoris a thorough 
 scrutiny of the aortic and cardiac conditions 
 becomes a necessity, especially for the presence 
 of an aneurysm in the aorta. The latter as well 
 as stenocardia equally arise from the same arte- 
 rial affections, for which reason they are fre- 
 quently companions. Some authors claim that 
 in this connection stenocardia is due to neuritic 
 affections of the aortic plexus, but, so far as I 
 know, a definite proof for this assertion has not 
 as yet been advanced. I have seen, however, 
 cases of periaortitis and plexus neuritis, i.e., a 
 lesion of sympathicus and vagus fibres arising 
 from a primary sclerosis of the aortic intinia. 
 There were present arteriosclerosis of the ascend- 
 ing aorta, recurrent asthmatic attacks, moderate 
 attacks of angina pectoris and persistent sym- 
 patheticus paresis of the eyes and of the left side
 
 HEART 71 
 
 of the face. The post mortem only can estab- 
 lish an affection of the aorta. 
 
 A question. Is there such a thing as febrile 
 stenocardia due to disease of the aorta or of the 
 coronary arteries? I once saw a patient who 
 complained about pains stretching diagonally 
 across the breast, especially behind the sternum 
 whether he was in motion or at rest. Subfebrile 
 temperature for three weeks or more. The at- 
 tending physicians diagnosed influenza. I found 
 a slight aneurysmatic dilatation of the aorta and 
 of the left ventricle and a positive Wassermann 
 as the patient admitted that he had had syphilis. 
 My diagnosis was angina pectoris due to syphi- 
 litic febrile aortitis. I saw this patient again 
 later on in a very severe anginose state. 
 
 When the attacks of true stenocardia come 
 in such rapid succession that there is scarcely 
 an interval between them, we speak of a status 
 anginosus. This does not, however, render the 
 diagnosis more difficult, unless there is an abnor- 
 mal situation in the pain itself. But if this is 
 not present, a confusion between such a state 
 and epistenocardiac pericarditis seems to me 
 excluded. True, the patient complains of con- 
 stant pain in the region of the heart; but this is 
 jaot as intense as the anginose pain is, and less 
 connected with violent sensations of anguish or 
 not at all. There is rise of temperature, peri- 
 cardiac friction and signs of fluid pericardiac
 
 72 GENERALIZED PAIN 
 
 cxudates. It is worthy of notice that after an 
 epistenocardiac pericarditis the anginose attacks 
 discontinue; also that an ordinary acute peri- 
 carditis may produce a modified status angi- 
 nosus. The slight rise in the temperature should 
 forestall any mistake so far as epistenocardiac 
 myocarditis is concerned in this connection. 
 
 It is much easier to err in the direction of 
 crises gastriques due to tabes, or other spinal 
 affections or also to diabetes mellitus. Generally 
 speaking, they dwell in the epigastrium or in 
 the entire abdominal cavity, but may localize 
 at times exclusively in the region of the heart. 
 But the presence of vomiting, "dry vomiting," 
 the fact that the pains are not so much localized 
 behind the sternum than rather in the cardiac 
 region, the other typical signs of tabes or other 
 causative diseases, should secure the diagnosis. 
 Difficulties might be encountered when tabes or 
 diabetes mellitus are also associated with insuf- 
 ficiency of the aorta, in which case a diagnosis 
 of angina pectoris might possibly result. But 
 such an error can be easily avoided if due regard 
 is given to the typical symptoms of these gastric 
 crises, proper localization of the pains is made 
 and the periodicity of the attacks is observed.
 
 Pain in the Sacrum 
 
 In cases of pain in the sacral region let the 
 patient first of all show the exact spot where 
 the pain is felt. Pain in the back is such a 
 general term among the people at large that 
 no specific meaning attaches to it. With some 
 it means the lumbar, with others the mesial or 
 also the sacral region, for which reason it is 
 quite proper here to give due consideration to 
 all the morbid conditions that may occur in these 
 different sections. For fuller particulars see 
 my book on "Abdominal Pain." Upon closer 
 examination it is generally found that the patient 
 eventually locates the seat of the pain above the 
 ilium below the 12th rib, in other words in the 
 direction of the caudal section, that is, the region 
 of the sacrum. 
 
 If the pain is lodged in the lower two-thirds 
 of the lumbar region, it portends undoubtedly 
 trouble in the muscular tissue. These pains in 
 the small of the back are provoked by gymnastic 
 exercises, digging in the garden, or chopping 
 wood or any kind of physical over-exertion. 
 But also in normal constitutions they may be 
 due to want of rest and loss of sleep, and are 
 found in myasthenia, in debility of the muse. 
 
 73
 
 74 GENERALIZED PAIN 
 
 erect, trunci, in Basedow's disease and in tetany, 
 likewise in all youthful individuals with a weak 
 muscular system. The derivation of the pain 
 and the tenderness to touch in the affected 
 muscles are sure guides for the diagnosis. The 
 same pains are experienced also after a long 
 surgical major operation, likewise in the spring 
 when heavy clothing is discarded for the lighter 
 apparel of the season. Emaciated people have 
 the same experience owing to an overburdening 
 of the muscles in the loins. And who has not 
 felt that pain after standing on one's feet for 
 a long time or after stooping down repeatedly? 
 
 This same pain is the steady companion of 
 certain infectious diseases. It springs from a 
 myalgia obtaining, for instance, in the secondary 
 stages of syphilis before and with the advent 
 of exanthema and other muscular pains in the 
 extremities. In this connection the pains are 
 generally sharper in the night time. The lum- 
 bar pains which generally follow in the wake of 
 various infectious diseases rest on the same basis, 
 i.e., musculo-asthenic or else nervous. As a rule 
 they travel in company with general fatigue, 
 muscular aching in the legs and low vitality 
 power; they disappear with progressing conva- 
 lescence and the gaining of strength. 
 
 Lumbago is without doubt the most formi- 
 dable muscular pain in the lumbar region. It 
 may come on in the form of an acute attack,
 
 SACRUM 75 
 
 or may exist as a chronic myalgia. In the 
 former case it arrives suddenly with a sharp 
 rapid pain; the latter is of a creeping, insinuat- 
 ing character. It would be an error to rest the 
 diagnosis upon the assertion made by the patient 
 that the pain is sharpened by bodily movement 
 or when stooping down and trying to erect the 
 body again. The same manifestation occurs in 
 spinal diseases and in intraabdominal affections, 
 for instance, of the kidneys, the stomach, the 
 intestines, the abdominal aorta, etc. The distin- 
 guishing symptom in the diagnosis of lumbago 
 is the exquisite tenderness to touch of the in- 
 volved muscles, especially of the musculus long- 
 issimus dorsi, or sacro-lumbalis and musculus 
 quadratus lumborum. In addition there are: 
 hyperalgesia of the skin to the electric current, 
 scoliosis in the lumbar segment (nearly always 
 on the sound side), the missing transformation 
 of the physiologic lumbar lordosis by erect pos- 
 ture into an arching kyphosis by a thoracic 
 forward movement, the limitation of the lateral 
 movement, the "ludicrous" sort of pain. 
 
 A traumatic affection of the lumbar muscular 
 system, the rupture of a muscular fasciculus or 
 fibre (traumatic lumbago) may easily be mis- 
 taken for the common form of lumbago. The 
 differential diagnosis should not offer any diffi- 
 culties in this connection. 
 
 If the pain has come on very suddenly after
 
 76 GENERALIZED PAIN 
 
 or during an overexertion, e.g., lifting a very 
 heavy burden, and if the patient has never been 
 subject to rheumatouratic troubles and there is 
 evidence of painful indurations, cords, callosities 
 in the affected muscles, we must look for a 
 muscular rupture. But do not forget that uratic 
 arthralgia or arthritis, or uratic myalgia or 
 myositis is often associated with a local trauma. 
 Whenever a headache comes on very suddenly 
 our attention should be directed to the possi- 
 bility of some acute, painful muscular affection, 
 especially in the lumbo-sacral sphere. Tetanus, 
 for instance, sets in with pains in the sacrum. 
 
 When these pains in the sacrum are very 
 persistent, especially in persons of unusual girth, 
 our thoughts should be turned to those morbid 
 processes in which an extravagant lordosis of the 
 lumbar vertebrae exists with subsequent unusual 
 weariness. This is frequently the case in the 
 later stages of pregnancy, and is also observed 
 in invalids who walk about with large ascites 
 (due to cirrhosis of the liver) or with a big 
 tumor in the abdominal cavity (ovarian cysts). 
 The pains disappear with the removal of the 
 cause. 
 
 Lumbar pains in people with a pendulous 
 abdomen are often enough associated with other 
 abdominal disorders, such as enteroptosis. We 
 find here anomalies of the intraabdominal circu- 
 lation, a dragging, pulling sensation in the
 
 SACRUM 77 
 
 mesenterium, sometimes only as a manifestation 
 in part of a generalized habitus asthenicus in 
 which the patient is apt for muscular reasons 
 impaired condition of the locomotorium to 
 complain of lumbar pain. A quick recognition 
 of the stigmata of the so-called constitutional 
 anomalies such as a chicken-breast, or a flat, 
 long thorax, a sharp epigastric angle and a 10th 
 costa fluctuans, should soon clear up the sit- 
 uation. 
 
 Any kind of static overstraining of the spinal 
 column due to anomalous conditions, e.g., flat- 
 foot, may give rise to pains in the sacral region 
 and in that way resemble lumbago. The same 
 may be said when lameness or the abbreviation 
 of one limb puts a special task upon the other 
 lower extremity; also in lumbar lordosis due to 
 the wearing of high heels on the shoes. 
 
 Pleuritis fibrosa after thoracotomy for em- 
 pyema must be mentioned here, also lumbo- 
 abdominal neuritis, especially when associated 
 with lumbar herpes zoster, likewise diaphrag- 
 matic pleuritis. 
 
 Next in order are the diseases of the vertebral 
 column. In acute attacks the first thought will 
 be of rheumatism in the vertebrae, often enough 
 the direct predecessor of articular rheumatism. 
 It may also happen that an acute attack of gout 
 primarily rests in the lumbo-sacral vertebrae and 
 thus leads to an erroneous diagnosis of lumbago
 
 78 GENERALIZED PAIN 
 
 or acute muscular rheumatism. A thorough 
 test of the purin metabolism is here the most 
 potent factor. In chronic uratic deathesis the 
 presence of pain in the sacrum seems to me 
 an expression of gouty affections in the lumbo- 
 sacral vertebrae. The trouble disappears under 
 antiuratic treatment. 
 
 Similar symptoms are observed in acute spinal 
 meningitis, in fact in all infectious diseases that 
 set in with headache Acute rheumatism is 
 frequently confounded with acute spinal menin- 
 gitis of tuberculous origin A proper differen- 
 tiation but not in cerebral rheumatism can 
 only result from a consideration of those accom- 
 panying symptoms which are foreign to acute 
 articular rheumatism, but pertain to meningitis. 
 Both have in common local pressure and throb- 
 bing sensations, immotility of the spinal column, 
 difficulty in sitting up or turning around, and 
 rise in temperature. But exclusively in menin- 
 gitis we find: violent initial headaches, hammer- 
 ing sensation in the cranium, turbulent conditions 
 in the sensorium, hyperesthesia of the skin or at 
 the trunks or extremities of the muscles, taches 
 spinales, Kernig's symptom, indrawn abdomen, 
 and stubborn obstipation. If only a few of 
 these meningitic manifestations are present, the 
 diagnosis for acute articular rheumatism falls. 
 That for meningitis will be corroborated by 
 lumbar puncture and the examination of the
 
 SACRUM 79 
 
 fluid obtained, which would also definitely elimi- 
 nate the question of cerebral rheumatism. 
 
 An epidemic cerebrospinal meningitis not 
 tuberculous might obscure the diagnosis, but 
 a careful scrutiny of the symptoms enumerated 
 above should easily dispel all doubts. . We must 
 not lose sight, however, of a possible early ap- 
 pearance of very acute herpes in the face, or 
 of an initial exanthema, but an examination 
 of the spinal fluid, also of the naso-pharyngeal 
 secretions, should bring the necessary light. I 
 wish to point out also that in epidemic cerebro- 
 spinal meningitis articular pains with or without 
 disfigurations in the articular outlines must claim 
 our attention. This is by no means strange, 
 because epidemic meningitis is a bacteriemic 
 disease in its nature. The fact that these articu- 
 lar pains set in only in the maturer and not in 
 the earlier stages of the disease should remove 
 what barriers there may be to an adequate diag- 
 nosis. 
 
 During the incipient stages of acute polio- 
 myelitis very intense lumbar and sacral pains 
 beset the victim and continue to hold sway dur- 
 ing a goodly portion of the course of the disease. 
 Hyperesthesia of the skin, differentiation of the 
 tendon reflexes (patellar reflexes are not pres- 
 ent), proclivity to perspire and leucopenia are 
 telling points in the diagnosis. 
 
 In all cases in which the patient complains of
 
 80 GENERALIZED PAIN 
 
 sudden attacks of severe headache it is our duty 
 to differentiate between the whole group of 
 infectious diseases that are accompanied by head- 
 ache throughout the whole course. Tetanus 
 belongs here when the port of entry of the 
 infection, i.e., the lesion lies in the sacral zone. 
 Variola, yellow fever, influenza, grippe, pseudo- 
 influenza, influenza nostras and exanthematous 
 fever are further members of this group. Yel- 
 low fever is specially discussed in the chapter 
 on "Muscular Pains." In exanthematous fever 
 the pains in the sacrum are sometimes so aggra- 
 vating that the patient can find no resting place 
 in the sickbed. We can always get a good 
 portrait of the disease from the contemplation 
 of the following signs: chills, rise of tempera- 
 ture in the continued fever, early acute splenic 
 tumor, the xanthic, dry coating of the fissured 
 tongue, roseola spreading rapidly over the whole 
 body, clouded sensorium, leucocytosis, Weil- 
 Felix reaction, progressive changes of the rose- 
 ola patches into petechiae, the decline of fever 
 between the tenth and fourteenth day of the ill- 
 ness, and the quick convalescence of the patient. 
 In g astro-intestinal malignant pustule epigas- 
 tric as well as lumbo-sacral pains are prevalent. 
 The remaining symptom complex resembles that 
 of a generalized septic disease with repeated 
 vomiting, diarrhea with traces of blood, meteor- 
 ism, early involvement of the circulatory appa-
 
 SACRUM 81 
 
 ratus and of the brain, and alarming dyspnea. 
 Bacteriologic examination of the stools, of the 
 blood and of the lumbar puncture fluid and con- 
 sideration of the occupational condition of the 
 patient should warrant a correct diagnosis. 
 
 Variola (smallpox) is always ushered in by 
 pains in the sacrum. An early recognition of 
 the other symptoms will promptly establish the 
 diagnosis. I enumerate here the following: 
 initial vomiting, headache, epigastric pains, 
 brisk rise in the temperature, symmetric initial 
 exanthema marked with small hemorrhagic 
 lines, somewhat resembling purpura, generally 
 in the ilio-femoral triangle or in the back, in the 
 armpit or on the palate. All these manifesta- 
 tions are of differential diagnostic import, also 
 in varioloid, except that the incipient stages, the 
 whole course of the disease, also the changes in 
 the temperature are of a milder character, unless 
 the typical exanthema has already set in. Se- 
 vere headaches are of rare occurrence in varicella 
 (chickenpox) a circumstance which distinguishes 
 it sharply from variola and varioloid. 
 
 Severe pains in the sacrum are more fre- 
 quently found in the plague than in spotted 
 typhus. 
 
 The diagnosis of influenza is firmly based on 
 the evidence of articular pains, catarrhal condi- 
 tions of the mucous membrane of the respiratory 
 tract, gastrointestinal symptoms, tenderness on
 
 82 GENERALIZED PAIN 
 
 pressure in the nasal cavities resp. the processes 
 of both the first trigeminus branches, also of the 
 occipital nerves, the bacteriologic findings of the 
 sputum and nasal secretions. 
 
 Of very pronounced intensity are the pains 
 in the sacrum and along the two ischial nerves 
 in contagious or infectious erythema. The spot 
 in the face where the affection appears feels 
 burningly hot to the touch. 
 
 An erroneous diagnosis of influenza may slip 
 in in cases of trichinosis. The patient complains 
 of lassitude, gastrointestinal disturbances and 
 poignant pains in the sacrum. Eosinophilia of 
 the blood, the evidence of trichinae in the muscles 
 and in the blood, muscular pains and edema save 
 the diagnosis. 
 
 In some infectious diseases pains in the sacrum 
 do not assume such a prominent position. I 
 include abdominal typhoid and the illnesses due 
 to inoculation with anti-typhoid serum beginning 
 with chills, giddiness, pains between the shoulder 
 blades, behind the ribs, especially on the left 
 side and also articular pains; paratyphoid, sep- 
 tic and acute leucemia, malaria, recurrent fever, 
 Weil's disease, Malta fever and dengue. In 
 the latter there is slight stiffness in the whole 
 spinal column. This might possibly be due to 
 impaired motility of the vertebrae. In Malta 
 fever we might look for a sympathetic affection 
 of the sacro-iliac vertebrae, and in Weil's disease
 
 SACRUM 83 
 
 for muscular affection. The rest of the acute 
 infections enumerated above are mostly based 
 upon toxic infectious hyperemia of the meninges 
 of the spinal cord. 
 
 Of different meaning are pains in the sacrum, 
 with preference on the right side (rather in the 
 lumbar region) in acute cystopyelitis, especially 
 during pregnancy and the lying-in state, but 
 also at other times in the female sex. An acute 
 feverish illness coupled with sacral pains should 
 always prompt us to look for a renal succussion. 
 Bacteriologic, microscopic, cultural and cytologic 
 examination of the urine, also when necessary 
 a cytoscopic examination, are in demand, as 
 otherwise the existence of an acute pyelitis might 
 be overlooked. Of course, sacral pains may 
 also arise from other affections of the kidneys, 
 such as renal tuberculosis. For fuller particu- 
 lars consult my book on "Abdominal Pain." 
 
 Gonorrhea likewise belongs in this category, 
 but only insofar as this disease does establish 
 itself at times in lumbo-sacral vertebrae. In 
 any case of recent gonorrhea the diagnosis should 
 offer no difficulties. But in cases of long stand- 
 ing where the affection of spinal vertebrae has 
 only crept in by a slow process, the diagnosis 
 
 I ay meet with obstacles. The fact is that such 
 gonorrhoic arthritis may within a given time, 
 perhaps, during a period of several years, settle 
 in the zone of the lumbo-sacral vertebrae, espe-
 
 84 GENERALIZED PAIN 
 
 cially when the latter have been exposed to 
 repeated traumatic influences. In the confusion 
 a diagnosis of traumatic neurosis, vertebral tu- 
 berculosis or chronic syphilitic meningitis may 
 erroneously result. Ankylosis of the affected 
 vertebrae in youthful individuals should always 
 be taken as a very suspicious symptom. Diffuse 
 rigidity in the upper portion of the spinal col- 
 umn is another interesting signal. 
 
 Syphilis may also lead to an analogous verte- 
 bral rigidity. But in this case the entire spinal 
 column is involved. The classic therapeutic 
 measures will promptly correct the malady. 
 
 Rhizomyetic spondylosis or rhizomyeUa or 
 chronic ankylosing spondylitis and arthritis de- 
 formam are concatinated with this series of 
 affections; arthritis deformans especially when 
 coxitis coexists. In both diseases the patient 
 complains sometimes that the pains appear after 
 he has been standing upright or stooping down 
 for a while. A change in the weather may bring 
 them about. In others they appear in the morn- 
 ing, decline during the day time and during 
 rest vanish altogether. There are manifestations 
 of neuritis in the roots (irradiating pains, hyper- 
 aesthesia, hyperalgesia, muscular irritation and 
 paralytic manifestations). In some cases rigid- 
 ity in the spinal column, difficulty in walking or 
 when resuming an erect position are the pre- 
 dominent complaints. The clinical picture does
 
 SACRUM 85 
 
 not often aid us in differentiating between the 
 two diseases, especially so in the earlier stages, 
 although arthritis deformans occurs nearly always 
 only in the later years of man's life. The radio- 
 ologist can usually solve the question. 
 
 There is a form of rigidity of the column of 
 myogenous origin in which there is no trace of 
 changes in the vertebrae, but pregnant sensi- 
 bility to pressure and very marked stiffness and 
 atrophy of the muscular plexus. The two last 
 named signs, however, may also be observed in 
 arthrogenous columnar rigidity. I am inclined 
 to believe that there is another form of rigidity 
 besides those mentioned here, viz., the arthro- 
 genous form in which no evidence of articular 
 changes appears on the X-ray plate. 
 
 Pain in the sacrum is a guest also in diseased 
 inflammatory conditions of the sacroiliac articu- 
 lation (synchondrosis) . The distinguishing 
 marks are: the patient seeks relief by inclining 
 the body to one side, there is pressure pain along 
 the line of communication between the sacrum 
 and ilium, the painfulness is sharpened under 
 bilateral compression of the pelvis, or an edema 
 in the sacro-iliac zone. 
 
 The pains arise from various causes. In 
 pregnancy, in parturition they are due to serious 
 infiltration of the joint ligaments or to merely 
 mechanical influences. Even a quite normal 
 menstruation, especially in mothers, may bring
 
 86 GENERALIZED PAIN 
 
 about sacral pains during the period through an 
 unusual relaxation of the sacro-iliac joints. 
 Furthermore, there is a possibility of painful 
 spells in this same joint in acute and chronic 
 articular rheumatism, more rarely in gonococcal 
 rheumatoids, but also in infectious septic rheuma- 
 toids. But all this happens chiefly when other 
 joints have been previously or are simultaneously 
 affected. Then and there it is the primary or 
 else the solitary seat of the articular affection 
 which may, however, also originate from osteo- 
 myelitis not necessarily tuberculous. I firmly 
 believe that gout itself may settle in the sacro- 
 iliac joints. In Malta fever the pain-stricken 
 sacrum is the result of an accompanying affec- 
 tion of the sacroiliac joints. In various static 
 conditions (flatfoot, pendulous abdomen) the 
 sacroiliac joints are the mischievous element in- 
 sofar as sacral pains are concerned. 
 
 Diseases of the bony substance of the verte- 
 brae and of the adjoining ribs will provoke 
 sacral pain. Besides fractures of the lumbo- 
 sacral vertebrae (breaking of the 5th lumbar 
 vertebra in lifting too heavy a burden, often the 
 cause of pain for a period of years) proved by 
 the X-ray, caries, syphilis, actinomycosis, infec- 
 tious (paratyphoid) spondilitis and neoplasms 
 belong in this place. Their diagnosis will receive 
 proper attention in the chapter on "Backache." 
 
 One item of interest, however, I must mention
 
 SACRUM 87 
 
 here, viz., that pressure and pulsation sensitive- 
 ness in the spinous processes of the sacral, or 
 else of the lowest lumbar vertebrae with pains 
 in the sacrum, also without any kind of disease 
 in the vertebrae themselves, are warning signals 
 of gastro-intestinal trouble (rectum, bladder, 
 internal portion of the genital organs). And 
 still another point may be added: pain in the 
 sacrum is often the register of a carcinoma meta- 
 stasis in the lumbo-sacral vertebrae. The pri- 
 mary neoplasm has not been manifest until the 
 sacral pain gives the signal for a hunt of its 
 favorite habitat either in the prostate, the tes- 
 ticles, the ovaries, the mamma, the thyroid, the 
 adrenals, or in the penis or the gastro-intestinal 
 canal. 
 
 Diffuse diseases of the skeletal frame fre- 
 quently start with pains in the sacrum, especially 
 osteomalacia. The fact that these pains arise 
 in the early stage of the puerperium, if they 
 have not already done so during the latter period 
 of pregnancy and that they are aggravated by 
 walking, points to the diagnosis of osteomalacia, 
 especially when we find the additional symptoms 
 of pressure sensitiveness in the sacrum or the 
 os pubis or the ilium the latter is easily evinced 
 by a quick lateral compression the rostrate ex- 
 tension of the symphysis, the cordiform pelvis, 
 waddling gait, spastic adduction, osteoscopic 
 pains (ribs, sternum), reduced stature.
 
 88 GENERALIZED PAIN 
 
 The late war has given us copious proof of 
 the existence of starvation malacia of the spinal 
 column. There is weakness in the legs, tremor, 
 incapacity for work coupled with pains, local 
 painfulness, axillary compression, impaired mo- 
 tility and a characteristic X-ray picture. 
 
 In congenital malformations of the pelvic 
 bones pains in the sacrum are of frequent occur- 
 rence. In such cases radiology is the imperative 
 adjuvant of the diagnosis. It will definitely 
 reveal any abnormal conditions that may exist 
 in the bony lumbo-sacral column such as spina 
 bifida occulta, hyperplastic changes in the trans- 
 verse processes of the fifth lumbar vertebra 
 with secondary bursitis and contraction of the 
 last lumbar vertebra with the sacrum. 
 
 It goes without saying that diseases of the 
 sacrum itself such as caries or osteomyelitis carry 
 local pains with them, especially in the softer 
 teguments, e.g., bedsores over the os sacrum. 
 
 The same is the case in affections of the spinal 
 cord and its membranes. In acute tuberculous 
 or epidemic meningitis, as has already been 
 pointed out, pain in the sacrum is the foremost 
 symptom. 
 
 In acute poliomyelitis there are not only pains 
 in the sacrum but also along the whole of the 
 spinal column. The differential diagnosis needs 
 to fall back in such cases upon the other symp- 
 tomatic manifestations of meningitis. Chronic
 
 SACRUM 89 
 
 spinal lumbar meningitis must not be forgotten 
 here. It is not unlikely that the lancinating 
 pains in the sacrum which so frequently appear 
 in tabes are really due to such a chronic menin- 
 geal affection. Internal spinal pachymeningitis 
 whether it is hemorrhagic in its nature or not, 
 and also the syphilitic form belong to this order. 
 The exceptionally intensive and often long con- 
 tinued pains in the sacrum so characteristic of 
 membranous tumors of the spinal cord should 
 always remind us of a possible morbid growth 
 or some other painful affection of the cauda 
 equina specially marked by unilateral pains, 
 paresthesias, pain in the region of the ischiadic 
 nerve and absence of achilles tendon reflexes, 
 while in tumors of the conus terminalis distur- 
 bances of sensibility in the ano-vesical and sexual 
 zones are more prominent. 
 
 In tumors of the cord itself pains in general, 
 particularly such in the sacrum are rare. They 
 may be distinguished from extramedullary pains 
 by the observation that in extramedullary tu- 
 mors pain is the primary symptom and con- 
 tinues to hold a predominating position for a 
 long time. The sacral pains in intramedullary 
 tumors are due to secondary compression of the 
 neighboring nerve roots. In true myelitis they 
 are of a less vicious character, but if they in- 
 crease in acuteness we are warned of a parallel 
 meningeal affection, i.e., meningomyelitis.
 
 90 GENERALIZED PAIN 
 
 Syringomyelia as well as multiple sclerosis, 
 tabes and paralysis, the paraplegic (pseudo- 
 myelitic) form of hydrophobia carry sacral pains 
 as companions with them, although they do not 
 appear so vividly in the clinical picture. 
 
 The sudden onset of sacro-lumbar pains after 
 a trauma arouses at once the suspicion of an 
 injury to the spinal column, not to speak of a 
 muscular breach. Meningeal apoplexy, even 
 without a preceding trauma, is not excluded. 
 The patient usually cries out aloud with pain 
 and collapses as both the lower extremities are 
 paralyzed. Hemorrhages in the substance of 
 the spinal cord, acute hematomyeUa may like- 
 wise be the activating cause of local lumbar 
 sacral pains, plainly due to compression of the 
 adjoining nerve roots. 
 
 Functional nervous diseases are fertile ground 
 for complaints of pains in the sacrum. Spinal 
 irritation, neurasthenic muscular pains in the 
 back arouse the fear of some kidney trouble or 
 affection of the spinal cord and promptly lead 
 the way to the consulting room. The patient 
 will tell you that he feels as if the small of the 
 back were broken in two, of physical and mental 
 fatigue, any kind of excitement provokes or 
 aggravates the sacral pains, while on the con- 
 trary and this is an important symptom 
 moderate exercise alleviates or banishes the pain 
 altogether. Add to this the proof that the pain
 
 SACEUM 91 
 
 is located in the lower lumbar zone or to one 
 side of it, that it radiates towards or along the 
 vertebral column, the constant change in its 
 intensity, the total absence of other usual objec- 
 tive symptoms excepting the neurasthenic signs 
 and the diagnosis should easily crystallize. 
 
 The proper understanding of such a condition 
 should largely influence our judgment that we 
 are dealing not with an organic, but with a 
 functional disorder, e.g., of the stomach or of the 
 heart. Nevertheless caution is necessary. In 
 sexual neurasthenia, for instance, the chief com- 
 plaint is that of pains in the sacrum, especially 
 after sexual exercise, or after masturbation or 
 pollution. Other complaints are strangury, 
 mostly in the day time, less so at night (in some 
 cases, especially of long standing, there is also 
 nocturnal pollakisuria), subjective hyperesthesia, 
 paresthesia of the external genitals, genital hy- 
 perhydrosis, permanent feeling of cold feet due 
 to spermatorrhea and nervous impotence (in 
 persons of advanced age suspicion of incipient 
 malignant neoplasms!), urethral or prostatic 
 neuralgia, orchiodynia and similar manifesta- 
 tions. Inadequate sexual satisfaction, excess in 
 venere, long continued coitus interruptus are also 
 frequently the parents of pain in the sacrum. 
 
 In hysteria these pains are not so common. 
 The diagnosis here must be based upon the 
 usual pertinent stigmata, the presence of local
 
 92 GENERALIZED PAIN 
 
 hyperesthesia of the skin, the fact that a deep 
 pressure often causes less pain, than a soft, 
 superficial touch, and the finding of a similar 
 painful zone at a higher section of the vertebral 
 column, commonly situated between the shoulder 
 blades. 
 
 Some psychiatrists have reported cases I 
 have no experience in this matter in which 
 backaches and pains in the sacrum have been 
 of so violent a character, that the afflicted per- 
 sons were unable to perform their vocational 
 duties, sometimes for a year or more during the 
 period of adolescence. This affliction has been 
 yclept "dementia precox." 
 
 Another source of hieralgia is every form of 
 retroperitoneal disease. The various renal and 
 adrenal affections including bacteriuria and al- 
 captonuria and all pancreatic diseases are com- 
 prised in this classification because all of them 
 father pains in the sacrum and in the lumbar 
 region. Splenic tumors likewise belong here. 
 Not only the primary but also the secondary 
 pains must be taken into consideration, for the 
 latter, radiating even into the shoulders, are 
 frequently symptoms of an ulcer in the posterior 
 wall of the stomach or in the duodenum with 
 proliferations into the pancreas, or of an ulcer 
 in the pancreas associated with a gastric car- 
 cinoma, or perigastritis which may lead to an 
 arrosion of the pancreas.
 
 SACRUM 93 
 
 So far as kidney affections are concerned it 
 may be said that pains in the sacrum appearing 
 on one, chiefly the right side only, are often the 
 sole complaint in acute or subacute strangury 
 in pregnant or parturient women. Fever and 
 renal succussion are not present because there 
 is no infection of the urinary apparatus. Never- 
 theless it is a hint that these pains, although 
 primarily due to the gravid state, may also arise 
 from a concomitant hydroureter. The fact that 
 in these cases the ureter is sensitive on pressure 
 in the iliac region, should easily prevent the error 
 of a mistaken appendicitis. This is also true in 
 some cases of chronic strangury in the male, for 
 instance in hypertrophy of the prostate. 
 
 In affections of the kidneys (also of the pan- 
 creas) the site of the pain is not always in the 
 upper lumbar region where it anatomically 
 belongs but apparently it is in the lower lum- 
 bosacral zone. In benign as well as in malig- 
 nant renal tumors this happens frequently. 
 
 Backaches in diseases of the gallbladder, in 
 cholelithiasis, cholecystitis, pylorostenosis and 
 duodenal ulcer deserve mention here. When 
 sacrolumbar pains are present in stenosis of the 
 pylorus they are due to a distension of the 
 stomach, unless they are caused by a pyloro 
 or gastrospasm. In this connection we shall 
 always find a high grade tension or flatulent sen-
 
 94 GENERALIZED PAIN 
 
 sation in the epigastrium which disappears with 
 spontaneous or voluntary ructus or vomiting. 
 
 Duodenal ulcer, both benign and malignant, 
 is not always of necessity associated with sacro- 
 lumbar pain. It passes away often enough 
 without them with the manifestations of a 
 chronic obstructive icterus insofar as a carci- 
 noma of the diverticulum Vateri is concerned. 
 But if in the course of the disease intensive 
 pains in the sacrolumbar region suddenly set in 
 the diagnosis of accessory retroperitoneal com- 
 plications may not be amiss. 
 
 This thought is quite opportune when such 
 pains turn up in infectious diseases of the small 
 pelvis which do not by nature carry sacrolumbar 
 pains with them, such as ascending phlegmons 
 of the retroperitoneal cellular tissues, lymphan- 
 gitis, retroperitoneal lymphangitis, arising from 
 primary lesions of the internal female genitalia, 
 or of the rectum (fissure), the internal male 
 generative organs, the external genitals, the 
 lower extremities, and also appendicitis, etc. 
 When tenderness to deep upward pressure along 
 the spinal column or arcual kyphosis of the 
 lumbar vertebrae are also in evidence, the diag- 
 nosis is made easy. 
 
 Neoplasmatic affections arising from a new 
 growth in the small pelvis, e.g., a uterine carci- 
 noma may be the causating element of these 
 pains. In this case, of course, not only the
 
 SACEUM 95 
 
 lymphatics but also the lymph glands them- 
 selves are involved. 
 
 Every disease of the retroperitoneal lymph 
 glands may provoke pains in the sacral and 
 median region (see my book on "Abdominal 
 Pain") for the obvious reason that an enlarged 
 gland naturally crowds the nerve roots of the 
 hypogastric and lumbar plexus. The glandular 
 swellings may be the outcome of tubercular or 
 lympho-granulomatous, of leucemic or aleucemic 
 or in rare instances of syphilitic origin. Their 
 presence is betrayed by these very pains in the 
 sacrum as well as by the entire clinical aspect 
 of the disease. Palpation is only possible when 
 a number of the affected glands are bunched 
 together into a lumpy mass (tuberculosis, leu- 
 cemia). We may be also dealing with a meta- 
 static neoplasm (sarcoma, carcinoma or a lym- 
 phosarcoma). In the latter case the diagnosis 
 will be surrounded by difficulties unless palpa- 
 tion is rendered possible for the reason afore- 
 said, or a splenic tumor or a lymphosarcomatous 
 disease of some other internal organ is a con- 
 comitant issue (tonsils, stomach, gastrointestinal 
 tract). The initial sacral pains are here a lead- 
 ing symptom, the same as in lymphogranuloma 
 of the retroperitoneal glands. In aleucemia and 
 in leucemia these pains rarely manifest them- 
 selves in the beginning of the disease, which is 
 also the case in chronic lymphatic leucemia.
 
 96 GENERALIZED PAIN 
 
 The observation of sacro- or median-lumbar 
 pains will prove a powerful adjuvant in the 
 diagnosis of metastatic growths in the retro- 
 peritoneal (para vertebral) cellular tissue follow- 
 ing a primary carcinoma of the stomach, the 
 intestine, the uterus, the esophagus or the mam- 
 ma. If these pains arrive now in successive 
 attacks and then again are of a protracted 
 character (not at all uncommon in carcinoma of 
 the stomach) there can be no doubt about the 
 diagnosis. It is further confirmed by a strong 
 pulsation both visible and palpable of the ab- 
 dominal aorta, and no less by a loud stenotic 
 bruit over it, even noticeable to the touch. 
 
 The situation is different when the gastric 
 carcinoma has a rearward tendency which by its 
 very nature is productive of sacral pains, or if 
 a companion sickness (metastasis) of the spinal 
 column or an extension of the carcinoma itself 
 into the pancreas put in an appearance. In such 
 a combination, especially in cases of direct arro- 
 sion of the pancreas through a gastric carcinoma 
 likewise through an ulcus ventriculi on the 
 posterior wall of the stomach the most intense 
 continuous pains are unleashed in the sacrolum- 
 bar circumference. (See "Abdominal Pain.") 
 
 As soon as the causative gastric disease is 
 recognized we shall promptly find the way to 
 the companion affection. But whether the lat- 
 ter is centered in the lymph glands or in the
 
 SACRUM 97 
 
 pancreas itself can only be established by the 
 finding of the other typical signs of the pan- 
 creatic function, eventually by the aid of the 
 X-ray. 
 
 Sacral pains in gastric carcinoma may also be 
 occasioned by overloading of the stomach, thus 
 causing hypertension. They may also be a 
 diagnostic roadsign when we waver between 
 carcinoma of the pancreas and that of the stom- 
 ach, pointing, perhaps, with preference to the 
 retroperitoneal space, i.e., the pancreas. 
 
 In enlargements of the retroperitoneal glands, 
 also in inflammations thereof, the pains have the 
 same localization, but are of lesser intensity, 
 especially when retroperitoneal phlegmons are a 
 possible additional factor, likewise morbid con- 
 ditions in the small pelvis or infections of the 
 lower extremities. 
 
 The same kind of pains are encountered when 
 there is an unusual strain on the mesenterium 
 of the peritoneum at the point of union with 
 the lumbar vertebrae, e.g., in mesenteric tumors. 
 Likewise, when a tumor embedded in the mesen- 
 terium (metastatic glandular tumor) causes hy- 
 pertension, or when a chronic, inflammatory 
 (tuberculous) disease contracts the mesenterium. 
 Such conditions cannot easily escape a watchful 
 eye. 
 
 All morbid processes which effect an acute 
 stretching of the mesenterium are associated with
 
 98 GENERALIZED PAIN 
 
 median-lumbar pains extending sometimes even 
 upwards into the dorsal vertebras. In cases 
 where we find such sacro-lumbo-dorsal pains 
 associated with obstructive strangulation our first 
 thought must be directed to the presence of an 
 intestinal axial torsion, especially of the small 
 intestine or the colon. Aneurysm of the abdom- 
 inal aorta claims attention here, as well as of the 
 aorta proper, and the entire venous system. 
 Phlebitis, or thrombophlebitis of the iliac vein 
 due to inflammation, suppuration or new 
 growths in the small pelvis or in the lower 
 extremities, may be the originators of sacral 
 pains in one or the other or in both sides. Con- 
 sidering this possibility and finding signs of 
 obstruction in the veins and their radicular 
 sphere, a detailed diagnosis should not be diffi- 
 cult. It is different, however, in cases of cellu- 
 litis or retroperitoneal lymphadenitis in which 
 the symptoms of congestion do not prevail. 
 
 Chronic ectasy of the pelvic veins in women 
 is another source of these pains, especially when 
 they come to the surface with the patient lying 
 down. The same relates to thrombosis, or throm- 
 bophlebitis of the pelvic vessels, which are fre- 
 quently the result of inflammatory or neoplastic 
 affections of the pelvic organs, mainly of the 
 male or female inner genitalia. Here hieral- 
 gia is often connected with local pains in the 
 rectum, in the perineum and in the buttocks,
 
 SACRUM 99 
 
 also in the groins. They are aggravated by 
 coughing or sneezing, in fact by every intra- 
 abdominal pressure. 
 
 In neuralgia of the celiac plexus they are a 
 partial factor only. 
 
 We may add chronic lead poisoning, in which 
 pains in the circumference of the navel radiating 
 into the sacrum and into the thighs are notorious. 
 
 Affection of distant organs may likewise be 
 provocative of pains in the sacrum. In women 
 they suggest morbid changes in the internal 
 sexual organism. 
 
 During the menstrual period complains of 
 sacral pain are ripe, especially in pregnant 
 women, primarily due to the menstrual moli- 
 mena. In joint hysteria the pains are often of 
 a most distressing, excruciating character, espe- 
 cially when there is a slight uterine retroflexion 
 or a congenital narrowing of the os or cervix 
 uteri. If the retroflexion is very pronounced 
 the pains are continuous. 
 
 Sacralgia often plays a part in the climacteric 
 process, and is caused by the contraction of the 
 pelvic connective tissue. We meet here vaso- 
 motoric disturbances, heat flushes, congestion in 
 the head, spontaneous perspiration, paresthesia 
 in the arms and legs, bluish tint and coldness 
 of the fingers, palpitation, cardiac pains, adipos- 
 ity, meteorism, Heberden's nodules, and pains 
 in the nerves and bones.
 
 100 GENERALIZED PAIN 
 
 There is a goodly number of diseases of the 
 female genital organs which travel together with 
 sacral pains. If of a very distressing character 
 they speak for some endometric affection, spe- 
 cifically uterine colics. Labor pains affect the 
 sacrum in like manner, and so does the accumu- 
 lation of blood-clots in uterine hemorrhages. We 
 find these pains also in affections of the walls of 
 the uterus and of the adnexa, in parametritis 
 and perimetritis of acute or chronic duration, in 
 descent or prolapse of the womb, in new growths 
 of the uterus and of the ovaries and in retro- 
 uterine hematocele. 
 
 It is evident that the presence of sacral pains 
 in one and the same gynecological disease may 
 be due to quite a number of different causes, 
 for instance in carcinoma of the uterus. There 
 might be a carcinomatous infiltration of the 
 pelvic connective tissue reaching up even into 
 the retroperitoneal cellular tissue, or there might 
 be a metastasis of the retroperitoneal glands or 
 in the field of the sacral vertebras, or else hemor- 
 rhages in the uterine cavity, all quite indepen- 
 dent of the primary uterine ailment. 
 
 I should like to give mention in this place 
 to a particular kind of sacralgia which occurs 
 in women who wear lingerie which is open in 
 the groins, and in consequence take cold locally 
 in semblance of a rheumatic affection. The 
 symptoms are easily recognized, viz., the pains
 
 SACRUM 101 
 
 are strongly influenced by chilly, damp weather, 
 brisk physical exercise, by running, jumping or 
 stooping, and there is delicacy to touch and 
 pressure in the dorsal muscles and the spinal 
 joints. 
 
 Coitus interruptus is another cause of sacral- 
 gia in the female. We hear complaints of a 
 dragging downward sensation, strangury and 
 general nervousness, no doubt due to a deficient 
 detumescence of a congested uterus during the 
 sexual act. 
 
 In prostatitis, carcinoma of the prostate and 
 tuberculosis and other affections of the male 
 genital organs, sacralgia is of rare occurrence. 
 I refer to this on purpose in order to forestall 
 a mistaken diagnosis of kidney trouble. 
 
 The rectum is very extensively responsible 
 for sacral pains. Hemorrhoids are the princi- 
 pal offenders. Copious bleeding from piles 
 often removes the pains from the sacrum, at any 
 rate for a time. Nevertheless, a thorough ex- 
 amination of the rectum for a possible fissure 
 or carcinoma should be made in every case. 
 
 Polypus may also give rise to rectal hemor- 
 rhages and pains in the sacrum. Rectoscopy 
 is here in order. 
 
 Affections of the colon, especially a deep- 
 seated carcinoma, have similar effects on the 
 sacral zone. Complaints about aches in this re- 
 gion often reach us when there is difficulty in
 
 102 GENERALIZED PAIN 
 
 getting rid of intestinal gases, in cases of 
 chronic constipation, or obstruction in the rectal 
 passage, also disturbances in the intestinal cir- 
 culation or chronic intestinal catarrh. 
 
 When a carcinoma of the rectum has been 
 positively diagnosed, our next thought must be 
 directed to every possible form of deep-seated 
 intestinal stenosis. Distension and wind in that 
 part of the colon which lies beyond the stenosis 
 generate pains in the sacrum, which eventually 
 are modified or cleared away, for a period at 
 any rate, by a copious alvine evacuation, or even 
 a satisfactory flatus. 
 
 Pellagra is another fertile cause of sacral 
 pains and backache. Its diagnosis is easy, for 
 the following reasons: its prevalence is limited 
 apparently to those countries in which maize is 
 a staple article of food. It occurs in the spring 
 or the autumn, it shows atypical erythema, there 
 are characteristic manifestations in the oral and 
 genital mucous membrane, there are digestive 
 as well as psychic disturbances, and pronounced 
 emaciation.
 
 Pain in the Buttocks 
 
 If a patient complains of pains in the coccy- 
 geal region, we generally have before us a trau- 
 matic surgical disease (a birth or a fall). It 
 may be a periostitis, a subluxation, or a luxation 
 of the coccyx against the sacrum, or a fracture, 
 or tuberculous caries or osteomalacia. If exam- 
 ination per rectum and the X-rays prove the 
 absence of all these affections, and if we are 
 satisfied that no rectal disorders (fissure, fistula, 
 neoplasm) or genital or pelvic defects that might 
 be mistaken for coccygodynia, are present, we 
 are still confronted by disturbances which may 
 be causative factors of pains in the nates. 
 
 There is the possibility of neuralgia of the 
 coccygeal plexus, frequently a sequel of mastur- 
 bation, sometimes the expression of a sexual 
 neurasthenia, or in rare cases the manifesta- 
 tion of gouty diathesis. I have seen two cases 
 of coccygodynia in men it occurs in women 
 with greater frequency which were indubitably 
 accompanied by chronic gouty diathesis. Both 
 diseases yielded promptly to therapeutic meas- 
 ures. Coccygodynia in the climacteric period 
 may, perhaps, be explained in this manner. 
 On the other hand, we come across cases in 
 
 103
 
 104 GENERALIZED PAIN 
 
 women in which this disease of the coccyx is 
 only a partial manifestation of a generalized 
 hysteria. 
 
 Besides tenderness to pressure of an other- 
 wise quite normal coccyx and localized cutaneous 
 hyperesthesia, we are bound to discover other 
 signs of hysteria, and as the causative element 
 an acute psychic trauma with the elimination of 
 which both coccygodynia and hysteria vanish. Of 
 course, we find in non-complicated hysteria also 
 pain and delicacy to touch, also cutaneous hy- 
 peralgesia in the coccygeal region as well as in 
 the sacrum, with deep pains in the pelvis radi- 
 ating into the corresponding vertebral sur- 
 roundings. 
 
 In females, coccygodynia is frequently more 
 a part of neurasthenia, or a spinal irritation. 
 Here, too, we find the paradoxical condition 
 that the soft touch awakens the pain, whilst a 
 slowly ascending, long-continued pressure gives 
 relief. Hot sponging or a weak electric current 
 may prove very painful. Local and generalized 
 vasomotoric manifestations are not uncommon 
 companions of pains in the breech. High feed- 
 ing and psychic influences are apt to remove 
 the complaint for good. 
 
 Finally, coccygodynia may be a partial symp- 
 tom of tabes dorsalis or the direct result of 
 flat foot.
 
 Pain in the Shoulder 
 
 The term employed here bears a double mean- 
 ing, viz., pain in the shoulder proper and pain 
 between the shoulder blades, i.e., between the 
 scapula and the spinal column or in the spinal 
 column itself or in the acromion. Pains in the 
 supraclavicular and supraspinous fossa natu- 
 rally are included. 
 
 Pains in the scapular region conjure up 
 thoughts of all kinds of affections of the shoul- 
 der joint. (Many particulars regarding this 
 matter will be found in the chapter, "Pains in 
 the Joints.") In many morbid articular con- 
 ditions the shoulder joint is, as a rule, the only 
 member to be considered, if not throughout, 
 at any rate for a notable period of the malady's 
 course. Traumatic and neurotic affections, pye- 
 mic metastasis localized exclusively in the shoul- 
 der joint, gonorrhea and syphilis, all are possi- 
 bilities. But in the front rank I mention the 
 various forms of arthritis, from acute to chronic 
 deforming omarthritis, and gout in the sense of 
 omagra. 
 
 The diagnosis is built up from the following 
 symptoms: seat of the pain, restricted motility 
 of the joint, especially in an upward and back- 
 
 105
 
 106 GENERALIZED PAIN 
 
 ward direction, the contrast between the rela- 
 tively free active motility and the pain caused 
 by a jerky movement of the joint by the phy- 
 sician, sensitiveness on pressure or percussion, 
 especially at the articular extremity; changes in 
 the articular outlines, the assistance of the 
 Roentgen ray. For a more detailed diagnosis, 
 I refer the reader again to the chapter on 
 "Articular Pains." 
 
 The shoulder joint may also be the seat of 
 arthropathy, especially in syringomyelia. Very 
 severe pain may be a reflex of a spinal affection, 
 e.g., multiple sclerosis. 
 
 When a patient speaks of pains in the shoul- 
 der or in the region of the shoulder joint, it is 
 not unwise to think of a different derivation. 
 In acute febrile conditions the nearest point must 
 needs be an acute osteomyelitis in the upper 
 arm. 
 
 A chronic inflammation (tuberculosis) or a 
 neoplasm in the osseous substance, the humerus, 
 will always prove to be painful conditions, and 
 really belong in the operating room. The in- 
 ternist is more interested in secondary metastatic 
 new growths of the scapular bones. Many's 
 the time that a patient complains about "rheu- 
 matic" pains in the shoulder, bothersome today, 
 missing tomorrow, coming on again the next 
 day, and is treated by his doctor for rheumatism, 
 when a closer examination reveals a primary
 
 SHOULDER 107 
 
 malignant neoplasm (prostate, ovary, testicle, 
 mamma, thyreoid, hypernephroma), and the 
 local conditions (pressure and throbbing pains, 
 X-rays), also blood test, leave no doubt of the 
 existence of a metastasis of the bones. (See 
 chapter on "Pains in the Bones.") 
 
 An acute painful affection of the muscular 
 plexus of the shoulder joint, of the deltoid, or 
 of the scapular, cucullar, pectoral muscles, an 
 acute scapular myalgia or omalgia may very 
 well give ground to complaints of shoulder 
 pains, in which condition the sick seek relief by 
 keeping this articulation as quiet as possible. 
 These pains are in reality caused, as a rule, by 
 overburdening or overtaxing the muscles, e,g., 
 in amateur sportsmen, carrying a heavy valise 
 or wearing a heavy overcoat, etc. The fact that 
 in these cases not to speak of a Roentgen 
 photograph of the affected joint the muscles 
 are very tender on pressure, should make the 
 diagnosis easy. When the pains, however, ra- 
 diate into the forearm, waist or even the fingers, 
 a neuritic condition might be a good guess. 
 But the lack of the other classic neuritic mani- 
 festations (sensibility disturbances, tenderness on 
 pressure in the nerves, nodules, vasomotoric and 
 trophic derangements) should be a decisive 
 factor. 
 
 In a similar fashion, bracJual neuritis is in 
 error often taken for omarthritis. This is quite
 
 108 GENERALIZED PAIN 
 
 excusable because a primary, inflammatory 
 articular affection is frequently accompanied by 
 secondary neuritic conditions of the nerves which 
 encompass or pass over the articulation. In 
 this case the pains radiate along the correspond- 
 ing nerve trunks and give rise to paresthesias 
 in the affected zone. On the other hand, there 
 may be an atrophy of the appertaining muscles, 
 but without sensibility disturbance and without 
 denegeration of the electric reaction, the latter 
 being only minimized. Some authors attribute 
 this muscular atrophy to a functional lesion of 
 the ganglion of the anterior columna. 
 
 The presence of actual neuritic changes may 
 seriously handicap a concrete diagnosis, because 
 the patient experiences, when moving the upper 
 arm, identically the same intense pains as if 
 the joint itself were affected. The differential 
 diagnosis between neuritis on the one hand and 
 omarthritis on the other may in consequence be 
 gravely influenced. In favor of neuritis speak 
 the following facts: the joint itself is not the 
 most sensitive part, pressure upon it from any 
 direction does not materially exacerbate the 
 pain, which is rather localized in the nerve 
 trunks and in the muscles of the upper arm, 
 the presence of paresthesias, sensibility distur- 
 bances and muscular, truly neuritic, atrophies. 
 But even this consideration will leave us in 
 perplexity if both anarthritis and neuritis run
 
 SHOULDER 109 
 
 a joined course. Yet if the anamnesis estab- 
 lishes the fact that the articular affection came 
 first and the neuritic conditions only as second- 
 ary manifestations, then Roentgen photography 
 will promptly make the differential diagnosis 
 positive. 
 
 On the other hand, there are patients who 
 locate the pain not only in the shoulder, but 
 ako in the nape of the neck, or in the upper 
 arm alone, or again in the whole arm from the 
 apex of the shoulder down to the very finger- 
 tips, and these pains are aggravated with every 
 movement. We find the nerve trunks hyper- 
 sensitive on pressure, also exaggerated tender- 
 ness of the skin, muscles and bones, but no dis- 
 turbances of sensibility or noteworthy muscular 
 atrophy. A great temptation, indeed, to attrib- 
 ute the cause of the pains to neuritis. And yet 
 there is anarthritis with secondary brachialgia. 
 The diagnosis is based here on the X-ray and 
 another point of great moment, viz., if we find 
 that pressure upon the shoulder joint, especially 
 forward in the intertubercular sulcus, is par- 
 ticularly painful, we have definite proof that the 
 motility of the shoulder joint is essentially im- 
 paired. The head of the humerus is firmly set 
 in the joint by muscular contraction so that the 
 joint can no longer be moved by fixation of the 
 scapula. Otherwise the scapula will involuntar- 
 ily follow every passive movement of the arm,
 
 110 GENERALIZED PAIN 
 
 giving the patient intense pains as far down 
 as the fingers. In this fixation of the upper 
 arm we have a definite proof of an existing 
 primary arthritis. 
 
 And yet there are patients who, contrariwise, 
 locate the pain in the shoulder blade when it 
 really is in the cervicobrachial plexus. It will 
 occur in restricted morbid conditions of the 
 supraclavicular fossa, e.g., of the superior pul- 
 monary lobe (tuberculosis, tumors, glandular 
 swellings), also of the mediastinum, with direct 
 or irradiating stimulation of the appropriate 
 nerve plexus. The diagnosis is simple enough, 
 for the reason that careful probing reveals a 
 strong sensitiveness to pressure in the plexus 
 above the clavicle, whilst there is no such reac- 
 tion in the joint itself. 
 
 Sometimes an articular affection seems to 
 exist, when in reality the pains are due to an 
 inflammatory process in a synovial sac, chiefly 
 behind the deltoid, especially in resorption of 
 tuberculous pleural exudates. The diagnosis in 
 this case is beset with great difficulties when 
 coarser configuration anomalies are lacking. If 
 there is no pressure pain anteriorly between the 
 acromion and the coracoid process, and also in 
 the direction of the axilla, if the shoulder joint 
 moves freely, if there is only localized tenderness 
 in the upper arm about three inches below the 
 acromium, a visible swelling in the bicepital
 
 SHOULDER HI 
 
 sulcus, pronounced reactionary inhibition, and 
 distressing painfulness when the patient is abed 
 or resting, the chances are that we are dealing 
 with a case of bursitis. A test for narcosis is 
 indicated when the morbid condition is of long 
 standing. Free articular motility should here 
 also point to bursitis. The X-ray picture will 
 be of service. 
 
 A subpectoral phlegmon will claim our atten- 
 tion when we find upon closer scrutiny a digital 
 lesion, high fever, malaise, septic conditions, a 
 feeling of tension when the arm is moved, or 
 else lymphangitis and lymphadenitis. 
 
 Pains in the shoulder radiating into the upper 
 extremity are in all probability of arterial ori- 
 gin; a surmise of intermittent dyspragia arising 
 from arteriosclerosis or arteritis is here a safe 
 conductor. The deciding factor is that the pain 
 sets in with the movement of the arm and ceases 
 when the member is at rest. But it may also 
 come on on a march or during a brisk walk, 
 only to disappear again when a halt is made. 
 Evanescence of the arterial pulse and the Roent- 
 genogram are typical proofs of this painful 
 affection, which is, however, sometimes also 
 recognized in the lower extremities. 
 
 Retrosternal pains in the chest that radiate 
 into the apex of the shoulder and thence into 
 the arm, nape of the neck, and with preference 
 into the left lower jaw, intimate an existing
 
 112 GENERALIZED PAIN 
 
 angina pectoris or aortalgia, even though this 
 irradiation does not in all cases extend beyond 
 the shoulder. It may likewise take the direction 
 of the right instead of the left shoulder. 
 
 Pains in the shoulder associated with aches in 
 the back and sacrum are often of "psychoge- 
 nous" origin in such diseases as hysteria, neu- 
 rasthenia, and psychopathies. The diagnosis in 
 these cases may be at times somewhat puzzling, 
 particularly when the patient attributes the pain 
 to a cold, or an overexertion or an unexpected 
 drenching. Negative clinical findings, proper 
 consideration of the general physical conditions 
 and radiology should grant a satisfactory so- 
 lution. 
 
 Rheumatic pains in the shoulder may be irra- 
 diations of nervous origin, f.i., ( of the phrenic 
 nerve, and extend from the abdominal region as 
 far as the cervical nerves. If the pains are in 
 the right shoulder (or both) we should be re- 
 minded of rupture of the liver, cholelithiasis, 
 abscess, gumma, tuberculosis of the liver; if in 
 the left shoulder (or both), rupture of the stom- 
 ach, ulcus ventriculi with or without perigas- 
 tritis, a ventricular carcinoma in the pyloric re- 
 gion, or rupture of the duodenum as a sequel 
 to duodenal ulcer, even of the stomach due to 
 a parapyloric ulcer, or of the jejunum after a 
 peptic ulcer thereof. Furthermore, we may ex- 
 pect affections of the left hepatic lobe (gumma,
 
 SHOULDER 
 
 carcinoma), with perigastritis, or splenic dis- 
 eases, e.g., perisplenitis, splenic infarcts or ab- 
 scesses, or rupture or echinococcus of the spleen, 
 or myelogenous leucemia, paranephritic abscess 
 or an acute pancreatic affection (acute pancrea- 
 titis, necrosis of the pancreas) (left shoulder). 
 In retroperitoneal growths of the retroperitoneal 
 cellular tissue (glandular metastases, acute in- 
 flammation, calosities, metastatic neoplastic in- 
 filtrations) they appear mostly on the left side, 
 likewise in all possible neoplasms within the 
 retromediastinal space, not to forget hemor- 
 rhages flooding the peritoneal cavity below the 
 diaphragm (tubal pregnancy). 
 
 Naturally the patient complains of pain in 
 the affected part ranging as far as the shoulder. 
 But he exhibits also other local signs, e.g., local- 
 ized tension of the abdominal muscles (rupture 
 of the stomach, of the duodenum, etc.), absence 
 of abdominal breathing or increased pain during 
 the act. Coughing or walking aggravate these 
 pains, which also possess the peculiarity that 
 local pressure over the seat of the tumor influ- 
 ences more the pain in the shoulder than that in 
 the abdomen. But I make the point that a 
 ventricular ulcer or carcinoma will throw the 
 pains to the right shoulder, when it and the 
 liver have grown together; likewise, that shoul- 
 der pains in appendicitis indicate a high location 
 of the vermiform appendix or an upward ex-
 
 114 GENERALIZED PAIN 
 
 tension of the morbid condition, i.e., towards the 
 liver or diaphragm. Sometimes this shoulder 
 pain is still further marked by the circumstance 
 that it is very much aggravated when the right 
 leg is somewhat overstretched in the hip joint. 
 
 In affections of the pleura (pleuritis) or con- 
 tractions of the phrenico-costal sinus, in empy- 
 ema, pneumothorax, in severances of pleural 
 adhesions, affections of the lungs or pericardium, 
 these self -same irradiating shoulder pains are 
 very annoying, just as they are in an artificial 
 pneumothorax or a sudden hemorrhage in the 
 pleural cavity from, for instance, a ruptured 
 aortic aneurysm. 
 
 I wish to lay emphasis on the fact that when 
 the patient complains exclusively of shoulder 
 pain, the seat of the trouble is for a certainty 
 to be found in the liver. There are two possi- 
 bilities: Uver abscess following amebic dysen- 
 tery, but after a long interval, echinococcus of 
 the liver. The enlargement of the liver proved 
 by pain upon lateral pressure against the hypo- 
 chondria the presence of a cystic bulging of 
 the liver towards the lung, and other individual 
 symptoms (color of the face, attitude of the 
 patient, leucocytosis, rise in temperature) and 
 the anamnesis should definitely settle the diag- 
 nosis of hepatic abscess, 
 
 We must always think of that when the sick 
 man who has had dysentery or any other in-
 
 SHOULDER 
 
 flammatory or suppurative process in the radicu- 
 lar area of the portal vein, begins to worry 
 about pains in the right shoulder. In echinococ- 
 cus there is pain in the right shoulder only when 
 the parasite is embedded immediately under the 
 diaphragm. In this case there is also a domelike 
 axillary bulging upwards of the diaphragm. 
 With the aid of the other characteristic symp- 
 toms of this cystic parasite and of subdiaphrag- 
 
 latic liver abscess, especially the X-ray, the 
 >roper diagnosis cannot be missed. 
 
 Sarcoma of the liver is likewise associated 
 with pains in the right shoulder. This affection 
 forms one or more nodes on the surface of the 
 liver which arch the diaphragm upwards. So 
 long as there is no dullness of sound over this 
 
 rch, a diagnosis of hepatic carcinoma can only 
 )e made when we find also in other parts of the 
 liver carcinomatous eminences which change the 
 
 lape of this organ so far as it is accessible to 
 the touch. Our suspicion should be aroused 
 
 rhen an elderly cachectic patient complains of 
 pains in the right shoulder, although we can 
 find no pathological changes either here or in 
 the vicinity (neck, lung, mediastinum). 
 
 Febrile gummata of the liver, associated with 
 cholelithiasiform, intensive, colicky attacks, gen- 
 erally start with severe pains in the right shoul- 
 der several days in advance of the colicky spells, 
 run a parallel course, and disappear with them.
 
 116 GENERALIZED PAIN 
 
 Cholelithiasis itself does not, as a rule, bring 
 these pains in the right shoulder with it; but I 
 once saw a case in which this did happen, with 
 the result of an erroneous diagnosis of neuritis. 
 
 In perihepatitis in those parts which incline 
 toward the diaphragm the same pains may be 
 expected, and we must keep a sharp lookout 
 for other morbid processes in the diaphragm 
 from which pains might travel via the phrenic 
 and by transmission to the fourth cervical nerve, 
 and thence to the cutaneous nerves of the 
 shoulder. 
 
 In subphremc abscesses this happens princi- 
 pally when the subphrenic suppuration proceeds 
 from the liver or the spleen. 
 
 More often is it advisable to think of dia- 
 phragmatic pleuritis when these shoulder pains 
 have come suddenly to the surface and have 
 continued for days as the most prominent mor- 
 bid symptom. The diagnosis may safely lean 
 here upon the other well-known signs of pleu- 
 ritis, which, by the way, may also harbor a 
 primary subpleural tubercular condition of the 
 lung. 
 
 Diaphragmatic hernias and eventration are 
 the homes of pain that radiates from the chest 
 to the shoulder, a sign of diagnostic value espe- 
 cially when also the stomach has passed through 
 the hernial breach in the pectoral space. With
 
 SHOULDEB 117 
 
 the intake of food the pains are naturally very 
 much exacerbated. 
 
 But shoulder pain may be the only and ex- 
 clusive complaint in any form of pleuritis which 
 leads to an irritation of the phrenic nerve. It 
 has even the peculiar habit of becoming more 
 severe with any movement of the right shoulder 
 joint, thus leading to a false diagnosis of om- 
 arthritis. The presence of phrenic pressure 
 points (those in the neck, sternum and spinal 
 column may miss and only the abdominal points 
 may react!), the non-participation of the af- 
 fected thoracic portion in the act of breathing 
 and the accelerated respiration will no doubt 
 facilitate the diagnosis even when no pleural 
 friction is perceptible. 
 
 The same applies to pericarditis and medias- 
 tinitis. 
 
 Of course, shoulder pains are always a sign 
 of any possible irritation of the phrenic nerve, 
 also of foreign bodies in the diaphragm itself 
 even a projectile often associated with hic- 
 cough. 
 
 In splenic affections, e.g., perisplenitis, domi- 
 nating pains in the left shoulder make the ab- 
 dominal hypochrondral pains of secondary con- 
 sideration to such an extent that the patient only 
 complains of the former. This often leads to a 
 mistaken diagnosis of rheumatism of the shoul- 
 der joint.
 
 118 GENERALIZED PAIN 
 
 When we can find no clinical or radiologic 
 evidence of changes or motoric defects in the 
 joint, nor typical pressure points, but hepatic 
 or lienic hyperesthesia of the skin or tenderness 
 iii the trapezius region and respiratory differ- 
 ences, we must look for other abdominal symp- 
 toms if we wish to find the correct diagnosis. 
 
 In rare cases only exclusive pains in the 
 shoulder are a sign of nephrolithiasis. The lum- 
 bar and hypochondral pains, however, some- 
 times radiate as far as the scapula. Only long 
 experience will prevent mistakes in these cases. 
 
 It will be seen that in most of the cases 
 quoted here tenderness in the trapezius muscle 
 is a usable diagnostic sign. I will mention here 
 that this delicacy is often the only available 
 symptom, shoulder pain being absent, and that 
 its discovery is an essential advantage for the 
 diagnosis of the subdiaphragmatic organic dis- 
 eases in question. 
 
 In all these diseases the shoulder pain, whether 
 it is isolated or irradiated, emanates beyond 
 from the phrenic nerve through a symptomatic 
 neuritis (neuralgia) thereof. 
 
 Insofar as idiopathic neuralgia of the phrenic 
 nerve is concerned, I speak with reserve. 
 
 In another chain of cases the patient does not 
 point to the shoulder joint or the space between 
 the shoulder blades, but rather to that part
 
 SHOULDEB 
 
 of the back which is occupied by the scapula 
 
 as the seat of pain. Cholelithiasis, for instance, 
 when associated with an ulcer, irradiates its 
 pain into or against the shoulder blade, or else 
 between the two blades. 
 
 Sometimes the movement of the scapula is 
 accompanied by a harsh, crackling sound which 
 is noticeable to the patient as well as to the 
 bystander. This noise is apparently due to the 
 formation of an accessory synovial sac and a 
 proliferating hygroma within it between the 
 anterior scapular plane and the posterior thoracic 
 wall, or, perhaps, by bony spurs on the ribs or 
 in the scapula, the work of pleuritis deformans, 
 or due to exostosis, a fracture or to syphilis. 
 
 Howsomever, a similar crepitus in the scap- 
 ula mostly discernible only in auscultation 
 also happens in very lean or emaciated persons, 
 no doubt caused by friction between the shoulder 
 blades and the ribs; it may also be due to some 
 muscular action and is most frequently heard 
 in pulmonary tuberculosis. The patient him- 
 self is not always aware of its existence. A 
 differential sign between the two forms is the 
 fact that in the latter case it proceeds with a 
 symmetrical rhythm and is painless except in 
 unilateral atrophy of the dorsal muscles. 
 
 And yet we come across patients who com- 
 plain of the annoyance occasioned by this noise, 
 as well as of the pain that accompanies it. Fur-
 
 120 GENERALIZED PAIN 
 
 ther questioning may elicit the fact that the 
 patient experiences the same sensation also in 
 other joints of the body. We are safe in at- 
 tributing the whole trouble to hysterical causes. 
 Emaciation, often enough superinduced by vol- 
 untary action, is evidently the originating factor 
 of the existing neurosis. The diagnosis can well 
 be based upon the claim that the crackling sound 
 prevails in diverse places, and also on the other 
 hysterical manifestations. 
 
 Pains in the scapular region may also be the 
 result of some anatomical defect in the shoulder- 
 blades, e.g., in caries or acute osteomyelitis, a 
 fact which is of interest to the surgeon. 
 
 We are strongly reminded here of morbid 
 conditions that may occur in the adjacent thora- 
 cic organs, especially of the pleura in a primary 
 affection of the lungs. Not only tuberculosis, 
 or any form of acute or chronic infection, ab- 
 scess or tumor of the lungs may cause these 
 pains by way of encroachment on the pleura 
 or in combination with pleural affections, but 
 we must also look for primary inflammations 
 or neoplasms of the pleura itself as the orig- 
 inating factors. In interlobar pleuritis (eni- 
 pyema), for instance, we are conscious of severe 
 pains in the region of the shoulder blades, prox- 
 imal to the spina scapulas. In suppurative, in- 
 flammatory processes of the bronchial glands
 
 SHOULDER 121 
 
 these pains are rather of an interscapular 
 nature. 
 
 Matterstock mentions a peculiar kind of 
 shoulder pain which deserves mention. When 
 we glide the hand with firm pressure along the 
 crista scapulae, the patient who is suffering from 
 lobar pulmonary tuberculosis speaks of severe 
 pain in the affected section. 
 
 Not counting any of the previously enumer- 
 ated ailments and leaving out of consideration 
 even a possible subscapular bursitis as sources 
 of pain, we are not falling into an error when 
 we accept a painful affection of the shoulder 
 blades as a manifestation of intercostal neural- 
 gia. The characteristic signs are: the seat of 
 the pain corresponds with the anterior angle 
 of the scapula, and the presence of pressure 
 points, especially in the vertebra. 
 
 Bilateral shoulder pains should direct us to 
 recognize deuteropathic intercostal neuralgia due 
 to a primary affection of the vertebras or of the 
 vertebral joints, of the ribs or of the spinal 
 contents. 
 
 One-sided pains of great intensity in one 
 shoulder blade only may also be the initial symp- 
 tom of an extramedullary tumor of the spinal 
 cord. Another possibility is a morbid process 
 within the chest, especially of the posterior 
 mediastinum in the form of intercostal neuralgia,
 
 122 GENERALIZED PAIN 
 
 or an aneurysm of the aorta or a broncho- 
 sarcoma. 
 
 There is a special form of pain at the apex 
 of the scapular angle. All morbid processes 
 that possibly may occur in the thoracic cavity 
 or its wall may here be involved, and must be 
 taken into consideration whenever these pains 
 come under our observation. 
 
 I strongly emphasize the fact that these pains 
 may, when coupled with local pressure sensitive- 
 ness, figure in a number of subdiaphragmatic 
 affections either as the most distinctive irradia- 
 tion pains or, at any rate for a time, as the 
 only and exclusive pains of the fundamental 
 disease. This is the case in cholelithiasis, in 
 cholecystitis, in ventricular ulcer or carcinoma. 
 I shall refer to this again later on. 
 
 Pains between the shoulder blades, at the apex 
 of the scapula, are of varying genesis according 
 to their localization either between the scapula 
 and spinal column or along the spinal column. 
 In the latter case the differential diagnosis must 
 follow the same course as outlined in the chapter 
 on "Pains in the Sacrum." 
 
 Affections of the spinal column (bones, joints 
 and cartilages) and its contents (membranes of 
 the spinal cord, nerve roots and the spinal cord 
 proper) claim our attention. Pains in the spinal 
 column at this level may originate from an at- 
 tack of functional neurosis (spinalgia, spinal
 
 SHOULDEB 123 
 
 irritation). The diagnosis must proceed from 
 the fact that the pain radiates from the sacral 
 region upwards into the shoulder blade, that the 
 skin is here exquisitely hyperesthetic, and that 
 the other typical symptoms are present. 
 
 Other morbid conditions in the posterior me- 
 diastinum loom up as possible causes of these 
 pains. Arrosion of the spinal column, aneurysm 
 in the arc of the descending aorta, carcinoma of 
 the esophagus involving one or several of the 
 vertebrae, are all possibilities. The diagnosis 
 can only meet with an obstacle when the patient 
 has no other complaint to make beyond these 
 local pains, as may very well be the case in 
 carcinoma of the esophagus or in the earlier 
 stage of aneurysm of the descending pectoral 
 aorta. If there is no pulsation or bruit laterally 
 to the spinal column, we are certain to find a 
 retardation in the crural, as compared with the 
 radial pulse, also a very conspicuous smallness 
 of the former as compared with the latter, and 
 above all the Roentgen picture will assist in 
 clearing away doubts that may exist in the 
 diagnosis. 
 
 There are certain affections of the posterior 
 mediastinum which do not directly involve the 
 vertebral column, and yet are associated with 
 pains in that part of the shoulder blade which 
 is adjacent to the spine. If we find here inter- 
 scapular sensitiveness to pressure and percussion
 
 124 GENERALIZED PAIN 
 
 in the spinous processes of the first to fourth 
 vertebra, we may be sure of an affection in the 
 mediastinum, or in the heart and the larger 
 vessels. Hyperesthesia between the fourth and 
 eighth vertebra, or even below the latter, points 
 to affections in the stomach, lower esophagus, 
 liver, ventricular ulcer or gastric carcinoma. 
 
 Pains between the shoulder blades, or between 
 the scapula and the vertebral column, give uls. 
 the impression that there is some primary dis- 
 ease of the spinal column or its contents which 
 exerts a pressure on the neighboring nerve roots. 
 There is quite a list of such possible ills, viz., 
 caries, spondilitis, new growths, divers affections 
 of the vertebrae, meningitis, meningeal apoplexy, 
 hypertrophic cervical pachymeningitis (syphil- 
 itic), tumors of the spinal cord or the membranes 
 thereof, inflammatory conditions of the cord with 
 lateral meningitis and hematomyelia, not to for- 
 get foreign bodies in the intervertebral foramina 
 and the massing together of neoplasmatic metas- 
 tases or leucemic pseudoleucemic or lympho- 
 granulomatous infiltrations. 
 
 Intercostal neuralgia between the shoulder 
 blades is another font of pain. It may be occa- 
 sioned by local conditions, e.g., by disease of the 
 neighboring ribs (neoplasms, syphilis, etc.) or 
 by some malformation in the spine (scoliosis) 
 or a bronchial or pulmonary affection (bronchial 
 carcinoma) or of the mediastinum (aortic aneu-
 
 SHOULDER 125 
 
 rysm, lymphosarcoma, etc.), or it may be merely 
 a pain caused by fatigue or exhaustion, or it 
 may be the forerunner of herpes zoster or its 
 companion. 
 
 Pains which are due to overtaxing or over- 
 tiring of the spinal column in the sense of 
 vertebral insufficiency, belong to this class. The 
 patient does not of his own accord generally 
 complain of backache, but rather of weariness 
 and languidness. But upon closer scrutiny we 
 find a decided tenderness on pressure and tap- 
 ping in the spine, exquisitely so between the 
 shoulder blades and laterally from the corre- 
 sponding vertebra?, also in the lumbar vertebra? 
 when tapped or pressed through the abdominal 
 wall. We also find complicating gastric dis- 
 turbances. This form of insufficiency may be 
 observed in almost any morbid condition of the 
 spinal column, such as scoliosis, osteomalacia, 
 chronic ankylosing articular inflammation of the 
 spine, after injuries (carrying heavy burdens), 
 in anomalies of the spine, especially at the age 
 when the normal bearing power of the column 
 is on the wane (fortieth to fiftieth year of age), 
 not any the less after wasting diseases or ab- 
 normal physical exercises or overexertions. The 
 costal region is, of course, included in this sec- 
 tion. There may be tuberculous caries, syphilitic 
 periostitis, arrosion of one or several ribs caused 
 by an aneurysm or similar materies morbi.
 
 126 GENERALIZED PAIN 
 
 Next in order are the morbid affections of the 
 muscular plexus. Foremost among them is 
 rheumatism of the interscapular muscles. 
 
 Rheumatic myalgia, myositis in syphilis (pre- 
 dominantly nocturnal pains!), polymyositis ossi- 
 ficans, and also trichinosis are harbingers of 
 heavy interscapular pains. We find them in 
 many vocational pursuits, e.g., among tailors, 
 cobblers, seamstresses and miners, and others 
 who have to lean over their work most of the 
 time. 
 
 Pains in the back count among the primary 
 signs of tetanus. The diagnosis may be dis- 
 turbed when the attack comes on top of a severe 
 cold thus misleading to the erroneous classifica- 
 tion of "a rheumatic cold." A study of the 
 other tetanic symptoms should correct the mis- 
 take. 
 
 In chlorosis, anemia, asthenia and orthotic 
 albuminuria we get plenty of grumbling about 
 backaches and bodily weariness. The fact that 
 rest in bed brings relief is a strong point in 
 favor of the correct diagnosis. The claim made 
 by some patients that leaning the shoulders 
 against the back of a high chair brings relief, I 
 do not consider of much value in this connection. 
 
 Back-shoulder pains due to some myocardial 
 weakness must be included in this paragraph. 
 General fatigue, pains in the loins or calves, 
 ache and dullness in the head, dyspeptic troubles,
 
 SHOULDER 127 
 
 dyspnea, cyanosis even after minimal physical 
 exertion, nycturia or oliguria and changes in 
 the heart itself, are all good pointers for the 
 diagnosis. 
 
 The dragging, cutting pains in the interscapu- 
 lar area can always be recognized as the earliest 
 symptoms of pulmonary tuberculosis, unless 
 they are due to a localized dry pleuritis or to 
 hyperesthesia of the skin. Such initial symp- 
 toms as painful palpation of the museums 
 cucullaris (also of the sterno-cleido-mastoid) 
 and sensitiveness on pressure in the cervico- 
 brachial plexus above the clavicle should give a 
 sound foundation to the diagnosis. 
 
 In various diseases of the mediastinum the 
 pains lay a preferential claim to the region be- 
 tween the left scapula and the spine. If they 
 come of a sudden they signal an inflammation 
 of the cellular tissue of the posterior mediasti- 
 num or its glands. Acute mediastinitis is gen- 
 erally of a phlegmonous nature, though it may 
 be also in the form of a localized mediastinal 
 abscess. It issues from some morbid process of 
 an adjacent organ, inflammations or new growths 
 of the esophagus, pericardium, the pleura or 
 lungs, or some subdiaphragmatic phlegmon 
 which has extended through the esophageal 
 hiatus into the posterior mediastinum, or from 
 a primary vertebral or costal lesion, tuberculous 
 caries being the most common among these.
 
 128 GENERALIZED PAIN 
 
 PrevertebraL actinomycosis may develop from 
 the oral cavity through the cellular tissue of the 
 neck or also from the esophagus. The diagnosis 
 should not be difficult if the primary port of 
 entry of the actinomyces is found in the oral 
 cavity (dental actinomycosis) or in the neck 
 or in the respiratory tract. (Remember, too, 
 that pulmonary actinomycosis may also be the 
 secondary outcome of a prevertebral actinomy- 
 cotic phlegmon.) Examination of pus and 
 sputum and the Roentgen-ray are important 
 adjuvants. 
 
 Acute inflammations of the anterior mediasti- 
 num also give rise to pains between the shoulder 
 blades. The diagnosis in this as well as in the 
 former instance is furthered by the fact that 
 the pains are interscapular and behind the ster- 
 num, and by the symptoms of mediastinal irri- 
 tation or displacement of any kind (trachea, 
 esophagus, bloodvessels, nerves, glands). Feb- 
 rile conditions are of a septic character. A 
 cutaneous edema in the jugulum on one side of 
 the sternum or above the clavicle and a swelling 
 in these sections or in the supraclavicular fossa 
 must be taken as warning signals of a possible 
 perforation of the mediastinal abscess. The 
 X-ray should not be neglected in all these 
 cases. 
 
 Dark field radiology is of special import in 
 chronic fibrinous mediastinitis which so often
 
 SHOULDER 129 
 
 follows in the wake of indurated pleuritis, medi- 
 astinal lymphadenitis and inflammatory affec- 
 tions of the lungs (phthisis, diseases of the 
 esophagus). The pains are retrosternal, or in- 
 terscapular with possible dysphagia or hoarse- 
 ness. Additional symptoms are a descending 
 laryngeal pulse (Oliver-Car darelli symptom), 
 aneurysm and dilatation of the aorta, medias- 
 tinal and intrathoracic glandular tumors, enter- 
 optosis and unusually accelerated heart action. 
 However, the pains between the shoulder plates 
 may in some cases be the only perceptible sign. 
 
 Inflammatory conditions in the mediastinal 
 cellular tissue as well as in the retromediastinal 
 glands are bound to give rise to interscapular 
 pains localized sometimes only on one side of, 
 but mostly within the spine itself and generally 
 on the level of the 2. to 4. dorsal vertebra. An- 
 gina with secondary infectious symptoms and 
 secondary hemorrhagic nephritis are often the 
 precursors of this situation. After the angina 
 has run its course and only nephritic residues 
 are left behind, we will often enough be able to 
 observe moderate pains between the shoulder 
 blades, not infrequently accompanied by diffi- 
 culty in swallowing, but always by a perceptible 
 rise in the temperature, to disappear gradually 
 within seven or eight days. I incline to the belief 
 that these pains are attributable to a receding 
 retromediastinal lymphadenitis originating in the
 
 130 GENERALIZED PAIN 
 
 anginose condition, but I have no definite proof 
 for it. 
 
 More often, however, these pains are basic 
 in a tuberculous mediastinal lymphadenitis, pri- 
 mary as well as that which runs parallel with 
 a fully developed pulmonary tuberculosis. Of 
 other causes it is meet that I mention here, 
 muscular affections, hyperalgesia of the skin, 
 affections of the bones and mediastinal pleuritis 
 (more about the latter later on) and in some 
 rare cases an acute phlegmon of the mediastinal 
 cellular tissue proceding from a tuberculous 
 cavity in the lung. Chronic indurated medias- 
 tenitis and plexus pains belong here also. 
 
 We can safely run the risk of looking upon 
 these lymphadenitic conditions as an early symp- 
 tom of phthisis. They are disclosed by spas- 
 modic coughs, cyanosis, dyspnea, interscapular 
 smothering, the Roentgen-ray, sensitiveness on 
 pressure either on the side of the 2. to 7. dorsal 
 vertebra or the corresponding spinous processes, 
 still more so by the pressure of enlargements in 
 the lymphatic glands, palpable in the median 
 axillary line of the thorax, chiefly in the 4?. inter- 
 costal space. But, be it said, the last named 
 condition does not in many cases came into 
 evidence until the tubercular state is fully de- 
 veloped in the lungs. If pains are evinced in 
 the aforementioned location during esophageal 
 probing (Neisser) we have definite proof of
 
 SHOULDER 131 
 
 glandular enlargements. A trial injection of 
 tuberculin followed by very pronounced shoulder 
 pains is an important sign for the diagnosis. 
 
 Lymphogranuloma of the mediastinal glands 
 and anthracoid conditions of the peribronchial 
 glands claim our attention also. The very na- 
 ture of the latter affection is bound to cause 
 pain in the indicated place, and so do also any 
 chronic inflammatory or indurated processes 
 which may originate from it in the periglandular 
 mediastinal cellular tissue (around the aorta, 
 esophagus or trachea). More frequently inter- 
 scapular pains are induced by neoplastic diseases 
 of the mediastinum and foremost of the medias- 
 tinal glands, be they of a primary (lymphoscar- 
 coma) or metastatic character. As a rule the 
 pains are not severe or at any rate are of a 
 negligible quality even when the Roentgen plate 
 shows already deep shadows. Radiology has 
 the same diagnostic value also in bronchial car- 
 cinoma. Additional diagnostic signs are: hem- 
 optysis in persons of advanced age with negative 
 tubercular conditions, bronchial stenosis, fetid 
 bronchitis, abscess or gangrene of the lungs, 
 apyrexia or subfebrile temperature and cachexia. 
 
 Fresh localized pleuritis and pleural adhesions 
 also give rise to such pains which are either of 
 a lasting or only of a temporary tenure but are 
 often exacerbated by local pressure, coughing 
 or deep breathing, etc. Such a localized pleuri-
 
 132 GENERALIZED PAIN 
 
 tis is apt to involve the posterior mediastinal or 
 the interlobar visceral pleura, or may degenerate 
 into an interlobar tuberculosis or also non-tuber- 
 culous pleuritis. 
 
 Patients afflicted with bronchial asthma or 
 asthmatic bronchitis feel these same pains be- 
 tween the shoulder blades. The diagnosis can 
 here always fall back on the peculiarly singing 
 character in bronchitis, the increased volume of 
 the lungs, the typical attacks, examination of the 
 blood and sputum (Charcot's crystals, Cursch- 
 mann's spirals, massive eosinophile cells, bacte- 
 rial deficiency). 
 
 Little attention has been given in this connec- 
 tion to chronic tracheitis and chronic asthmatic 
 tracheobronchitis. In these cases the interscapu- 
 lar pains are generally superceded by the par- 
 allel painfulness felt behind the sternum. I have 
 observed this in patients suffering from recurrent 
 hay fever (conjunctivitis, rhinitis, bronchitis and 
 asthma) when there were no traces of neurotic 
 stigmata. 
 
 In acute bronchitis, especially of the right 
 large bronchus, a dull, burning, stitching pain 
 between the scapula and spine is at times a 
 matter of complaint, possibly due to consensual 
 peribronchial lymphadenitis. 
 
 In lobar pneumonia the patient is likely to 
 complain of backache even before the clinical 
 symptoms are definitely developed. This is
 
 SHOULDEB 133 
 
 particularly so when the inflammation has been 
 restricted for some time to the hilum, that is to 
 say before the parietal pleura has been affected. 
 These pains would in such an event come from 
 the morbid spot in the mediastinal pleura as 
 has already been pointed out in a previous pas- 
 sage. This fact coupled with the manifestations 
 of compression and enlargement in the posterior 
 mediastinum should enable the shrewd observer 
 to recognize the true nature of the disease, espe- 
 cially if he calls the X-ray into service. 
 
 More frequently the causative element is 
 found in diseases of the esophagus. If it is a 
 case of carcinoma the osseous spine need not be 
 implicated, but the immediate surroundings of 
 the esophagus are bound to be affected. The 
 diagnosis should result from the collateral symp- 
 toms. In the first place note difficulty in deglu- 
 tition, then signs of congestion or enlargement 
 of the esophagus, the verdict of the probe and 
 the evidence of the X-ray plate. When the 
 pain manifests itself only during the act of 
 swallowing or is rendered more acute by it or 
 by the introduction of the stomach sound we 
 have additional proof of the existence of an 
 esophageal carcinoma. 
 
 Among the other painful diseases belonging 
 here I will mention peptic ulcer, syphilitic and 
 tuberculous tumors, suppurative conditions of the 
 mucous membrane due to acetic corrosion, sten-
 
 134 GENERALIZED PAIN 
 
 osis or dilatation of the esophagus associated 
 with pressure and oppression. The patient often 
 complains also of synchronous pains behind the 
 sternum, but at the lower end of it, in peptic 
 ulcer. Still I have seen cases in which no com- 
 panion pains were observed and the interscapu- 
 lar pains were quite independent of the act of 
 swallowing but set in during the night time, 
 being of an intensive, tearing, drawing nature, 
 especially in carcinoma or sarcoma of the 
 esophagus. 
 
 Rupture of an aortic aneurysm into the gullet 
 or of an esophageal carcinoma into the trachea 
 will always provoke interscapular pains, al- 
 though they are, as a rule, located by the patient 
 in the breast. 
 
 In abdominal diseases the pains extend fre- 
 quently into the interscapular district, though in 
 bilious colic and duodenal ulcer they prefer the 
 right, and in ventricular ulcer, rupture or per- 
 foration of the stomach and splenic affecting 
 the left shoulder. In ventricular pneumatosis 
 they also radiate into the retrosternal region. 
 
 In subdiaphragmatic diseases pains between 
 the shoulder blades are the most prominent, at 
 times even the only symptom that presents itself 
 to the observing mind. Cholelithiasis, for in- 
 stance, is one of these affections. But existing 
 doubts will be dispelled if we find that the cucul- 
 laris pressure pain is unilateral and that pressure
 
 SHOULDEB 135 
 
 in the gallbladder region increases the interscap- 
 ular pain. 
 
 Pains between the shoulders combined with 
 sacralgia are not uncommon in patients who 
 suffer from abnormal flatulence or defective 
 flatus due to chronic intestinal catarrh, or from 
 obstinate constipation, or also from abdominal 
 plethora, sclerosis of the intestinal arteries, por- 
 tal congestion, phlebitis or phlebosclerosis of the 
 visceral veins, (partly due to nervous conditions 
 or only to chronic obstipation, or also to swal- 
 lowing air). Complaint of abnormal gas pro- 
 duction, visible distension of the belly and if 
 needs be the Roentgen pictures are the founda- 
 tions of a true diagnostic finding. Appropriate 
 therapeutic measures will confirm it. 
 
 Diseases of the gallbladder, of the stomach 
 (ventricular ulcer or carcinoma), in rare cases 
 affections of the spleen, likewise morbid condi- 
 tions of the pancreas, in fact, of the entire 
 peritoneal cavity, belong in this category. 
 
 The interpretation of interscapular pains fol- 
 lowing upon diseases of the aorta is rather sur- 
 rounded by difficulties. The pains prefer the 
 left side, although at times they invest both sides 
 with a slight punctuation in the left. Of course, 
 I am speaking here of an aneurysrn situated at 
 the spot where the pectoral aorta arches off into 
 the descending aorta. The cogent points are: 
 visible and palpable pulsation in the left painful
 
 136 GENERALIZED PAIN 
 
 zone, systolic murmur, mediastinal engorge- 
 ment and compression, distinct retardation of 
 the crural pulse and that of the abdominal aorta 
 as compared with the pulse rates in the upper 
 thoracic sections, especially the apex impulse, 
 and the radiological finding. 
 
 Another peculiarity is that the pains are more 
 acute when the patient lies on his back, but 
 diminish when he turns around to rest on his 
 abdomen. And again they are sharpened by 
 physical exertion such as walking, running or 
 exercising the arms, whereby the aneurysmal 
 sac becomes extended and calls the accompany- 
 ing aortitis into action. 
 
 Similar conditions prevail, however, in any 
 other form of aortic disease, even without the 
 formation of an aneurysm, e.g., in syphilis or 
 sclerosis of the pectoral aorta. There is still 
 another resemblance between the pains in the 
 shoulders arising from aortic sclerosis and those 
 due to aneurysm of the pectoral aorta, but not 
 in a pathognomic sense. It is this: the patient 
 in either case will tell you that the pains are 
 materially softened when he presses the back 
 against some solid object, e.g., the back of a 
 chair, or under vigorous, punching massage in 
 the left interscapular region. 
 
 The fixation of sclerosis of the pectoral aorta 
 can be credibly established upon these symptoms 
 even when arteriosclerotic manifestations in the
 
 SHOULDER 137 
 
 other aortic and peripheral vessels are wanting. 
 A distinctly punctuated, or ringing second aorta 
 tonus above the descending pectoral aorta, i.e., 
 in the left interscapular space, is a leading 
 sign. 
 
 A certain anatomical affection, chiefly the 
 outcome of a true angina pectoris, must be men- 
 tioned here. I mean sclerosis (syphilitic) of the 
 coronary arteries,, i.e., a constriction at the point 
 of exit from the ascending aorta. In other 
 words : when a patient tells us that he is molested 
 by rather intensive sometimes only dull - 
 pains between the shoulder blades (perhaps for 
 months) we should always think of a possible 
 true angina pectoris. The question to decide 
 here is whether we are dealing with a sclerosis 
 of the ascending pectoral aorta or of the cor- 
 onary arteries, i.e., the ascending portion of the 
 supravalvular aorta. We shall arrive at a deci- 
 sion when we find definite proof of myocardial 
 changes such as chronic interstitial myocarditis, 
 or myofibrosis, or degeneration of the heart 
 muscle, or, maybe, an aneurysm of the heart 
 together with typical attacks of angina pectoris, 
 which latter may come on just as well when the 
 body is in motion or completely at rest. 
 
 If these conditions are still further aggravated 
 by acute weakness of the heart, unusual physical 
 debility, failing pulse, pallor of the face, cere- 
 bral symptoms, syncopal incidents, we have a
 
 138 GENERALIZED PAIN 
 
 strong intimation of the sudden thrombotic or 
 embolic occlusion of a coronary artery. 
 
 A rupture of the pectoral aorta generally 
 announces its arrival by a sudden most violent 
 pain between the left scapula and the spine, 
 though ordinarily it is preceded by a series of 
 minor pains. The rupture may find its way 
 into the left pleura, or into the left lung or 
 into the pericardium. There may be present 
 a pre-existing sclerosis of the aorta, an ordinary 
 or a dissecting aneurysm of the aorta. At times 
 we find a pronounced hyperesthesia of the skin 
 in the affected area, but always the typical signs 
 of internal hemorrhage. The outcome is fatal. 
 
 We should ever bear in mind that two of the 
 aforementioned diseases may simultaneously in- 
 habit the same body. It is by no means an 
 unusual occurrence that aortic or coronary scler- 
 osis travels side by side with a carcinoma of 
 the stomach or of the esophagus, or a gastric 
 tumor with an arteriosclerotic basis. 
 
 Pains in the apex of the shoulder not always 
 localized by the patient with exactness ever 
 point to the possibility of a spinal or intracere- 
 bral source. A cerebellar tumor or any morbid 
 condition that encroaches upon the occipital 
 space will cause such pains. The proper diag- 
 nosis can, of course, be made from the observa- 
 tion of other typical symptoms. In migraine
 
 SHOULDEB 139 
 
 with an occiptal base the pains travel via the 
 nape of the neck to the shoulders. 
 
 'Tains within the range of the scapula," or 
 rather within the circumference of the supra- 
 clavicular and supraspinous fossa require special 
 attention in this place. I do not refer to the 
 pains which originate in any of the organs that 
 lie within the supraclavicular fossa itself they 
 are dealt with in the chapter on "Pains in the 
 Neck" but rather to those which radiate from 
 the nuchal muscles and from the cervico-brachial 
 plexus into the shoulders. 
 
 The proof that certain pains are basic in the 
 nuchal musculature, chiefly in the cucullaris 
 muscle, is furnished by the fact that they are 
 felt only, or at any rate are exacerbated, when 
 the individual muscle comes into action. Pres- 
 sure, stroking or tapping of the muscle creates 
 a painful sensation. This is frequently the case 
 after unwonted physical, gymnastic exercise, in 
 which case the anamnesis should be sufficient 
 ground for a proper diagnosis. Gout and rheu- 
 matism and certain infectious diseases, e.g., 
 plague, are other causes that must be considered. 
 
 It is somewhat difficult to separate the initial 
 stages of multiple ossifying myositis from those 
 of the acute suppurative form. In both we find 
 local pain, swelling of a solid consistence, moder- 
 ate rise of temperature, and subsequent muscular 
 induration. When bone tissue sets up, the diag-
 
 140 GENERALIZED PAIN 
 
 nosis will be clear. All the other forms of 
 myositis show no specific tendency to attack the 
 muscles of the neck or back, except acute derma- 
 tomyositis in which disease the pains eventually 
 radiate from the brachial muscles into the nuchal 
 and dorsal plexus. 
 
 In angina pectoris and other cardiac affec- 
 tions (paroxysmal tachycardia with nodal heart 
 rhythm, acute dilatation of right ventricle with 
 venous engorgement), right - sided trapezius 
 hyperalgesia in periappendicitis, pains in the 
 shoulder muscles, especially in the cucullaris 
 and in the sternocleidomastoid are experienced. 
 The patient rarely complains of them, but we 
 find hyperalgesia when kneading or roughly 
 stroking the affected muscles. 
 
 In true angina pectoris and in aortalgia sub- 
 sequent to sclerosis of the aorta or of the cor- 
 onary arteries the patient often complains about 
 pains in the left shoulder. They are localized 
 either in the supraclavicular or supraspinous 
 fossa and are felt with physical movement or 
 exercise, but also at times when the body is at 
 rest. Muscular hyperesthesia is not in evidence. 
 In some cases the patient does not seem to notice 
 the pains at all, but when asked will speak of 
 a slight pressure in the chest but without painful 
 sensation. This is an important danger signal 
 not to be ignored in sclerosis of the aorta or 
 the coronary arteries.
 
 SHOULDER 141 
 
 That the cervicobrachial plexus is the causa- 
 tive factor of predominant pains in the shoulder 
 is demonstrated when the patient complains of 
 a sensation of weight, rigidity and acute pain- 
 fulness in the affected part. He inclines his 
 head backwards and away from the tender side 
 (shaving posture). The nerve fibres above the 
 clavicle are sore to the touch, the pains in the 
 periphery of the involved plexus radiate into 
 the arms, paresthesias and motoric weakness are 
 noticeable in many cases. 
 
 These pains are often due to new growths 
 which are forming in this region, especially in 
 the supraclavicular fossa, but may also branch 
 out from some morbid process in an organ which 
 has only a subordinate anatomical relation to 
 the supraclavicular group, or none at all. They 
 may be in part the manifestation of a poly- 
 neuritis or a mononeuritis with a local cause 
 perhaps in the spine or in the spinal canal or 
 in some morbid process that has already reached 
 ic corresponding supraclavicular fossa. There 
 
 the possibility of a swelling or a tumor 
 leveloping in the clavicle (osteomyelitis, caries, 
 gummata), a disease or enlargement of the 
 supraclavicular lymphatic glands, the formation 
 of an aneurysm of the subclavian artery all 
 easy to recognize or the elongation of the costi- 
 form process. In the latter case the X-ray will 
 furnish the proof where palpation fails. 

 
 142 GENERALIZED PAIN 
 
 In omarthritis the pains are not felt so much, 
 if at all, in the joint itself, but rather in the 
 zone of the cervico-brachial plexus above as well 
 as below the clavicle. (See also chapter on 
 "Pains in the Extremities.") 
 
 These plexal pains go, however, together also 
 with other quite independent diseases. It is by 
 no means uncommon that a patient who is 
 suffering from an aneurysm of the aortic arc 
 complains solely of pains in the right shoulder 
 if not in both shoulders, whence they radiate 
 first into the right and later on into both arms. 
 The same may be said of simple sclerosis or 
 dilatation of the aorta. A proper consideration 
 of the typical symptoms of these diseases should 
 reveal a correct diagnosis. 
 
 We shall find pains of a minor degree in the 
 chest but such of decided acuteness in the left 
 supraclavicular fossa in every attack of angina 
 pectoris based upon sclerosis of the aorta. 
 
 Aneurysm of the anonymous artery carries 
 with it very severe pains in the right shoulder 
 and arm. (See "Cardiac Pains.") 
 
 Solid tumors of the mediastinum produce 
 shoulder pains as an initial symptom. The 
 diagnosis can be made from the Roentgen pic- 
 ture, other typical symptoms such as mediastinal 
 sensitiveness to pressure, localized lack of reson- 
 ance in percussion, tympanitic dullness. Bron- 
 chial sarcoma is worthy of mention here also.
 
 SHOULDER 143 
 
 The sudden appearance of a pain in one of 
 the shoulders or in the supraclavicular fossa 
 should arouse our suspicion of a lesion in the 
 corresponding axpex of the lung or its pl|eural 
 coating. Pneumonia of the apex accompanied 
 by pleuritis of the apex pleura tends to an acute 
 perineuritis of the cervico-brachial plexus and 
 thus gives rise to considerable pain in the shoul- 
 der. We should recognize this condition from 
 the characteristic symptoms of the disease de- 
 scribed elsewhere. If the pains have been pres- 
 ent for some time we should look for some 
 chronic disease, especially tuberculosis of the 
 pulmonary apex. The pain combined with ten- 
 derness in the cervical plexus when the pressing 
 finger glides slowly in a forward movement over 
 it, will give proof of an indurated pleuritis and 
 subsequent chronic perineuritis (eventually neu- 
 ritis) of the cervico-brachial plexus. 
 
 The corresponding primary symptom of this 
 apex disease manifests itself in the shape of a 
 painful sensation in the cucullaris muscle when 
 it is rolled about or tapped with the finger. The 
 patient is not always aware of its presence until 
 the sore spot is touched which may also be the 
 seat of an amyotrophic condition. 
 
 Interstitial or chronic pneumonia, apex pleu- 
 ritis either fibrinous or exudative (suppurative), 
 also superior lobular tumors are generators of 
 scapular pains, which become a typical diag-
 
 144 GENERALIZED PAIN 
 
 nostic symptom when aggravated by moving or 
 raising the arm up high. 
 
 Pains in the fossa supraspinata emanate also 
 from an interlobar empyema. They disappear 
 when the pus has been drained off. 
 
 Proliferating growths on the superior pulmon- 
 ary lobe frequently cause similar pains when 
 extending upwards they encroach upon the 
 plexus that lies above the apex. I refer to 
 malignant and cystic (echinococcic) neoplasms. 
 The accompanying pain is of importance for 
 diagnostic purposes. 
 
 Shoulder pains awakened by tapping or ro- 
 tating the cucullaris muscle may also be due to 
 some inflammatory process in the diaphragmatic 
 region such as a local pleuritis, or also a perihe- 
 patitis, or any kind of inflammatory subphrenic 
 lesion, or perigastritis or perisplenitis. In these 
 cases a rearward pressure of the fingers will 
 elicit pain within the borders of the outer and 
 median third of the right cucullaris muscle. 
 
 Analogous conditions may prevail in acute 
 appendicitis even when the liver is intact and 
 the subdiaphragmatic, subhepatic and pleural 
 cavities are not involved (subhepatic suppura- 
 tions may give rise to pains in the right shoul- 
 der). The patient complains of pain in the 
 iliocecal region when drawing a deep breath. 
 In chronic appendicitis similar pains at times 
 make their appearance, especially in the right
 
 SHOULDER 145 
 
 supraspinate fossa and below the right clavicle. 
 The long continued fever and the emaciating 
 effect on the patient are apt to lead to an erron- 
 eous diagnosis of tuberculosis of the right apex. 
 
 But the pains may be also localized in the 
 left side when the primary affection is in the 
 left lobe of the liver (gumma, carcinoma) with 
 subsequent perihepatitis. 
 
 I include here diseases of the pancreas and of 
 the neck.
 
 Backache 
 
 The term "backache" carries a double mean- 
 ing. In the language of the patient it may 
 mean a pain which is felt either along the whole 
 or nearly whole of the vertebral column, or only 
 in a limited zone or on one side or the other of 
 the spine, that is to say in the region that lies 
 between the loins and the neck. As this book 
 deals with nuchal and scapular pains in separate 
 chapters, the reader will know that the pains 
 described in this chapter affect the district which 
 lies above the lumbar and below the interscapular 
 region. 
 
 Some patients will complain of pains in the 
 back which by other patients are described as 
 pains in the chest. We can easily guess that 
 that really refers to retrosternal pains which 
 belong to the chapter on "Pectoral Pains." 
 
 With these limitations in view we will first of 
 all consider the spine as the seat of pain claim- 
 ing our attention. This includes all the acute 
 and chronic diseases of the osseous part of the 
 column as well as the diffuse affections of the 
 spinal contents, viz., the cord, and its substance 
 and the meninges. 
 
 146
 
 BACK 147 
 
 So far as the acute affections of the different 
 vertebrae themselves are concerned full details 
 are given in the chapter on "Pains in the Sac- 
 rum." 
 
 As a preliminary remark I mention here that 
 a syphilitic vertebral periostitis may well involve 
 the entire spinal column even in an acute fashion 
 thus simulating acute articular rheumatism. So 
 far as the chronic vertebral affections are con- 
 cerned I wish to emphasize the fact that if the 
 whole of the spinal column is comprised in the 
 articular process a very characteristic picture 
 is framed: the physiologic spinal curvatures are 
 missing, the entire column has the appearance 
 of a rigid, straight tube, the patient bends his 
 knee- and hip- joints in order to maintain an 
 upright posture, and the head is pointedly in- 
 clined in a frontal direction. Such a diffuse, 
 chronic articular inflammation of the spine 
 makes us think of a possible ankylosing verte- 
 bral inflammation, of rhizomelia, or arthritis 
 deformans, such as we have already discussed in 
 the chapter on "Pains in the Sacrum," but, be 
 it said, identical conditions may also arise from 
 a gonorrhoic source. The fact that the gonor- 
 rhea happened some time, perhaps some years 
 ago, that the patient is still of youthful age, 
 that the erstwhile gonorrhoic attack was asso- 
 ciated with gonorrhoic arthritis in one joint or 
 another, e.g., in the knee, should always prompt
 
 148 GENERALIZED PAIN 
 
 a positive diagnosis. Perhaps, the day is not 
 far off when the Roentgen-ray will be an ad- 
 junct in such cases. That syphilis is another 
 etiological factor has already been mentioned in 
 the chapter on "Pains in the Sacrum." 
 
 The vertebrae themselves are also a possible 
 focus of pains. Habitual scoliosis claims here 
 our attention, and so do quite a number of mor- 
 bid conditions in the entire osseous skeletal 
 frame. For details see the chapter on "Pains 
 in the Bones." I only mention here passingly, 
 pains in the bony spine or in any part thereof 
 may be occasioned by osteomalacia especially 
 senile by multiple or diffuse neoplasia of the 
 vertebrae as a manifestation ex parte of diffuse 
 osseous neoplasia of primary or secondary origin, 
 also by Kahler's multiple myeloma, but rarely 
 by a late tracheitis or by leucemia. I make these 
 remarks here because primary and at times ex- 
 clusive complaints of these pains are ripe in these 
 cases and may even be accepted as early symp- 
 toms of a disease confined wholly to the spinal 
 region. Remember also that backache combined 
 with pain in the head and in the extremities 
 often of a lancinating character are not infre- 
 quent companions of acromegaly. 
 
 Local pains in the bony spine may be recog- 
 nized from divers objective symptoms, such as 
 deformities in the sense of angular or arcual 
 kyphosis, local painfulness aroused by percus-
 
 BACK 149 
 
 sion or digital tapping, radiating pains in the 
 waistline or in the extremities, pains by sudden 
 pressure on or impaired motility of the spine, 
 the secondary reaction of the disease on the 
 spinal cord and nerve roots, and, last but not 
 least, from the X-ray picture. Upon these 
 foundations we can readily build up the special 
 diagnosis of appurtenant diseases such as tuber- 
 culous spondylitis, neoplasms and syphilis of the 
 vertebrae. 
 
 In chronic tuberculous spondylitis the pains 
 are mostly localized between the dorsal and 
 lumbar or between the cervical and dorsal ver- 
 tebrae. But they may be felt in any other place 
 of the spine and come on when the patient has 
 been standing on his feet or been walking for 
 some time. In the initial stages of the disease 
 we may find very acute local painfulness when 
 we ask the patient to lie down in an arched 
 position, i.e., resting the body on the back of 
 the head and on the heels. Often enough the 
 patient does not succeed in assuming this posture 
 owing to the exceeding painfulness caused by the 
 attempt. Furthermore there is local sensitive- 
 ness on percussion and pressure especially in the 
 spinous processes of the affected vertebrae, also 
 when touched with a hot sponge or the electrode ; 
 there is distinct motoric restriction, exquisite 
 accentuation of pain by sudden brisk pressure 
 on the spine from above, e.g., a jolt on the
 
 150 GENERALIZED PAIN 
 
 shoulder or on the top of the head, and angular 
 kyphosis. The latter does not so clearly mani- 
 fest itself in some, particularly in the lumbar 
 vertebrae and generally only in the form of a 
 diminished physiologic convexity. The X-ray 
 findings and the manifestation of compression 
 of the spinal cord and its membranes and also 
 the intraspinal nerve roots complete the direc- 
 tions for the diagnosis. 
 
 The same symptom complex applies to every 
 other form of spondilitis or caries of the spine. 
 There is a chronic form of spondylitis which re- 
 acts painfully to the aforementioned downward 
 jolt on the shoulder, is accompanied by fever and 
 easily mistaken for Pott's disease. It is due to 
 staphylococcus infection, is of a gummatous, 
 typhoid, posttraumatic or metastatic character, 
 distinguished by central necrosis or abscess of 
 the bones, but rarely of a gonorrhoico-metastatic 
 or actinomycotic nature. Similarly a chronic 
 form of caries with formation of angular ky- 
 phosis the special diagnosis of which can only 
 be made from the combined clinical picture, with 
 the aid of the Roentgen-ray, from the serological 
 reactions and, so far as the actinomycotic state 
 is concerned, through the proof of the latter's 
 pressure in the respiratory tract. Echinococcus 
 and an aortic aneurysm may also attack the 
 spine and cause atrophy or kyphosis in several 
 vertebrae. The X-ray is here "first aid."
 
 BACK 
 
 Spondilitis may set in as an acute affection 
 and run its whole course as such, e.g., staphylo- 
 coccic osteomyelitis, strepto-staphylo-mycosis, or 
 other acute infectious spondylitic conditions of- 
 ten coupled with chills and high fever, local 
 stiffness, local symptoms in the spinal cord and 
 its meninges or nerve roots, or local edema. 
 The diagnosis will be guided by the X-ray, the 
 evidence of previous infection (in acute verte- 
 bral osteomyelitis, for instance, antecedent an- 
 gina or other diseases leading to suppurative 
 metastases) and the co-existence of an acute 
 suppurative osteomyelitis in some other bones. 
 
 But let us remember that a tuberculous spon- 
 dylitis may be, as is often the case, the imme- 
 diate successor of some acute infectious disease. 
 The chronic syphilitic and the actinomycotic 
 forms have the same pernicious habit. But this 
 is also the case in other morbid processes, e.g., 
 in aortic aneurysm which, though it be chronic 
 in its nature, will yet at times suddenly and 
 without apparent provocation arouse very dis- 
 tressing pains in the vertebral bodies. The same 
 conditions prevail also in metastatic vertebral 
 carcinoma. 
 
 It may do no harm to remind the reader that 
 tuberculous spondylitis is capable of attacking 
 the spine in several distinct places at one and 
 the same time, and that arthropathic vertebral 
 inflammations may be formed, e.g., in tabes.
 
 152 GENERALIZED PAIN 
 
 In so far as neoplasms of the spine are con- 
 cerned the internist must know that in sarco- 
 matous conditions of this organ the primary 
 forms prevail, while the secondary forms are 
 more in evidence in carcinomata of the vertebrae. 
 Myeloma and lymphogranuloma are also possi- 
 bilities, but the diagnosis of these two primary 
 neoplasms is more difficult to make than that 
 of the secondary malignant neoplasms (nearly 
 always carcinomatous) for the simple reason 
 that in the latter case the primary neoplasm is 
 capable of definite proof no matter whether the 
 secondary vertebral neoplasm has arisen from 
 a carcinomatous organism adjacent to the spine 
 or originates from a metastatic condition. If 
 the former is the case it may be rather hard in 
 the beginning of the disease to determine whether 
 the pains are really due to a co-affection of the 
 spine itself or only to a compression of the 
 peripheral nerve trunks. I think a satisfactory 
 solution is to be found in radiological examina- 
 tion and with the aid of a correct clinical differ- 
 entiation between a neuritis of the nerve roots 
 and that of the nerve trunks. 
 
 The local manifestations in vertebral neo- 
 plasia are principally the following: marked 
 intensity of the local pains. They are of a 
 boring character and never cease even when the 
 patient is at rest (it is otherwise in caries). The 
 irradiating pains are often accompanied by
 
 BACK 153 
 
 herpes zoster (this does not seem to happen in 
 caries) or by paraplegia dolorosa (an important 
 diagnostic factor). The local pains in the dor- 
 sal vertebrae are felt in neoplasms on the side 
 of the spine, but in caries more laterally in the 
 thorax. In caries and tuberculous spondylitis 
 pressure on and tapping of the spinous processes 
 or a brisk jolt from above stimulate the pain, 
 while in neoplasia deep pressure laterally from 
 the spinous processes has this effect. In caries 
 there is angular kyphosis, in neoplasia it is if 
 any at all of an arcuary form, that is to say 
 several vertebrae become evenly prominent. 
 
 It is not necessary to consider here other 
 primary tuberculous affections such as enlarge- 
 ments or scars of the glands, abscesses in de- 
 pendent parts, or the age of the patient, all of 
 which are factors of interest in caries. 
 
 The metastatic vertebral carcinomata are by 
 far the most common forms among the neo- 
 plasms of the spine and are from the diagnostic 
 standpoint of interest insofar as they, like the 
 primary new growths, escape recognition, espe- 
 cially in the thyreoid glands, in the ovaries, in the 
 kidneys (hypernephroma) and the suprarenal 
 capsules, in the prostate, sometimes also in the 
 mamma or in the testicles. Unless we find 
 additional affections of the bones (multiple 
 primary tumors, e.g., myeloma, or multiple 
 metastatases) the diagnosis is ever restricted to
 
 154 GENERALIZED PAIN 
 
 the aforementioned manifestations and to the 
 X-ray. 
 
 In these cases errors are bound to slip in in 
 the identification of neoplasms of the spine and 
 arthritic affections of the vertebrae, the anky- 
 lopoietic spondylarthritis or deforming arthritis. 
 And this is more likely to happen when the 
 patient is suffering also from a deforming osteo- 
 arthritis of some standing and complains of aches 
 in the back and spine. We shall be enlightened 
 by the milder intensity of the pains, by the 
 predominancy of the rigidity over the pains, 
 and above all by the X-ray picture. The blood 
 test and the more rapid appearance and prog- 
 ress of the vertebral neoplasm are also telling 
 factors. This is preeminently so when an ap- 
 parent vertebral tumor arises from a chloroma. 
 
 Uric arthritis in the appropriate vertebral 
 joints must not be forgotten. It may be 
 preceded by gouty changes in other joints (po- 
 dagra, etc. ) , yet this disease, may under circum- 
 stances, be the first manifestation of the morbid 
 condition. Look for retarded nucleic metab- 
 olism as the final means for a correct diagnosis. 
 
 Diseases of the adjoining ribs and of the 
 spinal contents are further causes of backache. 
 Pains which occupy the whole or at least the 
 largest part of the back are not infrequently 
 the initial symptom of acute as well as chronic 
 diffuse intrasjnnal morbid conditions, not only
 
 BACK 155 
 
 of the meninges but also of the very substance 
 of the spinal cord, for instance, in acute polio- 
 myelitis or multiple sclerosis. In pellagra the 
 same observation can be made, although in this 
 ailment the pains are sometimes only felt in the 
 scapular region, no doubt as a reflex action of 
 the toxin on the central nervous system. 
 
 Acute spinal meningitis belongs to this series. 
 The chronic, above all the postraumatic, serous 
 forms, it must be mentioned, often lack entirely 
 all the typical meningitic symptoms and travel 
 under the mask of neurasthenia; but the diag- 
 nosis can secure evidence from the complaint 
 of headache, backache, vertigo, abnormal excita- 
 bility and psychic moodiness, coupled with the 
 proof of increased pressure in the spinal fluid. 
 
 Encroaching diseases of the brain that raise 
 the intraspinal pressure of the fluid, especially 
 when situated in the occipital fossa, produce 
 pains within the nape of the neck and in the 
 back. Acromegaly has the same failing. 
 
 Myxedema arouses pain in the sense of rachi- 
 algia: extreme tired feeling, especially in the 
 early morning hours, heaviness and pain in the 
 extremities, menstrual disturbances (menor- 
 rhagia, amenorrhea), chills, subnormal tempera- 
 ture, hoarseness and obstinate constipation are 
 the predominant signs. 
 
 Any kind of irritation of the posterior roots 
 of the spinal cord is bound to react with a pain- 

 
 156 GENERALIZED PAIN 
 
 ful effect on the back. These pains are of an 
 encircling nature such as is described in the 
 chapter of "Pains in the Chest." If the pains 
 are confined to the level of a certain vertebra 
 we must bear in mind that they may originate 
 just as well from the bony part as from the 
 inter vertebral foramina, the spinal canal or the 
 spinal cord itself, or may also be due to a pri- 
 mary affection of the spinal ganglion (herpes 
 zoster). The pains may set in in an acute 
 fashion (poliomyelitis, myelitis, multiple sclero- 
 sis, hematomyelia, thrombosis or emboly), or 
 may also take a decidedly chronic course. They 
 are felt as a rule on both sides, but with excep- 
 tions. We must be guided by the seat and 
 development of the causative factor. 
 
 A purely functional neurosis provokes pain 
 in any isolated place or in several places or also 
 in the entire spinal column (in the whole of the 
 back). Such a rachialgia or spinal irritation is 
 simply a manifestation in part of an hysterical 
 or neurasthenic disease of the whole nervous 
 system. Insofar as the spinal irritation is con- 
 cerned we must not only expect a feeling of 
 painful fatigue, but also an affection of several 
 vertebrae and a strongly marked, often exces- 
 sive hyperesthesia or a hyperalgesia of the skin 
 over the stricken vertebral zone. The softest 
 touch is extremely painful, much more so than 
 a prolonged, increasing, deep pressure. The
 
 BACK 157 
 
 slightest movement of a cold or hot sponge or 
 the application of an ever so weak electric cur- 
 rent over the affected part produces a most 
 violently painful sensation. 
 
 The rachialgic pain in hysteria is characterized 
 by the fact that, when the attention of the pa- 
 tient is diverted, it abates or vanishes altogether. 
 Yet, for practical purposes this symptom is not 
 always applicable, for the reason that there are 
 many other anatomical lesions which respond in 
 a similar fashion, especially when associated with 
 neurotic conditions. 
 
 Owing to the abnormal vascular irritability 
 in spinal irritation we often find in the painful 
 zone a marked vasodilatatation to even a slight 
 mechanical stimulus (vasomotoric paresis!) and 
 vice versa also generalized vasomotoric mani- 
 festations in the sense of swooning seizures, in 
 rachialgia and hysteria, also cerebral convulsions. 
 In accordance with the individual neurotic con- 
 stitution of the patient we may also observe 
 other concomitant vaso-sympathetic manifesta- 
 tions such as abnormal pallor, dizziness, palpita- 
 tion of the heart, nausea, vomiting, polyuria, etc. 
 The neurasthenic and hysteric stigmata of the 
 patient are further adjuvants of a correct diag- 
 nosis. 
 
 Nevertheless, it is sometimes rather difficult 
 to separate such a purely functional disturbance 
 from an initial anatomical lesion, principally
 
 158 GENERALIZED PAIN 
 
 from an incipient vertebral caries, because rachi- 
 algia, or else spinal irritation may under circum- 
 stances be the only symptom of the existing 
 neurosis, despite the fact that it is confined to 
 one solitary vertebra. In such doubtful cases, 
 especially when a deformity is not yet apparent 
 in the spine, much help will come to us from 
 the consideration of the following points: in 
 neurosis the superficial touch is more painful 
 than deep pressure, in the anatomical lesion 
 (spondylitis) the intensity of the pain is in pro- 
 portion to that of the pressure; in spinal irri- 
 tation the attack affects several vertebrae and 
 pressure and tapping are felt in like measure 
 in each of them, in spondylitis and new growths 
 only one vertebra is sensitive (but not necessarily 
 so). In spinal irritation and in rachialgia there 
 is no locomotoric spinal restriction, on the con- 
 trary movement and diverting of attention ease 
 the pain, although this may be the case also in 
 rachialgia in which even cutaneous hyperalgesia 
 is at times missing. This naturally complicates 
 the differential diagnosis again. But if the 
 patient finds momentary relief from pain when 
 lying flat on his back despite spinal motoric 
 impairment, we can safely decide in favor of 
 rachialgia. Nevertheless, the same phenomenon 
 is apt to occur in tuberculous spondylitis. Other- 
 wise only protracted observation and the Roent- 
 gen-ray will furnish the necessary evidence.
 
 BACK 159 
 
 There is still another point which we must 
 bear in mind, viz., that it is by no means im- 
 possible for tuberculous spondylitis developing 
 from hysteria; likewise that the presence of an 
 abscess in a dependent part indicates vertebral 
 caries, although in the latter instance even a 
 clever diagnostician may be misled when dealing 
 with a case of hysterical rachialgia in which a 
 reflex muscular contraction simulates an abscess 
 in a dependent part. 
 
 Kiimmel's disease is sometimes erroneously 
 taken for a traumatic neurosis. The nosological 
 status of this traumatic spondylopaihia is not 
 yet quite clear to me. Some authors refer to 
 it as a rarefying spondylitis, others as a frac- 
 ture of the vertebra, or an infarction or a soften- 
 ing of the intervertebral cartilage. Perhaps the 
 X-ray will eventually clear up the situation. 
 
 Pains in the back and also in the sacrum 
 which interfere with occupational pursuits are 
 frequently the initial symptoms of dementia 
 precox in youthful persons. Observation by an 
 experienced psychiatrist is here called for. 
 
 Of course, backache is the logical sequel of 
 scapular affections which in their turn may be 
 merely an extension of any acute or chronic 
 inflammatory process in the ribs or spine. I 
 refer to acute osteomyelitis, typhoid or tuber- 
 culous osteoperiostitis and to primary or meta- 
 static neoplasmata of the shoulder blades. Their
 
 160 GENERALIZED PAIN 
 
 symptoms are fully described under the head- 
 ings of diseases of the ribs and spine and in the 
 chapter "Pains in the Bones." 
 
 Diseases of the dorsal muscles see also 
 "Pains in the Shoulder" are either of rheu- 
 matic or infectious toxic (influenza, Weil's dis- 
 ease) or myositic (nocturnal backache in syphi- 
 litic myositis) or metastatic neoplastic origin. 
 That backaches are caused by them goes without 
 saying. These local pains are also due to fatigue 
 in chlorosis, anemia, asthenia and orthotic albu- 
 minuria, or to overexertion in emphysema (re- 
 current, exasperating coughing). We must add 
 trichinosis and tetanus when the dorsal muscles, 
 especially the extensor dorsi, are involved. Epi- 
 demic cerebro-spinal meningitis belongs here also. 
 
 I have already mentioned under "Pains in the 
 Neck" that backache and nuchal pains may be 
 occasioned by septic infections or toxic injuries 
 of the muscles. 
 
 In the chapter on "Lumbalgia" I have like- 
 wise referred to the painful affection of the 
 dorsal muscles caused by sclerosis of the arteries 
 of the lumbar muscles. When resting, the pa- 
 tient is at ease, but when he goes into action 
 the pains in the lumbar region set in either on 
 one or both sides, coupled with stiffness and 
 weakness in the muscular tract. These pains 
 radiate in a frontal direction towards the twelfth 
 rib and the iliac crest, but there is no local
 
 BACK 161 
 
 sensitiveness on percussion, neither is there mo- 
 toric inhibition in the spine. The cause for this 
 lies in sclerosis of the arteries of the lumbar 
 muscles or that of the abdominal aorta, or an 
 aneurysm of the latter. 
 
 There is a form of spinal intermittent lame- 
 ness, which is due to sclerosis of the arteries of 
 the spinal cord. We can distinguish it from 
 the commoner peripheral form of intermittent 
 claudication by its peripheral arterial pulse and 
 by the infrequency of pain in the extremities. 
 The patient will, but not of necessity, complain 
 of pains in the back, which are felt in walking 
 but disappear when the limbs are at rest. The 
 legs feel weak and show increased tendon reflex. 
 The patient shows the Babinski sign, later spas- 
 tic paresis and bladder and rectal troubles. 
 
 In order not to repeat myself, I refer the 
 reader to the sections on "Pains in the Sacrum, 
 in the Extremities, Shoulders and Muscles," in- 
 sofar as the intercostal nerves, lymphatic glands, 
 synovial sacs, and also the skin of the back are 
 here concerned. I will only mention tubercu- 
 lous diseases of the bronchial glands as factors 
 causing backache and interscapular pains. Lo- 
 calized erythromelalgia, although a rare disease, 
 is another link in this chain. 
 
 In posterior mediastinal pUuritis the pain is 
 felt along the whole length of the dorsal spine, 
 including the interscapular region, no matter
 
 162 GENERALIZED PAIN 
 
 whether it is of a suppurating, serous or fibrin- 
 ous nature. The latter may be recognized by 
 a pleural friction noise, the other two by tender- 
 ness in the spinous processes of the upper and 
 median dorsal column and by an ascending 
 streaky dullness in the left transverse processes. 
 In further extension of the disease the breathing 
 is diminished, suppressed or stertorous, some- 
 times there is egophony; we also find symptoms 
 of mediastinal compression, e.g., of the trachea, 
 dislocation of the trachea and of the larynx to 
 the right, paralysis of the recurrent nerve, diffi- 
 culty in swallowing, convulsive coughing, dys- 
 pnea, constriction in the branchial portion of 
 the vena cava or the azygos vein, inspiratory 
 constriction of the intercostal spaces and of the 
 thoracic fossae, chills and high fever, and later 
 on expectoration of fetid sputum due to per- 
 foration of the pleural abscesses in the larger 
 air passages. The Roentgenogram shows a dis- 
 tinct dark line along the spinal column. 
 
 Posterior acute purulent mediastirutis pro- 
 duces lateral pains of the spinal column. The 
 general septic aspect, mediastinal irritation, con- 
 sideration of the causal element and the X-ray 
 are the essential requisites for establishing a 
 proper diagnosis. In pulmonary tuberculosis 
 this disease runs a rather insidious course. We 
 notice pains in the back and chest, sub febrile 
 temperature, anemia, emaciation and profuse
 
 BACK 163 
 
 sweating. The X-ray can be applied in the 
 fibrinous form only. 
 
 Indurated mediastinitis seems to confine itself 
 to dorsal pains. (See chapter on "Shoulder 
 Pains.") 
 
 Backache of lesser intensity, but coupled with 
 preponderating retrosternal pains, may be ob- 
 served occasionally in bronchial asthma. 
 
 Backaches in the region of the dorsal spine, 
 with irradiations in the armpit and nipple, and 
 in the arm itself, should remind us of a morbid 
 condition in the thoracic aorta such as arterio- 
 sclerosis, chronic aortitis, especially syphilitic, or 
 an aneurysm; also of a deep-seated, painful 
 affection of the esophagus, chiefly of a carci- 
 nomatous character. 
 
 A rupture of the thoracic aorta is heralded 
 by a most violent pain in the back in the zone 
 of the dorsal spine. It comes on very suddenly 
 and early death ensues. 
 
 If the pain is located between the tenth and 
 twelfth dorsal vertebra, it is definitely due to 
 some trouble in the thoracic descending aorta, 
 i.e., aneurysm. 
 
 Pain to the left or right side of the lower 
 dorsal column is a frequent manifestation of a 
 recent basal pleuritis, and therefore also indi- 
 rectly a sign of various diseases of the lungs 
 and other subdiaphragmatic or even more dis- 
 tant organs which give rise to such a pleuritis.
 
 164 GENERALIZED PAIN 
 
 But there is a form of dry pleuritis which is 
 strictly localized and essentially insidious in its 
 nature and for that reason very hard to recog- 
 nize. Only a post mortem will reveal the origi- 
 nating cause which may be a small abscess in 
 the lung or a bronchial carcinoma. 
 
 Both basal adhesive and diaphragmatic pleu- 
 ritis are pregnant with pains in the back. (Cf. 
 my book on ''Abdominal Pain," Rebman Com- 
 pany, New York.) 
 
 These pains are also a common sign, indeed 
 the initial sign of some pulmonary infarct preced- 
 ing by hours or even days the characteristic 
 bloody sputum and the other physical local mani- 
 festations. Only Mahler's sign, the presence of 
 slight and brief rises in the temperature after a 
 chill and the finding of the source from which the 
 infarction arises can make the diagnosis positive. 
 
 Gastric affections make their presence known 
 by pains in the level of the loicer dorsal vertebrae, 
 specially on the left side of the spine even before 
 the patient begins to complain of the usual dys- 
 peptic or gastric troubles. 
 
 But when these pains reach up to the eighth 
 vertebra they constitute the one and only absolute 
 though not always reliable sign of an exist- 
 ing carcinoma or ulcer in the posterior gastric 
 parietes. They are by no means dependent on 
 the quality or quantity of the food consumed, 
 but rather influenced by the position or physical
 
 BACK 165 
 
 movements of the body. There is no tenderness 
 to touch in the epigastric region, but frequently 
 we find hyperesthesia of the skin or of the spin- 
 ous processes sometimes only one vertebra is in- 
 volvedin the affected area. The pains resemble 
 at times in kind and intensity those observed in 
 caries. In some cases of ulcer in the pit of the 
 stomach they make the impression of intercostal 
 neuralgia emanating from behind the lower ribs 
 to the left of the median line. A genuine case of 
 ulcus or carcinoma ventriculi! A combination 
 of pains in the back and in the epigastrium 
 strengthens the diagnosis which can be made posi- 
 tive only by chemical and bacteriological examin- 
 ation of the gastric contents, of the feces for 
 occult hemorrhage, and by the Roentgen-ray. 
 
 There is still a different kind of backache 
 which occurs in gastric ulcer, but even more so 
 in carcinoma of the stomach. It may set in at 
 the very beginning of, or develop gradually dur- 
 ing the run of the disease. We hear the patient 
 complain of periodic attacks of very severe pains, 
 similar to tabetic crises. They persist for hours 
 especially in the dorsal position and are apt to 
 radiate into one or more of the lower left inter- 
 costal spaces or to spread fanlike over the lower 
 abdominal region. Practically speaking we are 
 justified in accepting these pains as a symptom 
 of a progressive carcinomatous metastasis in the 
 retroperitoneal glands, a carcinomatous prolifer-
 
 166 GENERALIZED PAIN 
 
 ation in the paravertebral tissues, a constriction 
 of the local intercostal nerves, or a direct invasion 
 of the pancreas by an ulcus or carcinoma ventri- 
 culi (ulcus penetrans). There is also the possi- 
 bility of an indurated growth expanding into the 
 retroperitoneal region. Similar conditions may 
 be occasioned by other localized primary diseases 
 of the duodenum or the pancreas, etc. Vertebral 
 affections, however, such as metastasis, do not 
 occur. This fact combined with a careful X-ray 
 examination should lead to definite conclusions. 
 Periodic or constant backache, though variable 
 in intensity, in the region of the last dorsal ver- 
 tebra to the right of the spinal column is a 
 definite sign of liver complaint, principally chole- 
 lithiasis of the gallbladder and acute as well as 
 chronic cholecystitis, in rare cases also of a gall- 
 stone that has been lodged in the ductus chole- 
 dochus above the ampulla of Vater. The patient 
 complains of pains in the back when leaning over 
 or wearing a tight belt (sword belt) , when stand- 
 ing erect for a while, or when sitting for some- 
 time in which latter position he finds relief by 
 pressing the body hard against the back of the 
 chair. We find tenderness to pressure and per- 
 cussion in the affected zone, very likely also in 
 the spinous processes of the 8.-10. dorsal ver- 
 tebra, hyperesthesia and hyperalgesia of the skin, 
 tenderness in the region of the hepatic fissure, 
 palpable changes in the liver or the gallbladder,
 
 BACK 167 
 
 demonstrable urobiligenuria (urobilinuria) and 
 itching of the skin. The proper contemplation 
 of this symptom complex together with the 
 anamnesis ought to forestall any possible error 
 in the diagnosis. 
 
 The same means for recognizing the disease 
 are applicable in other forms of cholelithiasis 
 (cholecystitis) except that the pains follow a 
 track which is the reverse of that indicated above. 
 The patient tells you that the pains start in the 
 nape on a level with and also in the shoulder 
 sometimes on the right, sometimes on both sides ; 
 thence they travel down the back along the dor- 
 sal spine as far as the apex of the liver where 
 they branch off into the gastric region. In some 
 cases they are continuous, in others they come 
 in isolated attacks, and may also be accompanied 
 by the feeling of weight and fullness in the 
 stomach. I saw a case in which these attacks 
 occurred every second night. In another patient, 
 a woman, the pains arose from the level of the 
 liver, ascended on both sides of the spine into the 
 shoulders and deflected thence either into both 
 breasts, or by change into the nape, the arms 
 and the chin. How difficult to separate from a 
 stenocardia! 
 
 If certain conditions such as described in 
 "Abdominal Pain" prevail, the pains arise in the 
 left side of the spine at the hepatic level. In 
 other words : the irradiation is erratic in its action.
 
 168 GENERALIZED PAIN 
 
 This caste of pains should put us in mind of 
 a possible duodenal ulcer in the male, or of a 
 duodenal carcinoma in either sex. The intake 
 of cold food or drink arouses or increases them. 
 All the other diseases which exhibit themselves 
 at the gate of the liver belong here, e.g. appen- 
 dicitis when the appendix is deflected in this 
 direction, for in all of them this particular por- 
 tion of the retroperitoneal space is involved. 
 
 With the same force all this applies to every 
 painful Uver complaint as well as to the whole 
 category of retroperitoneal growths below the 
 diaphragm (pancreas, abdominal and celiac 
 aorta, retroperitoneal glands, every form of sub- 
 diaphragmatic pleuritis, in which we must also 
 look out for tenderness in the spinous processes. 
 For particulars consult "Abdominal Pain," also 
 for mesenteric diseases and volvulus of the small 
 intestine. 
 
 When sudden, very vicious pains in the back 
 with collapse are witnessed, look for a perfora- 
 tion of the stomach or of the small intestine, even 
 though the abdominal symptoms (pain and 
 vomiting) should be missing altogether or be of 
 an uncertain nature (e.g. vomiting occurs also 
 in diseases of the pectoral organs). Howsome- 
 ever, true guides are found in the tension of the 
 abdominal muscles, the indrawn abdomen, the 
 exclusively thoracic breathing and the final col- 
 lapse.
 
 Pains in the Neck 
 
 This chapter is devoted to the pains occurring 
 in the restricted portion of the body which con- 
 nects the head with the trunk. This includes 
 the region of the inferior maxilla as far as the 
 jugular and supraclavicular fossa. 
 
 The first disease that engages our attention 
 is cervical myalgia localized in the sternocleido- 
 mastoid and also in the deeper cervical muscles. 
 When sudden pains set in after taking cold or 
 an unexpected drenching, we more than likely 
 are dealing with rheumatic myalgia and its after- 
 effects, i.e. caput obstipum (wry-neck, torticol- 
 lis) easily recognized by the etiology and the 
 local tenderness of the superficial muscles, espe- 
 cially of the sternocleidomastoid. However, 
 pain may be also reflected in the latter by a 
 morbid process in the cervical lymphatic glands 
 in which case a false diagnosis can easily deploy. 
 This may be obviated by ascertaining whether 
 the local tenderness is in the muscle itself or 
 rather lies in the deeper tissues beyond it. More- 
 over, we should bear in mind that stiffness in 
 the neck is often the reflex action of an irritation 
 in the sensible roots of the cervical muscles due 
 to some morbid process in the vertebrae, e.g. 
 
 169
 
 170 GENERALIZED PAIN 
 
 neoplasm or spondylitis, or else of the spinal 
 contents. 
 
 Polymyositis and dermatomyositis deserve 
 mention here as originators of pain in the nuchal, 
 dorsal and cervical muscles, causing also serious 
 trouble in deglutition. In trichinosis the pres- 
 ence of eosinophiles in the blood should clear 
 the view. In muscular gummata we find an 
 indolent, typically nocturnal pain. The differ- 
 ential diagnosis from carcinoma depends on the 
 outcome of the iodide test and on serological 
 reaction. 
 
 Pains in the cervical and nuchal muscles very 
 often follow an attack of influenza, the same as 
 they appear also in the thighs and calves, no 
 doubt due to myalgia or myositis. Fever with 
 leucocytosis and pains in the eye muscles are 
 typical companions. 
 
 The commonest source of pains in the neck 
 we find in diseases of the lymphatic glands and 
 vessels, in fact, in all acute affections of the face, 
 the oral and faucial cavities, the pyriform sinus, 
 the upper esophagus and the cervical spine, no 
 matter whether they are of infectious, traumatic, 
 toxic or thermic origin. These glandular en- 
 largements are present in all forms of cynanche, 
 as an indication of scarlatina but a contraindica- 
 tion of diphtheria. The plague infects the skin 
 of the face, the oral and pharyngeal cavities, the 
 mucous membrane of the nose, covers the in-
 
 NECK 
 
 ferior maxilla and the whole of the neck with 
 buboes which fuse into a solid edematous mass 
 very painful to pressure so long as the patient 
 retains consciousness. We find the same glandu- 
 lar swellings as accompanying signs in all forms 
 of periostitis and stomatitis (mercurial) with 
 pains in the neck as the logical result. 
 
 In acute leucemia, glandular enlargements in 
 the inferior maxilla and in the neck should be 
 looked for as a common but not regular initial 
 symptom. But more about this in another place. 
 
 What seems to me of moment is the fact that 
 these acute glandular swellings play in some 
 cases a quite independent role, because the pri- 
 mary port of entry of the infection has either 
 not yet been discovered or only comes into evi- 
 dence after the enlargement of the glands is 
 already fully developed. If the former is the 
 case, we should be on the lookout for acute 
 swellings of the whole glandular complex which 
 belongs to the periphery of the inferior maxilla, 
 the neck, behind the sternocleidomastoid and in 
 front of the cucullaris muscle, all the way from 
 the occiput to the clavicle. This totality of 
 symptoms combined with high temperature and 
 a general feeling of illness is recognized by some 
 authors as a disease per se and is yclept "glandu- 
 lar fever/' I do not share this opinion, but 
 incline rather to the belief that we are dealing 
 with an infection that emanates from the phar-
 
 172 GENERALIZED PAIN 
 
 yngeal or tonsillar region and escapes our at- 
 tention for the want of closer inspection. While 
 these conditions prevail principally in children, 
 they may be also observed in adults. 
 
 There is a number of tonsillar affections which 
 radiate into the adjacent lymphatic system of 
 the neck. They come under our notice only 
 when we suddenly discover sensitive dilatations 
 in the cervical glands, while the primary tonsilitis 
 remains in hiding until we question the patient 
 about difficulty in swallowing. In fact, there 
 are cases in which the causative factor has sim- 
 ply passed through the lymphatic apparatus 
 without leaving a trace of infection in it. If we 
 bear this well in mind we may often enough 
 find the key to the origin of many a septic 
 affection, even of an etiologically enigmatical 
 endocarditis, of acute nephritis or apparently 
 acute articular rheumatism without reaction to 
 salicylic drugs with or without purpura or ery- 
 thema nodosum. 
 
 Analogous conditions are prevalent in acute 
 appendicitis. I have seen cases in which the 
 typical symptoms of appendicitis were accom- 
 panied by slightly sensitive enlargements of the 
 cervical glands with a reddish hue in the tonsils, 
 and dysphagia. In such instances not only the 
 lateral cervical glands are involved, but also 
 those which are situated between the margin of 
 the sternocleidomastoid and the hvoid bone.
 
 NECK 173 
 
 On the other hand, it is also possible for the 
 primary disease to become demonstrable only two 
 to three days after the swelling in the appur- 
 tenant glands has already manifested itself. We 
 hear the patient complain of pain in the neck 
 when he turns his head to one side, thus inviting 
 the diagnosis of rheumatism in the local muscles. 
 A careful scrutiny leads to the discovery that 
 the seat of the pain is really in the muscular 
 processes and a true diagnosis of tonsillitis or 
 lymphadenitis is the result. 
 
 Of similar importance is that acute glandular 
 swellings, no matter whether they be spontane- 
 ously painful or only sensitive on pressure, under 
 the inferior maxilla or in the neck, ever remind 
 us of the possible existence of erysipelas, espe- 
 cially in the rhinitic zone. I have seen patients 
 in whom such an apparently independent glan- 
 dular swelling existed for twenty-four hours, 
 with fluctuating temperature, light headache and 
 scarcely noticeable disturbance in the general 
 conditions. But on the following day the outer 
 surface of the ala nasi betrayed the existence of 
 erysipelas. Rhinoscopy is the proper adjuvant 
 in such cases. 
 
 If we are confronted by chronic enlargements 
 of the lymphatic glands of the neck and the 
 inferior maxilla we must make the same careful 
 examination as described above. If this leaves 
 us still in doubt, we must inspect the oral 

 
 174 GENERALIZED PAIN 
 
 cavities and the scalp (eczema, pediculosis) for 
 the causative factor. These glandular swellings 
 are sometimes the first and most useful symp- 
 tom of a tumor at the base of the skull. 
 
 On the other hand, they may form a part of 
 the manifestations of a multiple or universal 
 glandular infection, such as occurs in syphilis, 
 scrofulous tuberculosis, strumous buboes, leu- 
 cemia, aleucemia and in lymphogranulomatous 
 and lymphosarcomatous conditions. Strictly 
 speaking, these affections do not belong here, 
 for as a rule they are not of a painful nature. 
 But I will add to the foregoing that the en- 
 largement of the cervical and inferior maxillary 
 glands may be a pathological condition per se, 
 and thus present a primary and independent 
 disease. If that is the case the diagnosis will 
 waver between lymphosarcoma or lymphogranu- 
 loma and tuberculous lymphoma. In any case, 
 the patient complains of an unpleasant feeling 
 of tension, slight pain in the glands, and in 
 tuberculous lymphoma of tenderness to touch. 
 However, more about this in the passage deal- 
 ing with "Glandular Swellings." 
 
 Phlegmons of the cervical cellular tissue are 
 by their very nature of a painful character. 
 They are by far the commonest results of in- 
 fectious inflammatory processes in the cervical 
 glands, for which reason a painstaking scrutiny 
 must be made of the oral, pharyngeal and nasal
 
 NECK 175 
 
 (accessory) cavities, of the ear, the upper re- 
 gion of the larynx and esophagus and the 
 thyreoid glands. The diagnosis should be obvi- 
 ous, even if, owing to adenitis or periadenitis, 
 we find a diffuse swelling in the affected cervical 
 region, together with reddening or a livid ap- 
 pearance of the skin, or perhaps fluctuation. 
 Nevertheless, the manifestations are not always 
 so plain. In fact, the most severe cases of 
 diffuse extension of the phlegmon do not show 
 them at all. Here the existing pain must guide 
 the diagnostician. His practised eye may be 
 able to detect a slight swelling and a scarcely 
 perceptible change in the skin. But it is the 
 manifest general symptoms, such as local fever 
 with almost normal body temperature, that con- 
 duct us to the discernment of the phlegmonous 
 conditions which are chiefly due to streptococcic 
 influences. 
 
 Angina Ludovid is a subordinate form of 
 cervical phlegmon, and owing to its proximity 
 to the larynx (edema of the glottis) is of a 
 dangerous character. It concerns the surgeon. 
 
 There is another form of cervical phlegmon 
 which also belongs in the domain of surgery, 
 but nevertheless is of interest to the internist. 
 I mean the actinomycotic phlegmon. It is easily 
 recognized if it is due to a carious tooth or 
 some morbid affection of the jaws. But it may 
 also originate in the adjacent cellular tissue of
 
 176 GENERALIZED PAIN 
 
 the neck. In both cases it is characterized by 
 a subacute or chronic course, trifling painfulness 
 and sensitiveness in the phlegmonous infiltration, 
 which is rigid and of irregular shape. Bluish- 
 red abscesses with a characteristic serous or 
 sero-purulent secretion and fistulous perfora- 
 tions are formed. In acute attacks, which are 
 not so uncommon, the formation of granulating 
 tumors and pus proceeds rapidly. This is sig- 
 nificant for the internist, as it indicates from 
 which direction the disease is descending into 
 the mediastinum or ascending into the cerebral 
 region. 
 
 Just the opposite direction is taken by the 
 diplococcus infection in pneumonia, i.e., the pro- 
 cess travels from the thoracic focus upwards 
 into the lymphatic vessels and cellular tissues 
 of the neck until it reaches the meninges. In 
 croupous pneumonia the diplococcus develops a 
 purulent meningitis. Few patients complain of 
 spontaneous pain in the neck, although some 
 tenderness in the intersternocleidomastoid region 
 is always observable. 
 
 It goes without saying that every form of 
 acute ascending mediastinitis is ripe with pains 
 in the neck. The inflammatory, suppurative 
 process generally deploys from the left supra- 
 clavicular fossa, although the incissura sterni 
 jugularis sometimes forms another gate. The 
 diagnosis is plainly staked out by the following
 
 NECK 177 
 
 tokens: the pains are felt behind the sternum, 
 whence they radiate into the back between the 
 shoulder blades and into the nape of the neck; 
 there is dysphagia, fever and generalized sepsis; 
 we find a primary affection in the adjacent 
 bones (ribs, vertebra) or in the neighboring 
 organs, such as the esophagus, trachea, lungs, 
 pleura, or in the abdomen (inflammatory sub- 
 diaphragmatic growths), or an edema in the 
 skin of the neck or above the sternum, and gas 
 formation in subcutaneous emphysema. 
 
 An acute inflammation of the submcurillary 
 glands is likewise a frequent cause of pains in 
 the neck which may reach a very high degree 
 of intensity when pus forms in the affected 
 glands occasioned by leucemia or leucemic 
 stomatitis. 
 
 There is hardly any appreciable pain in epi- 
 demic parotitis, though the swollen submaxillary 
 glands are sensitive to touch. When the en- 
 largement of the parotid as is usually the case 
 antedates that of the submaxillary glands the 
 diagnosis is self-evident. In this connection it 
 is worth while to remember that the infection 
 at times reaches the submaxillary ahead of the 
 auricular salivary glands, or may not even im- 
 plicate the latter at all. When this happens 
 at the beginning of an epidemic before typical 
 cases of mumps have developed the diagnosis 
 may be subject to errors, especially so if only
 
 178 GENERALIZED PAIN 
 
 one of the thyreoids is as yet involved. The 
 presence of fever or a general indisposition are 
 not much of help. But the diagnosis can be 
 made positive when the ovaries or testicles evince 
 tenderness on pressure. A blood test for eosin- 
 ophiles is also advised. 
 
 Inflammation of the thyreoid glands, puru- 
 lent as well as non-purulent (thyreoiditis or 
 strumitis), is heralded by pains in the neck and 
 when swallowing. Casually chills and fever 
 are initial symptoms. But the determinating 
 signs are swelling and painfulness in the thy- 
 reoid, or in a part thereof, the fact that the 
 pains radiate towards the head and the as- 
 cending swelling causes dysphagia. The in- 
 flammation soon establishes itself as a genuine 
 disease, supposedly through an infection of the 
 trachea or fauces the lymphatic and blood 
 vessels acting as carriers or it may be (when 
 afebrile) the drug reaction of iodide. It may 
 also be the expression of a generalized infec- 
 tion which has centered in the thyreoids, the 
 causative factors being the bacillus coli or other 
 pus-producing bacteria. 
 
 On the other hand, an inflamed thyreoid is 
 often merely a partial symptom of some fully 
 developed infectious disease; in other words, a 
 reflex of typhoid, pneumonia, erysipelas, sepsis, 
 pyemia, influenza, dysentery, malaria, cholera, 
 tuberculosis or syphilis. In a series of cases
 
 NECK 179 
 
 the inflammation and casual suppuration estab- 
 lished themselves in some section of the hitherto 
 normal tissue of the thyreoid gland in the nature 
 of an acute thyreoiditis. But when under this 
 condition the gland has already undergone goi- 
 trous changes, the pains are due to acute stru- 
 mitis. In rare cases a local hematoma of long 
 standing may be the exciting element, and lead 
 to a false diagnosis of carcinoma. 
 
 To the internist the secondary forms of thy- 
 reoiditis and strumitis are of great interest. As 
 they are mainly after-effects of some acute dis- 
 ease, for instance typhoid, a sharp eye must be 
 kept on the thyreoid glands which are the 
 favorite place for the colonization of the typhoid 
 bacillus. 
 
 Owing to the great similarity of the initial 
 symptoms in both diseases, these thyreoid affec- 
 tions are often mistaken for angina. Only a 
 very thorough examination of the patient can 
 prevent such an error. I mention here also that 
 Baxedow's disease may be the upshot of acute 
 thyreoiditis or strumitis. 
 
 Whenever we find in a patient an enlarged, 
 goiterlike and painful thyreoid gland, we must 
 look for a neoplasm, mainly a carcinoma. Rapid 
 extension and hardening of the growth, emacia- 
 tion and the anemic look of the patient point to 
 sarcoma in younger people, but to carcinoma in 
 older folks. The diagnosis will be confirmed by
 
 180 GENERALIZED PAIN 
 
 the rapid spread of the tumor, the fixation of 
 the thyreoid gland, when it cannot be moved 
 about by the examining hand, when the lateral 
 cervical nerve and vessels appear compressed, 
 and when dyspnea and dysphagia are present. 
 Nevertheless, it is sometimes difficult to dif- 
 ferentiate between strumitis and hemorrhage in 
 the struma or neoplasm, because high tempera- 
 ture, leucocytosis, pains, swelling, dyspnea and 
 dysphagia are all common symptoms. Yet it 
 seems to me that in strumitis the fever is higher 
 and the secondary character of the disease as 
 well as the local and general inflammatory 
 changes are demonstrable. For the diagnosis 
 of hemorrhage is of importance that the tumor 
 spreads with phenomenal rapidity for several 
 hours, comes to a standstill, and then gradually 
 recedes. 
 
 The Bloodvessels and Nerves as Irritating 
 Factors 
 
 Under this heading I mention first of all the 
 arteries. We can hardly speak here of real 
 pain. It is rather an aching tension or pressure, 
 an uncomfortable feeling which is produced by 
 any sclerotic or arteritic change in the coating 
 of the arteries, especially when the cardiac ac- 
 tion is accelerated. Attacks of genuine, some- 
 times very intensive pain along the line of the 
 carotids are rather attributable to some primary
 
 NECK 181 
 
 disease such as angina pectoris. The patient 
 generally complains of an irradiation of retro- 
 sternal pains along the left side of the neck into 
 the nuchal or inferior maxillary or dental zone. 
 These pains in the neck and teeth are at times 
 almost unbearable. A demonstrable arterio- 
 sclerosis, periodic anginose attack, hyperalgesia 
 during the intervals, and tenderness in the caro- 
 tids on palpation should furnish sufficient proof 
 of the anginose nature of this painful occurrence. 
 
 Spontaneous pains due to an affection of the 
 veins or nerves in the neck, I have never been 
 able to observe. But sensitiveness on pressure 
 in the vena jugularis interna or in the vagus 
 is not uncommon, and I consider this symptom 
 of high diagnostic value, especially in phlebitis 
 of the internal jugular vein. Such a phlebitis 
 may be the sequel of an otitis media or else of 
 an abscess in a dependent part descending from 
 the carotid triangle. 
 
 Moreover, tenderness in the lateral upper 
 region of the neck between the ramus of the 
 inferior maxillary bone and the mastoid process 
 is a serviceable early symptom of meningitis or 
 any other pressure on the brain. 
 
 In a similar fashion, a thrombosis of the 
 jugular vein, generally as a continuation of a 
 thrombosis of the superior vena cava, rarely as 
 a primary disease, may give rise to a slight feel- 
 ing of pain, or rather to an aching, oppressive
 
 182 GENERALIZED PAIN 
 
 sensation in the region behind the sternocleido- 
 mastoid muscle. The diagnosis can be made 
 from the swollen appearance of the face and its 
 bluish tint, or from a local edema in the region 
 of the parotis, of the skull or of the right arm 
 as well as on the neck or in the mucous mem- 
 brane of the oral cavities and the ectatic condition 
 of the cutaneous veins. 
 
 Furthermore, tenderness at the inner margin 
 of the sternocleidomastoid must direct our at- 
 tention to some possible disorder of the vagus 
 nerve. When young people complain of dys- 
 pepsia and gastric troubles and in consequence 
 have a haggard appearance, and I find tender- 
 ness at this spot, I am always prepared for 
 the beginning of a tuberculous affection in the 
 apex of the lung. 
 
 With gastric carcinoma the patient generally 
 suffers from want of appetite and nausea if 
 food is placed before him; but there are cases 
 in which the very opposite happens, i.e., intense, 
 constant craving for something to eat. In both 
 these cases the vagus itself need not be at all 
 involved, but remain absolutely intact. 
 
 But not only affections of the vagus nerve, 
 but also a neuritis or neuralgia of the phrenic 
 nerve (a concomitant in diseases of the heart, 
 of the pericardium, of the aorta, of the dia- 
 phragm or of the subdiaphragmatic organs), 
 leads to extreme local tenderness and even to
 
 NECK 183 
 
 spontaneous pains in the side of the neck, either 
 between tne posterior border of the sternocleido- 
 mastoid and the anterior margin of the scalinus 
 anticus muscle or between the two processes of 
 the first named muscle. The diagnosis of the 
 phrenic affection is notably based on the afore- 
 mentioned painful points lateral to the sternum 
 and spinal column, and also upon the abdominal 
 pressure point (bouton diaphragmatique) at the 
 crossing of the continued sternal line and the 
 connective line of the two 10. osseous ribs. 
 
 This involvement of the phrenic nerves the 
 fibres of which do not proceed only from the 
 4., but also in part from the 3. cervical nerve, 
 explains the presence of pains in the neck or in 
 the cervico-nuchal region which we have occasion 
 to observe in affections of the diaphragmatic 
 peritoneum and in liver complaints. The shoul- 
 der pains seem to be, however, the preponder- 
 ating element in these conditions. 
 
 In chronic lymphadenitis of the neck the 
 pains along the inner border of the sternocleido- 
 mastoid and also the local tenderness are of a 
 milder form. It generally originates as an 
 upshot of chronic tonsillitis from behind the 
 anterior process of the sternocleidomastoid and 
 in the retromandibular region (pain in the ear) 
 above the membranous hypothyreoid at the en- 
 trance of the laryngeus superior nerve and at 
 the port of entry of the facial into the internal 

 
 184 GENERALIZED PAIN 
 
 jugular vein and the paratracheal glands. This 
 disease is frequently mistaken for chronic articu- 
 lar rheumatism. 
 
 When pains in the neck are combined with 
 trouble in swallowing, we are led in the direction 
 of an irregularity in the esophagus. 
 
 An acute inflammation of the esophageal mu- 
 cous membrane (esophagitis) due to some me- 
 chanical, thermic or chemical injury or as the 
 Concomitant of an acute infection, will infest 
 the cervical portion of the esophagus with pain, 
 which radiates at times downwards behind the 
 sternum. 
 
 Deglutition increases the pain, especially in 
 cases of acid poisoning, movements of the cer- 
 vical spine have the same effect, food gushes 
 back, there is a copious flow of phlegm and 
 sputum, and tenderness at the side of the throat. 
 With these symptoms, with a careful examina- 
 tion of the oral cavities and the aid of a proper 
 anamnesis a mistake in the diagnosis is im- 
 possible. 
 
 In chronic esophagitis these symptoms are 
 generally missing, but not so in pharyngo-esoph- 
 ageal diverticulum. But even in the latter pain 
 as a symptom is of lesser value, if we except 
 that connected with deglutition and stenosis. 
 Nevertheless, there are cases of diverticulum in 
 which the patient suffers from very intensive 
 pains, no doubt caused by some inflammatory
 
 NECK 185 
 
 condition in the wall of the diverticulum itself. 
 The diagnosis should offer no difficulties as all 
 the symptoms are of a strictly characteristic 
 form. I mention: marked stenotic conditions, 
 tumor formation with a peculiar creaking sound 
 above it in the throat, the fetid breath and flow 
 of saliva. The X-ray should do the rest. 
 
 Globus Hystericus 
 
 It consists of an unpleasant, at times very 
 painful, choking sensation, partly due to hyper- 
 esthesia of the mucous membrane of the esoph- 
 agus, and partly caused by a spasmodic con- 
 traction of the pharyngeal and esophageal mus- 
 cles, commonly called "lump in the throat." 
 The patient has the feeling of a lump rising 
 from the esophageal orifice of the stomach to 
 the throat, where it stops. If other hysterical 
 symptoms are present, the diagnosis is plain 
 enough, but when there are no signs of hysteria 
 we meet with difficulties, for there are other 
 diseases which produce the same effect. 
 
 We all know what terrible spasms grip the 
 throats of patients affected with hydrophobia, or 
 tetanus, so there is no need for me to dwell on 
 this subject; but I deem if necessary to say 
 something about the differentiation between 
 lyssa and lissophobia. A thorough anamnesis 
 and the incubation period (6 weeks to 3 months) 
 coupled with the typical symptoms shoujd leave
 
 186 GENERALIZED PAIN 
 
 no doubts in our mind so far as the diagnosis 
 of lyssa is concerned. If the patient does not 
 show spasmodic conditions in the throat or in 
 the respiratory passages when we blow hard 
 upon the skin a most valuable, in fact a veri- 
 table pathognomic sign for rabies if there is 
 no excess of the reflex action, if he drinks water 
 freely and without untoward result, we may 
 ease his mind and our own and decide in favor 
 of lyssophobia, especially if the bite of a dog 
 or other mad animal is denied. By the way, 
 lyssophobia is catching, and may be transferred 
 from one person to another by mere suggestion. 
 
 It is different in tetanus. Here the spas- 
 modic contractions are the first sign of the dis- 
 ease, preceded, perhaps, by lockjaw (trismus). 
 
 Spasmodic contractions in the throat similar 
 to globus hystericus may constitute an impor- 
 tant accompanying symptom in other diseases; 
 for instance, in sclerosis of the aorta or of the 
 coronary arteries. Anginoid and anginose con- 
 ditions also manifest themselves in this form. 
 But they are of minor importance, because there 
 we have the evidence of the originally retro- 
 sternal localization of pressure and pain, their 
 irradiation, the fact that they are provoked by 
 bodily movements and the accompanying un- 
 easiness. Nevertheless, there is a suprasternal 
 form of angina pectoris in which the patient 
 complains exclusively and only of this painful,
 
 NECK 187 
 
 constricting sensation. Still an erroneous diag- 
 nosis of globus hystericus may slip :n if the 
 patient is a female who claims that the spasms 
 in the throat follow some psychic emotion. We 
 should then endeavor to ascertain whether they 
 do not also follow in the wake of some physical 
 exertion, whether they do not also come in the 
 night time, whether they are not felt in the 
 shape of an oppressive feeling in the chest or 
 in the epigastrium. If these questions are an- 
 swered in the affirmative, all doubts should 
 dwindle away. 
 
 Insufficiency and debility of the heart (espe- 
 cially Basedow's disease) give rise to similar 
 episodes. They crop up chiefly after an un- 
 usually heavy meal, especially when the patient 
 has made a long speech or smoked to excess. 
 The ordinary symptoms of cardiac insufficiency 
 should tell us the truth. 
 
 These pains are particularly disturbing in at- 
 tacks of essential or symptomatic paroxysmal 
 tachycardia. The diagnostic conditions are dis- 
 cussed on another page. 
 
 If in a mediastinal disease the pectoral vagus 
 is involved, these pains are turned into real 
 deglutition spasms, reaching sometimes into the 
 deeper registers of the esophagus. The experi- 
 enced observer will find the key to the solution 
 in the recognition of the primary affection, and in 
 the accompanying manifestations of dysphagia,
 
 188 GENERALIZED PAIN 
 
 bradycardia, arhythmia, occasional anginose at- 
 tacks, vagus asthma, pain in the nervous vagus 
 of the neck, and intermittent meteorism. 
 
 Spasmodic contractions in the throat caused 
 by flatulency or preceding the act of vomiting 
 are always pure and simple reactions of an 
 irritated nervus vagus. 
 
 In asthmatic attacks and in hay fever these 
 selfsame spastic pains are molesting elements. 
 
 But they are also at times partial symptoms 
 of pharyngeal crises in tabes, and may be ob- 
 served in botulism, in atropine poisoning and 
 in uremia.
 
 
 Pains in the Nape of the Neck 
 
 In order tg present a clear survey of this 
 subject, I am taking each layer of tissue that 
 constitutes the nape by itself as a possible seat 
 of pain. 
 
 I begin with the muscular system, for the 
 reason that local pains to some extent originate 
 in the nuchal skin through furuncles and an- 
 thrax, that they are produced by the movements 
 of the head in scleroderma on account of the 
 characteristic stiffness and hardening of the in- 
 tegument which is also the case in myxedema. 
 All those muscular affections which are men- 
 tioned in other sections of this bok as sources 
 of pain in the sacrum, in the shoulders, in the 
 back and in the muscular system are mutatis 
 mutandis discussed here also. 
 
 When the nuchal pains are only partial mani- 
 festations of other synchronous muscular pains, 
 the diagnosis cannot be imperilled. But they 
 may be just as well the primary signal of some 
 generalized muscular disease. Such is, for in- 
 stance, the case in tetanus, trichinosis; and be- 
 cause in Weil's disease the muscles of the nape 
 are so often primarily attacked with the most 
 
 189
 
 190 GENERALIZED PAIN 
 
 intensive pains the existence of an epidemic 
 "stiff-neck" has been variously mooted. 
 
 In Wolhynian and Pappataci fever severe 
 nuchal pains have been observed. Painful ten- 
 derness in the cucullaris points to chronic miti- 
 gated sepsis. Pains in the nape are also occa- 
 sioned by chronic traumatic myositis. 
 
 Diseases of the occipital fossa (tumor in the 
 cerebellum) or of the meninges may affect the 
 sensible posterior nerve roots and produce stiff- 
 ness in the nape connected with pain which im- 
 pairs the motility of the head. 
 
 The effect may also result from ever so many 
 morbid conditions in the spinal column, espe- 
 cially in the region of intervertebral foramina 
 (arthritis, rhizomyelia, tumors, infiltrations, i.e., 
 leucemic, interspinal canals, aneurysms, etc.), 
 or in the spinal contents; furthermore in all 
 possible expanding extramedullary diseases (tu- 
 mors, cervical hypertrophic or luetic or tuber- 
 culous pachymeningitis), likewise in intermedul- 
 lary affections (tabes, syringomyelia, multiple 
 sclerosis, myelitis, tumors). The pains are often 
 associated with local stiffness. 
 
 Of course, pain and stiffness in the nape are 
 very much in evidence in all forms of meningitis 
 and pseudomeningitis. The differentiation be- 
 tween these two diseases depends upon the re- 
 sults of lumbar puncture. The same may be 
 said of abortive forms of epidemic meningitis.
 
 NAPE OF THE NECK 191 
 
 Although the presence of pain in the nape, in 
 the head, the extremities, the throat coupled 
 with coughing and occasional vomiting arouse 
 suspicions which gain in strength by the addi- 
 tion of stiffness in the nucha, and the evidence 
 of Kernig's sign, yet it is always lumbar punc- 
 ture that makes the diagnosis positive, especially 
 when also meningococci are found in the nasal 
 and pharyngeal secretions. 
 
 In acute poliomyelitis intensive pains in the 
 nape are oftentimes undesirable guests, whilst in 
 superior myelitis without meningitic complica- 
 tions they may be looked upon as an associated 
 symptom. 
 
 Of the various spinal diseases in which these 
 pains constitute a predominant sign, I will men- 
 tion Pott's disease, malum Riwtii and tuber- 
 culous inflammations of the nuchal vertebras. 
 Distinguishing symptoms are: when the patient 
 is lying on- his side and wishes to raise the head 
 he is likely to support it with both hands; there 
 is local deformity in the spine; we find local 
 tenderness upon pressure or palpation, painful 
 reaction to the touch of a hot sponge or an 
 electrode, or to downward pressure on the head. 
 All the other affections which are discussed in 
 the section dealing with the spinal column be- 
 long to this category. 
 
 It may be of interest to point out that the 
 first four vertebrae are the privileged quarters
 
 192 GENERALIZED PAIN 
 
 for syphilitic affections of the spine. The 
 Roentgenogram, the anamnesis and serological 
 tests should make the differentiation from tuber- 
 culous or rheumatic conditions clear. 
 
 So far as the malum Rustii is concerned, I 
 will add that it may spring not only from a 
 tuberculous state in the two superior cervical 
 vertebrae, but also from a neoplasm, a gumma 
 or a fracture in that locality, not to forget 
 arthritis, rheumatism, gout or syphilitic gum- 
 mata. 
 
 Acute articular rheumatism and gonorrhoic 
 affections of the nuchal vertebrae are members 
 of this cotery. 
 
 Cervico-occipital neuralgia is the next item 
 before us. It is typified by the paroxysmal 
 character of the pains which radiate from the 
 nape into the occipital region, and also by 
 tenderness between the cervical vertebra? and 
 the mastoid process. Nevertheless, we should 
 not be too rash in making a positive diagnosis 
 from these symptoms, because similar pains may 
 be caused by some preceding primary disease, 
 e.g., by a tumor or by an ankylopoietic spon- 
 dylarthritis. The differentiation will be found 
 in the fact that the movements of the head are 
 free from pain during the intervals between the 
 attacks, while in anatomical lesions of the pos- 
 terior nerve roots there is continuous motoric 
 impairment together with other signs pointing
 
 NAPE OF THE NECK 193 
 
 to an affection located at the place of origin 
 of the nerves. 
 
 The lymphatic glands of the nuchal region 
 are another field in which local pains may arise 
 from some morbid condition, e.g., from lymph- 
 adenitis. The diagnosis will materialize from 
 the finding of glandular swellings and their 
 origin (primary infection in the head or tra- 
 chea), or, perhaps, from enlargements of the 
 glands in general, not uncommon, for instance, 
 in cases of the plague, although in this last- 
 named disease the pains in the nape and also in 
 the shoulders are more likely of muscular genesis. 
 
 In occipital migraine, pains in the nape and 
 headaches are steady companions. 
 
 Primary affections of the posterior oral cavi- 
 ties show at times painful reflexes in the nape. 
 In some cases of acute angina and tonsilitis the 
 patient complains of pains in the corresponding 
 nuchal zone. This happens particularly when 
 the tonsils are affected by an existing chloroma. 
 The greenish appearance of the tonsils and the 
 leucemic, sub- or a-leucemic condition of the 
 blood should prevent an error in the diagnosis. 
 It is always advisable to examine the oral cavi- 
 ties thoroughly whenever complaints of pain in 
 the neck are made by a patient. 
 
 Any disease of the pleural or pulmonary 
 apices, especially in the posterior section there- 
 of, in fact all acute or chronic inflammatory
 
 194 GENERALIZED PAIN 
 
 processes or neoplasms in that region, are con- 
 nected with pains in the nape of the neck, and 
 may constitute a symptom of impending phthisis. 
 In apical pneumonia these paLis are of great 
 diagnostic worth, as also in syphilitic aortitis. 
 
 In diaphragmatic pleuritis pains in the nape 
 are, no doubt, reflex actions emanating from the 
 3rd-4th cervical segment. 
 
 That an affection of the sub diaphragmatic 
 peritoneum or of the serous coating of the liver 
 often causes pain in the nape, in the neck, and 
 also in the shoulders, is not hard to undjrstand, 
 because the fibres of the phrenic nerve originate 
 not only from the 4th, but also from the 3rd 
 cervical nerves. 
 
 In the majority of cases, however, the pains 
 caused by these diseases, i.e., subdiaphragmatic 
 pleuritis and peritonitis ( perihepatitis, perisple- 
 nitis), are not spontaneous in their nature, but 
 are rather evinced in a certain part of the muscle 
 when we gently press the trapezius between our 
 fingers or tap the supraspinate fossa. The 
 middle portion of the trapezius seems to be most 
 susceptible to this reflex action. This tenderness 
 disappears with the decline of the serositis, but 
 returns with a fresh attack. That explains also 
 why the pain in the nuchal muscles is an appre- 
 ciable symptom of apical pulmonary tuberculo- 
 sis, and is otherwise a useful guide in the diag- 
 nosis of subdiaphragmatic morbid conditions.
 
 Pain in the Chest 
 
 Pain in the chest may be caused either by 
 morbid conditions of the thoracic frame or by 
 diseases of the internal organs of the pectoral 
 cavity, if not by complications involving both 
 regions. 
 
 Insofar as the internal organs are concerned, 
 the pains due to diseases of the heart are dis- 
 cussed in a separate chapter. 
 
 The pains originating in the wall of the thorax 
 are the result of affections of the skin, the mus- 
 cles, the intercostal nerves, the fascia, the sub- 
 pleural connective tissue, the ribs and the 
 mammae. 
 
 Among the cutaneous diseases there are not 
 many that are of direct interest to the internist, 
 excepting, of course, those which occur in the 
 zones of Head, and these will be discussed in the 
 sections dealing with the corresponding primary 
 organic troubles. 
 
 But medical writers report cases in which these 
 zones become so painful that the patient in- 
 stinctively avoids every contact with the affected 
 portion of the skin. 
 
 Cholelithiasis and hyperesthesia of the right 
 upper abdominal and lower thoracic integument 
 
 195
 
 196 GENEKALIZED PAIN 
 
 will cause the patient to keep his right arm 
 away from the affected part for fear of severe 
 pains elicited by contact with the skin. 
 
 If these pains are merely symptomatic of an 
 isolated skin disease, they belong in the province 
 of the dermatologist. But if they are a partial 
 manifestation of a general disease, e.g., of adi- 
 positas dolorosa (Dercum's disease), of "sym- 
 metrical" lipoma, or of neurofibromatosis, the 
 internist must take notice. I refer to this sub- 
 ject more fully in the chapter on "Pains in the 
 Extremities." And again, a skin disease may 
 be the superficial sign of a deep-seated morbid 
 condition. In this sense I include here only 
 those cutaneous and subcutaneous inflammatory 
 changes which are the reflex actions of in- 
 ternal organs of the thorax. The internist will 
 keep here a sharp lookout for subcutaneous 
 abscesses which originate from an empyema ne- 
 cessitatis, or, if situated in the precordial region, 
 are connected with the mediastinum, but not 
 with the pleura, or also may be a derivation 
 from some primary disease of the lungs. Peri- 
 pleuritic abscesses and pulmonary hernias belong 
 here, too. A carcinoma in the pleura is just as 
 likely to find its way to the surface of the 
 thoracic integument, thus forming an unmis- 
 takable symptom of the primary affection. 
 
 Empyema necessitatis, cysts with or without 
 involvement of the mediastinum, perforation of
 
 CHEST 197 
 
 a bronchiectatic pocket, peripheritic abscess, all 
 are subject to inflammatory conditions. This 
 makes it so easy to separate them from abscesses 
 due to perforation of a tuberculous sac (cold 
 abscess) or from a pulmonary hernia in which 
 there is febrile reaction of the skin. 
 
 The differentiation between the first three 
 aforementioned diseases should not offer any 
 difficulties. It is found in the condition of the 
 lungs or pleura (empyema or bronchiectasis). 
 Doubt can arise only when an abscess is formed 
 by some anaerobic bacteria which reach the 
 mediastinum. Where such a communication 
 does exist the diagnosis should not be difficult. 
 Where it does not exist, however, we run the 
 danger of being misled by the fluctuation and 
 crepitation over the tumor with additional gurg- 
 ling rales due to oscillations of intrathoraic pres- 
 sure. That the lung itself is apparently sound 
 does not prove anything to the contrary. But 
 in my opinion absence of the tympanitic percus- 
 sion sound which one might expect if the lungs 
 were involved, and also absence of typical res- 
 piratory inflation of the tumor by coughing are 
 definite contraindications. No doubt the Roent- 
 gen ray will on some not so very distant day 
 come to our assistance in this matter. 
 
 If no aerobic abscess is in evidence the differ- 
 ential diagnosis between peripleuritis and a per-
 
 198 GENERALIZED PAIN 
 
 forating pleural abscess will be rather puzzling. 
 It is easy enough to spot a perforation of the 
 thoracic wall by a pulmonary process when we 
 have definite proof of a primary lung disease 
 and unmistakable pulmonary symptoms before 
 us. But to use a strict localization of pains and 
 swellings for diagnosing a purulent peripleuri- 
 tis I do not consider practicable, because we 
 find these same conditions also in perforating 
 empyema, and pain is always associated with a 
 non-perforating pocket empyema. To my mind 
 the points of importance are: the absence of 
 all pulmonary symptoms, especially coughing 
 early severe dyspnea occurs in both diseases; it 
 is due to the painful breathing and there is no 
 dislocation of the mediastinal organs in spite of 
 obstruction and dilatation. In empyema neces- 
 sitatis I have never been able to see more than 
 one perforation point. The X-ray should be 
 very helpful in the diagnosis. 
 
 Local acute inflammation is not noticeable in 
 the perforation of a tuberculous sac into the 
 softer parts of the thorax, neither is there pain. 
 The skin does not seem to react to pain, although 
 it is bulgy and livid in color, crepitation, tym- 
 panitic sounds and rales are perceptible and the 
 tumor has a squashy, doughy consistence. The 
 condition may easily be mistaken for pulmonary 
 hernia. Still the diagnosis should yield positive 
 results from the observations of pocket symp-
 
 CHEST 199 
 
 toms, the presence of rales, the squashy consis- 
 tence of the tumor in pulmonary hernia the 
 tumor makes a creaky sound when squeezed 
 with the fingers the severe involvement of the 
 lungs and the favorite spot for the perforation 
 in the 1.-3. anterior intercostal space in pulmon- 
 ary tuberculosis, while pulmonary hernia prefers 
 the upper clavicular region or 6. to 9. anterior 
 intercostal space. 
 
 This applies with equal force to those cases 
 of pulmonary hernia which are not of traumatic 
 orgin, but arrive spontaneously owing to ex- 
 traordinary intrathoracic pressure on an other- 
 wise abnormally fragile tissue. 
 
 The recognition of actinomycosis arising from 
 the air passages and perforating the thoracic 
 tissue should offer no dilemma, because this dis- 
 ease is chiefly a chronic progressive infiltration 
 making its way to the surface from the deeper 
 tissues ; it is the formation of multiple subpleural 
 phlegmonous foci from which the pus works up 
 until it perforates the skin in the shape of mani- 
 fold fistulae. 
 
 A subcutaneous hematoma generally sets in 
 with sudden severe pains in the chest and dys- 
 pnea. When spontaneous in origin it is of 
 particular concern to the internist. As a rule 
 the affected part is tinged with a bluish red 
 color by which it can readily be recognized. 
 
 Aneurysms of the pectoral aorta generally
 
 200 GENERALIZED PAIN 
 
 cause only moderate pain as they gradually 
 expand under the skin. The abnormal bulging 
 of the skin and very strong pulsation together 
 with the Roentgenogram can leave no room for 
 an erroneous diagnosis. 
 
 Female patients often have occasion to com- 
 plain about pain in the Mamma. 
 
 Aside from mastitis and carcinoma, the only 
 organic disease that claims the attention of the 
 internist is hypertrophy which causes a dragging 
 pain in the affected mamma. Similar painful 
 feelings are caused by any infiltration of the 
 mammary glands in pregnancy or during the 
 lactation period, a sort of muscular fatigue. 
 They may assume a permanent form in leu- 
 cemic or aleucemic adiposity. A proper support 
 for the mammary glands relieves the pain or 
 removes it. 
 
 Mammary carcinoma, by the way, at times 
 causes periodic attacks of, if not continuous 
 lancinating pains which radiate into the arm, 
 especially when the seat of the tumor is in the 
 exterior upper quadrant of the mammary gland. 
 A hard, slightly sensitive, almost immovable and 
 irregularly formed node and the indrawn nipple 
 which exudes a sticky, serous moisture are most 
 reliable symptoms for a correct diagnosis. Such 
 a carcinoma may also occur in the adult male, 
 when it manifests itself in the lymphatics in the 
 form of nodules the size of a pinhead or pea
 
 CHEST 201 
 
 which produce a peculiarly painful sensation in 
 the superficial nerves of the chest. 
 
 Presenile or senile involvement of the mam- 
 mary glands, it is said, also is connected with 
 local pain. Of course, there are other appur- 
 tinant diseases but they belong in the domain of 
 surgery. What, however, is of concern to the 
 internist is pain in the mammary glands occa- 
 sioned by neurosis, neurasthenia and predomi- 
 nently by hysteria. In these conditions the 
 mamma, sometimes the nipple only, constitutes 
 a very strongly marked hyperesthetic zone. The 
 slightest friction of the clothing, even of the 
 flimsiest underwear evokes most intensive pains. 
 The presence of typical stigmata and particu- 
 larly that of psychic symptoms should guarantee 
 a positive diagnosis. 
 
 In hysteria and pointedly so in neurasthenia 
 the mammary pains may be due to mastodymia, 
 which after all is merely the expression of an 
 intermammary (at times even very stubborn) 
 intercostal neuralgia. The pains are of a shoot- 
 ing, burning, boring, tearing character and come 
 in periodic attacks; we find pronounced hyper- 
 esthesia of the skin, pressure points (external, 
 axillary, vertebral), an additional anatomical 
 lesion of the glands that by itself is a possible 
 originator of a deuteropathic mastodynia, all of 
 which combined form a proper basis for the 
 diagnosis.
 
 202 GENERALIZED PAIN 
 
 There are cases of what I may call "imitation 
 hysteria" in which the patient complains of all 
 the typical symptoms of such a mastodynia. 
 The condition is brought about by self-delusion 
 auto-hypnotism after the patient has visited 
 a friend who is suffering from the actual disease 
 and now imagines she has it, too. 
 
 Pains in the breasts are not uncommon during 
 the menstrual period, or in the early stages of 
 pregnancy, also during the climacterium, with 
 actual swelling of the mammary glands. These 
 are no doubt a reflex action of the genital glands 
 on the mammary glandular system. 
 
 Burning pains in the mamma which radiate 
 into the adjacent arm have also been observed 
 in cases of sclerosis of the mammary arteries. 
 I cannot speak here from personal experience. 
 
 So far as intercostal neuralgia is concerned, 
 I wish to point out that it is always risky to 
 judge from a bilateral condition of the existence 
 of a deuteropathic affection caused by a lesion 
 of the nerve roots either in the spine itself or 
 its joints or in the contents of the spinal canal. 
 Even in a case of stubborn unilateral intercostal 
 neuralgia there is always the possibility of an 
 existing tumor in the extramedullary spinal cord 
 or in one of the vertebrae. Chronic meningitis, 
 a serious mechanical injury of a nerve trunk 
 caused by a diseased rib (gummata) or by an 
 affection of the pleura (neoplasmata) or of the
 
 CHEST 203 
 
 mediastinal organs, e.g., anurysm of the descend- 
 ing thoracic aorta or a bronchus carcinoma, all 
 are included in this list of eventualities. Impor- 
 tant for the diagnosis is the fact that in just such 
 cases the characteristic pressure points are fre- 
 quently missing. But we should remember that 
 every form of neuralgia may originate from a 
 diseased condition of the central nervous system 
 as well as from general causes such as diabetes, 
 gout, malaria, chronic constipation, anemia or 
 chlorosis. 
 
 In cholelithiasis pain in the right eleventh rib 
 often resembles an attack of intercostal neu- 
 ralgia. 
 
 In some cases of true angina pectoris the 
 typical retrosternal pains are accompanied by 
 pains in the superior intercostal spaces. When 
 these are combined with deeper intercostal neu- 
 ralgias we may well take them as the signal for 
 an aneurysm of the pectoral aorta. 
 
 Pain in the intercostal nerves is a constant 
 companion of local herpes zoster during the 
 entire course of the disease, the symptoms of 
 which should be easily recognized. The pain 
 extends, belt like, over the whole affected inter- 
 costal space and the eruption consists of typically 
 grouped vesicles and subsequent scars. We 
 must not forget that herpes zoster, especially in 
 its bilateral form, is often a partial manifestation 
 of a secondary neuritis of the nerve roots, or of
 
 204 GENERALIZED PAIN 
 
 some mediastinal morbid condition, e.g., of an 
 aneurysm of the aorta. It may also be pro- 
 voked by arsenic or carbon dioxid poisoning. 
 
 If herpes zoster is the result of a morbid 
 process in the intervertebral ganglia it may give 
 rise to severe, continuous or only spasmodic 
 pains in the chest, especially in the posterior or 
 lateral portion parallel with the seat of the lesion. 
 But these pains are likely to prevail even when 
 the attack is not accompanied by herpes zoster. 
 This refers to all expanding growths in the 
 spinal canal or in the vertebral bones. 
 
 Such an irritation of the spinal roots is no 
 doubt the causating factor of those intense inter- 
 costal neuralgias which in company of headache, 
 neuralgic pains in other parts of the body, and 
 articular pains constitute the initial symptoms of 
 multiple sclerosis. 
 
 In tabes dorsalis lightning pains in the inter- 
 costal nerves are sometimes experienced with 
 preference in the lower hypochondriac intercostal 
 spaces. 
 
 The tabetic girdle sense is associated with un- 
 pleasant, slightly painful sensations in the chest. 
 When this symptom is the first and perhaps the 
 only complaint made by the patient the diagnosis 
 may not be so easy, especially so in cases where 
 the pain is confined to one side of the chest 
 only. 
 
 A similar girdle sense crops up not infre-
 
 CHEST 205 
 
 quently also in neurasthenia. But when this 
 happens it is advisable to make a thorough search 
 for some anatomical affection of the central 
 nervous system. If this proves fruitless and the 
 typical neurasthenic symptoms are demonstrable 
 the diagnosis may be made positive. 
 
 Furthermore, girdle-like paresthesias involv- 
 ing pain are likewise possible in many other 
 spinal diseases such as meningitis in all its forms, 
 syphilis of the spine, or a tumor, syringomyelia, 
 chronic multiple sclerosis, etc. Syphilitic neuri- 
 tis and also poliomyelitis are often ripe with 
 pains including the girdle variety in the back as 
 well as in the chest. 
 
 If in poliomyelitis girdle pains set in all of 
 a sudden and with great intensity we should 
 seriously look upon this condition as an initial 
 warning of acute multiple sclerosis, or hemato- 
 myelia, acute myelitis, embolism or thrombosis 
 of the arteries of the spinal cord. As a rule we 
 shall find a concomitant acute paresis if not 
 paralysis of the two lower extremities, or some 
 ailment of the bladder or rectum. In that case 
 the diagnosis would be patent. 
 
 This is also true of diseases of the spinal 
 column proper, e.g., spondylarthritis ankylo- 
 poietica, and furthermore of diseases of the bones 
 which cause a contraction of the dorsal vertebrae 
 e.g., osteomalacia. I mention also arteriosclero- 
 sis of the vessels in the posterior column of the
 
 206 GENERALIZED PAIN 
 
 spinal cord. The diagnosis in this case must be 
 established on the following symptoms: abnor- 
 mal fatigue, weakness and stiffness in the lower 
 extremities when walking (in the absence of pain- 
 ful intermittent dysbasia), pulsation in the arte- 
 ries of the foot, the Babinski sign during or after 
 walking but absent when at rest, increase of the 
 tendon reflexes in demonstrable arteriosclerosis 
 of the peripheral or inner vessels, presence of 
 other symptoms pointing to arteriosclerosis such 
 as angina pectoris, gastralgias and enteralgias, 
 etc. 
 
 These girdle pains are sometimes a very im- 
 portant manifestation of some retromediastinal 
 process. An aneurysm for instance of the de- 
 scending thoracic aorta at the point where the 
 latter passes through the diaphragm frequently 
 betrays its presence there by such girdle pains 
 in the diaphragmatic region. They are felt 
 during physical exertions, or, and mostly so, 
 when the patient lies on his back after the intake 
 of food. 
 
 Some patients suffering from syphilitic aorti- 
 tis complain of an "uncanny feeling" or girdle 
 sensation and even genuine pain in the region 
 of the asternal ribs. The cause for this seems 
 to me to be presence of an arteritis of the inter- 
 costal arteries, I mean a constriction at the point 
 where they branch off from the pectoral aorta. 
 The pains may be felt on both sides or on the
 
 CHEST 207 
 
 left side alone. Analogous observations have 
 been made in typical attacks of angina pectoris 
 and also in cervical tabes. In tabes dorsalis 
 some patients complain of a feeling as if the 
 skin over the cardiac region were being painfully 
 pinched. 
 
 The girdle pains due to clonic or tome spasms 
 of the diaphragm are generally confined to the 
 region of union between the diaphragm and the 
 thoracic wall. The chronic form of these spasms 
 manifests itself by singultus which may endure 
 for several days under very severe girdle as well 
 as epigastric pains. We observe this, in part 
 at any rate, in abdominal diseases which have 
 a reflex action on the phrenic nerve, e.g., in the 
 bladder when obnormally distented by a sur- 
 charge of urine, in prostatitis, in uterine affec- 
 tions ; likewise in central irritation of the phrenic 
 nerve due to anatomical lesions of the brain or 
 spinal cord (encephalitis, epidermic singultus) 
 or caused by toxic influences (spastic singultus 
 in uremia, sepsis, chronic alcoholism), in neuroses 
 (hysteria), in anemic and cachectic conditions, 
 in anatomical lesions of the trunk of the phrenic 
 nerve due to indurated mediastino-pericarditis, 
 possibly also following an aneurysm of the pec- 
 toral aorta accompanied as a rule, by indurated 
 or gummatous mediastinitis. We find this same 
 spastic singultus in direct irritations of the serous 
 coating of the diaphragm, for instance as a
 
 208 GENERALIZED PAIN 
 
 manifestation of a primary or more or less dif- 
 fuse peritonitis in the lower surface of the dia- 
 phragm, and also in rare cases of diaphragmatic 
 pleuritis. 
 
 It is more difficult, and perhaps only with the 
 aid of the Roentgen-ray, to recognize the tonic 
 form of diaphragmatic cramps. It occurs as an 
 accompanying sign of tetanus, also of tetany, 
 and in articular and muscular rheumatism due 
 to exposure to cold, and preeminently so in hys- 
 teria. The patient is likely to be attacked by 
 sudden, very intensive girdle-pains in the dia- 
 phragmatic circumference; dyspnea and cya- 
 nosis are very pronounced, the abdomen is 
 distorted and the pectoral organs are pushed 
 backwards. Minor attacks of this nature seem 
 to be not uncommon in hysteria. 
 
 In acute diaphragmatitis arising from pneu- 
 monia, pleuritis, peritonitis, perihepatitis or peri- 
 splenitis we are often called upon to witness 
 attacks of intermittent or also long continued 
 pains in the diaphragmatic zone. The patient 
 complains of girdle-like pains in that region, 
 also in the chest and back, seriously interfering 
 with deep breathing. This condition may easily 
 escape observation in a case of pneumonia or 
 cholecystitis; the more so when we are dealing 
 with a case of acute diaphragmatic pleuritis, 
 especially of a tuberculous nature. Under these 
 circumstances cholecystitis or ulcus ventriculi are
 
 CHEST 209 
 
 the predominant errors in the diagnosis. Proper 
 search for pressure points in the phrenicus and 
 the service of the X-ray are the only correctives. 
 
 Difformities in the thorax, chiefly scoliosis of 
 the spinal column, are common causes of pains 
 in the chest. A chronic affection of the inter- 
 costal nerves is possibly the originating factor 
 of these painful sensations which may be uni- 
 lateral only, but often enough are felt on both 
 sides. 
 
 If they are unilateral in the left inferior inter- 
 costal spaces and of a neuralgic character, they 
 point to the existence of an ulcus ventricuU. It 
 is always advisable in such cases to look most 
 diligently for gastric symptoms such as periodic 
 pressure in the stomach, pyrosis and indigestion 
 lest we be surprised by a sudden gastric hemor- 
 rhage. The gastric contents should be carefully 
 analyzed, a steady watch for gastric or intestinal 
 hemorrhages must be kept, also for hyperalgesia 
 of the epigastric skin, for Boas' sign, and for 
 deep pressure sensibility. 
 
 The larger superficial as well as the deeper 
 lying muscles of the chest may be the habitat of 
 local pains. By way of preliminary mention I 
 wish to point out that periodic attacks of pain 
 in the pectoralis muscle should always remind 
 us of a possible angina pectoris, and also that 
 subpectoral suppuration should always engage 
 the attention of the internist although as a rule
 
 210 GENERALIZED PAIN 
 
 its consideration and treatment is left to the 
 surgeon. 
 
 I have repeatedly seen in my clinic cases in 
 which the patient complained of intensive pains 
 in the chest and difficult breathing with chills 
 and fever which were taken by the intern as 
 manifestations of an acute attack in the respira- 
 tory tract. The examination gave negative re- 
 sults so far as the pulmonary conditions were 
 concerned, but there were indications of a gen- 
 eralized sepsis, enlargements in the anterior 
 section of the thorax, especially in the region 
 of one major pectoralis muscle, a slight edema 
 of the skin, very intensive local tenderness, and 
 a movement of the arm which contracted the 
 pectoralis major elicited most intensive pains in 
 that muscle. A diagnosis of subpectoral sup- 
 puration was made and confirmed by the attend- 
 ing surgeon by way of incision. 
 
 The diagnosis may be even a more difficult 
 problem when an empyema and a subpectoral 
 phlegmon run side by side. 
 
 That the muscles themselves are the carriers 
 of the localized pain, is demonstrated by local 
 tenderness and aggravated painful sensations 
 which accompany an attempt to activate the 
 appurtenant muscles. 
 
 After all, muscular pains in the chest are 
 generally only a reflex action of morbid condi- 
 tions in other muscles of the body. The charac-
 
 CHEST 211 
 
 teristic symptoms of the primary disease should 
 facilitate a true diagnosis. But due regard must 
 be had of the fact that a disease which involves 
 so large a district as the muscular complex of 
 the chest must needs carry with it respiratory 
 impairments (suffocation) and diaphragmatic 
 complications. If pulmonary troubles (pneu- 
 monia) accede or the examination of the patient 
 is carelessly made the diagnosis is apt to take an 
 erroneous trend. 
 
 In acute polyomyositis or trichinosis, in Weil's 
 disease and also in gout such a muscular invol- 
 ment is ever a contingency. 
 
 Independent muscular pains in the chest are 
 often due to athletic or gymnastic sports, like- 
 wise to violent and protracted fits of coughing 
 (pertussis, bronchitis, pulmonary emphysema). 
 They are also observed in occupational pursuits 
 seamstresses, cobblers, tailors, dentists and 
 are due to the constant strain on the muscles, 
 bones and nerves of the chest, not to forget 
 overfatigue. 
 
 Exquisite muscular pains in the chest are 
 seemingly the prerogative of pleurodynia and 
 rheumatism of the pectoral muscles. If the 
 superficial muscles are the site, the diagnosis 
 should result promptly, for we find in both 
 affections muscular tenderness and motoric 
 pains, in protracted cases also muscular twitch- 
 ing and formation of nodes.
 
 212 GENERALIZED PAIN 
 
 In more severe muscular diseases the patient 
 complains not only of pains when raising the 
 arm but also of such which accompany coughing, 
 sneezing, swallowing and deep breathing. The 
 latter is naturally and instinctively avoided and 
 leads to congestion of the bronchial secretions 
 with complicating catarrhal conditions. I raise 
 the question: Is a secondary catarrh the sequel 
 of a primary rheumatism of the pectoral muscles 
 or is it a primary bronchitis with secondary dry 
 pleuritis? 
 
 If in overfatigue the pains persist for a con- 
 siderable period of time we should remember 
 that pains in the pectoralis muscles are specifi- 
 cally the symptom of a chronic overtax of the 
 muscles due to abnormal growth of the pectoral 
 glands. 
 
 When the deeper muscles alone are involved 
 (pleurodynia) the differential diagnosis will be 
 concerned only with pleuritis sicca in which sharp 
 pains in the intercostal region are also a prevail- 
 ing symptom. Intercostal neuralgia is barred 
 owing to the peculiar characteristic of the pain 
 and tenderness along the intercostal space. 
 
 In the differential diagnosis between pleuro- 
 dynia and pleuritis sicca in the primary as well 
 as in the secondary form which latter may arise 
 from a morbid condition in the thoracic wall, 
 the lungs or the bronchi, we must be circumspect 
 and not place too much stress on what the
 
 CHEST 213 
 
 patient tells us. He is wont to complain of 
 increased painfulness when drawing a deep 
 breath or during coughing or sneezing. He will 
 instinctively put his hand to that part of the 
 thorax in which the pain is felt when the urge 
 for such respiratory excursions comes on and 
 he will take in the air in short draughts to fore- 
 stall pain. However, all these symptoms may 
 be observed in every form of thoracic neuralgia, 
 in every form of intercostal neuralgia as well 
 as in pleurodynia and pleuritis sicca. He will 
 also tell us that every more or less vigorous 
 movement of the thorax engenders the same 
 kind of pain also common to all the diseases 
 aforesaid. But when a deliberate, slow move- 
 ment provokes the pain more so than deep 
 breathing, we may take it as a pointer in favor 
 of intercostal myalgia or neuralgia. If the 
 thoracic movement towards the healthy side of 
 the body strongly exacerbate the pain we are 
 dealing with a tension of the pleura and may 
 incline to a diagnosis of pleuritis. In intercostal 
 neuralgia the same kind of movement towards 
 the affected side contracts the nerves and pain 
 follows, whilst in pleurodynia (myalgia) this is 
 not the case. In some cases the faradic current 
 passing through a moist sponge materially as- 
 sists the diagnosis of myalgia, because under 
 electric treatment the pain in the pectoral mus- 
 cles disappears.
 
 214 GENERALIZED PAIN 
 
 The presence of local tenderness carries no 
 weight, excepting the characteristic pressure 
 points of neuralgia. Local tenderness exists 
 in intercostal myalgia as well as in pleuritis sicca, 
 but if it extend over several intercostal spaces it 
 points to pleuritis. Fever exists both in mus- 
 cular rheumatism and in fibrinous pleuritis, and 
 both may have the same etiological genesis, i.e., 
 either of them may be the signal of acute rheu- 
 matism. Thus, there remains only one more 
 distinguishing mark, i.e., friction fremitus in the 
 pleura, and even this must be taken with caution 
 unless it is unmistakably perceptible in its typical 
 form. 
 
 We can hear in the affected part a fine crepi- 
 tant, crackling sound with inspiration as well 
 as expiration. It is of the same constancy no 
 matter whether the patient breathes deeply in 
 the regular fashion or coughs. It's nature is 
 that of an atelectatic crepitus caused by con- 
 tinued superficial breathing. The patient could 
 not draw a deep breath if he wanted to. Erro- 
 neously we call it pleural friction fremitus. I 
 had such a case under observation. Crepitus 
 was distinct and constant. The patient was 
 much relieved by the application of a compress. 
 I diagnosed fibrinous pleuritis surmising a pul- 
 monary infarct due to demonstrable arterio- 
 sclerosis and myofibrosis, but future events 
 proved clearly that it was a case of intercostal
 
 CHEST 215 
 
 neuralgia without pressure points and caused by 
 a carcinoma of the spinal column. This shows 
 that even a definite audible crepitus is not a re- 
 liable criterion and it is always advisable in such 
 cases to resort promptly and at the earliest possi- 
 ble moment to the electric current for assistance. 
 
 It follows that, whenever we are called upon 
 to decide whether a case before us is one of 
 pleuritis sicca or of unilateral intercostal neu- 
 ralgia with pressure points and local tenderness, 
 we should make a thorough examination of the 
 spinal column and of the ribs and ascertain 
 whether pain reacts more intensely to thoracic 
 movement than to deep breathing, and avoid the 
 palpable error of a diagnosis of pleuritis sicca. 
 
 Muscular pains in the chest are likewise a 
 sign of neurasthenia. The patient is in fear of 
 a heart disease. If the pain is aggravated by 
 movements of the affected muscle but is miti- 
 gated by walking the diagnosis is readily made. 
 
 In tetanus these pains are often erroneously 
 taken to be of a pleuritic nature, while in reality 
 they are due to morbid contractions of the pec- 
 toral muscles. 
 
 The pains released in the chest by a beginning 
 grippous affection and at times felt in the initial 
 stages of scurvy are at least in part due to 
 myalgia. In scurvy they are also caused by 
 hemorrhagic condition at the finals between the 
 cartilage and the osseous section of the ribs.
 
 216 GENERALIZED PAIN 
 
 Pectoral when combined with nuchal pains 
 (also in part at least as constituents of myalgia) 
 may be furthermore signs of a chronic septic 
 infection. 
 
 These pains in the chest occasionally come 
 from an overexertion of the abdominal muscles 
 in severe fits of coughing because their terminals 
 are situated in the bony frame of the thoracic 
 wall. 
 
 It is self-evident that a fibrinous, in fact any 
 inflammatory process of the pleura necessarily 
 leads to pains in the chest. An acute tubercu- 
 lous pleuritis, it is true, may set in with very 
 mild local pains, even without any at all, but 
 the purulent form is characterized by the very 
 intensity and constancy of these molesting con- 
 ditions. Exceptions, of course, are parapneu- 
 monic and metapneumonic empyema. 
 
 The only remaining part of the thoracic wall in 
 which pectoral pains may originate are the bones 
 themselves, mainly the ribs and the sternum, both 
 of which I shall now proceed to discuss. 
 
 May it suffice to just merely mention that 
 these two skeletal parts may be affected by an 
 acute periostitis or osteomyelitis, by a chronic 
 tuberculous (caries), luetic or actinomycotic 
 osteoperiostitis, by primary or secondary neo- 
 plasms, because they have already been fully 
 discussed in the chapter in "Diseases of the 
 Bones."
 
 CHEST 217 
 
 But I will apprise the reader here of the fact 
 that pains in the chest caused by primary or 
 secondary neoplasms of the bones come on at 
 times most abruptly and with such intensity that 
 deep breathing becomes impossible and that the 
 patient apprehensively avoids every kind of 
 movement. 
 
 In vertebral insufficiency pains in the chest 
 are, in part at least, attributable to the spinal 
 column. For diagnosis and symptoms the 
 reader is referred to the volume dealing with 
 "Abdominal Pain." 
 
 Pains in the sternum and in the ribs, the same 
 as those in the spinal column, may be only 
 partial manifestations of a generalized affection 
 of the bones, e.g., osteomalacia, osteoporosis, 
 rachitis, multiple primary or secondary neoplasm 
 or myeloma. (Details will be found in the 
 chapter on "Pains in the Bones.") For differ- 
 ential diagnostic purposes it is important to say 
 that these pains, similarly to those in the muscles 
 and pleura, are aggravated by coughing and 
 sneezing, etc., in fact coughing frequently starts 
 them. 
 
 In chronic myeloid leucemia we find exquisite 
 tenderness especially in the thoracic bones which 
 are so intense that the patient has the utmost 
 difficulty in dressing. 
 
 There are cases, however, of this last-named 
 disease in which the pains appear rather sub-
 
 218 GENERALIZED PAIN 
 
 dued, or may be missing altogether until pro- 
 voked by pressure and palpation. The sternum, 
 the ribs and the lower extremities are by prefer- 
 ence the seat of these pains. But this is not 
 unusual in other diseases such as severe anemias 
 of primary or secondary origin, chlorosis, Base- 
 dow's disease, in acute phosphoric poisoning, in 
 septic and pyemic affections, septic endocarditis 
 and acute leucemia. A valuable hint for the 
 diagnostician ever. 
 
 Malignant neoplasms, cold abscesses or gum- 
 mata, also arrosion of the sternum due to aneu- 
 rysm of the aorta, etc., are diseases localized in 
 the posterior section of the sternum. The clini- 
 cal examination shows no visible or palpable 
 changes, but local dullness of a higher degree 
 may be noticeable. Sternal pain and local 
 tenderness are present, i.e., conditions which 
 strongly resemble those enumerated in the pre- 
 ceding paragraphs and for that reason deserve 
 mention in this place. 
 
 A special form of sternal pain has its abode 
 in the region of the ensiform appendix and is 
 likely to remind us of an affection of the syn- 
 chondrosis of the ensiform cartilage with the 
 corpus sterni often enough witnessed as a par- 
 tial manifestation of gonorrhoic articular rheu- 
 matism or of a gouty diathesis. A fracture or 
 separation of these two bodies due to some 
 trouble in the bony skeleton, e.g., osteoporosis is
 
 CHEST 219 
 
 also a possibility. Chondrosis and perichondro- 
 sis of the aforesaid cartilage, with local tender- 
 ness or even enlargement (perhaps of syphilitic 
 origin) may also be at the bottom of these pains. 
 Furthermore, we must not forget that girdle- 
 pains arising from any irritation or inflamma- 
 tion of the posterior roots of the upper and 
 median dorsal segments may be focused in the 
 region of the ensiform cartilage. The sole 
 complaint the sufferer makes is of pains at the 
 bottom of the sternum, i.e., the ensiform ap- 
 pendix. 
 
 Pains behind the xiphoid occur in aortalgia 
 and angina pectoris. These attacks come on as a 
 rule with bodily exercise and produce a burning, 
 pressing painful sensation behind the ensiform 
 appendix with a tendency to gradually climb 
 upward behind the sternum into the left arm. 
 But if it remains stationaiy we must be prepared 
 to encounter further symptoms of epigastralgia. 
 
 Pains of a like nature supervene also in 
 diseases of the esophagus and cardia. I will 
 speak of this anon. 
 
 It is rather remarkable that this investigation 
 of pain is not always a correct indication of the 
 real seat of the disease. The patient who com- 
 plains of pains thus localized, especially during 
 swallowing, is undoubtedly suffering from car- 
 cinoma of the esophagus. But this carcinoma 
 is not located behind the ensiform process, but
 
 220 GENERALIZED PAIN 
 
 higher up on a level with the middle of the 
 chest. The pain, therefore, can only be the 
 reflex action of esophageal spasms. Another 
 patient complains of the same kind of spastic 
 pains, he can pass neither fluid nor solid foods. 
 The causative factor is a tumor in the pyloric 
 region. The painful cardiospasms are the reflex 
 action of the tumor. 
 
 Pains behind or close below the xiphoid pro- 
 cess are proper to gastroptosis, no doubt due to 
 a dragging of the cardia. They come on after 
 eating, or during walking or going upstairs. 
 
 Pains around the ensiform appendix are com- 
 mon in diseases of the diaphragmatic muscular 
 system. When associated with dragging pains 
 in the masseters, beginning trismus, epigastric 
 pains, pulling pains in the extremities, profuse 
 sweating, and sleeplessness, they are valuable 
 symptoms of tetanus. Later on they pair with 
 diaphragmatic shock. 
 
 Within a narrow, limited zone around the 
 sternum certain diseases originate which cause 
 very painful local sensations. I refer to the 
 affections of the sterno-clavicular joint and that 
 which connects the sternum with the 7. rib. The 
 most common among these are acute articular 
 rheumatism and gonorrhoic arthritis. Local 
 swellings, reddening of the skin, the general 
 symptoms and the X-ray will steer the diagnosis 
 into a safe port even in those rare cases in which
 
 CHEST 221 
 
 the two aforesaid diseases settle either momen- 
 tarily or even permanently in these joints. I 
 must add, however, aneurysms of the aorta, of 
 the anonyma and the subclavian arteries, which 
 are offenders in the same sense. 
 
 Pain behind the sternum should direct our 
 eye to the myocardium and the aorta. Acute 
 and chronic aortitis, sclerosis, aneurysm, insuffi- 
 ciency of the aorta, sclerosis of the coronary 
 arteries, acute and chronic pericarditis, acute 
 arteritis of the anonyma, are distinguished by 
 the fact that the spontaneous pains, character- 
 istic in all of them, are provoked by bodily 
 movements, but dormant when the patient is at 
 rest. On the other hand in acute myocarditis, 
 arteritis, aortitis and pericarditis the pains are 
 of a constant nature in the region of the heart, 
 i.e., behind or lateral to the superior sternum, 
 coupled with pronounced local tenderness on 
 pressure and palpation. 
 
 In true angina pectoris the pains are like- 
 wise localized behind the sternum. ( See chapter 
 on "Cardiac Pains.") 
 
 I must not neglect to mention thrombosis and 
 thrombophlebitis of the vena cava superior as 
 a possible cause of later o- sternal pains. A simi- 
 lar pain, resembling rather that connected with 
 angina pectoris, may also be provoked by an 
 aneurysm of the anonyma when it expands 
 downwards inwardly. The patient is apt to
 
 222 GENERALIZED PAIN 
 
 complain of pectoral pain in the direction of 
 the right shoulder joint. 
 
 Patients suffering from stenosis or obliteration 
 of the superior vena cava complain of constring- 
 ent pains behind the anterior wall of the chest. 
 The diagnosis should be: cyanosis and edema, 
 and collateral expansion of the superficial tho- 
 racic vessels and epigastric veins. 
 
 Sensitiveness in the upper sternum and the 
 adjacent intercostal spaces is likely to be induced 
 throughout the intervals between the attacks of 
 angina pectoris. It springs from an aneurysm 
 of the aorta with or without arrosion of the 
 sternum or from any other form of mediastinal 
 disease that gives injury to the posterior sternal 
 portion. I mention morbid conditions of the 
 retro-sternal antemediastinal lymphatic glands. 
 In tuberculosis of these glands painful tender- 
 ness chiefly on pressure and palpation exists in 
 a limited zone of the sternum corresponding with 
 the level of the 4.-6. thoracic vertebra. Analo- 
 gous pains are felt in syphilis of the same glands 
 and are coupled with acute inflammatory or 
 purulent changes. Anthracosis of the peribron- 
 chial glands with perforation into the air pas- 
 sages is not an uncommon incident. Important 
 for the diagnosis is the presence of acute or sub- 
 acute putrid bronchitis (unilateral) which degen- 
 erates into an abscess or gangrene of the lung 
 with expectoration of sputum which shows under
 
 CHEST 223 
 
 the microscope a free layer of black, crumby 
 pigment; there is dullness over the superior 
 sternum or laterally to it, the X-ray shows a 
 shadowy impression; we find spontaneous pain- 
 fulness over or laterally to the manubrium sterni 
 with tenderness. 
 
 The perforation may also be in the esophagus. 
 If it is latent in its character it has, as a rule, 
 been preceded by a traction diverticulum. If 
 infection supersedes the diagnosis will be mate- 
 rially advanced by the observation of pains 
 behind the sternum and between the shoulder 
 blades, sensitiveness in the spinous processes on 
 palpation, coughing, pain in swallowing behind 
 the manubrium sterni or the xiphoid process, 
 recurrent paresis, pupillary difference and heav- 
 ing up of evil smelling, caseous, purulent, bloody 
 masses. 
 
 This list would be incomplete without the 
 inclusion of benign and madignant tumors of 
 the mediastinum or the appertaining glands, 
 also inflammations thereof (diffuse or localized 
 mediastinal abscesses of an acute, purulent or 
 sanious character, or arising through continuity 
 or metastasis, or of a chronic, indurated or 
 syphilitic nature, likewise actinomycotic medi- 
 astinitis), also tumors of the thynius, substernal 
 struma with strumitis, carcinoma of the bron- 
 chus, mediastinal pleuritis and pericarditis. The 
 same manifestations of severe, periodically in-
 
 224 GENERALIZED PAIN 
 
 creasing pains behind the upper sternum or 
 within the reach of the intercostal nerves are 
 individual to all these diseases whether they are 
 associated with an affection of the sternum 
 proper or not. 
 
 Of course, combinations of these diseases are 
 not impossible and we may well anticipate the 
 presence of severe retrosternal pains when each 
 of them separately is capable of producing them. 
 
 Carcinomata of the lung or the bronchus call 
 forth severe pains which resemble neuralgia very 
 closely and radiate into the arms. They arise, in 
 part at least, from the aforementioned glands, 
 but also from the bronchus, and bear the char- 
 acter of pulmonary infiltrating carcinomata. 
 The clinical picture will be complete for diag- 
 nostic purposes when we observe: irritating 
 coughs, want of thoracic participation in the act 
 of breathing, dyspnea, slight involvement of the 
 lungs, general indisposition, absence of respira- 
 tory sound or crepitus, sputum tinged with 
 blood, metastasis in the glands, in the supra- 
 clavicular fossa and in the skin and sometimes 
 subfebrile temperature. The Roentgen-ray is 
 bound to render good service. 
 
 We will turn our attention now to the trachea 
 and the esophagus. 
 
 Among the tracheal pains the commonest is 
 that observed in acute as well as in chronic 
 trachcitis. There is a feeling of dryness, tick-
 
 CHEST 225 
 
 ling, burning and soreness behind the sternum. 
 There is cough with copious expectoration, a 
 distinct deficiency of bronchial symptoms, but 
 decided treacheoscopic evidence. A complex of 
 unmistakable symptoms for the diagnostician. 
 Sensitiveness on pressure and palpation is usu- 
 ally absent, but the pains are highly sharpened 
 by paroxysms of coughing which may also be 
 provoked by pressure on the first treacheal ring. 
 The retrosternal pain in pertussis may be ex- 
 plained in the same manner, and likewise that 
 experienced in chronic stenosis of the windpipe. 
 
 It is hardly necessary to mention that foreign 
 bodies in the treacliea cause local pain. Re- 
 peated paroxysms of coughing and attacks of 
 suffocation and gagging indicate their presence 
 as well as the existence of a subsequent purulent 
 or sanious tracheitis, if the anamnesis has not 
 already given us the required information. The 
 arrival of the substance in the windpipe or in 
 one of the bronchi and its expulsion or removal 
 are connected with retrosternal pains, no doubt 
 caused by an injury to the mucous membrane. 
 Similar retrosternal pains are also the compan- 
 ions of other morbid tracheal or bronchial affec- 
 tions, such as syphilis or carcinoma. 
 
 A perforation, e.g., of an esophageal carci- 
 noma into the windpipe also releases retrosternal 
 pains combined with local tenderness owing to 
 mediastinitis produced by the disease.
 
 226 GENERALIZED PAIN 
 
 Bronchial asthma confronts us likewise. The 
 pains come in sudden attacks behind the sternum 
 and are a collateral manifestation of the periodic 
 paroxysms, and are undoubtedly due to spasms 
 in the bronchial and tracheal muscles and to 
 acute hyperemia of the mucous membranes. 
 
 In broncholithiasis the pains in the chest are 
 very vicious and insufferable. Spasmodic cough- 
 ing similar to whooping cough, dyspnea, the 
 sensation as if a lump were rising and falling 
 in the windpipe, periodical hemoptysis and the 
 final expulsion of the stone are clear indications. 
 
 It is needless to say that the inhalation of 
 poisonous fumes irritates the air passages and 
 causes severe local pain. Chlorine, brass, zinc 
 and the terrible gases employed in warfare are 
 striking examples. 
 
 Diseases of the esophagus proper are fre- 
 quent factors in retrosternal pains. Soup, coffee, 
 tea, milk or other beverages that are too hot, or 
 a morsel of food that is too large, etc., may 
 cause severe pain and even injury to the gullet. 
 Analogous painful sensations in the act of swal- 
 lowing are caused by inflammatory processes in 
 and around the esophagus (esophagitis, medi- 
 astinal pleuritis, pericarditis, mediastinitis, etc.) ; 
 by every possible form of functional or organic 
 stenosis of this organ, or by local tumors. In 
 carcinoma they are accompanied by local tender- 
 ness and aggravated by deglutition or when the
 
 CHEST 227 
 
 patient is in a prone position. In this affection 
 but not exclusively these retrosternal pains 
 are not only experienced during the intake of 
 food, but may be present constantly and more 
 so in the night time. Dysphagia is apt to prove 
 a fatal complication. A deep-seated esophegeal 
 diverticulum may also during ravenous eating 
 cause severe pains in the chest, likewise dyspha- 
 gia and palpitation of the heart. Prompt relief 
 ensues from emptying the contents. 
 
 In peptic ulcer the pain is generally localized 
 in the epigastrium but often reaches up behind 
 the sternum in the neighborhood of the nipples. 
 They come on in periodic attacks for days or 
 weeks the same as is the case in ulcus ventriculi 
 or duodeni and last for a minute or hours with 
 remissions and intermissions and cycles of abso- 
 lute painlessness. Fairly reliable indications 
 are: when the patient throws up profuse masses 
 of blood, when swallowing of solid food and 
 eventually of liquids becomes more and more 
 difficult. Of course, in such instances the dif- 
 ferential diagnosis lies between carcinoma and 
 intermittent esophagospasm. Radioscopic ex- 
 amination should furnish the proof. 
 
 In the diagnosis of esophagism my advice is 
 to proceed with caution, because it is so fre- 
 quently the consort of an anatomical lesion, e.g., 
 ulcus or carcinoma of the esophagus. 
 
 The retrosternal pains which accompany that
 
 228 GENERALIZED PAIN 
 
 rather rare disease, dysphagia lusoria, are local- 
 ized high up behind the sternum and are due 
 to pressure on the esophagus by the right sub- 
 clavian artery. 
 
 Pyrosis or heartburn is another offending 
 member of this family of pains to which belongs 
 also a whole string of gastric affections, diseases 
 of the liver, the pancreas and the adrenals. I 
 have already touched on this subject in the chap- 
 ter on "Cardiac Pains." Our mind turns auto- 
 matically to the gastric or lower esophageal 
 region when a patient complains of pains behind 
 the lower third of the sternum. A carcinoma of 
 the heart or an infiltrating scirrhus of the stom- 
 ach naturally give rise to such pains, especially 
 when they announce themselves during meal 
 time. But this "warning" localization of pec- 
 toral pains is by no means always a requisite 
 sign of gastric trouble. The pains may lie 
 higher up. I saw not long ago a case of hour- 
 glass stomach in which the patient placed the 
 pains behind the middle of the sternum. An- 
 other patient who suffered from gastric carci- 
 noma told me that when going down hill his 
 whole body shook with pain. The same hap- 
 pened in a case of adhesive perigastritis of the 
 small curvature. In stenocardia, on the con- 
 trary, this motoric pain arrives with the going 
 up hill. 
 
 In peracute engorgement of the liver the
 
 CHEST 229 
 
 patient likewise experiences a similar motoric 
 pain and also pressure in the retrosternal region 
 when he is going down hill, but epigastric and 
 dextrohypochondral painful sensations are also 
 present. (Cf. volume on "Abdominal Pain.") 
 
 Some patients suffering from liver colic local- 
 ize the pain immediately behind the sternum, i.e,, 
 the lower median region, or about the height of 
 the 2. rib, with less intensive pain behind the 
 right costal arch. For a proper diagnosis it is 
 important to note especially in a differential 
 diagnosis of angina pectoris that the patient 
 does not quite correctly localize the pain as being 
 behind the sternum, it is more to the right of 
 it on a level with the mamma or nipple, also 
 that he experiences no motoric pains, unless it 
 be during the night, that he finds relief with 
 flatus, that the liver is enlarged, that the urine 
 contains urobilinogen or urobilin, that we find a 
 slight rise in the temperature, pressure pain in 
 the cucullaris on the right side and, perhaps, 
 icterus. 
 
 The last three of the aforesaid symptoms 
 suffice sometimes to make the diagnosis positive 
 in those rare cases of colica hepatica calculosa ( I 
 have seen three of them) in which exclusive 
 pains, and very light at that, are felt behind 
 the sternum or simultaneously also to the right 
 or left of it. 
 
 From my own- experience I can say that
 
 230 GENERALIZED PAIN 
 
 oppressive pains behind the sternum 2 hours 
 after eating and also after some psychic excite- 
 ment may well be accepted as a symptom of 
 chronic cholelithiasis. 
 
 This selfsame disease may furthermore, run 
 its course with boring, stitching and oppressive 
 pains in the chest and, perhaps, in the back. 
 Sensitiveness on pressure in the region of the 
 fissure of the liver is a valuable hint. 
 
 Ulciis duodeni produces the same kind of 
 pain as hepatic colic, but exclusively behind the 
 sternum and to right and left of it in the nipple 
 line. We find minor tension in the upper right 
 rectus, tenderness on deep prodding palpation 
 to the right of the median line near to the gall- 
 bladder, hyperesthesia of the skin, the latter also 
 in the back on the right side of the spinal 
 column over the 12. vertebra; likewise hyper- 
 acidity, hypersecretion, gastrectasis, possibly oc- 
 cult hemorrhages in the intestine, and a very 
 instructive Roentgen picture. 
 
 Addison's disease harbors pains which are 
 felt oppressively behind the sternum some time 
 after eating. The diagnosis is not difficult to 
 make from the typical symptoms of the ailment. 
 
 Similar pains are noticeable in disease or 
 insufficiency of other internal secretory glands, 
 e.g., in agenitalism or hypogerutalism. They 
 frequently cause sleepless nights. The same 
 may be said of Basedow's disease, which should
 
 CHEST 231 
 
 always remind us of a substantial struma or an 
 enlargement of the thymus as the possible cause 
 of the pain. 
 
 We must reckon with an expanding subdia- 
 phragmatic morbid process, especially of the liver 
 (abscess of the liver, echinococcus cyst below 
 the diaphragm, large gummata or carcinoma- 
 tous growths), when the patient complains of 
 an unpleasant, incommoding feeling behind the 
 sternum. 
 
 Neurosis in the form of nosophobia is distin- 
 guished by pains which are felt only in a very 
 limited part of the sternum. We may observe 
 it in neurasthenic people who have suffered an 
 acute psychic shock or are eshausted by over- 
 exertion in mental work after a previous attack 
 of syphilis. It is not uncommon among medical 
 men who are liable to make an individual erro- 
 neous diagnosis of sclerosis of the coronary 
 arteries, or of an aneurysm of the aorta, or even 
 a retrosternal gumma. The negative Roentgen 
 picture, negative clinical findings, repeated nega- 
 tive Wassermann reaction and the proof that 
 the pains are not due to physical overexertion 
 but rather to a mental strain, soon calm the mind 
 of the patient and remove the pain. 
 
 In anginoid conditions it is not pain so much 
 than a feeling of oppressive constriction behind 
 the sternum, that is felt by the patient. If this 
 sensation combines with a similar feeling in the
 
 232 GENERALIZED PAIN 
 
 throat it bears another meaning for the particu- 
 lars of which I refer the reader to "Pains in the 
 Neck." 
 
 Asthmatic people complain of sensations such 
 as are described above. 
 
 In chronic indurated mediastinitis the Oliver- 
 Cardarelli sign and the Roentgenogram are both 
 of value. Pain is of minor significance because 
 it is very faint, but there is a sort of timid, 
 incommoding feeling behind the sternum to- 
 gether with slight signs of dysphagia. 
 
 A similar molesting, oppressive, retrosternal 
 sensation I agree with Rosenbaclis theory is 
 often experienced by people who, for instance, 
 bend over a desk for a long time when engaged 
 in strenuous work. They breathe little and 
 superficially, forget it almost, so to speak, and 
 are forced to take in quick and deep draughts 
 every now and then. An oppressive strain 
 makes itself known near the xiphoid process 
 and in the adjacent sternum, in the neighboring 
 parts of the chest, in the muscles of the neck 
 of the lower thorax and the abdomen. Whether 
 the triangular muscle of the sternum is involved 
 is a mere matter of speculation. In fact we 
 have no knowledge of any disease by which this 
 muscle is affected. 
 
 When the pains are localized not behind but 
 at the side of the sternal margins with local 
 sensitiveness we should be on the lookout for
 
 CHEST 233 
 
 hysteria. It is well-known that the parasternal 
 pressure points form an important hyperalgesic 
 region for the diagnosis of this disease. 
 
 Neuritis, possibly also neuralgia, of the 
 phrenic nerve is chiefly the sequel of diaphrag- 
 matic pleuritis, or pericarditis or subdiaphrag- 
 matic peritonitis or perihepatitis or peripleuritis. 
 It is characterized by a pressure point in the 
 neck between the sternocleidomastoid and the 
 scalenus anticus, by the bouton diaphragmatique, 
 i.e., a pressure point at the crossing of the outer 
 sternal margin and an imaginary 10. rib, also 
 by painfulness on pressure along the 9. and 10. 
 rib on a level with the line of attachment of the 
 diaphragm, and finally by a pressure point at 
 both sides of the sternal margins in the first 
 intercostal spaces and laterally from the spine. 
 
 Morbid affections of the mediastinum (bron- 
 chial carcinoma), mediastinitis, also diseases in 
 the diaphragmatic cavity (spleen, liver, peri- 
 toneum) often cause pain behind and lateral 
 from the sternum with or without involvement 
 of the phrenic nerve. Whether there is a paral- 
 lel idiopathic neuralgia of the phrenic nerve is 
 uncertain. 
 
 Pain on the sides of the sternal margins, some- 
 times spontaneous, but always on pressure, are 
 often the sign of a gouty diathesis, evidently 
 due to gouty changes in the sternocostal joints. 
 The diagnosis must be based on the presence of
 
 234 GENERALIZED PAIN 
 
 tophi, pains in the tendon sheaths and in the 
 articulations (mostly without deformities), skin 
 affections (itching, chronic eczema, etc.), diges- 
 tive troubles, hemorrhoids, cramps in the calves, 
 renal colic, gouty pains in the feet or in certain 
 nervous zones (ischias) preceding acute articular 
 gout, overrich food, sumptuous living, hereditary 
 taint, and above all on the chemical examination 
 of the blood. 
 
 Pain in the chest which lies beyond the ster- 
 num directs us to the bronchial and pulmonary 
 regions. We are dealing here chiefly with pleu- 
 rodynia. 
 
 When we are told of stitching pains in the 
 armpit or around the nipple, especially during 
 coughing, etc., we shall have to decide between 
 thoracic myalgia, intercostal neuralgia and dry 
 pleurisy. Friction fremitus is one of the char- 
 acteristic signs of dry pleurisy. But friction 
 fremitus is a tricky symptom and leads to many 
 an erroneous diagnosis. We must know how to 
 distinguish between peritonitic, perihepatic and 
 perisplenitic friction. It is either a primary 
 inflammatory morbid process of the peritoneum, 
 mostly of a tuberculous nature, or it is caused 
 chiefly by primary diseases of the liver, the 
 spleen or other intraperitoneal organs. 
 
 In endocarditis (of recent origin or the revival 
 of a former affection of the heart), especially 
 in endocarditis lenta the false diagnosis of dry
 
 CHEST 235 
 
 pleurisy on the basis of a pulmonary infarct is 
 most frequently made, when in reality it is a 
 case of perisplenitis on the basis of an infarct 
 in the spleen. I have seen a diagnosis of left 
 fibrinous exudative pleuritis made in a case of 
 unmistakable leucemic tumor of the spleen 
 coupled with fibrinous perisplenitis which origi- 
 nated from myeloid leucemia and a large soli- 
 tary tubercle of the spleen. 
 
 The deciding point in such cases is the deep 
 focal seat of the maxinal distinctness of the 
 friction fremitus just beyond the lower margin 
 of the lung. This fremitus is often perceptible 
 away high up in the lungs and cannot always 
 be strictly localized within distinct limits. If 
 that is the case then deep palpation and the 
 presence of maximal sensitiveness in the inter- 
 costal space below the inferior pulmonary bor- 
 der will come to our assistance. The absence 
 of irritation to cough is only of problematical 
 value, because this may be observed in fibrinous 
 pleurisy as well. 
 
 It is scarcely necessary to mention that dry 
 pleurisy is a complicating element in the major- 
 ity of pulmonary diseases, and even in bronchitis 
 when this approaches the pleura! surface, and 
 that it is often the natural cause of pleurodynia. 
 The latter is also observed (in the 10. to 12. 
 intercostal space) in cases of independent upper 
 lobar pneumonia, when the pain is not due to
 
 236 GENERALIZED PAIN 
 
 pleurisy but is rather the reflex action of pain 
 in the pectoral muscles or those of the diaphragm 
 (phrenicus). I wish to point out also that 
 despite the central localization of pneumonia 
 (recognizable only by the aid of the X-ray) 
 pleurodynia is often the sign of a pleural in- 
 volvement. 
 
 Stitching pains in the left side are frequently 
 present at the beginning and also during many 
 infectious diseases and are due either to peri- 
 splenitis or to an acute swelling of the spleen 
 with painful tension in the splenic capsule. 
 Chronic malaria is a striking example. 
 
 The same quality of pain adheres to acute 
 empyema, especially in the interlobar form; like- 
 wise to diaphragmatic pleuritis, but sharper dur- 
 ing deep inspiration and coupled with dysphagia. 
 
 When a patient complains of such stitches in 
 the chest, either in the anterior or posterior, es- 
 pecially in the lower sections (in a line with the 
 lower intercostal spaces) or near the borders of 
 the costal arches and sharpened by deep breath- 
 ing or by coughing, we must look for a fibrin- 
 ous and exudative inflammation below the dia- 
 phragm, especially for a subphrenic abscess. 
 (Fuller particulars will be found in the volume 
 on "Abdominal Pain.") 
 
 The diagnosis is based primarily upon the 
 correct differentiation from a basal pleuritis, 
 because both have in common diffuse dullness,
 
 CHEST 237 
 
 absence of Litten's sign, but delicate breathing, 
 weakened fremitus and consonance of the voice, 
 pleural friction at the upper border of the dull- 
 ness. (Fuller details may be found under 
 "Pleuritis.") 
 
 Similar pains reach the side of the trunk in 
 acute inflammatory conditions within the retro- 
 peritoneal space, such as acute pyelitis, peri- or 
 para-nephritis. Respiratory complications are 
 not unusual. It requires the most painstaking 
 examination to arrive at a satisfactory conclu- 
 sion. 
 
 When the pain is localized chiefly in the left 
 side, between the diaphragm and the heart, with 
 a sensation of fullness, chronic constipation is 
 indicated, or congestion in haustris of the colon, 
 distension of the flexura coli linealis (rarely of 
 the flexura hepatica), which severely taxes the 
 left diaphragm, especially when local adhesions 
 are present. Free and copious discharge of 
 gases and intestinal contents generally brings 
 relief and clears the diagnostic aspect. 
 
 Also in muscular affections of the diaphragm, 
 we find pain in the chest and sides, particularly 
 in cases of influenza, trichinosis and acute poly- 
 myositis. Of course, in trichinosis the pains are 
 essentially due to the invasion of the respiratory 
 muscles by the trichinae, but the fact that these 
 pains are frequently associated with difficulty 
 in breathing and even attacks of suffocation,
 
 238 GENERALIZED PAIN 
 
 and that the patient has a dry cough, should be 
 sufficient proof of diaphragmatic involvement, 
 especially if the other characteristics of the 
 disease are carefully studied. Moreover, the 
 absence of Litten's diaphragmatic phenomenon, 
 and the X-ray picture will be adjuvants. 
 
 Overfatigue from gymnastic exercise, run- 
 ning, racing or any kind of sport which requires 
 unusual respiratory action, spasmodic coughing 
 or sneezing or singultus, violent retching or 
 laughing are apt to cause stitching pains in the 
 sides. The diagnosis can be easily made when 
 we know the causative factor, when the pain 
 ceases with rest, and we can find no abnormal 
 conditions in the organs. Nevertheless, we 
 should not forget that the primary cause may 
 lie in hyperemia of the liver or spleen. 
 
 If the pains continue and we are unable to 
 attribute them to any of the aforesaid causes, 
 we should turn our attention to subacute or 
 chronic affections of the pleura. 
 
 Persons who have had pleurisy, sometimes 
 years ago, may be suddenly attacked by violent 
 pains in the sides when panting heavily after 
 running or some specially strenuous physical 
 exertion, that one is seriously tempted to think 
 of a return of the original disease, possibly due 
 to pleural adhesions. If they are chiefly local- 
 ized in the lower sections of the lungs, we should 
 look for weaker sometimes stronger vesicular
 
 CHEST 239 
 
 breathing, atelectatic crackling, dullness of sound, 
 change of vocal fremitus and an ever perceptible 
 rasping noise in the bronchi. 
 
 Pleural adhesions may also be the after-effect 
 of a former injury to the lung (bullet, bayonet, 
 knife) which healed up with a smooth surface 
 of the skin. The clinician may surmise its pres- 
 ence from the history of the case, but he cannot 
 diagnose it. The Roentgen ray is the only 
 means by which it can be discovered. This is 
 also the case in pleural adhesions which have 
 developed after pleural puncture. The pains in 
 this condition are very severe and associated with 
 dyspnea, agony and oppressive feelings, they 
 are all over the chest, no matter on which side 
 the patient lies. If he turns on the sick side, 
 the pleural sinus contractions push the abdom- 
 inal organs downwards; if he turn to the other 
 side, they are pushed upwards, and so in either 
 case there is painful tension on the adhesions. 
 
 But when these pleural adhesions are local- 
 ized in other than the lower sections of the 
 lungs, the diagnosis is beyond our ken. Only 
 the Roentgen-ray and, in marginal adhesions of 
 the heart, i.e., in pleuropericardial adhesions, the 
 presence of cystolic and presystolic contractions 
 (of the apex impulse, or of a certain part of 
 the precordia, or of the marginal parts of the 
 heart) can give us information. These contrac- 
 tions, according to my own studies on the sub-
 
 240 GENERALIZED PAIN 
 
 ject, may be explained on the ground that the 
 lung is unable to fill in the place left vacant 
 by the shrinking heart owing to interference by 
 the local adhesions. 
 
 But not all pleural adhesions are due to acute 
 fibrinous or fibrinous-exudative pleurisy in which 
 long continued pains are suffered. There is 
 another form which is not adhesive, but also 
 associated with persistent pains in the sides, and 
 which, it seems to me, is not sufficiently appre- 
 ciated by the profession. The pain as well as 
 the audible, sometimes even palpable, friction 
 fremitus is due here to enlargements of con- 
 tiguous connective tissues which rub against each 
 other. The identification of large pleural ad- 
 hesions should offer no difficulty when a thoracic 
 contraction cannot be explained on any other 
 basis or in post-pleuritic scoliosis of the spine. 
 
 It is much harder to trace to their origin 
 these severe pains in the breast, coupled also 
 with dyspnea, which are due to a chain of inter- 
 lobar cicatrices. In some cases it is utterly 
 impossible for the patient to lie down. Only 
 the Roentgen-ray can enlighten us in this con- 
 dition. The cicatricial tissue forms a solid union 
 between the mediastinum and the lateral wall 
 of the thorax, so that, no matter on which side 
 the patient may lie, a painful tension on the 
 cicatricial cord ensues. 
 
 In a case of pleurisy it need be only of a
 
 CHEST 241 
 
 serous character without cytologic conditions, 
 in which complaint is made of very severe, in- 
 creasing pains, be they spontaneous or following 
 a pleural puncture, we should think of a malig- 
 nant neoplasm in the pleura. I know, on ac- 
 count of the slight temporary rise in the tem- 
 perature and the youthful age of the patient, 
 the diagnosis in these cases generally reads: 
 "Serous, very likely tuberculous pleurisy." But 
 in the course of a few weeks a slight constric- 
 tion of the posterior and lateral sections of the 
 thorax manifests itself; the intercostal spaces on 
 the affected side seem to have grown narrower. 
 We have either a thick pleural induration, with 
 a possible exudate behind it, or a malignant 
 neoplasm of the pleura before us. Whenever 
 the regular symptoms fail us, i.e., absence of 
 metatastic glands, of cachectic edema, of ectasia 
 in the superficial veins of the trunk, of thoracic 
 edema, or absence of a primary tumor; if we 
 cannot find an hemorrhagic, but do find a 
 serous exudate, and no cytologic conditions of 
 diagnostic value, but a slight upward tendency 
 in the temperature, then, and in that case, a 
 complaint of severe and ever-increasing pains 
 in the affected side of the chest should awaken 
 in us the suspicion of a neoplasm. This thought 
 has often been my guide in making a correct 
 diagnosis. A test puncture in the painful zone, 
 with a careful laboratory diagnosis, will forestall
 
 242 GENERALIZED PAIN 
 
 errors. The use of the X-ray should not be 
 neglected. 
 
 Subacute or chronic actinomycosis is another 
 condition in which very severe pains in the chest 
 give the impression of a pleuritic affection. 
 Here, also, we find a tendency to the formation 
 of very extensive constricting pleural indura- 
 tions. With this possibility before us we are 
 already far advanced on the road to a proper 
 diagnosis. A local puncture, bacteriological ex- 
 amination and the complement fixation test will 
 do the rest. 
 
 The same may be said of pleural syphilis. 
 If the W ' assermann reaction is more positive in 
 the exudate, if such exist, than in the blood, 
 and the presence of spirochetes in the exudate 
 are the pillars of the diagnosis. 
 
 We must not forget that even a feeling of 
 slight oppression or of fullness in the chest or 
 pains of a lesser degree in the side may indicate 
 a pneumothorax that has developed overnight, 
 or, perhaps, a sanious empyema or a pyopneu- 
 mothorax, all of which are causative factors of 
 severe painful sensations. 
 
 Not only the vicious character of the pains, 
 but their characteristic localization, on the right 
 near the fourth rib, on the left in the fifth inter- 
 costal space, are powerful indications of a spe- 
 cial subordinate form of pleural exudation, i.e., 
 of interlobar pleurisy, particularly interlobar
 
 CHEST 243 
 
 empyema. In addition to these specific pains, 
 we also find the so-called "suspended" dullness 
 in the interlobar fossa, or in a part thereof, 
 displacement of the heart with slight dullness, 
 and what I call the paravertebral circular seg- 
 ment. With these symptoms and the aid of the 
 Roentgen-ray the correct diagnosis is bound to 
 evolve. 
 
 Not only primary affections of the pleura, 
 but also diseases of the lungs involving the 
 pleura, give rise to severe stitching pains in the 
 chest. In the presence of such pains our mind's 
 eye is naturally directed to all kinds of acute as 
 well as chronic inflammatory processes in the 
 lungs, including acute active congestion, new 
 formations, parasitic growths, the diagnosis of 
 which is to be found in another chapter of this 
 book. I will only point out that the localization 
 of the painful focus is not always a clinical proof 
 of the seat of the disease. In croupous pneu- 
 monia, for instance, the patient generally points 
 to the healthy side as the seat of the pain. Per- 
 haps anastosmosis of the intercostal nerves must 
 bear the blame for this error. 
 
 If in the course of such a disease, e.g., pul- 
 monary echinococcus , the hitherto only slight 
 painfulness should turn suddenly into an attack 
 of very severe pleurodynia, we must be prepared 
 to find cystic suppuration. 
 
 Moreover, a sudden attack of pleurodynia,
 
 244 GENERALIZED PAIN 
 
 localized in a specially limited area, is nearly 
 always the symptom of a small, superficial 
 pulmonary infarct. A slight acceleration of the 
 breathing act and the cardiac rhythm, and de- 
 sultory participation of the affected part of the 
 chest in the respiratory movements, may be 
 noticeable. The localized pleural friction may 
 limp behind or be completely corrected. 
 
 In pulmonary tuberculosis the pains are most- 
 ly felt in the lobar region, and are generally a 
 sign of an aftergrowth which has reached the 
 surface with or without a demonstrable dry 
 pleurisy. These pains may, however, also be due 
 to a complicating attack of adhesive pleurisy 
 or to tension from pleural adhesions. 
 
 Morbid conditions of the mediastinum or of 
 the mediastinal pleurae are further causes of 
 pectoral pain. We have here acute fibrinous 
 or exudative mediastinal pleurisy, not unusual 
 accompaniments of pneumonia or tuberculosis. 
 The latter betrays itself by systolic friction, 
 which dies away at the height of the inspirium. 
 
 I have already mentioned that sclerosis of the 
 aorta frequently provokes pressure sensitiveness 
 in the upper intercostal spaces. I wish to add 
 here that similar pains occur in sclerosis of the 
 intercostal arteries in the form of an intermit- 
 tent dyspragia. 
 
 Aneurysms of the aorta and mediastinal tu- 
 mors generally settle rather in certain parts of
 
 CHEST 245 
 
 the ribs than in the sternal region. The patient 
 complains of pain in the mamillary line, with 
 irradiations in the back. They are not of a 
 constant, but rather of a piercing, more or less 
 violent, nature, coming on in successive attacks, 
 and last for half an hour or so. Analogous 
 pains between the sternum and the nipples oc- 
 cur in mediastinal pleurisy, and may continue 
 during the whole course of the disease. 
 
 The fact of the matter is, that all diseases 
 which cause irritating or inflammatory condi- 
 tions in the posterior spinal roots of the upper 
 or median segment of the thorax will also give 
 origin to girdle feelings around the chest and 
 to pleurodynia. 
 
 Insofar as mediastinal tumors are concerned, 
 I animadvert only acute or chronic affections of 
 the mediastinal lymphatic glands, particularly 
 the pulmonary hilum gland. 
 
 I have repeatedly seen cases of acute tonsillar 
 infections in which the patient complained of 
 piercing and shooting pains either to the right 
 or to the left of the sternum in the second or 
 third intercostal space, and outside the para- 
 sternal line, which radiated also in the back. 
 Local pressure and signs of bronchitis were 
 present, but conspicuously often only in the 
 region of the upper middle lobes around the 
 pulmonary hilum. I think there is good reason 
 to attribute these pains to an acute swelling of
 
 246 GENERALIZED PAIN 
 
 this hilum gland. The same, no doubt, is also 
 the case when the patient complains about 
 stitches and pressure around that point in the 
 presence of tracheitis or dry bronchitis, possibly 
 combined with local tenderness. Signs of fibrous 
 mediastinitis were never observable in any of 
 these cases, and I am certain the trouble was 
 due to defective nasal breathing, or chronic ton- 
 silitis, if not to an analogous infection of the 
 lymphatic pharyngeal tissues. The Roentgen- 
 ray proves of extraordinary value in such cases. 
 
 A primary bronchial disease, a foreign body 
 or stone in the bronchial tube gives rise to simi- 
 lar pains in the chest. 
 
 The pain in the chest which is experienced by 
 patients afflicted with a mitral affection during 
 any kind of bodily motation is by some authors 
 attributed to an acute congestion of the bronchial 
 mucous membrane. The claim is made that the 
 bronchial veins resp. the veins of the medias- 
 tinum are so congested that the blood, instead 
 of being discharged into the vena cava, runs 
 back into the cardiac chambers, and in this man- 
 ner produces the severe pains in the chest. 
 
 In hysteria, spontaneous pains in the chest are 
 hardly ever observable, but pain may be elicited 
 by pressing the finger on the so-called intercostal 
 points. This tenderness is generally found at 
 the lower margin of the ribs, about two inches 
 in front of the anterior axillary line, sometimes,
 
 CHEST 247 
 
 however, only in the eighth or ninth intercostal 
 space. 
 
 Subacute or chronic diseases of the diaphragm 
 (hernia, eventration) are frequently the cause 
 of pectoral pains which may be mistaken for a 
 symptom of pleurisy. 
 
 Diseases of the trunk, of the intercostal 
 nerves, the muscles and the bones are apt to 
 give rise to stitching pains in the sides. In fact, 
 some forms of metastatic neoplasms announce 
 their presence through them. 
 
 A special form of complaint is observed in 
 patients who are suddenly visited by exceed- 
 ingly boisterous pains in the breast. Sometimes 
 only one side is involved, but in many cases the 
 pain goes right through the whole of the chest, 
 or through the middle field thereof, in the region 
 behind the sternum and around the precordium. 
 So far as affections of the heart are here con- 
 cerned, the reader will find a satisfactory account 
 in the chapter on "Cardiac Pains." 
 
 I mention only thrombosis of the pulmonary 
 artery and of the right ventricle, diseases of the 
 mediastinum and sub diaphragmatic affections as 
 causal elements of pectoral pains. 
 
 Embolism of the pulmonary artery is still more 
 culpable in this respect than even thrombosis. 
 
 When the thrombus settles in the trunk or in 
 the main branch of this artery, the pains come
 
 248 GENERALIZED PAIN 
 
 on most suddenly together with an enormously 
 deep pressure, and with a feeling of suffocation. 
 The diagnosis can be made without fail when 
 we can promptly and properly localize the seat 
 of the thrombus, i.e., in the right ventricle (in 
 all diseases of the mitral valves, sometimes in 
 tricuspid, also in arteriosclerosis of the pulmon- 
 ary artery), or in peripheral veins of the body 
 (in puerperal phlebitis, phlebitis and phlebo- 
 thrombosis of the lower extremities, in all kinds 
 of infected peripheral wounds, in anal-resp. 
 hemorrhoidal veins, etc.). 
 
 Sudden severe pains behind the sternum, 
 coupled with anxious moments, may indicate 
 a perforation of the esophagus (foreign bodies, 
 tumor, scald or burns, overtension, rupture in 
 inveterate drinkers), or a suddenly arising com- 
 munication between the gullet and the windpipe 
 (trachea, large bronchus). The bursting in the 
 gullet of a carcinoma or diverticulum, mediasti- 
 nitis or purulent pericarditis or an abscess in a 
 dependent part are some of these causal factors 
 readily portrayed by the X-ray. There is a 
 sensation as if "something had given way" in 
 the chest. The patient complains of retrosternal 
 pain when swallowing. Food in its passage 
 causes a fit of coughing, and is regurgitated. 
 
 Similar pains may be observed in youthful 
 individuals who have suffered from fever, ex- 
 cessive sweating, emaciation, loss of appetite,
 
 CHEST 249 
 
 distressing irritating coughs or intrascapular 
 pains. The patient generally recovers after 
 having thrown up some ill-smelling, bloody, 
 purulent phlegm or a clod of blood streaked 
 with pus and a black carbon pigment. In some 
 cases a localized bronchitis, broncho-pneumonic, 
 gangrenous or caseous pneumonic focus is 
 formed, caused by the perforation of anthracotic 
 or tuberculous mediastinal glands. 
 
 The perforation of (mycotic) aneurysms of 
 the aorta into the larger air passages or into 
 the gullet is generally accompanied by pains in 
 the chest, but they are of lesser intensity, some- 
 times missing altogether or coupled with inter- 
 scapular pains. Hemoptysis and subsequent 
 death from suffocation are the usual result.
 
 II. Pains Only in One Side of the Trunk 
 
 Here the trend of mind is turned to the con- 
 sideration of various morbid processes that may 
 exist in the pleural space, not to speak of uni- 
 lateral embolism of the pulmonary arteries or 
 infarction of the lungs. 
 
 Not only in recent, but also in old, cases of 
 fibrous unilateral pleurisy, sudden severe pains 
 in the chest, with dyspnea, may rise to the sur- 
 face. They generally go away gradually in the 
 course of a week or so, owing, I think, to the 
 rupture of a pleural adhesion with local rupture 
 of the lung through violent coughing. 
 
 Similar pains are frequently a coexisting 
 symptom when a communication between lung 
 and pleura is being formed. This may take 
 place when a free or sacculated purulent or 
 purulent-sanious, sometimes serous pleuritis or 
 an echinococcus of the pleura or else some dia- 
 phragmatic process enters the lung or bronchus 
 through the pleura. We generally find coex- 
 isting acute dyspnea, typical expectoration, and 
 even pneumoihorax. On the other hand, a 
 pneumothorax is much more frequently the se- 
 quel of a perforation from the lung into the 
 pleura. The diagnosis should evolve from the 
 
 250
 
 CHEST 251 
 
 typical clinical symptoms, supported by the 
 X-ray picture. 
 
 When a pulmonary echinococcus bursts in the 
 pleural cavity, sudden severe pains with dyspnea, 
 and possibly collapse, are the natural conse- 
 quence. Of course, if we were not aware of 
 its pre-existence, the diagnosis might be a rather 
 complicated matter. But the Roentgen -ray 
 should reveal the true state of affairs, especially 
 if we look for eosinophilia of the blood and a 
 supervening urticaria. 
 
 The perforation of an aneurysm of the pec- 
 toral aorta, chiefly into the left pleural cavity, 
 is always associated with sudden serious pains 
 in the chest which are apt to radiate also into 
 the corresponding shoulder. The general clin- 
 ical aspect of the hemorrhage should suffice for 
 making a proper diagnosis. 
 
 Not only the perforation of a supraphrenic, 
 but also that of a subphrenic organ into the 
 pleural cavity gives rise to such pains, but only 
 when a contraction with the diaphragm and with 
 the diaphragmatic pleura existed, and not with 
 the lung. This happens, for instance, in ab- 
 scess of the liver or spleen, in gastric tumors 
 and cancer of the stomach. The formation of 
 a pleural empyema, pyopneumothorax, hemato- 
 thorax is the natural result. 
 
 When a trauma, affecting the thorax, has 
 directly preceded the onset of pain, especially
 
 252 GENERALIZED PAIN 
 
 in the left side, we must think of a possible 
 diaphragmatic hernia. No matter whether it is 
 congenital or acquired, it will always lead to 
 severe, continuous, though fluctuating, pains, 
 which may even reach up into the shoulders, 
 when stomach or intestines or both protrude 
 through the diaphragm into the thoracic space. 
 If the hernia is acute and due to a traumatic 
 condition, it may be mistaken for a pneumo- 
 thorax. The Roentgen portrait will clear up 
 the situation, and also show the differentiation 
 between hernia and eventration. 
 
 It is well to remember that in both these 
 morbid conditions the pains in the chest are 
 relatively often only incidental; I mean to say, 
 after the intake of food when the stomach is 
 distended. The sensation of weight on the chest, 
 digestive troubles, and palpitation of the heart 
 are frequent companions. 
 
 The perforation of a subphrenic organ, or the 
 formation of subphrenic abscesses, pneumotho- 
 rax or hematomata (of the spleen or adrenals), 
 also a sudden hemorrhage in a subphrenic cyst 
 originate pains in the abdomen as well as in 
 the lower section of the chest (cf. "Abdominal 
 Pains"). The anamnesis, an early examination 
 of the patient and the evidence of internal hem- 
 orrhage should remove all doubts so far a? the 
 diagnosis is concerned. 
 
 If in the course of a fibrinous or even a mild
 
 CHEST 253 
 
 sero-eacudative pleurisy the patient complains of 
 sudden severe pain in the chest or in one side 
 thereof, or else and particularly in the region 
 below the left costal arches, we must be pre- 
 pared to encounter an attack of paresis in the 
 left side of the diaphragm. Here we find sud- 
 den pain, periodically labored and rapid breath- 
 ing, accelerated pulse, inhibition of the left tho- 
 rax and deficiency of Litten's sign. We observe 
 further anteriorly on the left a deep tympanitic, 
 full, sonorous sound (not unlike that in pneu- 
 mothorax) which ascends to within the fourth 
 rib, extending to the middle of the sternum on 
 the right into the median axillary line on the 
 left. Instrumental percussion is positive, there 
 are no physical defects in the left lower posterior 
 region with the exception of pleural friction and 
 a minor basal pleuritic dullness, unless a parallel 
 infiltration of the left inferior lobe exists or a 
 dull tympanitic sound is heard by stronger per- 
 cussion over the left lower posterior side of the 
 primary lesion. The heart is shifted upwards 
 toward the right. This clinical picture, which 
 is almost the type of an acute diaphragmatic 
 eventration, presents many features of a saccu- 
 lated pneumothorax, a subphrenic pneumotho- 
 rax, a diaphragmatic hernia and an acute dila- 
 tation of the stomach. That the Roentgen-ray 
 can give valuable information is self-evident. 
 Of course, a careful clinical examination paves
 
 254 GENERALIZED PAIN 
 
 the way. Against pneumothorax is the unmis- 
 takable tympanitic character of the percussion 
 sound. And, again, the displacement of the heart 
 towards the right and upwards differentiates it 
 from pneumothorax. As for subphrenic pneu- 
 mothorax and diaphragmatic hernia, it will be 
 observed that the appurtenant etiological factors 
 are missing. Acute dilatation of the stomach is 
 the only other condition that craves closer 
 scrutiny. 
 
 The thought of an acute dilatation of the 
 stomach forces itself involuntarily on our mind 
 when the patient suddenly complains of an at- 
 tack of severe pain and weighty oppression in 
 the chest. As a rule, it seems to me, the pain 
 is rather localized in the epigastrium resp. the 
 left hypochondrium. Moreover, the upward 
 tympanitic tendency, the displacement of the 
 heart, the other physical signs, including the 
 pleximeter symptom, are also observed in acute 
 diaphragmatic eventration. But there is one 
 moment which speaks definitely for gastrectasis, 
 viz., dry vomiting. The necessity to remove the 
 stagnating gastric contents with the stomach 
 pump, the etiological factor and the quick relief 
 in the knee-elbow position soon make the diag- 
 nosis positive. 
 
 Of course, there may be complicating circum- 
 stances which render the diagnosis more difficult. 
 If in a case of gastrectasis the patient complains
 
 CHEST 255 
 
 of sudden oppressive pains in the chest, perhaps 
 in the right side only, we must not be surprised 
 when an attack of acute cholecystitis (cholelithi- 
 asis) is under way. There is no complaint of 
 hypochondralgia or epigastralgia or of sudden 
 retrosternal stern pain. The sensation is exclu- 
 sively that of excruciating pain with terrible 
 oppression in the breast. If the reader wishes 
 to get fuller details of the diagnosis he will find 
 them in "Abdominal Pain," under "Hypochon- 
 dralgia dextra." 
 
 When a sudden, most excruciating, splitting 
 pain the patient frequently speaks of stitches 
 in the side is experienced in the lower section 
 of the lung near the hypochondria we must not 
 forget that the muscular tissue, and not the 
 serous, pleural or peritoneal membrane of the 
 diaphragm is the most likely causal factor. I 
 have spoken about this on another page of this 
 book. 
 
 In conclusion I will say a few words about 
 that apprehensive, oppressive feeling in the chest 
 nearly always coupled with labored breathing, 
 but not with tangible pain. It may be as well 
 to let all the originating causes of this condition 
 pass here before our eyes in a short review. 
 First of all the diseases discussed under "Car- 
 diac Pain" are worthy of mention. These are 
 followed by the morbid conditions which affect 
 the thoracic envelope (skin, muscles, nerves,
 
 256 GENERALIZED PAIN 
 
 bones) and those of the abdomen (elevated posi- 
 tion of the diaphragm or painful respiration!). 
 They will be further discussed in the section 
 dealing with dyspnea. A similar sensation is 
 also experienced in cerebral toxic affections. 
 Patients afflicted with uremia or diabetes speak 
 of it as a feeling that comes on before an onset 
 of coma, and so do patients who are distressed 
 by the effects of narcotic poisons without being 
 stupefied (chloroform, morphine) ; those who 
 suffer from shock or collapse and such as are 
 in a pre-agonal stage and yet are in the full 
 possession of their senses. 
 
 I may be allowed a final remark. There are 
 persons who pass painlessly through an illness 
 which is as a rule associated with most intensive 
 pains in the chest. I do not wish to be under- 
 stood as saying that this is due to a physiologic 
 subnormal quality of sensibility. The patient 
 is rather blessed with an unwonted anesthesia of 
 the pleura due to certain pathological conditions. 
 As an illustration I mention the case of a lady 
 that came under my observation. She was af- 
 flicted with tabes dorsalis and passed away. The 
 post mortem showed a severe pleural pneumonia. 
 Another female patient had a sanious pyopneu- 
 mothorax due to the perforation of a gangrenous 
 tuberculous pulmonary carcinoma. Neither of 
 them ever uttered a single word of complaint 
 about pain.
 
 Pains in the Extremities 
 
 If pain in the extremities is properly localized 
 in the muscles, joints or bones the reader will 
 find full particulars in the chapter specially 
 devoted to these three subjects. But if the pain 
 cannot be rubricated under any of these head- 
 ings, then it is very likely the reflex action of 
 pains that exist in some other part of the anat- 
 omy, unless it is exclusively confined to the 
 extremital regions. 
 
 For the better understanding of the subject 
 we will first of all turn to the study of pain 
 which is localized in one of the extremities only. 
 
 Its field of action may be in the skin, a mani- 
 festation which is of common occurrence in many 
 internal diseases. Demonstrable skin lesions al- 
 ways facilitate the diagnosis very considerably. 
 
 The first in order is erythema nodosum. Its 
 favorite place of attack is the skin in front of 
 the tibia to which region it seems to be rigidly 
 confined. Analogous eflorescences may, how- 
 ever, be also observed around the knee joints, 
 the thighs and forearms, even on the trunk of 
 the body and in the face. They consist of mul- 
 
 287
 
 258 GENERALIZED PAIN 
 
 tiple, raised, rosy patches, round or oval, from 
 one-half to three inches in diameter and are 
 exquisitely tender, tense and shiny. The condi- 
 tion chiefly occurs in children and delicate young 
 women. 
 
 Sometimes the patient complains of sponta- 
 neous pains in these patches and of febrile 
 attacks. When the pains radiate into limbs and 
 joints the disease presents the features of a 
 generalized infection with an acute tumor of 
 the spleen. 
 
 This affection is of double interest to the in- 
 ternist, because it frequently follows on the heels 
 of an acute angina, or is the accompanying 
 symptom of articular changes in articular rheu- 
 matism, a fact which explains its ready asso- 
 ciation with inflammatory processes in the 
 endocardium or pericardium. To my mind there 
 is no doubt that erythema nodosum is the expres- 
 sion of a bacterial toxemia or bacteriemia of a 
 different kind altogether, and we must not be 
 surprised to find an analogous exanthema during 
 the career of other septic diseases, for instance, 
 in phthisis or in gonorrhea, etc. The diagnosis 
 should offer no difficulties as it is easily differ- 
 entiated from erythema exudativum multiforme 
 which is confined to the back of the hands. 
 Moreover, in the latter affection we miss the 
 severity of the general symptoms, but we find 
 a tendency in the patches to run together and
 
 EXTREMITIES 259 
 
 spread out towards the periphery (erythema 
 gyratum, herpes iris), and the fact that they are 
 absolutely painless. 
 
 It might be more difficult, perhaps, to distin- 
 guish erythema nodosum from the deuteropathic 
 form, especially when the latter sets in after a 
 septic affection. But when we consider the 
 favorite seat of the patches, the benign course 
 so typical of erythema nodosum, the cytologic 
 condition of the blood (always normal with the 
 exception of a possible slight polynucleosis 
 so far as I am aware bacteria have never been 
 found in the blood in this disease) and the co- 
 existence of septic patches of a different char- 
 acter in the skin, no doubts should arise in our 
 mind as to a correct diagnosis. 
 
 In anasarca pains in the extremities are not 
 very severe, unless the onset of the disease is 
 very sudden and then only when the affected 
 spot is exposed to pressure or friction of any 
 kind. This is also the case in edema due to 
 thrombosis of the vena cava inferior. 
 
 It may be of interest to the reader to mention 
 here that I have seen cases of anasarca in which 
 the skin was treated by drainage. Several quarts 
 of fluid had been drawn off when the patient 
 began to complain of pain in the skin at the 
 affected spot, which molested him day and night 
 for a considerable while. Even paresthesias were 
 observed. The cause for these pains and pares-
 
 260 GENERALIZED PAIN 
 
 thesias is not yet clear to me. Neuritic symp- 
 toms? There were none. Perhaps it was the 
 toxic effect of the concentrated detritus which 
 remained in the subcutaneous cellular tissue. Or 
 did physical changes take place in the skin itself? 
 I do not know. 
 
 In some rare cases of subacute hematoma 
 local pains in the limbs have been observed. 
 They may also be due to bedsores on the heels, 
 in the region of the trochanters, and on the knee- 
 joints, likewise to furuncles and generalized 
 furunculosis. 
 
 Glanders is another infectious disease which 
 may produce painful inflammations on one of 
 the lower extremities. This affection is fully 
 discussed in various other sections of this book. 
 
 In erythromelalgia the pains in the extremities 
 are coupled with certain changes in the skin. 
 The characteristic symptoms of this disease are 
 reddening of the skin of the hands (fingers) and 
 of the feet, principally of the big toe and the 
 heels, severe local burning pains, perceptible 
 swelling in the affected parts and copious sweat- 
 ing towards the end of the sickness. But the 
 pain may also be only an accompanying symp- 
 tom of other affections such as Basedow's dis- 
 ease, or chlorosis, diseases of the posterior or 
 lateral grey substance of the spinal cord, of 
 syringo, tabes, neuritis, or hysteria. It occurs 
 likewise as a combination with Reynaud's dis-
 
 EXTREMITIES 261 
 
 ease, for instance, in the foot of nervous indi- 
 viduals who suffer from chronic nicotinism. I 
 speak from personal experience. I have also 
 seen a case of erythromelalgia on the right foot 
 coupled with sclerosis of the arteries of the right 
 leg and foot, also caused by nicotinism. The 
 X-ray confirmed the diagnosis. 
 
 Furthermore, diseases of the internal secre- 
 tory glands are a source of these pains, e.g., 
 Addison's disease, myxedema and periglandular 
 insufficiency. 
 
 Similar conditions prevail in the catatonic 
 form of dementia precox. We find here char- 
 acteristic swellings, reddening and cyanosis ac- 
 companied by coldness and dampness of the 
 extremities. 
 
 Adipositas dolor osa or Dercurris disease is 
 characterized by irregular, sometimes symmetric, 
 deposits of fatty masses in various portions of 
 the body, preceded by and attended with, pain. 
 It is chiefly localized on the exterior side of the 
 upper arm, in the region of the deltoid and on 
 the leg (sometimes on the abdomen but never in 
 the head, in the face, the hands or feet). When 
 the pains are localized only in one leg of a very 
 stout person the diagnosis may be in doubt as 
 similar pains are also caused by phlebectasis. 
 But in the latter case the pains are hardly felt 
 on palpation, if at all. They rather manifest 
 themselves when the patient is standing or walk-
 
 262 GENERALIZED PAIN 
 
 ing, but are modified when he lifts the leg up 
 high or is at rest. 
 
 Here is another point. Dercum's disease is 
 often attended with neurotic, vasomotoric and 
 trophic disturbances. This is apt to lead to an 
 erroneous diagnosis of "neurosis." Careful pal- 
 pation of the skin should forestall the mistake. 
 Some authors claim that adipositas dolorosa is 
 further associated with sudden, shooting and 
 cramp -like pains of a very severe character, 
 especially in the night time. I have never been 
 able to notice it. 
 
 The features described just now are attributed 
 by some authors to painful symmetrical lipoma. 
 Perhaps not without cause. But in lipoma the 
 pains are of a rheumatic, gouty character, change 
 about from one place to another, are not local- 
 ized in the extremity only, but affect the trunk 
 as well. If palpation does not furnish us with 
 satisfactory evidence for a positive diagnosis, 
 the unusual corpulence of the patient and the 
 attending troubles such as short and labored 
 breathing, palpitation of the heart, etc., should 
 still arouse in us the suspicion of a painful adi- 
 positas. Moreover, it seems to me that in many 
 cases of symmetrical lipoma the pains consider- 
 ably antedate the formation of the fatty tumor. 
 
 Neurofibromatosis of the skin is still another 
 source of the pains under consideration. They 
 are caused by the formation of multiple nodes
 
 EXTREMITIES 263 
 
 in the subdermal tissue and along the nerve 
 trunks. At first they feel to the touch like 
 pinheads, but later on may assume the size of 
 a plum, are very painful on palpation and dis- 
 tinguished from those typical of lipoma by their 
 harder consistence. Besides, abnormal pigmen- 
 tation and thickening of the skin, and trophic, 
 vasomotoric and psychic manifestations are fre- 
 quent symptoms. 
 
 I must not forget to mention erysipeloid, a 
 peculiar affection of the palms of the hands and 
 soles of the feet. It is characterized by zones 
 of violaceous red eruptions with burning and 
 itching and due to wound infection. It is also 
 met in persons who eat meat that is going bad, 
 high game or overripe cheese or any kind of 
 unsound food. The diagnosis offers no obstacles. 
 
 These symptoms at once establish the differ- 
 entiation from erysipelas which only in rare cases 
 attacks the upper or lower extremities. If it 
 does the patient complains of heat in the affected 
 portion and the pains are severe. There is local 
 reddening, shiny appearance and swelling of the 
 sensitive skin the patches are shaped like the 
 wings of a butterfly. We find regional enlarge- 
 ment of the lymphatic glands, general indispo- 
 sition, chills and fever, constant thirst, loss of 
 appetite and possible complicating conditions in 
 the spleen and kidneys. These symptoms should 
 confirm the diagnosis with ease.
 
 264 GENERALIZED PAIN 
 
 It will be more perplexing, however, when 
 we have to differentiate between erysipelas and 
 phlegmon. Of course, plegmonic indurations 
 are harder and the coloring is a deeper red, but 
 the sharp delineation of the patches is the distin- 
 guishing feature of erysipelas. We may en- 
 counter another difficulty. Erysipelas frequently 
 originates from an old ulcer of the leg, the 
 cutaneous tissue around the sore is very much 
 swollen and indurated, the patient is generally 
 well advanced in years and may have suffered 
 from previous attacks of erysipelas. In conse- 
 quence the local and general conditions would 
 show different characteristics. The red tint is 
 paler, the local swelling is less pronounced, and 
 the sharp demarcation of the patches and local 
 sensitiveness are almost wanting. The diagnosis 
 must here be guided by the slow progress of the 
 disease which is also confined to a much nar- 
 rower area, the want of distinctive symptoms 
 and very slight rises in the temperature. In 
 cachectic and anemic patients the reddening of 
 the skin is scarcely perceptible, but local sensitive- 
 ness and elevation and demarcation of the cuta- 
 neous tissue are typical. The name of erysipelas 
 pallidum is here applicable. 
 
 Pains in the extremities may also be due to 
 a thrombosis of the arteries of the skin on the 
 basis of syphilitic or local endarteritis, or to an
 
 EXTREMITIES 265 
 
 embolism of the same vessels in bacterial endo- 
 carditis. 
 
 Pains in the fingers and hand, also rheuma- 
 toid or neuralgiform pains in all the extremities, 
 coupled with vasomotoric crises (blue coloring 
 of the ends of the limbs, cold, hyperesthesia, sud- 
 den sweats) and fever are the initial signs of 
 sclerodermia (sclerodactylia). The patient dozes 
 off easily, gets hard of hearing, feels chilly and 
 is molested with itching in the fingers. Such 
 symptoms should arouse our suspicion. The 
 diagnosis may then be confirmed, when we 
 observe the characteristic thickening and harden- 
 ing of the skin it is glossy, like parchment, 
 does not wrinkle and does not slide about over 
 its base. If similar conditions prevail in other 
 parts of the body, the diagnosis is still easier. 
 I may add that in sclerodactylia the formation 
 of painful trophic ulcers is another cause of 
 pain in the fingers. 
 
 Affections of the superficial nerves are bound 
 by their very nature to cause neuritic or neu- 
 ralgic pains in the extremities. Of course, there 
 are forms of neuritis in which a mixed variety 
 of nerves is affected but without motoric symp- 
 toms; and again, there are other forms which 
 affect only the sensitive nerves, i.e., they provoke 
 pain with or without paresthesias but no motoric 
 symptoms whatsoever. 
 
 Central chiefly spinal disorders which usually
 
 266 GENERALIZED PAIN 
 
 lead to deep, deeper or superficially localized 
 pains in the extremities, may sometimes mani- 
 fest themselves through cutaneous pains only. 
 Tabes dorsalis is an example. The pains in this 
 disease are as a rule of a lancinating, dull, deep- 
 seated character, but I have seen cases with 
 superficially localized pains in the skin alone. 
 
 Symptoms similar to those of sclerodermia we 
 find in acroparesthesia, in conditions of over- 
 fatigue, in neurasthenia or hysteria and, as addi- 
 tional signs, in various other diseases. The 
 patient falls asleep, feels cold, has creeping, 
 stabbing and burning sensations, suddenly turns 
 pale, one or more fingers, especially the tips, 
 get numb and icy a typical sign of peripheral 
 vasoconstriction. 
 
 What, however, puts the typical stamp of 
 idiopathic neurosis upon acroparesthesia is the 
 relative frequency of the nocturnal attacks due 
 to thermic influences, i.e., heat and cold. They 
 do not play the same predominant role in vaso- 
 constricting conditions of neurasthenia and hys- 
 teria in which psychic emotions are the most 
 frequent causative factors. 
 
 In speaking of deuteropathic acroparesthesia 
 I will mention that similar paresthesias in the 
 fingers and toes are often accompanying symp- 
 toms of osteomalacia or osteoporosis. 
 
 If these pains are of a tearing, stabbing 
 nature they may be accepted as forerunners of
 
 EXTREMITIES 267 
 
 chronic articular rheumatism. They have a 
 nocturnal and early matutinal habit. 
 
 In anemic and wasting diseases they again 
 assume the part of accompanying symptoms. 
 I refer to all forms of secondary, acute and 
 chronic, anemias, to chlorosis and pulmonary 
 phthisis. Cold hands and feet and drowsiness 
 are frequent signs in all of them. 
 
 In arteriosclerosis, in chronic myocarditis and 
 in nephrosclerosis they are important additional 
 symptoms and undoubtedly provoked by over- 
 stimulation of the vessels. 
 
 They are also at times the manifestation in 
 part of anatomical disorders of the central ner- 
 vous system, e.g., tabes or multiple sclerosis. 
 Note the contrast between the other character- 
 istic signs of this disease and those of acro- 
 paresthesia. 
 
 In diabetes mellitus these paresthesias in the 
 extremities are an early and unmistakable warn- 
 ing, and based upon some sclerotic vascular 
 disorder or on neuritic conditions. 
 
 In migraine they are the directing and con- 
 trolling element. The pains seize as a rule both 
 arms, but may be also confined to one only. 
 The pains in the head promptly arrive with the 
 vasomotoric disturbances in the arms. Of course, 
 other vasomotoric manifestations are by no means 
 excluded, e.g., peripheral angiospasm, sweats 
 and vesicular formations in the skin.
 
 268 GENERALIZED PAIN 
 
 In epilepsy pretty well the same conditions 
 prevail. We must make a distinction here be- 
 tween a sensible and vasomotoric, and a vaso- 
 motoric and sensible epileptic aura. In the 
 sensible and vasomotoric form the sensible aura 
 is recognized by paresthesias or pains in the 
 extremities which, starting at the distal parts, 
 rise to the center, and the vasomotoric is distin- 
 guished by simultaneous vascular spasms coupled 
 with hyperesthesia (hyperesthesia angiospastica). 
 It is not difficult to identify this form because 
 in it the characteristic epileptic convulsions with 
 loss of consciousness develop. 
 
 The diagnosis of the so-called vasomotoric 
 epilepsy, on the other hand, is beset with diffi- 
 culties. The vascular convulsions involve most, 
 if not the whole, of the system. The attack is 
 confined to the limbs only although it may have 
 its starting point there. Sweating is profuse, 
 the temperature high and secretion of urine is 
 reduced; if loss of consciousness also supervenes, 
 the diagnosis is simple enough. Our difficulties 
 begin when these manifestations are accompanied 
 by the so-called psychic epileptic element. The 
 same conditions present themselves in the sen- 
 sible form of this disease. The patient com- 
 plains of a sudden creeping sensation as if ants 
 were crawling over him. This always starts in 
 the same extremity gradually extending over 
 the whole side of the body and reaching over to
 
 EXTREMITIES 269 
 
 the other half. The patient does not know for 
 the moment where he is, but in a short time 
 recovers himself and the fit is over. A proper 
 and thorough anamnesis is a wonderful support 
 in making the diagnosis. 
 
 It is a matter of common knowledge that 
 paresthesia attended with vasomotoric manifes- 
 tations in the distal parts of the extremities, 
 especially in the fingers, is the usual initial symp- 
 tom of oncoming convulsions in tetany (gastric 
 tetany included). When the convulsions with 
 the typical obstetric position of the hand follow 
 immediately behind the sensible, vasomotoric 
 disturbances, the diagnosis is assured, particu- 
 larly so when we observe the other characteris- 
 tics, i.e., facial phenomena, Trusseau's or, per- 
 haps, ScTile singer 's sign, and mechanical or elec- 
 tric sypersensibility of the nerves. It is these 
 very symptoms which differentiate attacks of 
 tetany from similar pseudotetanic actions in hys- 
 teria. Note also, that in hysteria the facial 
 phenomenon may be arrested by giving the 
 facial nerve a hard blow or applying some other 
 harsh mechanical force to it. 
 
 In tetany Trousseau's sign may produce 
 paresthesias without spasms resulting from the 
 mechanical pressure. 
 
 There are also, what I take the liberty of 
 calling frustraneous forms of tetany or tetanoid 
 conditions in which the patient complains of
 
 270 GENERALIZED PAIN 
 
 periodical attacks of paresthesia in the extremi- 
 ties. That they are a rudimentary form of this 
 disease may be confirmed by the fact that the 
 majority of persons who suffer from genuine 
 tetany suffer from these attacks, e.g., cobblers 
 and tailors; also they like tetany itself are usu- 
 ally observed in the springtime of the year and 
 in places in which the malady is endemic. The 
 symptomatology given above applies here in like 
 measure, excepting, however, Trousseau's sign. 
 
 Acroparesthesias and pains in the extremities 
 especially in the hands may be solitary symp- 
 toms of latent tetany, in which there are no 
 classic tonic muscular spasms. But Trousseau's, 
 Chvostek's and Schlesinger's phenomena and 
 mechanical and electric hypersensibility of the 
 nerves are the betraying symbols. 
 
 Whether the paresthesias observed in the ex- 
 tremities of pregnant women are the expression 
 of tetany, i.'e., a lesion of the epithelial bodies 
 caused by the gravid state, is questionable. 
 
 In paroxysmal tachycardia the same condi- 
 tions prevail as in tetany and epilepsy, sometimes 
 on one side only an aura of the attack. 
 
 Sudden attacks of paresthesia, preferably in 
 the left, but at times also in the right upper 
 extremity, arising in various cardiac diseases, 
 bear a different meaning. When coupled with 
 an oppressive feeling in the chest, with tachy-
 
 EXTREMITIES 271 
 
 cardia and pallor of the face they are the sign 
 of angina pectoris, but there are no pains in the 
 chest or in the left arm. (Cf. "Cardiac Pain.") 
 For the prognosis they are of lesser significance. 
 The patient may suddenly succumb without a 
 sign of a typical attack of stenocardia, while 
 severe anginose attacks may repeatedly come on 
 throughout the period of many years. 
 
 Occupation neurosis, writers' and pianoplay- 
 ers' cramps are caused by overexertion of the 
 hands and fingers. There are no motoric dis- 
 turbances. Pains and paresthesia in the limbs 
 are the only symptoms. 
 
 Reynaud's disease (symmetrical gangrene and 
 local asphyxia) is characterized by peripheral 
 vasoconstriction, pallor, coldness, the so-called 
 dead fingers and toes with intensive pains. We 
 find strongly marked sensibility disturbances 
 (hyperalgesia, hypesthesia and anesthesia), a 
 livid blue or bluish-black coloration and symmet- 
 rical gangrene of the affected parts. It may 
 exist as an independent disease, but it also may 
 be a secondary or associated symptom of other 
 affections, such as diseases of the nervous system, 
 or of the spinal cord (tabes, syringomyelia, etc.), 
 the individual symptoms of which should mate- 
 rially assist in arriving at a satisfactory conclu- 
 sion. But note, that in these cases gangrene is 
 not symmetrical. I must add also sclerodermia 
 (sclerodactylia), Basedow's disease and hysteria.
 
 272 GENERALIZED PAIN 
 
 Extremity-paresthesia is sometimes the fore- 
 runner of Quincke's edema, e.g., of the hands. 
 
 Chronic kypertrophic acroasphyxia is a dis- 
 ease which has only recently come under obser- 
 vation. Its distinctive features are a slowly 
 progressive asphyxia of the distal ends of the 
 extremities with extension into the softer tissue 
 at the same places. These swellings are sym- 
 metrical in form, very seldom unilateral. Pale- 
 ness, cold hands, at times painless and hardly 
 ever sensitive. Differentiation between hysteria 
 and syringomyelia, and between acromegaly and 
 osteoarthropathy is required for a proper diag- 
 nosis. 
 
 In organic nervous diseases it is rather the 
 paresthesias accompanied by vasomotoric mani- 
 festations, than the pains, that play the predomi- 
 nant role. We must not forget, however, that 
 even the slightest mechanical strain or pressure 
 on a nerve trunk is liable to elicit paresthesias, 
 for instance, when sitting we cross one leg over 
 the other. As a rule no significance is attached 
 to them, unless it be, that in neurasthenics they 
 occur more frequently and more easily than in 
 normal people, for instance the hands go to 
 sleep, pins and needles in the fingers, upon the 
 slightest pressure on the nerve trunks. It is a 
 different matter altogether when these manifes- 
 tations set in whilst the body is kept in one and 
 the same, even quite natural, position for an
 
 EXTREMITIES 273 
 
 unconsciously long time. I have seen cases of 
 aneurysm of the aorta in which the patient never 
 complained of pain or paresthesia in the right 
 upper leg. But as soon as he turned on his 
 right side, they would promptly appear and 
 molest him so that he could not go to sleep. 
 The apparent cause was undoubtedly the shift- 
 ing of the aneurysm. We may find herein a 
 hint that phenomena of this kind are likely due 
 to the pressure of some organic lesion in the 
 nerves. 
 
 These purely functional changes in the peri- 
 pheral nerves pave the wuy directly to those 
 lesser grades of peripheral neuritis which are 
 generally attended by paresthesia, e.g., alcohol 
 neuritis. And again, pressure on the radialis 
 will arouse the sleeper with a painful sensation. 
 This goes away so long as he keeps awake only 
 to return again with the next nap. 
 
 The same condition may be observed in any 
 kind of mechanical lesion of the nerve trunk, 
 or in secondary neuritis through toxic or thermic 
 influences. 
 
 These phenomena are of importance to the 
 internist in cases of tumor, e.g., of the supra- 
 clavicular glands, or in aneurysm of the sub- 
 clavian aorta, in mediastinal tumors, in diseases 
 of the pulmonary lobar pleura with a contracted 
 apex pleura and in perineuritis ; likewise in 
 paresthesia of the upper arms. Their presence
 
 274 GENERALIZED PAIN 
 
 here may mean the involvement of a sternal rib. 
 At other times they are merely forerunners of 
 a true neuritis. As typical symptoms may be 
 considered: increasing painfulness, local tender- 
 ness in the nerves and muscles, sensibility dis- 
 orders, change in the tendon reflexes, trophic 
 disturbances, muscular paralysis, change in the 
 electric reaction and demonstrable thickening of 
 the affected nerve trunks. 
 
 I wish to point out that this "forerunner sta- 
 dium" in chronic neuritis may endure for a 
 considerable space of time. This is, for instance, 
 the case in alcohol neuritis, which is also attended 
 with vasoconstriction in the fingers. If a trau- 
 matic condition has preceded the attack of neu- 
 ritis, the diagnosis may be somewhat involved, 
 but it will find a firm hold in the facts: that the 
 manifestations are constant, though fluctuating 
 in intensity, that periodical total intermittence 
 is wanting, that they are confined to a definite 
 nervous zone, that there is proof of local sensi- 
 tiveness in the aforesaid limited nervous area, 
 and the absence of hysterical symptoms. 
 
 Certain cases of chronic poisoning carbon- 
 oxysulphid used in vulcanizing india - rubber 
 tubes cause true toxic neurosis. Paresthesia 
 of the extremities is an essential symptom. 
 Other signs are cyanosis of arms and legs, tre- 
 mor, giddiness, loss of memory, parosnia and 
 pareugesia, dyspepsia, gastric troubles and con-
 
 EXTREMITIES 275 
 
 stipation. Most of these cases are based upon 
 a functional as well as an anatomical lesion of 
 the peripheral and central nervous system. 
 
 A paresthesia of this kind may be a constant 
 solitary symptom of a limited peripheral neu- 
 ritis or of a multiple cutaneous neuritis. Local 
 sensitiveness in the nervous processes and in- 
 creased painfulness in motation should indicate 
 the proper course for the diagnosis. The sensa- 
 tion of icy cold, icy draughts, numbness in the 
 nervus cutaneus femoris externus should re- 
 mind us of paresthetic mercdgia. For differen- 
 tial diagnostic purposes it is of value to remem- 
 ber that it may be, etiologically speaking, the 
 result of any given form of neuritis (gout, dia- 
 betes, cold, trauma, chronic lead poisoning, post- 
 infections, etc.), or it may be in part the mani- 
 festation of tabes dorsalis, or may also originate 
 from flat foot. 
 
 Equally important is the fact that paresthesia 
 in the inner region of the thigh (down to the 
 knee) coupled with incarceration signs point to 
 an existing obturator hernia. 
 
 Intestinal auto-intoacication and flatulent dys- 
 pepsia also have their paresthesias, such as creep- 
 ing sensations in the hands, heaviness in the legs, 
 together with a number of vasomotoric manifes- 
 tations. We observe flushing of the face and 
 heat in the neck, dizziness, headache, psychic 
 changes, anguish, irritability; the patient is dis-
 
 276 GENERALIZED PAIN 
 
 gusted with his work or unable to perform his 
 task, or tired of life, there are symptoms of 
 diaphragmatic elevation, of palpitation of the 
 heart and shortness of breath, especially during 
 the night when the intestinal gases are stagnat- 
 ing. Insufficient stools, flatulency, increase of 
 ethereal sulphuric acid in the urine, regulation 
 of the bowels and checking of the intestinal 
 fermentation by the proper diet are important 
 factors which require close attention. A very 
 strong formation of intestinal gas, of course, is 
 chiefly only a secondary phenomenon of irregu- 
 lar circulation in the intestinal blood vessels, 
 but it may also mean sclerosis of the intestinal 
 arteries, abdominal plethora, polycythemia, the 
 initial stage of insufficiency of the heart, inade- 
 quate diaphragmatic rhythm or retarded portal 
 circulation. All these points are worth studying. 
 
 Uremia is another endogenous intoxication in 
 which we have occasion to observe the condition 
 of "dead fingers or toes" or syncope of the 
 hands. It may exist as an independent disease 
 or may be the partial manifestation of uremic 
 migraine. I shall refer again to Raynaud's dis- 
 ease later on. 
 
 Paresthesias in one or several limbs are also 
 known as signs of spinal affections, but chiefly 
 as companions of painful sensations. We find 
 them in tabes when the patient complains of 
 formication in the extremities, especially in the
 
 EXTREMITIES 277 
 
 ulnar side of the fingers (they feel furry), of a 
 peculiar, indefinite sensation in the soles of the 
 feet as if he were walking on india rubber or 
 on cotton batting, the feet feel as if they were 
 wrapped around with fur, he is not sure whether 
 he is walking on a carpet or on a wooden or 
 stone floor. The hands feel as if they were in 
 woolen gloves. When we find such symptoms 
 it behooves us to look for further signs charac- 
 teristic of tabes and we must not forget that 
 the incipient manifestations of a tabes superior 
 are to be found in the upper extremities together 
 with patellar reflexes, whilst the usual signs in 
 the lower limbs are totally wanting. I mean lan- 
 cinating pains and ataxia. In these cases pupil- 
 lary symptoms, ataxia, hypoatony and sensibility 
 disorders in the upper extremities, symptoms in 
 the optic and cerebral nerves (trigeminus) are 
 not unimportant, but I lay particular stress upon 
 the fact that these paresthesias occur by prefer- 
 ence in the region of the ulnaris, and that anes- 
 thesia of the triceps tendon, likewise analgesia 
 of the ulnar nerve at the elbow frequently attend. 
 
 Some tabetic patients complain of sudden 
 painful itching with goose-flesh formation in the 
 skin of the extremities. But when paresthesias 
 appear in the articular region we must look upon 
 them as the advance agents of a coining tabetic 
 arthropathy. 
 
 In syringomyelia similar paresthesias are
 
 278 GENERALIZED PAIN 
 
 observed in the extremities (and the trunk) 
 attended with vasomotoric disorders. If the 
 patient is insensitive to heat and pain, but shows 
 symptoms of degenerative muscular atrophy in 
 the distal ends of the upper extremities, trophic 
 disturbances, intensified tendon reflex, scoliosis 
 and bulbar disorders, the diagnosis should be 
 plain. 
 
 Multiple sclerosis is another affection of the 
 central nervous system in which paresthesias in 
 the arm or in the hand alone are the preceding 
 initial symptom of the disease. They may be 
 associated with pains but exist also without them. 
 We hear of numbness and formication in the 
 limbs. For the early diagnosis I draw attention 
 to impairment of the sense of touch, the patient 
 is unable to judge of depth or position of things 
 and is awkward, clumsy in his actions. The 
 differential diagnosis may be difficult under these 
 circumstances, but if we reflect on the absence 
 of subjective as well as objective pain, the ques- 
 tion of neuritis will be eliminated. Moreover, 
 the stronger tendon reflex in the lower extremi- 
 ties, the want of muscular atrophy and the ab- 
 sence of reflexes in one side of the abdominal 
 wall, at any rate, speak decidedly against 
 neuritis. 
 
 Another alternative is cerebro-spinal syplulis. 
 But this question can easily be settled by the 
 Wassermarm reaction and by the cytologic and
 
 EXTREMITIES 279 
 
 chemical analysis of the cerebro-spinal fluid. 
 The disturbance of the stereognostic sense might 
 turn our mind also to a cerebral lesion localized 
 in the parietal lobe, the more so as the patient 
 frequently complains of periodic headache and 
 dizziness. The want of cerebral pressure cannot 
 be used without risk against a local expanding 
 lesion in the lobe. A safe diagnosis can only be 
 based on the general course of the disease, the 
 conspicuous fluctuations and the regression of 
 the symptoms, the complete disappearance of 
 the brachial symptoms and the evidence of the 
 classical signs of multiple sclerosis, signs which 
 may not set in for years after we have seen the 
 patient for the first time. Analogous pares- 
 thesias in the hand or in the fingers frequently 
 enough are observed during the progress of the 
 disease. 
 
 In arteriosclerosis of the spinal cord with the 
 spinal form of dysbasia angiosclerotica pares- 
 thesias of the lower extremities are likely to 
 occur. (See "Pains in the Chest.") 
 
 Pernicious anemia travels in company with 
 paresthesias in the extremities arising from spinal 
 causes. The same conditions prevail also in 
 other forms of anemia and in severe cases of 
 cachexia (carcinoma, tuberculosis, syphilis, dia- 
 betes mellitus, alcoholism). 
 
 Paresthesias abound in all diseases of the 
 spinal cord, viz., myelitis, syphilis, tumors, hem-
 
 280 GENERALIZED PAIN 
 
 orrhages, in all expanding diseases of the colum- 
 nar canal (leucemic infiltrations). In all of 
 them, meningitis included, they are surpassed 
 by the pains. 
 
 As prodromal symptoms they figure in acute 
 spinal affections; so in epidemic cerebrospinal 
 meningitis. 
 
 They play a subordinate role in hydrophobia. 
 If we are dealing with the mitigated form in 
 persons who have been vaccinated with anti- 
 rabietic serum we shall find sudden symptoms 
 of debility and paralysis in the lower extremities, 
 bladder and rectal disorders, facial paralysis and 
 salivation. The anamnesis and the consideration 
 of the prodromal manifestations, i.e., restless- 
 ness, insomnia, depression, loss of appetite, pains 
 in the head, sacrum and joints should lead the 
 way to a proper diagnosis. 
 
 But they may just as well be the prodromal 
 symptoms of true rabies when they appear in 
 the part of the body which has been bitten by 
 a mad animal. In this respect they remind one 
 of the paresthesias and dragging pains which 
 are so often observed in the form of a tetanic 
 aura in tetanus in the affected part before mus- 
 cular contractions and convulsions set in. They 
 are always a most serious warning of an impend- 
 ing outbreak of tetanus when a tetanus (wound) 
 infection is suspected. 
 
 From what has been said in the foregoing pages
 
 EXTREMITIES 281 
 
 it will be clear that paresthesias of the extremi- 
 ties may be due to different causes in one and 
 the same disease. If in the legs they may be 
 provoked by the encroachment of a leucemic 
 gland upon the peripheral nerve trunks, or they 
 may be due to pressure of a leucemic infiltration 
 on the nerve roots in the intervertebral foramina 
 or to a leucemic infiltration of the meninges. In 
 some rare cases of accompanying pernicious 
 anemia we may have to decide whether the spinal 
 processes do not in an analogous manner cause 
 the paresthesias. 
 
 When the patient complains of paresthesias 
 in one only or in both extremities of the same 
 half of the body we must think of a cerebral 
 affection. Diseases of the brain occupy the area 
 of the trigeminal nerve which is the original 
 habitat of paresthesias. I mention here the sen- 
 sation of numbness in one-half of the face, espe- 
 cially about the angle of the mouth and around 
 the nose; the feeling as if that part of the face 
 were entangled in a cobweb when the patient is 
 suffering from an intrapontine disease or from 
 a basal affection of the posterior cranial fossa, 
 or from a cerebellar tumor, cerebral tabes or 
 syringomyelia. On the other hand we must not 
 forget that paresthesias also occur in the arm 
 or in the arm and leg on the same side of the 
 body either independently or in combination with 
 paresthesias in the trigeminal region as a symp-
 
 282 GENERALIZED PAIN 
 
 torn of a cortico-cerebral lesion. This is obvious, 
 because the sensible cortical centers lie behind 
 the central groove in the posterior central con- 
 volution, but overlap only a minimal part of 
 the motoric region. Moreover, the localization 
 in the extremities is often subject to definite 
 laws. For instance, in tabes or in affections of 
 the cauda the favorite place is in the region of 
 the nervus cutaneus exterior. 
 
 If the patient complains of sudden numbness 
 in the arm, or hand, or in the arm and corre- 
 sponding leg and in the same side of the face, 
 but lasting only a short time, and motoric im- 
 pairment is not noticeable we may take it as a 
 symptom of cerebral arteriosclerosis with insuffi- 
 ciency of the hemicerebral circulation. This 
 alone is capable of bringing about recurrent par- 
 esthesias in the extremities, which, however, may 
 also be superinduced by multiple minor hemor- 
 rhages in the brain or by minimal multiple 
 softening processes (cerebrosclerosis). The co- 
 existence of these with sclerosis of the cerebral 
 arteries can only be confirmed by unremitting 
 cerebral morbid manifestations. It follows that 
 paresthesias in the extremities are a possible, 
 though not unequivocal symptom of a cerebral 
 hemorrhage. The other symptoms of cerebral 
 arteriosclerosis are headache, dizziness, amnesia, 
 psychic changes and frequently a feeling of heat 
 in the top of the head.
 
 EXTREMITIES 283 
 
 Thrombosis or embolism in a branch area of 
 the anterior arteries of the brain may produce 
 the same kind of manifestations. The topo- 
 graphical diagnosis offers no difficulties if the 
 unilateral character of the sensible disturbance 
 caused by the paresthesias is demonstrable. This 
 is also the case when the disturbance is confined 
 to one extremity only generally the arm, espe- 
 cially when the fleeting nature of the manifesta- 
 tion, its recurrent tendency, the advanced age of 
 the patient and the presence of sclerotic con- 
 ditions in other arteries as well are observed. 
 Often enough the remaining characteristic signs 
 of cerebral arteriosclerosis have already preceded 
 the attack. In some cases even precursors of 
 hemiparesthesia, a transient hemiparesis or hemi- 
 plegia or impediments in speech may have been 
 observed. (The temporal intermittence is fre- 
 quently reversed.) 
 
 A similar situation in juvenile individuals 
 should remind us of syphilitic cerebral endar- 
 teritis, in which we may also find additional signs 
 of weakness in the affected extremity. Of course, 
 in some cases the transient symptoms are entirely 
 due to the endarteritic conditions themselves or 
 to thrombosis of a branch artery, to the latter 
 particularly if the cerebral disturbances persist 
 for a long time. 
 
 Essential arterial hypertension is another cause. 
 This condition may prevail for a number of
 
 284 GENERALIZED PAIN 
 
 years without molesting symptoms, yet there 
 comes the time when the patient begins to com- 
 plain of flatulence, dyspnea after meals, indi- 
 gestion, headache, dizziness and nycturia; we 
 find a second aorta tonus, cardiac hypertrophy 
 and permanent arterial hypertension. Recent 
 observations attribute the cause to a limited scle- 
 rosis of the arteries of the medulla oblongata 
 and subsequent irritation of the vasomotoric 
 center. 
 
 A tumor of the brain in the motoric or adja- 
 cent region may produce paresthesias of the 
 extremities. Sometimes they are of a permanent 
 character and combined with progressive cere- 
 bral hemiparesis which at first affects only one, 
 but later on both of the unilateral extremities, 
 and subsequent convulsions. But, the same as 
 in sensible epilepsy, these paresthesias may also 
 come on in the form of regular attacks on the 
 affected portion or cover the entire body, or else 
 in combination with motoric convulsive condi- 
 tions (Jackson's epilepsy). The attacks may 
 also alternate with attacks of cortical epilepsy. 
 This applies to tumors of the parietal lobe with 
 like force. 
 
 Of course, the diagnosis cannot be evolved 
 from these symptoms alone. We must look for 
 other important signs, such as headache, cerebral 
 vomiting, psychic changes, infiltration of the
 
 EXTREMITIES 285 
 
 optic nerve and other local motoric and sensible 
 irritating manifestations. 
 
 In tumors of the central ganglia, especially 
 of the optic thalamus paresthesias appear in the 
 contralateral extremities. The diagnosis of a 
 tumor of the optic thalamus will not be difficult 
 to make if we bear in mind the characteristic 
 symptoms, which are: pain, objective sensibility 
 disturbances (hyperesthesia and anesthesia) ; 
 signs of a motoric and paralytic character, i.e., 
 hemiplegia, one-sided convulsions with tremor 
 and position involuntarily assumed, contralateral 
 hemianopsia, hemichorea, hemiathetosis, mimic 
 facial paralysis and cerebral pressure. Tumors 
 of the pons are likewise associated with pares- 
 thesias. Alternating hemiplegia is the cardinal 
 symptom of this pontile affection. 
 
 A tumor localized in another part of the brain 
 may in the same manner affect the sensible cen- 
 ters and produce contralateral paresthesias, for 
 instance a tumor of the peduncle of the brain, 
 but particularly a tumor of the cerebellum. 
 
 Paresthesia of the extremities, hyperesthesia, 
 paralysis of individual groups of muscles and 
 impaired memory frequently survive a heatstroke 
 for a considerable time. 
 
 There are other regional affections of the brain 
 in which paresthesias of the extremities also but 
 only occasionally occur. I have, however, in the 
 foregoing section paid more attention to those
 
 286 GENERALIZED PAIN 
 
 cerebral diseases in which paresthesias appear 
 rather as early symptoms or at any rate as 
 momentary guiding manifestations and in con- 
 sequence are of special significance for the diag- 
 nosis. But there are also further morbid pro- 
 cesses of the brain which up to the present time 
 have not yet been properly localized, I mean 
 hemichorea and hemiparalysis agitans (forms of 
 disease which are unilateral in the beginning, 
 but become generalized later on). In these 
 affections paresthesias coupled with pains con- 
 stitute often enough the incipient stages but 
 may prevail throughout the whole course of the 
 disease. 
 
 But if the attack sets in on both sides then 
 the accompanying paresthesias and pains in the 
 extremities are also the predominant initial 
 symptom of the disease (chorea, paralysis agi- 
 tans). The question is still sub judice whether 
 paralysis agitans is not a disease of the secretory 
 glands rather than an affection of the brain. 
 But we know with certainty that various diseases 
 of the hematopoietic glands begin and progress 
 with paresthesias and pains in the extremities, 
 e.g., myasihenia, the nosology of which is like- 
 wise not yet clearly established, also Basedow's 
 disease ~, myxedema, Addison's disease, acrome- 
 galy and tetany. 
 
 In acromegcHy nocturnal pains and even more 
 severe rheumatoidal pains as well as vasomotoric
 
 EXTREMITIES 287 
 
 disorders are significant prodromal symptoms. 
 Unless measurable alterations in the distal parts 
 of the extremities are discernable, the diagnosis 
 may be somewhat intricate. However, irregu- 
 larities (cessation) of the menstrual flow, or 
 impotence in the male, genital atrophy, pres- 
 sure symptoms in the brain (hypophysis tumor!) 
 bitemporal contraction of the face (hemianopsia) 
 might prove reliable guides. The course of the 
 disease itself ought to confirm our suspicions. 
 The X-ray should be used early and often. 
 
 The ovaries are another source of paresthesias 
 and pains in the climacteric period (pseudo- 
 gout). As predominant features of the meno- 
 pause may be mentioned: a feeling of cold in 
 and blue coloring of the distal parts, heat rushes, 
 congestion in the head, profuse sweating, dizzi- 
 ness, fainting fits, abnormal nervousness, tremor, 
 palpitation and accelerated action of the heart, 
 pains in the small of the back, in the bones, back- 
 ache, neuralgias in the trigeminus, in the ischiatic 
 and intercostal nerves and Heberden's nodes. 
 The anamnesis is the main prop of a correct 
 diagnosis. But we must not disregard the fact 
 that climacteric disorders may put in an appear- 
 ance years before the menstrual flow ceases and 
 also for a long time afterwards. There exists 
 a very strong interrelationship between the ova- 
 ries and the motoric centers, proof of which we
 
 288 GENERALIZED PAIN 
 
 see in the manifestation of various paresthesias 
 during the menstrual molimina. 
 
 Paresthesias in osteomalacia due to vasocon- 
 striction are a part of the initial symptoms. 
 
 In the caisson disease the paresthesias consist 
 at first of formication in the extremities and 
 very annoying itching of the skin to be followed 
 by severe boring, gnawing and lancinating pains 
 with subsequent weakness in and paralysis of 
 the legs. The pains, no doubt, are due to irri- 
 tation of the spinal roots by gaseous vesicles in 
 the spinal fluid, while the paresthesias may be 
 attributed, if not to the same cause, then to the 
 presence of gas in the cutaneous capillaries. 
 
 Very stubborn paresthesias in the extremities, 
 (the finger tips and soles of the feet) are not 
 unusual during the convalescent period in scarlet 
 fever. But when coupled with angiospasms or 
 with vasodilation they point to chronic malaria. 
 (Cf. "Malaria.") 
 
 Chronic ergotine poisoning deserves mention 
 here. The diagnosis of this "creeping sickness" 
 is based on the symptoms of contraction of the 
 flexor muscles in the toes, wrists and fingers, 
 and of the extensor muscles of the big toe, knee 
 and elbow, and, if tonic cramps of the muscular 
 system of the extremities and the thorax and 
 manifestations of peripheral gangrene are want- 
 ing, then on the creeping sensation and the 
 anamnesis. When the microscope shows the
 
 EXTREMITIES 289 
 
 presence of ergot in the stools, further proof 
 of ergotism is hardly required. 
 
 Hemiparesthesia and hemialgesia are associ- 
 ated with chrome nicotinism. We also find dif- 
 fuse, dragging, lancinating pains in the extrem- 
 ities. Headache (pressure), dizziness, mental 
 sluggishness, neurasthenia, fainting fits, tremor, 
 depression, anguish, cardiac arythmia, anginoid, 
 even anginose conditions and visual disturbances 
 are among the salient features. Of course, it is 
 self-evident that these hemiparesthesias have 
 their genesis in unilateral spasms of the cerebral 
 arteries (intermittent limping!). 
 
 Of different origin are the paresthesias in 
 chronic arsenic poisoning. They are the first 
 symbol of toxic arsenical neuritis and are soon 
 joined by severe pains in the lower extremities, 
 later on by missing reflexes. As classical warn- 
 ing signals we may consider the existence of 
 certain catarrhal conditions in the mucous mem- 
 branes (conjunctivitis, rhinitis, pharyngitis, 
 bronchitis, gastroenteritis, colic and diarrhea) ; 
 likewise generalized neurotic states (fatigue, 
 headache, giddiness, sleeplessness), cutaneous 
 lesions (erythema, papules, herpes, furunculosis, 
 brownish coloration of the skin) and fever. 
 Laboratory tests of the excreta (urine, stools, 
 vomitus) furnish additional evidence. 
 
 In lead poisoning, paresthesias are of minor 
 importance; but there are exceptions, because in
 
 290 GENERALIZED PAIN 
 
 certain cases paresthesias in the upper extremi- 
 ties spring very prominently into the fore- 
 ground. The blue line, lead colic, arthralgia, 
 paralysis and punctated erythrocytes should as- 
 sure a positive diagnosis. 
 
 Paresthesias in the most diverse areas of the 
 skin are typical of pellagra. We find them in 
 the characteristic erythema itself, but also in 
 other places, such as the arms, shoulders and 
 epigastrium; all no doubt of neuritic origin. 
 
 Paresthesias in the upper extremities, espe- 
 cially the upper left, and coupled with vaso- 
 motoric disorders, form an essential constituent 
 of angina pectoris vasomotoria. But they are 
 no less an accompanying, if not an initial, symp- 
 tom of true coronary arteriosclerosis. This item, 
 however, belongs in the chapter on "Cardiac 
 Pains." 
 
 Similar conditions come under our notice in 
 dyspragia angiosclerotica (intermittent). Inso- 
 far as the lower extremities are concerned, this 
 disease is also known by the name of intermittent 
 claudication, or intermittent dysbasia. Although 
 paresthesias and vasoconstriction usher in and 
 accompany the attack, yet the pain is the pre- 
 ponderating symptom. 
 
 I wish to emphasize the fact that in some 
 rare cases of dysbasia intermittens angioscler- 
 otica the subjective troubles consist chiefly in 
 the paresthesias, possibly coupled with paleness
 
 EXTREMITIES 291 
 
 and low temperature in the affected limb. If 
 this happens in the arm, it is rather significant, 
 because it might easily lead to a differential 
 diagnosis of occupational neurosis. But the fact 
 that in this disease the paresthesias attack ex- 
 clusively those parts of the anatomy which come 
 into immediate action by the exercise of the 
 vocational calling (piano players, writers' 
 cramps, cigar and cigarette makers) should 
 prevent a plausible mistake. The more so as 
 in dysbasia the paresthesias closely follow upon 
 every kind of muscular overexertion. Besides, 
 here we also find arteriosclerosis and other arte- 
 rial constrictions. 
 
 On the one hand we know that dysbasia (resp. 
 dyspragia) is conditioned by an anatomical 
 morbid process of the arteries, chiefly sclerosis 
 or arteritis, but not absolutely. On the other 
 hand, we are also aware of the fact that every 
 patient who complains of paresthesias such as 
 described above, i.e., a feeling of numbness and 
 cold in the hands and feet, is the possible victim 
 of arteriosclerosis or endarteritis obliterans in 
 the affected parts. It is likewise a matter of 
 common knowledge that endarteritic or scler- 
 otic arteries are subject to vasomotoric attacks 
 on the ground of hyperirritation of their own 
 vasomotors through arteriosclerotic or arteritic 
 
 processes. 
 
 Again, the constriction of the arteries caused
 
 292 GENERALIZED PAIN 
 
 by sclerosis in itself, i.e., without the co-efficiency 
 of the vasoconstrictors, prepares the ground for 
 paresthesias. This explains why we find at times 
 paresthesias in the ulnar side of the left upper 
 arm, or still more so in the left forearm and in 
 the left hand, sometimes in union with pains, 
 hyperalgesia, more rarely hyperesthesia, in the 
 paresthetic area as an individual sign of aortic 
 sclerosis. The thought also lies near that every 
 form of restricted circulation in the extremities 
 is a likely cause of local paresthesias. For in- 
 stance, a constriction of the subclavian artery 
 due to exclusive sclerosis of the aortic arc (i.e., 
 pure aortic sclerosis), or due to an aneurysm 
 of the anonyma, a distortion of the subclavia by 
 a mediastinal induration or by the expansion 
 of a mediastinal tumor, may give rise to pares- 
 thesia in the appurtenant region, if only in the 
 fourth or fifth finger. 
 
 The diagnosis is not hard to make, especially 
 in the face of diminished pulse beat on the 
 constricted side, the low temperature in the 
 affected extremity, the subjective feeling of 
 cold, paleness, marbling or cyanosis of the skin, 
 hyperesthesia, change in the tendon reflexes, 
 conspicuous difference in the blood pressure 
 between right and left, or swelling of the 
 extremity. Constriction of the abdominal aorta 
 superinduced by an embolus developing in its 
 bifurcation and aggravated by a secondary
 
 EXTREMITIES 293 
 
 thrombosis in the embolus can at all times give 
 rise to paresthesias in the lower extremities. 
 
 But not only a constriction, but any other 
 kind of impairment of the venous circulation 
 in the extremities, will give rise to local pares- 
 thesias (varices, thrombosis). 
 
 Phlebectasia is affiliated with sensations of 
 creeping, numbness and heat in the extremities, 
 especially when the patient has been on his feet 
 for a long time. 
 
 In thrombosis, also, there is a feeling of cold, 
 heaviness, numbness and formication. These 
 may be even the first perceptible symptoms. 
 In chlorosis, for instance, a convalescent, run 
 down by a long spell of illness, will complain 
 of paresthesias in the leg caused by thrombosis 
 of the deeper muscular veins. When these alone 
 are thrombosed and no superficial veins are 
 involved, the diagnosis is not always so easy to 
 make, because the common local symptoms of 
 thrombosis, the formation of an edema in the 
 skin, are frequently wanting, and the throm- 
 botic cord cannot always be felt by the palpat- 
 ing finger. Yet, to speak from my own experi- 
 ence, the cardinal symptom of thrombosis is 
 always sensitiveness on pressure in the deeper 
 muscles (of the calf) when combined with par- 
 esthesia and a slight swelling of the glands, at 
 any rate in diseases which tend to marantic
 
 294 GENERALIZED PAIN 
 
 thrombosis, e.g., insufficiency of the cardiac 
 muscle, blood diseases, cachexia, etc. 
 
 Paresthesias in the extremities are not only a 
 possible sign of an existing thrombosis, but they 
 are also apt to precede the disease, and thus 
 constitute a premonitory symptom. Of course, 
 numbness, an enfeebled constitution and heavi- 
 ness in the extremity are not always deciding 
 factors. I lay more stress upon subfebrile tem- 
 perature, and above all on the finding of a 
 climbing pulse, although some authors deny the 
 significance of the latter. 
 
 It is not unimportant for the diagnostician 
 to remember that ever recurring paresthesias in 
 one limb may have their genesis also in other 
 mechanical disorders of the vascular system. I 
 have seen female patients who complained about 
 creeping, cold or heat in one or both lower ex- 
 tremities, without any apparent cause for the 
 trouble. I recommended not to lace the foot- 
 wear so tight and use more elastic garters. 
 Relief came promptly. Close-fitting boots and 
 crossing the knees are other causes of these 
 tribulations. But it is not only congested cir- 
 culation, but also the effect on the peripheral 
 and vascular nerves, and, not any the less, cold 
 dampness which produce these anesthesias and 
 painful sensations. 
 
 In hysteria, the vasoconstricting manifesta- 
 tions are generally wanting and the paresthesias
 
 EXTREMITIES 295 
 
 are less characteristic, but instead we have 
 strongly marked sensibility disorders and other 
 hysterical stigmata, all of which are typically 
 different from genuine acroparesthesias. 
 
 In neurasthenia, spontaneous paresthesias are 
 relatively uncommon, excepting sexual neuras- 
 thenia with its sensations of cold in the ex- 
 tremities. But when they do occur a differen- 
 tiation from genuine neurosis can be made from 
 the general clinical picture, from the other 
 neurasthenic symptoms, and also from the sex 
 of the patient (neurasthenia prevails in men, 
 acroparesthesia in women). Moreover, in neu- 
 rasthenia, paresthesia is not spontaneous, but 
 rather due to some minor lesion of the nerves, 
 the sensation persists after the nerve trunk has 
 been pressed for a short time, or it comes on 
 when one foot is resting on the other or the 
 leg is a bit tired out. 
 
 Cold hands and feet are often the reflex ac- 
 tion of vasomotoric neurosis due to adynema. 
 Lank, lean young persons, with a glaring stare 
 or a floating rib, who suffer from enteroptosis 
 or orthotic albuminuria, etc., are good subjects 
 for this form of neurosis. 
 
 That complains of cold feet or hands caused 
 by any other form of impaired circulation, such 
 as arteritis, arteriosclerosis, phlebectasy, phlebo- 
 sclerosis, partial thrombosis of the veins, weak- 
 ness or paralysis of the vascular nerves (peri-
 
 296 GENERALIZED PAIN 
 
 pheral or central), is an important sign of 
 myxedema resp. hypothyreosis due to excessive 
 use of coffee or tea, is only mentioned. 
 
 Raynaud's disease is another deuteropathic 
 acroparesthesia which is of special interest to 
 the diagnostician. The patient complains of 
 cold, paleness or else livid coloration of the 
 fingers or toes (dead fingers, dead toes). Such 
 an "isolated" acroparesthesia (digitus semimor- 
 tuus) has a double bearing: (1) It is fre- 
 quently an accompanying, if not an initial, sign 
 of true angina pectoris; (2) it is also a common, 
 if not the most essential, sign of uremic intoxi- 
 cation. Albuminuria, cylindruria, hematuria 
 (all of these may be missing for a long time 
 in contracted kidney), reduction in the urinary 
 output, low specific quantity and light coloring 
 of the urine, nycturia, pollakisuria, strong sec- 
 ond aorta tonus, high blood pressure, increased 
 tendon reflex, dyspepsia, uremia, very dry, car- 
 dio-renal-edematous skin, changes in the fundus 
 of the eye (retinitis, hemorrhage), congested 
 secretion (chlorine, iodide, sugar of milk) in the 
 kidneys, increased retention of nitrogen, indi- 
 canuria, Ambard's coefficient and abnormal con- 
 tent of urea in the cerebrospinal fluid, are suffi- 
 cient indications for a correct diagnosis. 
 
 Chlorosis is often distinguished by this mani- 
 festation of dead fingers with severe pains dur- 
 ing regular intervals. The diagnosis should be
 
 EXTREMITIES 297 
 
 obvious because this disease is almost exclusively 
 confined to young women. The peculiar look 
 and appearance of the patient, menstrual disor- 
 ders, the condition of the blood, the absence of 
 other anemic signs, the effect of iron and arsenic 
 treatment, are other points of interest. 
 
 Some cases of arteriosclerosis, myocarditis and 
 nephrosclerosis are on record in which acro- 
 paresthesia was restricted to one finger. 
 
 II. Pains in the Bloodvessels 
 
 When vascular lesions are the source of pain, 
 the first disease to think of is angina pectoris, 
 with its irradiations into the left, rarely in both, 
 and very seldom in the right arm alone, espe- 
 cially on the side of the little finger, and also 
 on account of its initial and concomitant vaso- 
 constricting symptoms. For particulars I refer 
 the reader to the chapter on "Cardiac Pains." 
 
 I will touch, however, on a few facts which 
 really appertain to this section. First of all, 
 it is by no means impossible for these typical 
 irradiations to reach out into the lower extrem- 
 ities or loins, or even the testicles. Secondly, 
 painful attacks in the upper, or also in the 
 lower, extremities are liable to represent the 
 initial symptom of angina pectoris; in fact, 
 manifest, recurrent pains in the left arm, or 
 perhaps only in the left forearm, may very well 
 be the solitary symptom of this disease. I will
 
 298 GENERALIZED PAIN 
 
 go even further and claim that pains in the left 
 wrist, sometimes encircling it like a tight brace- 
 let, at other times settling only in the palmar 
 side, are a grave warning especially when com- 
 bined with a terrible feeling of agony of a fatal 
 anginose attack. 
 
 In all these cases of peripheral angina pec- 
 toris, it seems to me that the pain is centered 
 in the nerves of the bloodvessels, if not entirely, 
 then in part for certain, whence it radiates into 
 the neighboring nervous fields. The diagnosis 
 cannot go wrong when we observe a simulta- 
 neous and continued extension of the pains in 
 the chest accompanied by anguish and the other 
 signs of stenocardia. Analogous irradiations of 
 pain in the arm are observable also in anginoid 
 conditions, companions of acute or chronic myo- 
 carditis or pericarditis. 
 
 Arterial constriction in the extremities is a 
 very ordinary cause of painful sensations in the 
 legs. I aim here at dyspragia resp. dysbasia 
 inter mittens, intermittent claudication, no matter 
 whether caused by arteriosclerosis or endarteritis 
 obliterans or syphilitic endarteritis with or with- 
 out vasoconstriction, or even provoked by the 
 latter alone. I have already spoken at length 
 about this affection in a previous section and, to 
 avoid repetition, I refer the patient reader to 
 that part of my book. 
 
 The painful attacks connected with this dis-
 
 EXTREMITIES 299 
 
 ease are obviously due to overtaxation of the 
 peripheral vessels. We can find the evidence in 
 the absence of arterial pulsation without claudi- 
 cation, in the missing pulse during the attack; 
 or else, in the typical claudication of the remain- 
 ing pulsation; and again, in claudication based 
 on vasoconstriction alone (in anemia, neurosis, 
 nicotinism), and finally in unilateral claudication 
 when the trunk of the crural artery is sclerosed 
 on both sides and the arterial pulse is missing 
 in the smaller branches. This bronchial defect 
 will be found on that side in which an old peri- 
 colitic (post-dysenteric) exudate pinches the 
 ischiadic nerve (thus producing a onesided 
 ischias) and hyperexcites the vascular nerves by 
 this constriction. 
 
 Similar conditions may arise from sclerosis 
 of the trunk of the crural or iliacal arteries or 
 any other local constriction or acute arteritis. 
 It is hardly necessary to add that dysbasia is 
 often followed by gangrene. In chronic nico- 
 tinism intermittent dysbasia may be caused by 
 periodic or continuous angiospasm when the 
 arterial walls remain quite normal (the X-ray 
 gives the required information). The pulses are 
 modified during the attack but never entirely 
 missing. 
 
 Chronic lead poisoning, ergotism, neurasthenia, 
 chlorosis and juvenile anemia must be rubri- 
 cated here also. In addition be it said that a
 
 300 GENERALIZED PAIN 
 
 combination of several different etiological fac- 
 tors may produce a focus from which dysbasia 
 is set in motion. Is it necessary to say that there 
 is a form of neuritis which takes its genesis from 
 arteriosclerosis and that in consequence neuritic 
 manifestations are also observed in dysbasia? 
 But this does not justify us to apply the term 
 "neuritic dysbasia" to a form of dysbasia which 
 is conditioned by neuritis. 
 
 As changes in the arterial, so may anomalies 
 in the venous passage ways of the blood give 
 rise to intermittent dysbasia, in fact the more so 
 when the arteries have already been attacked. 
 Phlebectasy and phlebosclerosis are the chief 
 offenders. The diagnosis is facilitated by the 
 ectatic state of the veins of the skin which is 
 plainly visible. In women who have offspring 
 or are with child, in persons who are forced to 
 stand most of the time, or in very corpulent 
 individuals the veins are not always very visible. 
 In such cases the bloodvessels can be made prom- 
 inent if the patient is asked to let the lower limbs 
 hang down loosely for a while. In some cases 
 of phlebectasia the trunks of the veins are not 
 perceptibly enlarged, but we shall always be able 
 to find a bluish network of the smaller vessels 
 on the bridge of the foot or else on the inner 
 surface of the thigh. When the muscular veins 
 are very strongly varicosed while the cutaneous 
 vessels show only slight traces of ectasy we may
 
 EXTREMITIES 301 
 
 with safety ascribe an existing dysbasia to that 
 condition. Errors in the diagnosis can always 
 be avoided by a careful clinical examination. 
 Nevertheless, for safety's sake, I will add a few 
 hints. 
 
 It will happen that ischias is diagnosed when 
 it is really a case of dysbasia and not without 
 reason. There are cases of ischias in which the 
 pain is very much aggravated by walking. But 
 we may be safeguarded when we take into con- 
 sideration that the ischiatic pain is constant, 
 perhaps only in a milder form, when the leg is 
 at rest. Moreover, we have the typical localiza- 
 tion of the pain in the region of the ischiadic 
 nerve, local sensitiveness there, sharpening of the 
 pain when the abdominal press comes into action 
 (during coughing, defecating), tenderness in the 
 lower lumbar vertebrae, Lasegue's sign, change 
 in the Achilles tendon reflex, lower temperature 
 in the patellar skin of the affected part. The 
 diagnosis of radicular ischias will be discussed 
 later on. 
 
 Peripheral neuritis is another stumbling block, 
 because here also the pains are exacerbated by 
 walking, the affected muscles are stiffened and 
 indurated. But the diagnosis can be made from 
 the typical signs of neuritis, eventually pseudo- 
 tabes (sensitiveness of the nerve trunks and 
 muscles, muscular atrophy, trophic disorders,
 
 302 GENERALIZED PAIN 
 
 motoric inhibitions, ataxia, changes in the tendon 
 reflexes, reaction to the electric current). 
 
 Another source of error consists in a subor- 
 dinate form of neuritis in the legs, i.e., arterio- 
 sclerotic neuritis which rests on the same basis 
 as dysbasia, i.e., sclerosis of the arteries. The 
 pains, noticed at first during walking, later on 
 also when at rest, are localized either in the 
 crural or ischiadic zone, or in both together. 
 
 Sensibility disturbances and tenderness in the 
 nerve trunks are hardly ever present. But a 
 differentiation is rendered possible by the decline 
 of the tendon reflexes, the presence of muscular 
 paresis and atrophy, and also by the existence of 
 the arterial pulse in arteriosclerotic neuritis. In 
 complications between the two diseases the ten- 
 don reflexes and the arterial pulse in the foot 
 are wanting. 
 
 Another important point is that both neuritis 
 and arteriosclerotic dysbasia may have a parallel 
 existence, independent of arteriosclerosis as a 
 causative element. 
 
 I know full well that despite this apparent 
 parallelism, dysbasia can only exist as a uni- 
 lateral disease. Still my contention is that wher- 
 ever the nerves of the extremities are most 
 vulnerable, there and in that place intermittent 
 claudication may also take its exclusive abode. 
 Also, insofar as the development of dysbasia is 
 concerned, we must reckon with two factors,
 
 EXTREMITIES 303 
 
 i.e., stability of the vascular affection and the 
 transitory element of the nervous system, espe- 
 cially of the vasomotors. 
 
 Acinesia algera causes pains in the arms or 
 legs. It is easily recognized and distinguished 
 from dysbasia by the fact that the pains set in 
 at once when the patient even attempts the 
 slightest movement, in consequence he remains 
 motionless. There are no morbid changes in the 
 bloodvessels. The pains are felt with the same 
 intensity in other parts of the body, chiefly in 
 the back and in the head. We also find gen- 
 eralized neurotic symptoms of hysteria, neuras- 
 thenia or psychosis. 
 
 Neurasthenia is sometimes a regular counter- 
 feit of intermittent dysbasia. The patient does 
 complain of rather moderate pains after a long 
 walk, but soon finds rest again. We shall not 
 go astray if we keep a careful eye on the fol- 
 lowing points: no changes in the bloodvessels, 
 no trace of other causal movements, but presence 
 of other neurasthenic signs, the youthfulness of 
 the patient (generally male), proof of preceding 
 psychic emotion and overexertion. The prog- 
 nosis is favorable. 
 
 In meralgia paresthetica the pains come on 
 with walking, at first the exercise modifies but 
 later on aggravates them and they disappear 
 only when the patient comes to rest. The pain- 
 fulness, however, is clearly confined to the region
 
 304 GENERALIZED PAIN 
 
 of the nervus cutan. femoris externus with 
 hypesthesia or anesthesia of the skin. 
 
 Flat foot accounts for another error in the 
 diagnosis of dysbasia. It is one of the common- 
 est causes of pain in the lower extremities and 
 for that very reason so often misunderstood, 
 simply because the patient very rarely complains 
 of pain in the foot. He rather speaks of a pain- 
 ful tension in the calves or knees, of paresthesia 
 in the outer side of the thigh (meralgia), or in 
 the hips, so that an erroneous diagnosis of ischias, 
 or of a painful affection of the knee or hip 
 joint easily slips in. And yet the diagnosis is 
 plain and simple enough, if we only bear in 
 mind that not every patient who comes to us 
 for advice must of necessity be the carrier of 
 an internal disease. In a way flat foot resembles 
 dysbasia, that is to say, the patient complains 
 in both of pains in the leg, i.e., in the calves, in 
 the nates and in the loins, pains which are awak- 
 ened by walking but disappear during the resting 
 time. If they are mitigated or even vanish 
 during a longer walk we have evidence against 
 dysbasia. We know very well that flat foot 
 patients suffer from severe pains when they have 
 been standing on their feet all day long. In 
 the morning no pain is felt but it comes on and 
 increases in intensity as the hours go by. This 
 is not the case in dysbasia. Here the pains 
 cease so soon as the extremity is put out of
 
 EXTREMITIES 305 
 
 action. Moreover, there are definite external 
 signs by which a pes planus can be recognized, 
 the instep appears inflected, the inner condyle 
 is prominent, a vertical line drawn from the 
 middle of the popliteal space through the achilles 
 tendon deflects outwardly instead of hitting the 
 median line of the heel. The patient walks on 
 the outer border of the foot and wears out the 
 heels of his shoes on the outer side. Flat feet 
 are, as a rule, abnormal in length. Hallux val- 
 gus of the big toe and corns on the little toes 
 are other characteristics worthy of notice, and 
 so are pains in the foot itself or when following 
 passive supination of the foot in which case they 
 generally radiate in the knee and hip joints and 
 even into the small of the back as an expression 
 of static arthritis. 
 
 A common sequel of flat foot is venous ectasy 
 further complicated by subsequent dysbasia. We 
 must bear this in mind when a patient afflicted 
 with perceptible ectatic veins complains of pains 
 in the legs, especially for the reason that the 
 self-same causes may also originate phebectasy, 
 e.g., preceding pregnancy. Of more common 
 occurrence still is intermittent arteriosclerotic 
 dysbasia combined with flat foot. We shall 
 recognize it when the arterial pulse in the foot 
 is wanting. 
 
 Of course, it is understood that all forms of 
 talipes cause pains in the feet and legs. They
 
 306 GENERALIZED PAIN 
 
 belong really in the province of the orthopedic 
 surgeon. 
 
 Achillodynia is a symptom complex which 
 forces the patient to complain of intensive pains 
 in the process of the achilles tendon when the 
 feet and legs are in motion. We generally can 
 find a small local tumor about as hard as the 
 tendon itself. It is due to some slight injury, 
 a pinching shoe, periostitis or tendovaginitis and 
 of interest to the internist for the reason that 
 it may also be the effect of gout, gonorrhea, 
 malaria or even syphilis. A purely psycho- 
 genous hysterical form of achillodynia seems also 
 to exist. 
 
 A long forced march or some other unusual 
 overexertion of the lower extremities is fre- 
 quently followed by an attack of very painful 
 dysbasia. The patient can walk no further on 
 account of muscular cramps in the calves, or in 
 severer cases owing to a traumatic rupture of 
 some muscular fascia. The diagnosis is simple 
 and plain enough. 
 
 Myotonia is a muscular affection which owes 
 its origin to some primary disease of the nervous 
 system. Its special symptom is a painless rigid- 
 ity of the muscles following prolonged physical 
 exercise especially when the patient has been 
 inactive for a considerable space of time previous 
 to the overexertion. Yet there are cases in 
 which painful tension in the thighs and calves
 
 EXTREMITIES 307 
 
 is caused by walking. The pressure of hyper- 
 tonus in an otherwise well developed muscular 
 system, the fact that the symptoms disappear 
 in continued exercise, the absence of vascular 
 signs, and Erb's myotonic reaction facilitate the 
 proper diagnosis. 
 
 Resembling myotonia and for that reason 
 often mistaken for dysbasia are certain rare 
 cases of trichinosis when the patient complains 
 of cramps and stiffness in both calves, which 
 makes walking difficult but disappear again with 
 rest. 
 
 There are also sporadic cases of osteomalacia 
 in which intermittent limping is caused by vaso- 
 constricting cramps in the vessels. The charac- 
 teristic symptoms (see chapter on "Pains in the 
 Bones") suffice for the diagnosis. 
 
 At first sight we may gain the impression of 
 dysbasia in certain cases of arteriosclerosis. The 
 patient complains of pains in the legs which, 
 however, are not at all due to the sclerotic condi- 
 tion but to an entirely different cause. I remem- 
 ber such a case. The patient complained of 
 pains every time he made an attempt to walk 
 and showed all the characteristic symptoms of 
 arteriosclerosis. But the fact that he felt pain 
 in the legs when he turned around in bed and 
 that constant severe pains were present in the 
 sacrum turned my attention to the retroperi-
 
 308 GENERALIZED PAIN 
 
 toneal space. Upon closer examination I found 
 a carcinoma in the pancreas with fatal result. 
 
 Dysbasia or rather dyspragia in the upper 
 extremity must be suspected when the patient 
 complains of pain provoked by movements of 
 the arm. The cause for this congestion in the 
 circulation may be either sclerosis of the arteries 
 and their branches, or a sclerotic constriction of 
 the subclavian artery with abnormal vasomotoric 
 irritation, or, less frequently simple vasoconstric- 
 tion. 
 
 The differential diagnosis between dyspragia 
 and occupational cramps can be made from the 
 fact that in the latter no anatomical changes in 
 the walls or in the lumen of the vessels are 
 perceptible, that there is no difference in the 
 blood pressure on the affected and healthy side, 
 and also from the quality of the pulsation, all 
 of which are characteristic symptoms of dys- 
 pragia, where the arterial pulse may be even 
 entirely wanting in the affected side. Further- 
 more, in dyspragia the pains come on with any 
 kind of physical activity, e.g., during meal time 
 or when combing the hair and not rarely with a 
 definite occupation, e.g., writing or playing on 
 a musical instrument. Again, dyspragia mani- 
 fests itself sometimes only when the patient is 
 walking attended with paresthesia, paleness and 
 cold in the affected part. All this is due to 
 sclerosis or dilatation of the appurtenant aorta,
 
 EXTREMITIES 309 
 
 or to pressure of a cervical rib on the under- 
 lying cervical plexus and on the subclavian 
 artery. Here, too, paresthesia may manifest it- 
 self shortly after motation of the arm. Stitches, 
 cold or hot feeling in the skin, motoric weakness 
 amounting to a quasi paralysis incommode the 
 patient to such an extent that an object he holds 
 in the hand falls to the ground. 
 
 Diseases of the vascular system give also rise 
 to other varieties of pain in the extremities. 
 
 First of all I mention here that sclerotic arte- 
 ries give rise to moderately painful sensations 
 along their whole length or wall by way of the 
 vascular nerves. Perhaps we find the artery 
 sensitive on pressure, i.e., when we squeeze and 
 roll it between the fingers. We may also detect 
 changes in the arterial wall when we palpate 
 it with the finger nails. This is a valuable hint 
 which I have tried out on my own arteries. 
 
 Long continued pains in one or both lower 
 extremities combined with intermittent limping 
 is the natural sequel of arteriosclerosis with 
 secondary vascular cramps superinduced by ex- 
 cessive smoking or a psychic shock or some 
 physical overexertion. 
 
 Arteriosclerosis of the extremities the same 
 as endarteritis in younger persons is the causa- 
 tive factor of local pains, especially in the distal 
 parts of the extremities owing to defects in the 
 circulation. I have already pointed out that
 
 310 GENERALIZED PAIN 
 
 paresthesia, pain, coldness in these distal parts, 
 marbled, livid, pale skin, smallness of the peri- 
 pheral pulse are the ruling symptoms for the 
 diagnosis of such arterial affections possibly fol- 
 lowed by subsequent gangrene. Arteriosclerotic 
 neuritis and radiculitis are other means by which 
 arteriosclerosis is able to provoke very intensive 
 pains in the extremities. These pains, at times 
 intermittent, may, in fact, constitute the one 
 solitary symptom of the disease, because, as a 
 rule, tenderness of the nerves and muscles and 
 other objective sensibility disturbances are com- 
 pletely missing. The differentiation from arte- 
 riosclerotic dysbasia rests on the finding of the 
 arterial pulse. 
 
 Arteriosclerosis of the extremities (arteritis 
 obliterans) and Raynaud's disease are the origi- 
 nators of the highest degree of pains in the 
 extremities (the distal parts) when they culmin- 
 ate in gangrene. It follows that, when we are 
 confronted by gangrenous conditions, we will 
 have to decide to which of these two diseases the 
 present state is due. If due to arteriosclerosis 
 the pains have preceded the attack by several 
 weeks, if Raynaud's disease is the cause they 
 have existed for several years. In Raynaud's 
 disease, moreover, the gangrene is exquisitely 
 symmetrical and synchronous in both extremities 
 and remains confined to the same locality, whilst 
 in arteriosclerosis it is of a progressive nature
 
 EXTREMITIES 311 
 
 with total loss of pulsation. And yet there are 
 cases in which these points do not afford a con- 
 vincing differential proof, when even the Roent- 
 gen picture fails to come to our assistance. This 
 will happen, for instance, when Raynaud's dis- 
 ease likewise erythromelalgia runs a parallel 
 course with arteriosclerosis. 
 
 Very sudden pain in one of the extremities 
 may at any time be ascribed to some disease of 
 the arteries. Acute, toxic, infectious arteritis 
 obliterans ranks first in this connection with 
 some rare cases of severe acute infections (ty- 
 phoid, influenza). In its secondary stage it is 
 apt to give rise to thrombosis of the arterial 
 trunk. The manifestations of arterial ischemia, 
 i.e., the absence of pulsation, pallor and coldness, 
 hyparthesia and anesthesia of the extremities are 
 sufficient guides for the diagnosis. According 
 to recent observations a severe cold in the form 
 of acute rheumatic arteritis is a likely factor 
 when it has directly preceded the attack of arte- 
 ritis of the trunk. It may be known by the 
 sudden onset of severe, cramp-like pains in the 
 extremity on physical movement or even when 
 the patient is resting, the absence of the peri- 
 pheral pulse being probably the solitary demon- 
 strable sign. An interesting point which should 
 not be lost sight of, is that pneumonia is apt to 
 supervene in such cases with subsequent spastic 
 hemiplegia in the right side of the body and
 
 312 GENERALIZED PAIN 
 
 motoric aphesia, but without apoplectic condi- 
 tions. 
 
 Arterial pain in the extremity may be the 
 sign of a sudden occlusion of one of the branches, 
 or of the trunk itself. I have in mind here 
 embolism of the subclavian or brachial, the fe- 
 moral or popliteal artery, if not thrombosis. If 
 it is an embolism we shall have no difficulty in 
 finding the thrombotic focus nearly always in 
 the left ventricle, likewise local asphyxia, sudden 
 loss of pulsation, icy coldness, hyperthesia and 
 anesthesia with secondary symptoms of gan- 
 grene. 
 
 Of course, the primary thrombotic focus may 
 also be localized in the aorta ( atheromatous 
 ulcer) or in the pulmonary veins in which case 
 it will be beyond recognition. But if it be in 
 the heart itself we are dealing with a recent 
 endocarditis or a thrombosis in the left side of 
 the heart, i.e., either in the left ventricle or in 
 the left auricle. In the latter instance stenosis 
 of the mitral ostium is the cause of the throm- 
 botic condition. A ball thrombus is distinguished 
 by mitral stenosis and supervening gangrene in 
 both lower extremities. This gangrene may 
 originate either from thrombosis of the arteries 
 in the legs, or from an embolism generated by 
 the ball thrombus in the auricle. When the 
 embolism affects both popliteal arteries and runs 
 parallel with an ascending thrombus in both,
 
 EXTREMITIES 313 
 
 an occlusion though not necessarily total of 
 both femoral arteries is the natural result. 
 
 There is still another form of occlusion of the 
 arteries either in both legs or in one only which 
 is attended with most maddening pains in the 
 occluded area. Here mitral stenosis generates 
 thrombosis in the left auricle with a subsequent 
 embolism of the abdominal aorta. The end 
 result is an embolism of the common iliac artery, 
 with severe pains in the abdomen and legs. 
 Paresthesia may have preceded or may accom- 
 pany the attack, but there is no definite change 
 in the arterial pulse. On the other hand motoric 
 weakness and decline, if not total absence of the 
 patellar reflexes is always noticeable. The pains 
 gradually subside only to come on again sud- 
 denly with renewed vigor, at first in one leg 
 only from the knee down to the toes. This is 
 followed by missing pulsation in the arteries of 
 the foot, pallor and coldness in the foot and in 
 a part of the leg and anesthesia. The process 
 repeats soon after in the other leg also. What 
 I have said is taken from my own practical 
 experience. 
 
 In some cases thrombosis or an embolism of 
 the abdominal aorta localized in the bifurcation 
 of the common iliac artery alone is sufficient to 
 produce a high grade ischemia in it and in its 
 branches. We find pains in the abdomen and 
 in the lower extremities (sometimes in the lower
 
 314 GENERALIZED PAIN 
 
 part only), pale appearance of the skin which 
 feels cold to the touch, hypesthesia and anes- 
 thesia, missing or very small peripheral arterial 
 pulse, painful paraplegia and gangrene. I have 
 seen cases, however, in which all these symptoms 
 were wanting, but instead I found a very pro- 
 nounced stenosis of the mitral ostium with 
 thrombosis of the left auricle, and in all toes 
 and their adjacent parts symmetrical signs of 
 a very severe venous stasis and arterial ischimia, 
 strongly resembling initial gangrene. And yet 
 there was no evidence of thrombosis or embolism 
 of the arteries, but anatomico-histological signs 
 of severe venous stasis with secondary terminal 
 thrombosis of the venous trunks and strong 
 constriction of the arteries could be noticed. 
 
 When an embolism in the branches or in the 
 trunk of an artery in the lower extremity or 
 in the region of the abdominal aorta produces 
 sudden very intensive pains, a mistaken diag- 
 nosis of neuralgia is frequently made. The same 
 may be said with equal force of thrombosis, 
 especially in the initial stages of the disease and 
 before a secondary constricting and occluding 
 thrombosis has supervened. The symptoms of 
 local asphyxia and gangrene are, of course, the 
 same in both cases, for which reason the differ- 
 ential diagnosis is sometimes hard to make unless 
 synchronous abdominal pains indicate the locali- 
 zation of the occlusion.
 
 EXTREMITIES 315 
 
 Arterial constriction is always a possibility 
 when the patient complains of continuous pains 
 in one of the extremities or in a distal part 
 thereof no matter whether paresthesia is in evi- 
 dence or not. 
 
 All that has been said in the foregoing pages 
 about pains in the lower extremities applies in 
 like manner to the upper extremities. It should 
 not be difficult to recognize analogous affections 
 of the anonyma or the subclavian artery. 
 
 In the chapter on "Muscular Pain" I have 
 already said that severe pains in the extremities 
 may arise from an attack of periarteritis nodosa, 
 for which reason I only mention the subject 
 here. 
 
 I will now speak of morbid conditions in 
 the veins as a possible source of pains in the 
 extremities. 
 
 Acute thrombophlebitis occurs more frequently 
 in the lower extremities and is attended by very 
 severe pains, a climbing pulse and premonitory 
 rise in the temperature. Fever, edematous con- 
 ditions along the entire course of the affected 
 vein (marantic thrombosis in the radicular zone), 
 local painfulness and the unyielding consistence 
 of the vein when palpated are adequate symp- 
 toms for a correct diagnosis which may be 
 further strengthened by the consecutive forma- 
 tion of collateral cutaneous veins or the accession 
 of a pulmonary embolism or, if the foramen
 
 316 GENERALIZED PAIN 
 
 ovale be open, of paradox embolism. These 
 symptoms are not always very distinct, but the 
 painfulness of the affected vein and the differ- 
 ence in the local temperature will help us to 
 avoid an error. 
 
 When once satisfied that we are dealing with 
 a case of thrombophlebitis we shall have to hunt 
 for the originating factor. It behooves us here 
 to consider that the cause of the affection may 
 not only be an infection localized in the radicular 
 zone of the vein, but may just as well consist 
 of an inflammation in any part of the venous 
 wall. I call attention to the frequency of phle- 
 bitis in the lower extremities when the patient 
 is suffering from an infectious disease of the 
 uterus (puerperal thrombosis), to other morbid 
 processes in the small pelvis or in the retroperi- 
 toneal space, e.g., of the male genitals or the 
 bladder, appendicitis, perityphlitis, pericolitis, 
 perisigmoiditis, acute ulcerous colitis, perine- 
 phritis, pyelitis, renal neoplasm or a disease of 
 the pelvic bones. Phlebitis may also have its 
 genesis in a general septic infection, e.g., ty- 
 phoid, influenza, smallpox, syphilis, etc. 
 
 Marantic or cachectic thrombosis is the sequel 
 of insufficient cardiac action, of generalized 
 cachexia, severe anemia, or venous constriction 
 due to encroaching tumors or else to dilatation 
 of the veins, etc. The pains arrive suddenly 
 generally in one of the lower extremities with
 
 EXTREMITIES 317 
 
 local coldness and blue pigmentation of the skin. 
 A thrombus can be palpated in the vein which 
 feels like a quill, the distal collateral veins are 
 enlarged (frequently the first and solitary sign 
 of the thrombotic condition) to which may be 
 added an edema in the radicular zone of the 
 morbid vein. But I warn the observer not to 
 take such an edema as a conditio sine qua non. 
 Many errors have sprung from this assumption, 
 because in many cases it does not exist, espe- 
 cially when the affection is in the deeper muscu- 
 lar veins. The presence of pain mild though 
 it be in many instances of local sensitiveness, 
 enlargement of the collateral cutaneous veins, 
 no doubt, will guide our judgment in such cases, 
 particularly when we are able to palpate the 
 hard, waxy consistence of certain neighboring 
 muscles. 
 
 The next thing to do is to ascertain the pri- 
 mary cause of the disease. With regard to that 
 I repeat again that not only local defects in 
 the circulation such as varicose veins, or con- 
 traction of the venous trunks, but also general- 
 ized infections may breed such thromboses. We 
 call them cachectic thromboses because they may 
 follow after any form of cachexia. 
 
 Every case of thrombosis in the extremities 
 is a warning signal of a latent carcinoma, and 
 in the same measure, thrombosis in a vein of 
 the arm points to an expanding morbid process
 
 318 GENERALIZED PAIN 
 
 in the mediastinum with constriction of the supe- 
 rior vena cava. Be it remembered that throm- 
 bosis of the superior as well as the inferior and 
 also of the iliac vein is hardly ever associated 
 with pain, because it seems to me, the affected 
 extremity derives a competent supply of blood 
 from collateral veins, which, however, is not the 
 case when the principal vein is choked up. Per- 
 haps, this explains the occurrence of thrombosis 
 in the inferior vena cava with edema in only 
 one of the lower extremities. 
 
 Thrombophlebitis or phlebothrombosis of this 
 kind in one of the lower extremities is indicated 
 when the patient complains of sudden pains in 
 the affected part, when we find livid coloration, 
 coldness, wanting pulse, anesthesia and initial 
 gangrene. As a rule we are inclined to ascribe 
 these symptoms to a defect in or an arrest of 
 the arterial circulation, e.g., arteriosclerosis, end- 
 arteritis, embolism or thrombosis. And yet an 
 error may creep in as I know from personal 
 experience. In one case the post mortem showed 
 a recent endocarditis; while the arteries in the 
 legs were quite intact there was thrombophebitis 
 of both the crural veins. 
 
 Another case presented an ulcerating carci- 
 noma of the stomach in a man over 60 years old, 
 who three days before his death suffered keen 
 tearing pains in the left foot with coldness, 
 cyanosis, wanting pulse and anesthesia. The
 
 EXTBEMITIES 319 
 
 post mortem showed a marantic thrombosis of 
 the left popliteal vein, very rigid arteries and 
 atrophy of the heart. 
 
 A third case was that of a female patient, 
 fifty-one years of age, who was afflicted with 
 stenosis of the mitral ostium, insufficiency of the 
 mitral valve and of the heart. The post mortem 
 revealed defective arterial circulation causing 
 venous stasis, secondary venous thrombosis and 
 the clinical symptoms of an initial gangrene 
 which could not be anatomically recognized. 
 
 Simple phlebosclerosis and also phlebectasia 
 lead to paresthesias, an individual form of inter- 
 mittent dysbasia, and rather moderate, dragging 
 pains, especially in the calves. We find trem- 
 bling, tension, a feeling of heat and itching in 
 the lower extremities, symptoms which are sharp- 
 ened by standing or otherwise overtaxing the 
 muscles of the extremities. The pains come on 
 also when the patient has been walking a long 
 distance or is carrying a heavy burden, but 
 disappear when he quickens the pace or is 
 climbing steps. The diagnosis has already been 
 discussed but I will add that here, too, mistakes 
 may be made when the pains announce them- 
 selves in an unwonted fashion. Flat foot and 
 varicose veins are possible sources which are 
 frequently overlooked. 
 
 Phlebosclerosis bears the same stigmata as 
 phlebectasia. The most prominent among them
 
 320 GENERALIZED PAIN 
 
 is thickening of the venous walls, easily demon- 
 strated by clinical means and the X-ray. Edema 
 of the knuckle is common to both. It becomes 
 troublesome in the evenings and if the disease 
 is protracted it may assume proportions which 
 resemble elephantiasis. The overlying skin is 
 rigid and immovable but pigmented with a 
 diffuse brownish tint owing to frequent local 
 hemorrhages. 
 
 The same symptoms, i.e., pain, edema and 
 perceptible enlargement of the collateral veins 
 are attached to chronic phlebitis. It can be 
 distinguished from simple phlebectasia by the 
 intercurrent acute exacerbation of the inflam- 
 mation and by the proof that it arose from an 
 acute attack. 
 
 It is self-evident that pains in the lower ex- 
 tremities, especially in the calves, belong to the 
 initial signs of a beginning congestion in the 
 inferior vena cava and in consequence of muscu- 
 lar insufficiency of the heart. The other symp- 
 toms of the latter such as fatigue, headache, 
 dyspepsia and dyspnea will assist the diagnosis 
 materially. 
 
 Inflammatory wandering diseases of the lym- 
 phatic vessels are also attended with pains in 
 the extremities. Acute lymphangitis as well as 
 acute, subacute and chronic lymphadenitis are 
 frequent causes of such pains, especially in the 
 arms. The former stands out by the manifesta-
 
 EXTREMITIES 321 
 
 tion of chills and fever, general indisposition, 
 long streaks of reddening, slight infiltration but 
 very decided painfulness of the affected parts. 
 Lymphadenitis, on the other hand, is distin- 
 guished by painful swelling of one or more 
 lymphatic glands, especially in the axilla and in 
 the groin. 
 
 Pains, swollen lymphatic glands, edema and 
 infiltration of the periglandular skin (hemor- 
 rhages and vesiculation) and absence of lym- 
 phangitis are the most prominent signs of 
 bubonic plague. The patient complains from 
 the very beginning of pain in the glandular 
 region (groin, armpit, neck) and of local ten- 
 derness. 
 
 The seat of pain in the extremities, of course, 
 may also be in the muscles, in the nerves, joints, 
 tendons, fascia, ligaments or synovial sacs, in 
 the bones or in several or all of these organs. 
 For fuller details I refer the reader to the re- 
 spective chapters on these various subjects con- 
 fining myself in this place to the discussion of 
 pain arising clearly and definitely from nervous 
 disorders only. 
 
 III. Pain in the Nerves 
 
 I will not go into details here about pains in 
 the extremities which arise from peripheral neu- 
 ritis, but only mention that a lesion of the peri- 
 pheral nervous system does not always attack
 
 322 GENERALIZED PAIN 
 
 the entire system in equal measure, but may 
 only affect a certain portion of it; for instance, 
 chronic alcoholism is often manifested by pains 
 or paresthesia in one extremity only. Further- 
 more, I wish to point out that in neuritis of one 
 nerve-trunk the pains are localized solely in the 
 distal parts of the affected extremity that is to 
 say in the peripheral branches of the nerve, e.g., 
 in neuritis of the ischiadic nerve (ischias) the 
 pain exists in the knee or in the heel, or in 
 neuritis of the brachial plexus it is in the tips 
 of the fingers. In such cases the behavior of the 
 tendon and skin reflexes and the presence of 
 nerve-pressure points are of decided diagnostic 
 merit. And finally, let me add, that injuries 
 of a nerve or a nerve-plexus may be associated 
 with paresthesias and pains not only in the 
 affected extremity, but also in the corresponding 
 extremity, no doubt via the shortest route of 
 sympathetic irritation. 
 
 Pains in one or in both extremities may arise 
 from any kind of morbid conditions which irri- 
 tate the trunk of the nerves proximal to the 
 extremity or the radicular zone of it either by 
 compression or by way of a perineuritis. We 
 can recognize these truncal pains by their irradi- 
 ation into the appurtenant branches, by synchro- 
 nous paresthesia, by their neuralgiform character, 
 their permanence with periodic, often excessive 
 exacerbations, tenderness in the nerve-trunks,
 
 EXTREMITIES 323 
 
 sensitiveness in the pertinent muscles. We must 
 also look for sensible and motoric disorders in the 
 affected nervous area, changes in the tendon 
 reflexes, muscular atrophy and fibrillary twitch- 
 ings as well as electric, trophic and vasomotoric 
 reactions. Nevertheless, there are cases in which 
 some if not all of the aforementioned symptoms 
 are wanting, but then the nerve itself will very 
 likely make itself known as the irritating cause 
 of the pain. 
 
 If the pain is unilateral its originating cause 
 is to be found in a nerve-trunk of the extremities. 
 It then either occupies the whole bronchial terri- 
 tory or is confined only to a certain area of the 
 plexus, most frequently in the distal parts of the 
 extremity. 
 
 Apart from the primary diseases of the nerve- 
 trunks, insofar as the lower extremities are con- 
 cerned, we must also consider as irritating causes 
 of pain all morbid processes of the true pelvis, 
 of the retroperitoneal space and of all organs 
 that for morbid reasons may in any way en- 
 croach on this cavity which is so to speak a 
 common meeting place of all sorts of pain. It 
 is rather of interest to notice that even in affec- 
 tions of azygous median organs in this region 
 unilateral pains in the extremities may exist. 
 For instance, pain in the right leg makes us think 
 of prostatic carcinoma. Other accompanying 
 symptoms will help us to find the right diagnosis,
 
 324 GENERALIZED PAIN 
 
 for instance: parallel irradiation of the pains 
 into the abdomen and genitals, simultaneous 
 psoas position as a sign of renal or pararenal 
 (paranephritic) inflammation or suppuration. 
 
 Of equal importance is the fact that similar, 
 rather light pains in the anterior side of the 
 thigh, more distinct, however, in the right foot, 
 combined with abdominal and sacral pains with 
 fever or without, with vomiting or otherwise, 
 are an indication of a possible acute periappen- 
 dicitis, in which the vermiform appendix presses 
 on the psoas muscle and produces an acute initia- 
 tion of the crural nerves (perineuritis of the 
 crural nerves). In these cases we often miss 
 every symptom of peritonitis, chiefly vomiting, 
 and the stormy onslaught of the disease alto- 
 gether. The diagnosis is materially advanced 
 by the radiating nature of the pain in the foot 
 and by the fact that in active contraction of the 
 psoas muscle (raising of the foot) the local 
 pressure pain in the ileocecal region is much 
 severer than when the leg is at rest. Palpation 
 per rectum is painful and there is considerable 
 tension of the abdominal muscles. The patient 
 feels the pains in the thigh, but the abdominal 
 pains do not seem to incommode him to any 
 extent. That the abdominal pains are either 
 provoked or sharpened by movements of the 
 hip joint appears to me to be an important sign 
 of acute or chronic periappendicitis.
 
 EXTREMITIES 325 
 
 These pains in the anterior side of the thigh 
 are likewise a valuable symptom of renal dis- 
 eases (tuberculosis, neoplasm, hydronephrosis) 
 and in other retro peritoneal affections. Still, we 
 must not lay too much stress upon this sign, 
 because there are cases of intraperitoneal tumors 
 which extend so far rearwards that they, too, 
 may give rise to retroperitoneal pains. 
 
 In paroodmal hemoglobinuria pains are expe- 
 rienced in the lower extremities during the at- 
 tack, but they are superseded by those in the 
 loins and in the region of the spleen and liver. 
 
 Pains and casually paresthesia on the inner 
 side of the thigh down to the knee together with 
 signs of sudden incarceration are the strongest 
 hints of an existing hernia obturatoria. Distinct 
 painfulness on deep pressure against the fora- 
 men obturatorium and a slight arching in the 
 region of the oval perforation confirm the diag- 
 nosis. 
 
 A unilateral pain in the upper extremity in- 
 troduced or accompanied by paresthesia warns 
 of an expanding morbid process in the medias- 
 tinum. In my own opinion, which, however, is 
 not shared by all authorities, pains in the right 
 very seldom in the left arm (and shoulder) 
 point to an aneurysm of the ascending aorta or 
 its arc, likewise to solid or cystic, less frequently 
 chronic inflammatory tumors of the mediastinum, 
 especially of the glands therein (lymphogranu-
 
 326 
 
 lomatosis). According to their anatomical lo- 
 calization these tumors produce pains in one of 
 the arms, but also in both. These pains and 
 possible parenthesias are at times the sole symp- 
 tom of the prevailing disease and as such are 
 of signal merit for the diagnosis. 
 
 Only a few cases are on record in which acute 
 processes in the mediastinum provoked pains in 
 an arm, but not also at the same time in the 
 chest or back. I do not speak here of pericar- 
 ditis when the pains radiate into the left arm 
 as is their wont in angina pectoris. 
 
 These pains in the extremities have a special, 
 characteristic habit of setting in when the patient 
 is lying on his back but to vanish when he bends 
 over forwards. The same happens also in aneu- 
 rysms of the aorta and solid tumors of the medi- 
 astinum. In the prone position the aneurysm 
 or tumor tears and presses on the adjacent 
 nerves and thus exacerbates the pains, which, 
 however, may also be sharpened by physical 
 overexertion. 
 
 Tumors of the superior pulmonary lobes and 
 acute as well as chronic inflammatory diseases 
 thereof, e.g., of the pleural apex give rise to 
 analogous irritation of the cervico-brachial plexus 
 in the supraclavicular region and hence to neuro- 
 genous pains in the arm. They must always 
 remind us of lobar pneumonia (with pleurisy 
 of the apices and perineuritis of the cervical
 
 EXTREMITIES 327 
 
 plexus) or of acute apical pleurisy, or chronic, 
 retracting lobar indurations of tuberculous gene- 
 sis or otherwise, also of tumors in the same 
 locality, i.e., the pleura. Mark this also: remit- 
 tent-interremittent pains in one arm are the first 
 signs of carcinoma in the upper pulmonary lobe 
 or its pleural apex, or in the main bronchus. 
 
 It is, perhaps, easier to understand that an 
 analogous irritation of the aforesaid plexus with 
 subsequent pains in the arm, paresthesia, like- 
 wise hyperesthesia, weakness, paresis, apoplexy, 
 may also emanate from any expanding or in- 
 flammatory morbid condition in the supraclavi- 
 cular fossa (diseases of the lymphatic glands, 
 of the clavicle, aneurysm of the subclavian artery 
 or of the anonyma, etc.). The diagnosis comes 
 easy because the disease is open to our senses, 
 we can see it, we can feel it. Of course we 
 cannot look upon this if we except metastatic 
 tumors (glands) as a definite proof that the 
 place of origin of the tumor and of the subse- 
 quent pains in the arm was from the very start 
 localized in the supraclavicular fossa. There 
 are, indeed, cases in which the patient complains 
 of pains in the arm but not a trace of tumor in 
 the supraclavicular fossa can be found in the 
 beginning, although it puts in appearance later 
 on: in other words the original mediastinal 
 malign tumor has forced its way into the supra- 
 clavicular fossa.
 
 328 GENERALIZED PAIN 
 
 If we overlook this point, if the anamnesis is 
 incomplete and we have neglected to make a 
 scrupulous examination of the whole chest not 
 to forget the X-ray we may readily meet with 
 bitter disappointments. 
 
 Palpation and perception of the supraclavi- 
 cular fossa at times yield absolutely negative 
 results. A cervical rib, for instance, may escape 
 our observation for a considerable time, although 
 it be the sole cause of unilateral or dual pains 
 in the upper extremities. They are produced 
 by motation, or under the influence of cold, 
 ushered in by paresthesia, associated with mo- 
 toric, trophic and secretory troubles, sensibility 
 disturbances (i.e., typical neuritic disorders), 
 high pressure in the subclavian artery, with 
 whirring, hissing, blowing systolic noises above 
 it. Only the most thorough palpation and the 
 X-ray are able to discover the true source of 
 the pains. What has been said may also be 
 applied to malignant struma. 
 
 The aforesaid intrathoracic diseases require 
 equally our attention where the pains in an arm 
 are the reflex action of pains in the chest, but 
 if they are reflected from pains in the abdomen 
 (epigastrium, hypochondrium) they indicate 
 subdiaphragmatic irregularities and go in com- 
 pany with pains in the shoulder. Witness chole- 
 lithiasis, perihepatitis and perisplenitis, gastric 
 diseases (ulcer, carcinoma, perigastritis) and
 
 EXTREMITIES 329 
 
 diseases of the pancreas. In some cases the 
 pains may constitute, when of a neuralgiform 
 character, the first symptom, e.g., of ulcus ven- 
 triculi in the left brachial plexus. 
 
 Unilateral neurogenous pain localized cen- 
 trally from the process of the extremity is not 
 only due to an affection of the nerve trunk 
 beyond the extremity but may just as well origi- 
 nate from a morbid condition in the intrasjnnal 
 nerve roots. Of course, analogous painfulness 
 in the contralateral extremity matures during 
 the course of the disease. The bilateral and 
 symmetrical nature of the pains constitutes the 
 characteristic sign of these lesions of the nerve 
 roots because their fibres lie so close together. 
 Nevertheless, a regional disease can just as well 
 have a unilateral influence on the nerve roots. 
 
 The question arises here how to differentiate 
 between affections of the roots and those of the 
 nerve-trunks. In the first place it is important 
 to note that in fascicular (trunk) affections 
 objective pressure sensibility is present in the 
 entire nerve trunk (I mean isolated pressure 
 points) which in affections of the roots are either 
 totally wanting or of a negligible quantity, while 
 in their place pressure points in the spinous 
 processes are to be found. Secondly, the pains 
 have a radicular character, that is to say they 
 are as in tabes very keen lancinating pains pro- 
 voked by motation or overexertion, hyperactivity
 
 330 GENERALIZED PAIN 
 
 of the abdominal press, e.g., when sneezing. In 
 the third place in radicular neuritis not the whole 
 plexus, but only one or several branches are 
 involved. Fourthly in radicular neuritis objec- 
 tive sensibility disturbances are of frequent 
 occurrence while in truncal neuritis they are 
 inconstant. And lastly in radicular neuritis the 
 objective sensibility disturbances run in the 
 spinal-segmental type, i.e., generally at the ex- 
 tremities in' horizontal but in the thorax in 
 circular patches, whilst in truncal neuritis they 
 follow the peripheral type, i.e., the direction of 
 the peripheral nerves. 
 
 Unilateral pain in the upper or lower extremi- 
 ties or in both or only in a section of one points 
 to a possible cerebral genesis. I do not refer 
 here to the sensible aura of epilepsy or to hemi- 
 plegia, but rather to those very molesting and 
 severe attacks of exacerbating neuralgiform 
 pains which manifest themselves in hemiplegic 
 extremities, especially the arms. Sometimes they 
 accompany hemiplegia, at other times they fol- 
 low in the wake of it or arrive before the attack 
 sets in in the form of premonitory pains owing 
 to irritation of the intracerebral sensible course 
 through the central focus (focus of hemorrhages 
 or softening, cysts, tumors) or arising from the 
 meninges. Paresthesias associated with these 
 eccentric pains originate from certain centers in 
 the cortex, or in the vicinity of the thalamus
 
 EXTBEMITIES 331 
 
 opticus, or in the pons or the cerebellum. We 
 can localize the cerebral seat of the pain by the 
 fact that other cerebral manifestations accompany 
 it, i.e., hemiparesis, hemiplegia, hemispasms, 
 hemiclonus, hemiathetosis or hemianesthesia in 
 the opposite side (hemianesthesia dolorosa thal- 
 amus affection). 
 
 In some rare cases we have to deal with sensi- 
 ble manifestations of this kind only. Then the 
 diagnosis will be guided either by changes in the 
 tendon or skin reflexes or of the deep sensibility 
 (stereognostic sense), or by other cerebral local 
 or generalized symptoms, or perhaps solely by 
 the anamnesis in the sense of a preceding apo- 
 plectiform insult (in a thalamus focus not recog- 
 nizable!). These pains of cerebral origin in 
 hemiplegic extremities are unfortunately too 
 often taken for rheumatic pains because they are 
 like those lancinating pains in diseases of the 
 spinal cord so much influenced by weather con- 
 ditions. I mention here that the same character- 
 istics attach also to pains which are based on 
 anatominal lesions (stenocardia) or on functional 
 disorders (neuroses). 
 
 Of interest are also the attacks of pain in an 
 arm or leg attended with high fever and hyper- 
 algesia which come on sporadically in progressive 
 paralysis and disappear again within a few 
 hours. They are undoubtedly of central origin 
 and will be properly understood if we take into
 
 332 GENERALIZED PAIN 
 
 consideration the other psychic and somatic signs 
 of the disease as well as the anamnesis, and apply 
 the Wassermann reaction and lumbar puncture 
 (three tests). 
 
 It is easy to understand that in neuritis the 
 pains are present in the affected nerve-trunks in 
 both sides and frequently assume the role of 
 symptomatic manifestations of the causating 
 disease, e.g., chromic alcoholism or leprosy, mor- 
 bid conditions in the true pelvis or in the retro- 
 peritoneal cavity. So, too, a bilateral ischias is 
 a valuable indication of prostatic carcinoma or 
 multiple tumors in the pelvis, if not of diabetes, 
 malaria or gouty diathesis or chronic constipa- 
 tion. Pains in both the lower extremities and 
 in the hip joints, particularly in women, are the 
 first sign of tuberculous peritonitis. 
 
 Radicular neuritis and spinal disorders are 
 further irritating factors of bilateral pains either 
 in the upper or in the lower extremities. I refer 
 to tumors, tuberculosis, gummata of the verte- 
 bras, compression of the intraspinal ganglia, 
 morbid conditions in the meninges and intra- 
 medullary diseases. Likewise to multiple scle- 
 rosis, syringomyelia, myelitis, cerebro-spinal 
 syphilis, tumors of the spinal cord, acute polio- 
 myelitis, chronic meningitis, epidemic cerebro- 
 spinal meningitis, tabes superior, pachymenin- 
 gitis (chronic hemorrhagic, syphilitic or tuber- 
 culous), hemorrhages in the spinal cord (trau-
 
 EXTREMITIES 333 
 
 matic), in hemorrhagic diathesis, scarlet fever, 
 scurvy, pernicious anemia, and tumors of the 
 spinal cord (extramedullary). 
 
 Also leucemic or lymphoid infiltrations in the 
 epidural tissue of the lower vertebral canal 
 deserve mention here. In vertebral insufficiency 
 it will be noted that pains in the spinal column 
 or in the back are of rare occurrence, as they 
 predominate in the chest and abdomen, legs and 
 arms. If we have proof of sensitiveness on 
 pressure and percussion in a definite zone of the 
 spinous processes, if we find spasms in the dorsal 
 muscles, collapse of the spinal column or deform- 
 ing curvature of the body with relaxation of 
 these symptoms when the patient is resting, we 
 should have no difficulty in forming a satisfac- 
 tory diagnosis. 
 
 I include those extremity crises in tabes dor- 
 salis in which the patient complains of violent, 
 dragging and tearing pains with subsequent 
 cramps in the calves and local hyperesthesia. 
 Likewise those pains in the lower extremities 
 which follow the interspinal injection of a cold 
 fluid not properly warmed up, and also those 
 very keen pulling pains in the arms and legs of 
 which we see so much in epidemic encephalitis 
 the latter, however, may be also due to purely 
 cerebral influences. 
 
 Pellagra generally sets in with pains and par- 
 esthesia in the extremities, no matter whether it
 
 334 GENERALIZED PAIN 
 
 affects the spinal cord or the peripheral nervous 
 system. 
 
 In paraplegia dolorosa we witness intensive 
 pains in the back which radiate thence into the 
 paralyzed, debilitated extremities. Carcinoma of 
 the spinal column is the most pronounced char- 
 acteristic of this disease, a fact which accounts 
 for the violent pains mentioned just now. 
 
 In the diseases heretofore discussed the pains 
 are wont to sneak in gradually and increase in 
 intensity more or less rapidly. But there are 
 other chronic affections of the spinal cord and 
 its membranous envelope as well as of the os- 
 seous parts which introduce themselves with a 
 very sudden, apoplectiform initial pain in one 
 if not in both corresponding extremities. I am 
 not referring, however, to tuberculous spondi- 
 litis, but rather to extramedullary tumors of the 
 spinal cord which after a slow latent growth 
 suddenly spring into evidence with a stroke-like 
 terrible pain in the extremities. Their invasion 
 which is accompanied by a feeling as if the spinal 
 cord were severed in two must arouse in us at 
 once the suspicion of hematomyelia. Although 
 this disease is in itself pregnant with pains, still 
 it is wise even here to remember that the greater 
 the intensity of pain, the stronger is the proba- 
 bility of a membranous involvement of the spinal 
 cord. 
 
 A hemorrhage as well as a sudden vascular
 
 EXTREMITIES 335 
 
 occlusion of the spinal cord leads to very severe 
 pains in the lower extremities with a quick local 
 relaxation in the power of motion and with 
 sensibility disturbances reaching even into the 
 hypochondrial region, witness certain cases of 
 dissecting aneurysm of the thoracic aorta with 
 hemorrhage into the aortic tube cutting the circu- 
 lation in a portion of the intercostal arteries. 
 
 An ordinary aneurysm of the descending thor- 
 acic aorta (also of the abdominal aorta) is in the 
 same manner liable to produce paresthesia and 
 pain in the lower extremities through spinal 
 influence, i.e., when a vertebra is worn down by 
 friction and an opening into its canal is formed 
 which naturally results in pressure on the spinal 
 cord. The superceding symptoms of the trans- 
 section of the spinal cord (backache, paraparesis 
 or paraplegia of the legs, gastric and bladder 
 troubles, etc.) should put the diagnosis on a 
 sound foundation. To find the cause for it in 
 an aneurysm of the aorta may be difficult at 
 times, but the difference in the arterial pulses 
 of the upper and lower extremities and the 
 X-ray are reliable guides in that direction. 
 
 Unilateral and why not bilateral pain in the 
 nerves of the extremities, however, are not only 
 dependent on neuralgia or apparently neuralgic 
 conditions, but may just as well originate from 
 any common cause. 
 
 Certain infectious diseases, such as malaria,
 
 336 GENERALIZED PAIN 
 
 syphilis, gonorrhea, tuberculosis, typhoid, influ- 
 enza, etc., are creators of neuralgia in its divers 
 forms. Exogenous and endogenous intoocica- 
 tions are frequently at the bottom, such as dia- 
 betes mellitus, hyperglycemia, gout, uremia, 
 chronic obstipation, alcohol, lead, arsenic, car- 
 bon dioxid poisoning, in fact all disorders of 
 metabolism. 
 
 For the sake of substantiating this claim I 
 will pick out as an example ischias. When the 
 patient complains of such a pain in the ischiadic 
 plexus we must be conscious of the fact that it 
 is due to a lesion either of the corresponding 
 nerve-roots or of the nerve-trunks. But we 
 should also remember that there is such a thing 
 as ascending neuritis (though very seldom ap- 
 plicable in ischias) ; in other words that an 
 infectious disease in the radicular zone of a 
 nerve may lead to an ascending inflammation 
 of the trunk and its branches. From this we 
 are safe to draw the conclusion that in cases 
 of ischias we have before us a long string of 
 possible complications. 
 
 There are expanding morbid processes of all 
 kinds in the spinal canal whether they originate 
 from the meninges (pachymeningitis, leptomen- 
 ingitis, tumors), or from the spinal cord proper 
 or from the cauda equina (tumor) ; diseases of 
 the nerve-roots in the lumbo-sacral vertebrae and 
 their interarticular ligaments (neoplasms, spondi-
 
 EXTREMITIES 337 
 
 litis, rhizomyelia) or in the intervertebral fora- 
 nina (inflammatory, neoplastic, leucemic infiltra- 
 tions) ; inflammatory or compressing processes 
 in the region of the loins and sacrum, no matter 
 whether they arise from affections of the bones, 
 of the connective tissue, or of retroperitoneal 
 lymphatic glands or organs (kidneys, adrenals) ; 
 analogous morbid conditions in the pelvic area 
 (pregnant uterus, tumors, inflammations, dis- 
 eases of the ovaries, of the prostate, chronic 
 constipation) ; inflammatory and constricting 
 processes in the lower extremities; diabetes, 
 gouty diathesis, malaria, etc. 
 
 Local traumata, diseases or infiltrations, also 
 sclerosis of the arteries (arteriosclerotic neuritis), 
 varices of the venous nerves, all these conditions 
 may lead to ischias. We must also differentiate 
 between true ischias and neurotic (hysterical) 
 pseudoischias. So far as the latter is concerned 
 we must fall back on the typical characteristics 
 of hysteria, the fluctuating localization of the 
 pains, the fact that a gentle pinching of the skin 
 causes severer pain than hard, deep pressure 
 and that the pains subside under the influence 
 of mental distraction. The diagnosis finds fur- 
 ther subsidy from the behavior of the tendon 
 reflexes (decrease of the achilles tendon reflexes 
 in true neuritic ischias), from the special char- 
 acteristics of the pains, the pressure points, 
 Lasegue's symptom, increase through the ab-
 
 338 GENERALIZED PAIN 
 
 dominal press, coldness of the knees and last 
 but not least, from the Roentgen ray, 
 
 IV. Other Pains in the Extremities 
 
 All these symptoms must be carefully con- 
 sidered whenever we hear complaints of pain in 
 the small of the back and in the breast and the 
 diagnosis balances between ischias and lumbago. 
 Incidentally, these two diseases may run a paral- 
 lel or alternating course, unless lumbago is in 
 itself a neuritis of the ischiadic branches. 
 
 Slight, vague pains which are hard to localize 
 in the muscles and which radiate into the bones 
 and joints consisting more of a painful drag- 
 ging, but acute under the influence of general 
 indisposition and mostly attended with fever are 
 a clear indication of an acute infection. Every 
 form of infection, every kind of vaccination may 
 begin with these sensations. But in some they 
 are more pronounced than in others, the com- 
 monest among them being the ordinary nasal 
 catarrh (coryza, snuffles) and influenza (grippe). 
 (Cf. chapter on "Muscular Pains.") In small- 
 pox, recurrent fever (pains in the bones, joints 
 and muscles, especially in the legs), erysipelas 
 (most intensive muscular and nervous pains), 
 but also in influenza these pains are very severe 
 and of a boring, tearing character not only in 
 the incipient stages, but throughout the run of 
 the infection and sometimes far beyond that.
 
 EXTREMITIES 339 
 
 In typhoid and paratyphoid this is not so often 
 observed. Pappataci fever has articular pains, 
 and glanders pains in the shinbones as com- 
 panions. 
 
 In spotted typhus paresthesia and pains in 
 the extremities are not only the expression of 
 the generalized infection, but may also be the 
 precursory sign of gangrene characteristic of this 
 disease. I have already said previously that 
 gangrene of the extremities follows also other 
 acute infections such as typhoid, influenza, etc. 
 In all these diseases, especially in exanthemic 
 fever the pains endure at times for weeks with- 
 out subsequent gangrene. They are evidently 
 due to specific attacks of arteritis. 
 
 Of Wolhyman fever another causative factor 
 of these pains I have spoken already in several 
 places. 
 
 Pains in the extremities which come to the 
 fore in septic diseases must remind us of meta- 
 static conditions in the bones or in the muscles 
 such as abscess or necrotic foci. 
 
 Periarteritis nodosa is often surrounded by 
 symptoms which strongly resemble a septic af- 
 fection. There are pains in the extremities 
 which are evidently due to morbid changes in 
 the arterial walls. We also find irregular at- 
 tacks of fever, anemia, physical debility, tachy- 
 cardia, leucocytosis, polynucleosis, edema and 
 nephritis, articular swellings, cutaneous hemor-
 
 340 GENERALIZED PAIN 
 
 rhages, cyanosis, dyspnea and abdominal pains. 
 The diagnosis (cf. "Abdominal Pains") can 
 only be secured when we can palpate the en- 
 larged local arterial walls. Syphilis seems to 
 be the originating cause of this disease in some, 
 but by no means in all cases. 
 
 Pains in the extremities are not only initial 
 and concomitant symptoms, but may also be the 
 sequel of infectious diseases, i.e., signs of con- 
 valescence, as it were. The patient is run down 
 and feels as if he had been beaten up after a 
 severe attack of influenza, for instance, or small- 
 pox. The same may happen even after slight 
 infections, such as dysentery which was taken for 
 simple diarrhea, a short acute attack of gastro- 
 enteritis. The toxic after-effects retard recovery 
 and bring fatigue and pain with them. 
 
 In mild forms of trichinosis pains in the limbs 
 are not uncommon although they do not bear 
 the stamp of characteristic significance. Yet 
 when they are associated with pains in the 
 muscles of the neck and chest and with gastro- 
 intestinal troubles, they should be of assistance 
 in finding the right solution, especially when we 
 detect an edematous lesion in the eyelid and 
 eosinophilia in the blood. 
 
 This applies also to mitigated forms of acute 
 articular and muscular rheumatism. Here we 
 get a hold on the diagnosis when local pressure 
 sensitiveness and heavy sweating are present.
 
 EXTREMITIES 341 
 
 The effect of salicylic treatment is another 
 adjuvant. 
 
 Complaint of mild pains sometimes very per- 
 turbing, boring, tearing especially in the tibia 
 is an introduction to scurvy. 
 
 In metabolic infections the patient is apt to 
 localize the pains in the joints and muscles of 
 the extremities. Upon closer scrutiny we find 
 that they rather affect the tendons and fascia, 
 also the nerves and synovial sacs. I am refer- 
 ring to gout, but not to the typical acute, nor 
 the irregular, but to that form which we know 
 as gouty diathesis or a typical irregular gout 
 not dependent on previous gouty articular affec- 
 tions. The pains are of a transient nature and 
 wander about from one place to another. Clini- 
 cally speaking there are no typical signs of gout 
 and the diagnosis must be in most cases merely 
 a good guess, justifiable, indeed, in stout persons 
 with a familial gouty record, persons who in- 
 dulge in sumptuous living, meat eaters, persons 
 who eschew green vegetables and fruit, "bon 
 vivants." They generally suffer from abdominal 
 plethora, hemorrhoids, enlarged liver, skin dis- 
 eases, such as chronic eczema, also from urticaria 
 and chronic dyspeptic troubles. We find neu- 
 rasthenic symptoms such as headache, dizziness, 
 migraine, abnormal irritability, chronic lassitude, 
 etc., without a specific causal element. Renal 
 calculus is common in these patients. The
 
 342 GENERALIZED PAIN 
 
 diagnosis derives much benefit from a proper 
 urinary analysis and tentative drug treatment. 
 According to my own very wide experience this 
 disease is very common among city-dwellers who 
 eat too much and do not take sufficient physical 
 exercise and are hereditarily predisposed to such 
 attacks. It is very difficult to properly localize 
 the pains as they vary so much in different 
 individuals and even in the same person as to 
 time of appearance. Yet in the majority of 
 cases we shall be able to spot a typical neuralgia 
 (e.g., ischias), pseudorheumatic muscular and 
 articular pains. 
 
 Tarsalgia must be mentioned on account of 
 its close connection with gout and diabetes mel- 
 litus. The patient complains of dull, though 
 sometimes very severe pains in the heel of the 
 foot, especially in the lower plane thereof, corre- 
 sponding with the process of the achilles tendon. 
 Sometimes the outer margin of the heel is very 
 sore to the touch. The pathologic anatomical 
 causes for these pains (achillodynia) are quite 
 a few. I mention affections of the achilles ten- 
 don (peritendinitis achillea, recognized by a 
 peculiar friction fremitus in the movement of 
 the tendon), enlarged synovial sacs which can 
 be felt with the finger, morbid condition in the 
 calcaneum or in the peripheral nerves (e.g., 
 diabetic neuralgia or ischias), inflammation of 
 the local adipose tissue. Some authors claim
 
 EXTREMITIES 343 
 
 that peripheral arteriosclerosis or a similar affec- 
 tion of the arteries of the bones is a causative 
 factor as can be demonstrated by the aid of the 
 Roentgen-ray. Tarsalgia as a rule is bilateral 
 with pains in the median knuckle or correspond- 
 ing with the cuboid bone. If dealing with a 
 traumatic affection of the synovial sac, or an 
 exostosis of the calcaneum (calcaneous spur) 
 (Roentgen picture!) it is of importance for the 
 internist to ascertain whether the cause is not 
 to be found in flat foot, or gout or gonorrhea, 
 or else in rheumatic conditions. The gonorrhoic 
 form is distinguished by the fact that the pains 
 are not only centered in the heel but involve 
 also the sole of the foot (1. to 5. metatarsophal- 
 angeal joint). 
 
 But a calcaneous spur may also be congenital, 
 or due to syphilis, a trauma, flat foot or osteo- 
 arthritis. Bear also in mind that pes planus and 
 a calcaneous spur may co-exist. 
 
 Pains in the foot are also due to affections of 
 the plantar aponeurosis, viz., fasciitis plantaria 
 aponeurotica, due to gout, gouty diathesis, hence 
 due to the presence of urates in the plantar 
 fascia. The etiologic diagnosis is based on the 
 characteristics of gouty conditions. It is also 
 claimed that rheumatic indurations in the plantar 
 fascia give rise to local pains. 
 
 Acute fasciitis is also among the sequels of 
 acute infections, especially of influenza, and may
 
 344 GENERALIZED PAIN 
 
 be recognized by radiating pains and tenderness 
 in and around the aponeurosis. From my own 
 esperience I cannot state with certainty but it 
 seems possible that the pains in the feet observed 
 in typhoid fever are due to a similar cause, if not 
 more correctly to neuralgic influences. 
 
 Dysbasia angiosclerotica with symptoms sim- 
 ilar to those here discussed may be observed in 
 inveterate cigarette smokers. 
 
 In metatarsalgia, i.e., Morton's disease, a pe- 
 culiar kind of pain in the feet occurs. It is 
 centered in the metatarso-phalangeal joint, 
 mostly of the 4. toe, radiates upwards and be- 
 comes so distressing in walking (narrow shoes 
 the likely cause!) that the patient must stand 
 still and rest. When the footwear has been 
 removed and the painful parts are massaged, 
 the pains generally disappear. Local reddening 
 and swelling are seldom observed and I am not 
 prepared to state in how far anatomical changes 
 in the joint, or anomalies in the fascia or pressure 
 on the ramus communicans by the head of the 4. 
 metatarsus are the responsible factors. But I 
 think that X-ray examinations should be made 
 freely. If gout be the irritating cause it will 
 be shown by local reddening and swelling. The 
 differentiation from pes planus lies in the narrow 
 limitation of the pains; and the presence of 
 pulsation in the pedal arteries separates it easily 
 from dysbasia angiosclerotica.
 
 EXTREMITIES 345 
 
 When the patient complains of pains in the 
 soles of the feet whilst walking or standing, with 
 local tenderness now in the heel, then in some 
 other part of the sole, we must think of neuras- 
 thenic and hysteric podalgia. The diagnosis 
 offers some difficulties even if we observe signs 
 of neurasthenia and hysteria and no possible 
 anatomic causes can be found. At times it is 
 made positive only when the pains suddenly 
 vanish. 
 
 But if the pains are vague in character and 
 cannot be localized with ease, neurasthenia is 
 the most likely causal factor. However, in neu- 
 rasthenia the pains in the extremities are very 
 rarely of great intensity. As a rule, the patient 
 complains chiefly of headache, pains in the small 
 of the back and in the chest, but rather of a 
 painful feeling of fatigue in the limbs, burning 
 neurasthenic dysbasia and podalgia. But what 
 I consider the distinguishing features of this 
 painful weariness, consists in the fact that the 
 patient feels more jaded in the morning than 
 at eventide, broken up, so to speak, all over the 
 body, that the pains are not sharpened by local 
 pressure, that they eventually are mitigated by 
 moderate physical and mental activity (a nice 
 walk in the open air), that we cannot find an 
 essential reduction of the rude motoric power, 
 though the patient tires out much quicker, and 
 finally that we can always discover the typical
 
 346 GENERALIZED PAIN 
 
 neurasthenic stigmata, foremost among them 
 abnormal psychic and mental conditions. 
 
 In nicotinism and a good many diseases of 
 the internal secretory glands (Addison's disease, 
 myxedema) pains in the extremities are linked 
 with initial symptoms. 
 
 A similar painful sensation in the muscles of 
 the extremities is often experienced by epileptics 
 in the stadium between the fits, but then these 
 unfortunates suffer from all kinds of neuras- 
 thenic symptoms during that period. 
 
 In hysteria (traumatic hysteria as well) the 
 incessant complaint of pain is the ground pillar 
 of the symptomatic structure. So far as the 
 extremities are concerned, we must distinguish 
 between two subdivisions, viz., tropalgia to which 
 arthralgia and pains in the periosteum belong 
 (cf. chapters on "Articular Pain" and "Pains 
 in the Bones"), and secondly neuralgiform pains, 
 rether rare, however. The diagnosis takes root 
 in the fact that these pains are attended by dis- 
 tinct cutaneous hyperesthesia of a circulary 
 character and nearly always by pains in other 
 parts of the anatomy, e.g., in the mammas, pit 
 of the stomach or in the back and also by the 
 other manifestations of hysteria. 
 
 In pulmonary emphysema the patient always 
 suffers from "rheumatic" pains in the leg near 
 the ankle-joint. In some instances there is no 
 apparent connection between these pains and the
 
 EXTREMITIES 347 
 
 existing emphysema, for instance, in a case of 
 concurrent alcoholism, when a closer examina- 
 tion divulges alcoholic neuritis. In other patients 
 the pain rests in the bones, especially in the 
 tibia above the knuckle with strongly localized 
 tenderness. It is a sort of miniature edition of 
 osteoarthropathie pneumique caused by chronic 
 bronchitis and dilatation of the bronchi, so com- 
 mon in emphysema. 
 
 If we find dragging pains in the extremities 
 and the patient cannot tell whether they are in 
 the bones, muscles or joints we must think of 
 "growing pains" in youthful individuals. If 
 there are no traces of organic defects the diag- 
 nosis is patent, even if dyspeptic troubles and 
 slightly febrile conditions might tempt us to 
 think of another disease. 
 
 I append here a diagnostic observation of 
 some value. We come across patients some- 
 times who cannot localize a pain in the leg which 
 comes on after standing or walking for some 
 time, possibly due to overtaxing the limb. It is 
 advisable in such cases to make a careful search 
 for a morbid process in the contralateral extrem- 
 ity. We may find muscular atrophy or an ab- 
 normal shortening of this extremity. Likewise 
 examine the spine for deformities or other de- 
 fects. The cause may also lie in occupational 
 overexertion. 
 
 Extraordinary forced marches reveal many
 
 348 GENERALIZED 
 
 such cases among troops. The tibia, the peri- 
 ostium and the processes of the muscles are here 
 the seat of the pains. We find similar condi- 
 tions in porters who carry heavy loads, and in 
 very fat people. 
 
 Among the various pains in the extremities 
 those in the bones receive, as a rule, the least 
 attention, especially when they are of an un- 
 steady nature, are changeable as to time and 
 localization, and morbid changes in the bones 
 which are not palpable. I refer the reader to 
 the different chapters on "Pains in the Bones, 
 Muscles, Joints." 
 
 Of course, it goes without saying that pains 
 in the extremities may be due to several parallel 
 causes. I have seen cases in which arthritis 
 deformans coxse dextrse, ischias, pes planus and 
 varicose veins were all bunched together in one 
 and the same carrier. 
 
 In some rare cases pains in bilateral extremi- 
 ties may derive their origin from a bilateral 
 cerebral lesion. Just the same they may also 
 proceed from a single morbid focus, e.g., a 
 tumor in the pons may provoke paresthesia (also 
 anesthesia) in the extremities on both sides of 
 the body, and corresponding pains, too; or else 
 in the arms only or in the legs or in three extrem- 
 ities with analogous disturbances in both sides 
 of the face. 
 
 A special subspecies of pains in the extremi-
 
 EXTREMITIES 349 
 
 ties, mostly bilateral, are the so-called lancinat- 
 ing pains. They are intermittent in character, 
 come on very suddenly, and penetrate the deeper 
 muscles like a shot. The patient generally 
 speaks of them as very severe rheumatic pains. 
 At times they arrive in the form of a shock, 
 moving the affected limb with an abrupt con- 
 vulsive jerk. When this happens we should 
 look for some lesion of the spinal nerve-roots, 
 but if the pains recur with unusual frequency 
 they are a possible warning of tabes dorsalis. 
 Look for divers missing or diminished patellar 
 with increased abdominal reflexes, absence of 
 achilles tendon and triceps reflexes. We shall 
 very likely find abnormally small pupils which 
 are painful under the influence of light, constant 
 accommodation and convergence reaction, Barn- 
 berg's phenomenon and disturbances of super- 
 ficial and deep sensibility. From the observance 
 of ataxia, of bladder and rectal disorders, changes 
 in the innervation of the exterior ophthalmic 
 muscles, and in the fundus of the eye, together 
 with the aforesaid symptoms, the proper diag- 
 nosis will easily crystalize. When the lancinat- 
 ing pains are the first apparent sign of the dis- 
 ease the situation may be more intricate. A 
 thorough probing for ataxia in the lower extrem- 
 ities is then indicated (especially in athletes, 
 tourists, and persons who are given to violent 
 bodily exercise). The tendon reflexes should
 
 350 GENERALIZED PAIN 
 
 receive careful consideration and also the ques- 
 tion of previous syphilitic infection. Globulin 
 reaction, lymphocytosis of the cerebrospinal fluid 
 and the Wassermann reaction are further adju- 
 vants in the diagnosis. 
 
 Errors are, perhaps, more frequent when these 
 lancinating pains enter the arms or only one 
 arm at a time. Still, the symptoms described 
 just now should suffice to promptly establish 
 the existence of a superior or cervical tabes. 
 
 However, not only tabes or taboparalysis, but 
 all encroaching diseases of the vertebras and their 
 marrow, are apt to irritate the intraspinal nerve 
 roots to such an extent that lancinating pains 
 are the result. In gout, a deposit of urates in 
 the dura mater and in the nerve roots indubitably 
 has this effect. 
 
 All morbid intraspinal processes, such as syr- 
 ingomyelia, myelitis, multiple sclerosis, tumors 
 of the spinal cord as well as peripheral forms of 
 neuritis, are possible causes of lancinating pains. 
 Apparently few mistakes occur in the diagnosis 
 when the lower extremities are concerned. But 
 I must admit that when the arms are attacked 
 by these lancinating pains, the diagnosis gener- 
 ally goes wrong, i.e., in the direction of rheu- 
 matism, gout, neuralgia, etc. The obvious rea- 
 son is that this form of pain is affected in a 
 similar fashion, as in rheumatism by weather 
 conditions, thermic influences, and sudden
 
 EXTREMITIES 351 
 
 changes in the atmospheric temperature. The 
 diagnosis should be made from the most care- 
 ful consideration of the characteristic tabetic 
 signs, especially in the eyes, and proper thought 
 must be given to other diseases that are likely 
 to affect the spinal cord. I have seen quite a 
 number of cases of multiple insular sclerosis in 
 which neuralgiform, lancinating pains in the 
 upper extremities endured for years; in fact, 
 were the sole perceptible morbid symptom. In- 
 tention tremor, irregularities in the vocal mech- 
 anism, BabinsWs toe phenomenon, abdominal 
 wall reflexes missing on one side and increased 
 tendon and periosteal reflexes should be decided 
 aids in diagnosing such cases generally observed 
 in persons of youthful age. 
 
 In caisson diseases, lancinating pains in the 
 extremities are prominent among the initial 
 symptoms. 
 
 They are likewise the most significant con- 
 comitant manifestation of peripheral neuritis. 
 In diabetes mellitus they appear in the lower as 
 well as in the upper extremities, and prevail 
 likewise in nicotinism. 
 
 It is these lancinating pains, combined with 
 missing patellar reflexes, eventual ataxia and 
 paralysis of the eye muscles which make diabetes 
 mellitus resemble tabes dorsalis in so many cases 
 when glycosuria attends the latter. 
 
 Lumbar puncture is an important factor here.
 
 352 GENEBALIZED PAIN 
 
 Of course, we must not forget that both diseases 
 may also exist alongside of each other. But 
 there is one point which does not seem to have 
 received adequate attention in medical circles. I 
 mean the fact that lancinating pains of great 
 intensity in the extremities, combined with anal- 
 ogous shooting pains in the breech and in the 
 chest, are not uncommonly a warning sign of 
 an impending coma in diabetes, despite the fact 
 that the patient has not previously experienced 
 similar, not even neuritic (neuralgic) pains. 
 
 Peripheral pseudotabes, i.e., chronic alcohol- 
 ism, ergotism and other intoxications, are like- 
 wise associated with lancinating pains in the 
 extremities. To this list must be added aneu- 
 rysm of the abdominal aorta, abdominal and pel- 
 vic and intraspinal tumors, especially when the 
 pains occupy only one side of the body. Never- 
 theless, there are cases of tabes dorsalis on rec- 
 ord in which continuous unilateral lancinating 
 pains were observed. 
 
 In acromegaly, in hypophysis tumors, they are 
 initial symptoms. Owing to their neuralgiform 
 character, to the loss of vision, to diminished or 
 wanting patellar reflexes, the erroneous diagno- 
 sis of tabes dorsalis or progressive paralysis is 
 apt to be made. It is probable that a secondary 
 degeneration of the posterior column of the 
 spinal cord is the causative factor of these mani- 
 festations. The usual symptoms of acromegaly
 
 EXTREMITIES 353 
 
 should govern the diagnosis in that direction. 
 Polyuria, signs of adipose genital degeneration, 
 hemianopsia and hypophyseal tumors are possi- 
 bilities to be reckoned with. The X-ray offers 
 good opportunities. 
 
 Exceptionally, tumors of the brain exercise 
 an irritating influence on the cerebro-sensible 
 centers, e.g., in the thalamus opticus, especially 
 in the pulvinar. I have in mind a tumor of the 
 perineal body. Lancinating pains in these af- 
 fections are common. 
 
 Tome spastic conditions in the muscles are 
 correlated with pains in the extremities, and may 
 be part of the symptoms of intermittent dys- 
 pragia, as they are the essential element of occu- 
 pational cramps. 
 
 Muscular cramps, especially in the calves 
 during walking, belong to polyneuritis, unless 
 they are caused by muscular sural rheumatism. 
 The diagnosis of all these affections should 
 easily result from the pertinent typical symp- 
 toms described in other pages of this book. I 
 include here also all forms of tetany comprising 
 hysterical pseudotetany . 
 
 When we encounter painful muscular cramps 
 which resemble tetany we must look for some 
 anatomical lesion, primarily tetanus. Here we 
 may find at first only twitchings and muscular 
 spasms (aura tetanica) in the extremities which 
 are strictly localized and associated with drag-
 
 354 GENERALIZED PAIN 
 
 ging or tearing, sudden, violent pains. The dif- 
 ferentiation between convulsions in tetanus and 
 tetany is based upon the fact that in tetanus 
 the cramps affect principally the masseter (slight 
 degrees of trismus!), also the nuchal muscles 
 opisthotonus), which is not the case in tetany; 
 further, that tetanus is caused by a wound which 
 in many cases has been overlooked by the pa- 
 tient, not to speak of tetanus infections in the 
 uterine cavity, in the air passages or in the in- 
 testines. Moreover, in tetanus the characteristic 
 generalized muscular spasms and other typical 
 signs (fever, although not uncommon also in 
 tetany, heavy perspiration, eosinophilia of the 
 blood) soon manifest themselves. 
 
 There are, however, certain rudimentary forms 
 of tetanus in which a painful spastic stiffening 
 of the muscles is the only perceptible symptom. 
 
 If we fail to find the cause for the tetanus 
 infection (men working in the soil or stable, or 
 wound in the body), if the animal test with the 
 blood, fecal matter or bronchial secretion of the 
 patient yields negative results, the diagnosis may 
 be hard to make, and we may have to fall back 
 upon other means for assistance. 
 
 There is a third form of painful muscular 
 spasms in tetanus which must be mentioned here, 
 i.e., they are definitely and permanently confined 
 to an individual area of the body, mainly to one
 
 EXTREMITIES 355 
 
 of the extremities, and thus constitute the car- 
 dinal symptom of "local tetanus." 
 
 Painful muscular spasms resembling tetany 
 are likewise found in a large number of exoge- 
 nous, acute intoxications, and are always com- 
 bined with other cerebral symptoms (arsenic, 
 phosphorus, saltpeter, filix mas, etc., poisonings). 
 The differential diagnosis is self-evident, and 
 need not be discussed here. 
 
 Nocturnal cramps in the calves, in the soles 
 of the feet and in the abductor hallucis concern 
 the physician only from the etiologic standpoint. 
 
 A sudden attack of unilateral cramps in the 
 calf may be the result of a muscular rupture; 
 if recurrent, due to an induration in the muscles 
 as a sequel of the primary rupture. 
 
 The causes for these spasms are either local 
 or general. Nocturnal bilateral cramps call for 
 urinary analysis. They may be symptomatic of 
 diabetes mellitus or of uremia. In gout, they 
 are accompanying symptoms sounding a warn- 
 ing note of an impending severe painful attack, 
 or they act as an expression of chronic diathesis. 
 Cramps in other muscles, e.g., of the thigh, arm, 
 back or abdomen, often attend the sural spasms 
 in gout. I have spoken of the presence of 
 uratic crystals, hyperuricemia and uricemia, etc., 
 in connection with this disease in another place 
 to which I refer the reader. 
 
 Ectogenous poisons (alcohol), abuse of to-
 
 356 GENERALIZED PAIN 
 
 bacco and physical overexertion (late hours) are 
 other exciting factors, to which may be added 
 gastralgia, cold, wet feet and spastic constipa- 
 tion, affections of the peripheral nerves, of the 
 pyramidal tracts (multiple sclerosis, spastic 
 spinal paralysis). 
 
 Anhydremia is often attended with muscular 
 pains in the upper extremities a valuable symp- 
 tom in asiatic cholera and cholera nostras. These 
 cramps in the calves are also observed in other 
 diseases which run a course similar to cholera, 
 such as paratyphoid, dysentery, malaria or fun- 
 gus poisoning. 
 
 In gastrosuccorhea they come in with the 
 periodical gastric attacks, but whether they are 
 due here to toxic influences or to abnormal thick- 
 ening of the blood is questionable. There are a 
 good many other toxic conditions which assume 
 the character of cholera and in which tonic 
 spasms radiate from the sural region over the 
 whole muscular system, such as arsenic, chrome, 
 saltpeter, ptomain poisoning, and botulism. 
 
 Painful cramps in the calves are also due to 
 flat foot and osteomalacia, to defective circula- 
 tion in the veins, e.g., phlebectasia, phlebitis and 
 phlebothrombosis. They also originate from 
 ischias or polyneuritis, or constitute the solitary 
 symptom of an initial compression of the ischia- 
 dic nerve. Perhaps this, as well as congested
 
 EXTREMITIES 357 
 
 circulation, are the provocative element of 
 cramps in the calves of pregnant women. 
 
 Sometimes they are caused by stretching the 
 feet, and may then be a sign of latent tetany or 
 an accompanying symptom of tabetic crises in 
 the extremities. But they may also be directly 
 due to a disease of the sural muscles, for in- 
 stance to a cysticercus or to trichinae. If the 
 former is calcified, the Roentgen picture will 
 show its presence. Subacute and subchronic 
 periarteritis nodosa must be mentioned also. 
 
 If in perfectly normal and healthy persons 
 these cramps are sometimes observed, we shall 
 very likely find that they are due to overexer- 
 tion or overfatigue, e.g., after a long march or 
 walk, climbing high stairs or mountains, riding 
 on horseback, athletic exercises etc. The diag- 
 nosis should offer no difficulty. 
 
 The so-called cramp neurosis gives rise to such 
 pains in the calves. I have had no opportunity 
 to observe cases of this kind but it seems to me 
 that the only causative element is a peculiar 
 predisposition to this ailment. 
 
 A retrospect of the foregoing pages will tell 
 us that pains and paresthesias in the extremities 
 are to a great extent manifestations of the same 
 diseases; the paresthesias, in fact, often fore- 
 runners, if not substitutes of the pains. We 
 also have learned that these pains may have a 
 totally different meaning in one and the same
 
 358 GENERALIZED PAIN 
 
 disease. For instance, when the patient com- 
 plains of such pains during or after an attack 
 an acute infection, especially during the puer- 
 peral stage, the differential diagnosis revolves 
 around phlebitis and acute neuritis. Muscular 
 tenderness is common to both, but tenderness in 
 the nerve trunks, subjective paresthesias, sub- 
 jective and objective sensibility disorders, pri- 
 marily increased, later diminished, tendon re- 
 flexes, temporary muscular paresis, palpable 
 nodes in the nerve trunks, assure us of neuritis, 
 whilst infectious or post-infectious phlebitis is 
 clearly indicated when the veins feel like cords 
 and cyanosis and edema of the skin are found 
 in the region along the whole venous trunkline. 
 
 I wish to say something here about a mistake 
 which I made once, at any rate for several hours. 
 In a case that was brought to me, I diagnosed 
 acute hysteria, whilst in reality it turned out to 
 be acute thrombophlebitis of one of the lower 
 extremities, with resultant hysterical conditions. 
 My diagnosis would have been more reserved, 
 if not correct, had I given more mature thought 
 to the fact that every form of anatomical dis- 
 ease in an hysterical individual is apt to awaken 
 a slumbering neuritis. 
 
 Before I conclude this chapter, I wish to 
 state that flat foot may also be the cause of 
 local pain in the foot itself. I mention it be-
 
 EXTREMITIES 359 
 
 cause it has been my experience that it is very 
 frequently overlooked in the diagnosis. I have 
 in a previous place stated that pains caused by 
 pes planus generally disappear when the feet 
 are resting, but this is only the case when there 
 are no local inflammatory conditions which so 
 frequently affect the ankle joint. 
 
 It is not uncommon that persons with flat 
 feet complain of painful muscular cramps in the 
 soles of the feet after standing for a longer 
 time, which also appear in the plantar flexions 
 of the toes, attended with local paresthesias. 
 Perhaps a secondary neuritis of the plantar 
 nerve is at fault here. 
 
 A long list of morbid processes in the feet 
 and hands which leads to local pains belongs in 
 the field of surgery. I refer to luxations, sub- 
 luxations, caries, etc., etc. But I think it proper 
 to mention Morton's disease and also the fact 
 that there is an individual form of neuritis of 
 the hands and feet. A careful examination of 
 the fascia and ligaments should always be made 
 when a patient complains of pains in the soles 
 of the feet, particularly so after the attack of 
 an infectious disease such as influenza, typhoid, 
 etc., because in such cases the irritating cause is 
 frequently to be found in neuritis, plantar phle- 
 bitis, fasciitis or ostitis. Pains in the heel or in 
 the knee are often due to neuritic affections of 
 the ischiadic nerve (ischias).
 
 360 GENERALIZED PAIN 
 
 Inflammations or new growths in the tendon 
 sheaths or in the synovial sacs are likewise possi- 
 bilities not to be neglected. They are often 
 enough, especially when symmetical in form, the 
 result of articular rheumatism, syphilis, tuber- 
 culosis, pyemia, scarlatina or smallpox. I re- 
 member a case of multiple almost perfectly 
 symmetrical hygroma combined with chronic 
 articular rheumatism which was the effect of 
 diphtheria. Tendovaginitis and hygroma are 
 not only congenital diseases, but just as often 
 the manifestation of some gouty affection or of 
 hydrops hypostrophos. 
 
 In conclusion, a word about pains in the arm- 
 pit or in the groin. They arise from some 
 primary disease, unless they are merely irradia- 
 tions of a morbid condition in the nerve trunk. 
 Pains in the groin point to the appendix or 
 some disease of the cecum (if on the left side 
 they direct our attention to the sigmoid flexure) ; 
 in fact, to any organ in the pelvic cavity. I 
 name retroperitoneal muscular hematoma due 
 to hemophilia. Affections of the male genital 
 organs, particularly of the spermadic cord, of 
 the testicles or of the epididymis, are possibilities 
 here which we should ever bear in mind. Al- 
 though they belong mainly in the province of 
 surgery, they concern the internist equally as 
 well. I have a case of pendulous abdomen in 
 mind which came under my observation. It
 
 EXTREMITIES 361 
 
 caused the patient (female, otherwise not abnor- 
 mally stout) very severe pains in the groins. 
 Dietetic and balneotherapeutic measures and a 
 properly adjusted corset removed the cause of 
 the pains in a comparatively short time.
 
 Muscular Pains 
 
 Muscular affections are generally indicated 
 when the patient complains of pains in the 
 "fleshy" parts of the body. By rolling and 
 pressing the muscles in the affected part be- 
 tween the fingers we should be able to find local 
 tenderness, and thus localize the pain, unless 
 functional conditions (cramps) or morbid 
 changes in the tissue itself (indurations, nodes, 
 infiltrations, cords) have already furnished the 
 necessary information. But it is well to bear in 
 mind that sensitiveness on pressure in a certain 
 muscle or in a complex of muscles is by no 
 means always a definite proof of a muscular 
 affection, because it may just as well be due 
 to a morbid process in the intramuscular nerves 
 or veins, or to a complication such as neuro- 
 myositis. 
 
 Where muscular pain exists the differential 
 diagnosis revolves around the question whether 
 it is due to a primary affection of the muscles 
 themselves or to intramuscular neuritis or to a 
 disease of the muscular veins (neuritis, phlebitis, 
 phlebothrombosis, phlebosclerosis) . 
 
 In intramuscular neuritis the muscles are de- 
 cidedly sensitive on pressure, and the diagnosis 
 
 862
 
 MUSCLES 363 
 
 must be based on other symptoms. In some of 
 these cases the nerve trunks are also very sensi- 
 tive and show localized swellings (nodes). We 
 also find paresthesia or sensibility disturbances, 
 abnormal tendon reflexes or trophic disorders of 
 the skin, epithelial formations, if not muscular 
 convulsions. All these symptoms are calculated 
 to harden the diagnosis of neuritis. The anam- 
 nesis is also likely to reveal certain etiologic 
 factors (intoxications, e.g., arsenic or a preced- 
 ing infectious disease) or some concomitant 
 manifestation of the disease (a weak heart, an 
 edema in beri-beri). 
 
 On the other hand, there are cases of neuritis 
 in which only the muscular branches of the 
 nerves are apparently affected. Whilst all other 
 neuritic symptoms are missing, we only find 
 local pain and tenderness. Here a differentia- 
 tion between true muscular and intramuscular 
 nervous diseases is simply impossible, at any rate 
 in the initial stages. This explains the reason 
 why some very eminent authorities the leading 
 figure among them is A. Schmitt look upon 
 so-called muscular rheumatism primarily as a 
 disease of the branches of the muscular nerves; 
 in other words, they consider rheumatic myalgia 
 to be neuralgia. 
 
 Where complaint is made of pains which have 
 persisted for some time in the lower extremities, 
 particularly where the muscles of the calves are
 
 364 GENEKALIZED PAIN 
 
 sensitive on pressure, we might attribute these 
 conditions to phlebosclerosis resp. to phlebectasia 
 of the muscular branches of the veins. The 
 existence of ectasy of the superficial cutaneous 
 veins (trunks as well as branches), the presence 
 in the evening of edema in the knuckles and 
 increased pain when the patient stands on his 
 feet for some time will help greatly to make 
 the diagnosis concrete. 
 
 But when such pains suddenly arrive chiefly 
 in the muscles of the calves, we should think of 
 intramuscular phlebitis resp. thrombophlebitis. 
 If, then, manifestations of phlebitis of the cuta- 
 neous veins or of the trunks of the veins accede, 
 the diagnosis becomes self-evident. If, however, 
 such an exclusively intramuscular phlebitis con- 
 tinues to exist by itself, the diagnosis is re- 
 stricted solely to subjective pains and objective 
 sensitiveness. It will gain, however, by the 
 anamnesis, for we know that intramuscular 
 phlebitis is the commonest sequel of a long- 
 continued infection, more rarely of intoxications. 
 
 When, however, the two aforesaid etiologic 
 factors are wanting and pain in the muscles is 
 coupled with local sensitiveness, we are justified 
 in looking upon the muscular system as the 
 place of origin of such pains. We then have 
 two alternatives before us, viz.: the affection is 
 either purely local so far as place and time are 
 concerned, or we are dealing with a morbid
 
 MUSCLES 365 
 
 condition which involves multiple muscular 
 groups or an extensive area of the muscles of 
 the body. In both cases the pains are either 
 acute and of a short duration, or they have ex- 
 isted already for some time. 
 
 I. Locally Limited Unilocular 
 Muscular Pain 
 
 Most of the details concerning this subject are 
 contained in other chapters of this volume, as 
 well as in Volume I, "Abdominal Pain." I will, 
 however, repeat collectively this much. When 
 a patient complains of pains in a restricted or 
 even rather extended muscular area and we are 
 satisfied that it is a case of myalgia, we must 
 not look for sensitiveness in the whole area. It 
 may be present only in a limited part of one 
 muscle, especially in its processes, and, again, it 
 may only react under the influence of the elec- 
 tric current. Moreover, there are two phases of 
 acute localized myalgia; one is the rheumatic 
 form muscular rheumatism in the erector 
 trunci or in the muscles of the shoulder the 
 other is traumatic myalgia. In the latter case 
 the painful condition is either due to an over- 
 exertion of primarily normal muscles (sport, 
 athletic exercises, etc.), or to constitutionally 
 weak muscles which cannot stand any kind of 
 normal exercise, e.g., in anemic or physically 
 run-down individuals.
 
 366 GENERALIZED PAIN 
 
 Pains that are localized in or restricted to one 
 extremity or part thereof, also painful muscu- 
 lar convulsions, are often the initial signs of 
 tetanus, both local and generalized. 
 
 Chronic pains in a definite single muscle or in 
 a certain group of muscles point to the various 
 forms of chronic myositis, primarily the fibrous 
 chronic type, which attacks not only the lower 
 extremities, but also independently the muscles 
 of the nape of the neck, of the back and of the 
 arms. The patient complains of dragging, 
 rheumatic pains; soon the muscles become rigid, 
 a tumor-like, hard swelling is formed which 
 grows together with the skin and the bones. Of 
 course, so long as this union is not formed, the 
 diagnosis is easy to make from the palpable 
 muscular swelling. Radioscopy and histological 
 examination of an excised piece of muscle will 
 help greatly, and also the fact that in chronic 
 fibrous myositis local sensitiveness is not very 
 pronounced. 
 
 Still easier is the diagnosis of localized myo- 
 sitis ossificans due to muscular overstrain (horse- 
 back riding, military exercises). The patient 
 suffers from severe localized pains (in trauma 
 due to the tendency of the original hematoma 
 to ossify) provoked by the activation of the 
 affected muscles. After a week or two a hard 
 tumor may be felt similar to that found in intra- 
 muscular hematoma, syphiloma and osteosar-
 
 MUSCLES 367 
 
 coma. The Roentgen picture is sufficient for a 
 proper diagnosis. 
 
 I implicitly affirm that localized muscular 
 pains must ever remind us of all possible neo- 
 plastic (also echinococcus), acute as well as 
 chronic inflammatory (gummatous, tuberculous 
 and gonorrhoic) changes in the muscular system. 
 The differential diagnosis, however, affects the 
 surgeon more than the internist. 
 
 Not only new growths in the muscles, but also 
 diseases of the bones, especially myeloma, are 
 attended with localized, often severe muscular 
 pains, for which reason the wrong diagnosis of 
 lumbago or muscular rheumatism is an everyday 
 occurrence. 
 
 An attack of sudden severe pains in a definite 
 group of muscles, if not in multiple areas, espe- 
 cially when they bound from one group to an- 
 other without fever or, perhaps, with fever for 
 a day or two indicates acute muscular rheuma- 
 tism or rheumatic polymyalgia. It may also be 
 the manifestation of an infectious disease the 
 character of which has not as yet come to the 
 surface, but very likely due to catarrh. Toxic 
 conditions with a possible secondary inflamma- 
 tion of the endocardium or of the pleura, of the 
 pericardium or myocardium, are also to be 
 considered. The affected muscle appears swol- 
 len, hypertonic when palpated in relaxation. 
 The same may be said of subacute or chronic
 
 368 GENERALIZED PAIN 
 
 muscular rheumatism, in which, however, certain 
 muscular fascia feel to the touch more like very 
 hard cords. We also find at the deeper inser- 
 tion of the muscles nodules hard as bone and 
 about the size of a pea, which are very painful 
 at times. In muscular rheumatism the processes 
 of the affected muscles are particularly painful 
 on pressure. Lifting the muscles and pressing 
 them between the fingers elicit exquisite pain. 
 The patient feels the pains very intensely when 
 he rises in the morning, but they relax as he 
 gets about. They come on all of a sudden 
 when he sneezes, stumbles or rides over a hard 
 road, etc., also with a change in the weather. 
 Antirheumatic drugs give generally desired 
 relief. 
 
 Homogeneous muscular pains localized in a 
 definite zone (lumbago, myalgia of the head or 
 of the shoulder blades or neck and arms), also 
 when of a shifting character, are often the sign 
 of uratic diathesis. They have no basic value for 
 the differential diagnosis, and we must look for 
 other symptoms. So far as gout is concerned, 
 we may be guided by: inclination to cramps in 
 the calves, cutaneous affections, itching, chronic 
 eczema, hemorrhoids, indigestion, neuralgic 
 pains, inflammations of the synovial sacs, tophi 
 (cf. chapter on "Pains in the Chest"), heredi- 
 tary conditions, personal habits (meat-eaters, 
 luxurious living), examination of urine, retarda-
 
 MUSCLES 369 
 
 tion of the nuclear metabolism, persistent uri- 
 cemia by purin-free diet and slow secretion of 
 uric acid after the administration of nucleinic 
 natrium. 
 
 In diabetes mellitus and in chronic alcoholism 
 we find analogous shifting pains. The etiologic 
 diagnosis should offer no embarrassment. 
 
 Neurasthenia is likewise the source of vague, 
 sometimes very intensive muscular pains. We 
 find them particularly in the chest, back, loins 
 and extremities. The patient anticipates some 
 trouble in the lungs, kidneys, or in the spinal 
 cord. Local tenderness in the muscles and sen- 
 sitive reaction to the electric current reveal the 
 seat of the pain. 
 
 Chronic pains in the muscles are nearly al- 
 ways there in Addison's disease. They chiefly 
 affect those in the back, arms and legs, in the 
 shape of a painful feeling of fatigue, but when 
 the disease becomes more acute they gain in 
 intensity and therapeutic measures seem to 
 afford but little relief. Morbid changes in the 
 muscles are not in evidence, and electric reaction 
 remains the same. Mechanical hyperreaction 
 in the muscles, painful or otherwise, is a definite 
 expression of Addison's cachexia. The diag- 
 nosis can only be made with the aid of the other 
 characteristic symptoms of this classical disease 
 (melanodermia, adynemia, low blood pressure).
 
 370 GENERALIZED PAIN 
 
 Myxedema, resp. hypothyreoidism, is another 
 {disease of the internal secretory glands which 
 provokes sleep-disturbing muscular pain. Be- 
 cause pains in the back, a feeling of cold and 
 abnormal psychic and physical fatigue, espe- 
 cially in the morning, accompany this disease, 
 it is often mistaken for neurasthenia or anemia. 
 But if we note the bloated face, the swollen 
 eyelids, the puffed lips, the tendency to sub- 
 normal temperature, epilation, trophic changes 
 in the nails, menstrual disorders (amenorrhea, 
 menorrhagia), slight swellings in the joints, con- 
 stipation and changes in the psychic and physical 
 disposition of the patient (apathy, sleeplessness, 
 sluggishness of the mental faculties), we have 
 all the diagnostic facts before us. 
 
 In sporadic cases of Basedow's disease, mus- 
 cular pains associated with signs of severe myas- 
 thenia have been observed. Whether an affec- 
 tion of the thymus gland is responsible for this 
 condition is questionable. 
 
 There is also a case of tumor of the hypophy- 
 sis with intense muscular pains on record. The 
 presence of the typical signs of this disease may, 
 perhaps, remove a possible doubt, but there is 
 still the likelihood that these pains have their 
 genesis in another morbid endocrine gland. 
 
 If slight pains have persisted in various parts 
 of the musculnr system, chronic lead poisoning 
 may be the irritating cause. But the clinician
 
 MUSCLES 371 
 
 must look here for further adjuvants, such as 
 lead colic, anemia, the blue line, articular pain, 
 paralysis of the radialis and punctated red blood 
 corpuscles. The pains are of a vicious, boring 
 and tearing nature, especially during the night- 
 time, and affect the joints and bones as well. 
 
 Subacute mercury (sublimate) poisoning is 
 characterized by pains of short duration in the 
 extremities, especially the legs. But I have seen 
 a case in which this intoxication provoked ex- 
 ceedingly severe spontaneous and pressure pains. 
 
 If a patient complains of acute, at first short- 
 lived pains which at the beginning are confined 
 to a limited group of muscles but soon spread 
 to other groups, or if from the very start vari- 
 ous zones of the muscular system are involved, 
 we will have to decide between acute polymyo- 
 sitis, neuromyositis and dermatomyositis. 
 
 Dermatomyositis may be acute, subacute or 
 chronic, and is typified by: acute beginning, 
 high fever, facial edema, especially in the eye- 
 lids, spontaneous and exquisite pain on pressure 
 and on motation at first in a certain group of 
 muscles, generally in one side of the calf, thence 
 reaching over into the contra-lateral calf, and 
 extending from there into the femoral muscles 
 and even those of the trunk. With every fresh 
 localization the general condition of the patient 
 grows worse as new symptoms manifest them- 
 selves, such as eruptions of the skin which
 
 372 GENERALIZED PAIN 
 
 strongly resemble erythematous conditions, or 
 urticaria, or roseola, or even erysipelas. Later 
 on we notice a hard edema in the skin over the 
 affected muscles which does not yield to pres- 
 sure, so that the extremities look like shapeless 
 columns, and the face and trunk appear de- 
 formed. When the edema subsides the muscles 
 remain strongly indurated. Profuse sweating 
 is common and frequent. 
 
 The muscular symptoms of neuromyositis are 
 a compound of those belonging to dermatomyo- 
 sitis and multiple neuritis. 
 
 Acute hemorrhagic polymyositis and acute 
 polymyositis combined with erythema nodosum 
 are rather of rare occurrence. Both have a 
 certain symptom complex in common, i.e., febrile 
 conditions, the attack is confined to the extremi- 
 ties and manifests itself in local pains, local, at 
 times soft edema of the skin, local swelling of 
 the muscles and painful muscular tumor. The 
 muscular system of the trunk is not affected. 
 The acute hemorrhagic form is specially char- 
 acterized by hemorrhages and sugillations of the 
 skin over the affected muscles, hemorrhages in 
 the mucous membrane (intestinal hemorrhages). 
 The other form is typified by comph' eating ery- 
 thema nodosum and frequently enough by addi- 
 tional acute articular inflammations. 
 
 These three forms of polymyositis are so 
 strongly marked that a differential diagnosis be-
 
 MUSCLES 373 
 
 tween them and other diseases is rigidly ex- 
 cluded. 
 
 Of course, the matter assumes a different 
 aspect when acute or subacute dermatomyositis 
 is in question. If the disease sets in with fever, 
 edema of the eyelids, forehead or temples, ac- 
 companied by muscular pains in the extremities 
 and thorax, which are at times so severe that 
 the patient lies motionless, if the muscles are 
 swollen and hard, and we find profuse perspira- 
 tion and cutaneous exanthemata similar to those 
 of dermatomyositis, the diagnosis must be trichi- 
 nosis. A differentiation between these two dis- 
 eases is always necessary and can easily be made, 
 especially when trichinae are found in the blood, 
 in the muscular tissue or in the stools, and the 
 biceps muscle is particularly affected. Involve- 
 ment of the diaphragm and of the muscles of 
 the eyes, jawbones, and throat is not ordinarily 
 connected with acute dermatomyositis, but per- 
 haps more common than in trichinosis. 
 
 In milder cases of trichinosis, when the pa- 
 tient complains merely of general indisposition, 
 unusual fatigue and slight muscular pain, and 
 the rise in the temperature is insignificant, the 
 danger lies near to mistake the disease for acute 
 muscular rheumatism. The same error may be 
 made when the symptoms of trichinosis taper 
 down into a softer character towards the end 
 of the illness.
 
 374 GENERALIZED PAIN 
 
 In recent years eosinophilia has been ob- 
 served in muscular rheumatism, especially in 
 cases of acute relapse. A muscular induration 
 of old standing may be the possible remainder 
 of a pristine invasion of trichinae and invite a 
 false diagnosis of muscular rheumatism. The 
 excision of a small bit of muscular tissue should 
 with the aid of the microscope promptly correct 
 the error. 
 
 Cysticercus is another parasite which pro- 
 duces, though not of necessity, spastic pains in 
 the muscles and through pressure in the nerves. 
 The presence of the parasite in the muscular 
 tissue or else in the fundus of the eye or in the 
 brain is sufficient evidence not to speak of eosin- 
 ophylia of the blood. Pains are rarely felt in 
 this disease, which may be erroneously taken for 
 a fibroma. 
 
 The differentiation between polymyositis and 
 purulent myositis, which sets in with localized 
 painfulness, swelling and induration of a certain 
 muscle, should offer no difficulties. The collat- 
 eral edematous condition of the skin, with early 
 local fluctuation, the general symptoms, state of 
 the blood and evidence of suppuration are typi- 
 cal enough of the nature of the disease. 
 
 It is different, however, when the initial stages 
 of acute dermatomyositis are localized in one 
 extremity only, e.g., in the muscles of the calf 
 or some other lower portion of the leg. A sud-
 
 MUSCLES 375 
 
 den onset of fever and pain in the extremities, 
 local sensitiveness and motoric inhibition, local 
 edema of the skin have misled many a clinician 
 into making a diagnosis of acute dermatomyo- 
 sitis, or acute myositis, when the patient was in 
 reality suffering from an attack of thrombo- 
 phlebitis of the crural vein. The error would 
 not have happened if more careful attention had 
 been paid to the following facts: In thrombo- 
 phlebitis the edema shows an indentation; it does 
 not do so in dermatomyositis ; in the former 
 the patient perspires profusely and the edema- 
 tous condition of the skin does not permit us to 
 palpate the thickened, painful collateral ectatic 
 veins. I will also mention that thrombophlebitis 
 may also occur in young people when the sus- 
 picion of acute syphilitic myositis lies near. But, 
 let us remember that the latter disease carries 
 with it pain, swelling and induration in the af- 
 fected muscles, but is hardly ever attended with 
 edema of the skin; but if it is, the edema is 
 hard the same as in ordinary dermatomyositis. 
 Besides, tentative specific treatment and the 
 complement fixation test should soon clear the 
 situation. 
 
 Acute infectious diseases are a prolific source 
 of muscular pains. We may here be dealing with 
 a true infectious myositis indicated by swelling 
 and hardness of the painful muscles, e.g., the 
 rheumatic or gonorrhoic form of myositis. The
 
 376 GENERALIZED PAIN 
 
 former is either a preceding or an accompanying 
 manifestation of acute articular rheumatism, or 
 takes on the form of a subsequent relapse. The 
 second form is easily recognised, being, as it is, 
 merely a coincidence of a gonorrhoic articular 
 inflammation. 
 
 The commonest form is acute pyemic metas- 
 tatic myositis, associated with many different 
 kinds of blood infection (myositis acuta mal- 
 leosa) . 
 
 Purulent myositis may also supervene by con- 
 tinuity in primary inflammations of the skin or 
 bones. 
 
 Myalgia is of frequent occurrence in the ma- 
 jority of acute infections, and we are strongly 
 reminded here of articular rheumatism (rheu- 
 matic hyalgia). 
 
 Typhoid fever belongs here, too; and we may 
 be justified to use the term "myotyphoid" in 
 this connection. 
 
 Muscular pains are not so unusual in para- 
 typhoid either. In typhoid fever, these pains 
 are often caused, in the 2. to 4. week of the dis- 
 ease, by the waxy degeneration of the abdominal 
 as well as other muscles of the femoral adduc- 
 tors. The muscles feel soft like wax even when 
 they are contracted. Error of peritonitis is pos- 
 sible here. (Cf. "Abdominal Pain.") 
 
 But there is another type of similar muscular 
 pains which often set in at the height of a fever.
 
 MUSCLES 377 
 
 They attack by preference the oblique and 
 straight muscles of the abdomen and the adduc- 
 tors, likewise the muscles in the back. We should 
 be careful not to attribute these pains to a waxy, 
 but rather to a toxic parenchymatous degenera- 
 tion of the abdominal muscles. From a clinical 
 standpoint it will be, perhaps, difficult to make 
 a differentiation. 
 
 Similar muscular changes occur in other acute 
 infections such as pneumonia, sepsis, pyemia, 
 influenza and cholera. But it may be observed 
 that these morbid conditions are, as a rule, not 
 associated with subjective pain, but rather with a 
 feeling of muscular fatigue and local tenderness. 
 
 Whenever the patient complains of vague, 
 dragging pains in a certain group of muscles, 
 pains which have a tendency to jump from one 
 group to another, we are safe to diagnose an 
 attack of chronic mitigated sepsis in the oral, 
 pharyngeal cavities (teeth, tonsils). Particulars 
 will be found in "Abdominal Pain" and in the 
 chapter on "Nuchal Pains." Furthermore, there 
 is also a form of mixed infection of sepsis and 
 tetanus. During the World War many such 
 cases were observed and the opportunity was 
 utilized to study the genesis of this peculiar 
 complication. 
 
 There are cases of pneumonia diplococcus 
 infection and also sepsis (pyemia) in which the 
 muscular painfulness may be due to a bacterial
 
 378 GENERALIZED PAIN 
 
 invasion of the muscular arteries, i.e., to a true 
 acute embotic myositis. Here, too, the sensation 
 hardly ever passes beyond the stage of muscular 
 fatigue or tenderness. 
 
 In recurrent and in exanthematous fever mus- 
 cular pains are predominant. They are com- 
 bined with initial chills, and localized in the 
 calves and in the margin of the cucullaris, in the 
 axillary folds and in the processes of the sterno- 
 cleidomastoid of the sternum. We may look 
 upon them as a characteristic symptom caused 
 by a waxy degeneration of the muscles. 
 
 In typical cases of malaria, especially tropical, 
 intensive muscular pains accompany every attack 
 of fever. We find them in dorsal and lumbar 
 muscles as well as in those of the extremities. 
 
 During the prodromal stadium of the plague 
 severe muscular pains are experienced in the 
 nape of the neck and shoulders. And in Wol- 
 hynian fever they attack the calves, thighs, del- 
 toid, back and chest. 
 
 The influenza patient complains of very se- 
 vere, tearing pains with exquisite tenderness in 
 the swollen muscles of the thigh, the calf, nape 
 of the neck and back, particularly during the 
 night time. They are not so much due to toxic 
 influences but rather to localized influenzal myo- 
 sitis. The diagnosis can be easily made from 
 the characteristic symptoms of the disease. But 
 there is always a possibility of post-influenzal
 
 MUSCLES 379 
 
 myalgia and myositis accompanied by muscular 
 pains. Complications with other diseases such 
 as typhoid, etc., are not excluded. 
 
 Pappataci fever belongs to this same category. 
 I have already spoken about the diagnosis of this 
 disease in another place. 
 
 Poliomyelitis is apt to be confused with articu- 
 lar rheumatism or influenza. I refer the reader 
 to the chapter on "Articular Pains." 
 
 Muscular and articular pains accompany yel- 
 low fever in its second stage. In epidemics the 
 diagnosis is self-evident nearly throughout. But 
 in solitary cases it can be made from the initial 
 symptoms of generalized infection, high fever, 
 headache, lumbar, muscular and articular pains, 
 vomiting, feeling of pressure in the epigastrium, 
 hemorrhages and icterus. 
 
 In Weirs disease we find among the earliest 
 symptoms fever, chills, vomiting, diarrhea, fol- 
 lowed by muscular pains, especially in the calves, 
 the nape of the neck, chest, abdomen, sacrum 
 and thighs, acute splenic tumor, and within three 
 to five days icterus, enlargement of the liver, 
 acholia in the stools, nephritis, delirium, nose- 
 bleed, hemorrhages of the skin and mucous mem- 
 branes, herpes leucocytosis, polynucleosis and 
 lymphopenia. The disease might be taken for 
 infectious cholangitis or typhoid with icterus, but 
 the detection of spirochetoe in the blood should 
 soon correct any such error.
 
 380 GENERALIZED PAIN 
 
 Paroxysmal hemoglobinuria manifests itself 
 by chills and fever, high temperature, urobilin- 
 uria, hemoglobinuria and cylindruria together 
 with muscular pains. 
 
 In chronic as well as in acute cases of over- 
 fatigue we find pains in the muscles, sleepless- 
 ness, muscular twitching, paresthesia, abnormal 
 irritability, neuralgia, palpitation of the heart, 
 trembling, burning sensation in the chest and in 
 the extremities. 
 
 In Weil's disease hemorrhages in the muscular 
 tissue cause local pains, and in scurvy pains in 
 the calves are provoked by intramuscular herna- 
 tomata. 
 
 Muscular pains in the loins, sacrum and thigh 
 are initial symptoms of hemoglobinuria after 
 forced marches and other strenuous military or 
 athletic exercises through which the hemoglobin 
 content of the muscles is used up. 
 
 Periarteritis nodosa is a subacute or chronic 
 infection in which multiple muscular pains are 
 frequently very prominent in various areas. It 
 is sometimes attended with fever and paresis or 
 paralysis of a degenerative character of the 
 affected muscles. Acute nephritis, diarrhea with 
 bloody stools, profuse intestinal hemorrhages and 
 severe colic are other complications, likewise 
 abdominal pain, peritonitis and strongly marked 
 cachexia coupled with anemic conditions. The 
 diagnosis, however, can be made positive only
 
 MUSCLES 381 
 
 when we find noduliform swellings in the small 
 cutaneous arteries. If syphilis is suspected the 
 Wassermann reaction may enlighten us. It is 
 advisable to think of periarteritis in all cases 
 which suggest the existence of polymyositis or 
 trichinosis. 
 
 Muscular pains of a minor degree or rather 
 an abnormal feeling of fatigue in the muscles 
 frequently accompany the period of recovery 
 from an infectious disease of the muscles in the 
 sacrum, loins or extremities, such as smallpox, 
 influenza, erysipelas and certain rudimentary 
 forms of dysentery. 
 
 Local or generalized muscular pains indicate 
 also chronic infections, e.g., tuberculosis or syphi- 
 lis, which are apt to present pseudoneurasthenic 
 conditions of a continuous, remittent or inter- 
 mittent character. They are also forerunners 
 of lactic exanthema. The usual local and gen- 
 eralized pertinent symptoms are the necessary 
 requisites for a correct diagnosis. 
 
 Pains in the muscles of the calves are a com- 
 mon early symptom of edematous diseases. The 
 diagnosis results from abnormal fatigue, hypo- 
 tonous bradycardia and polyuria in addition to 
 the edematous conditions. 
 
 In the chapters on "Pains in the Shoulders" 
 and "in the Nape of the Neck" I have pointed 
 out that pains which radiate particularly into 
 the muscles of the shoulders should remind us
 
 382 GENERALIZED PAIN 
 
 of some morbid process in the lungs, primarily 
 of tuberculosis, but also of other subdiaphrag- 
 matic or intraperitoneal affections, although as 
 a rule they are not spontaneous in character but 
 rather elicited by local pressure. Similar tender- 
 ness in the trapezius, rhomboideus and pectoralis 
 muscle is also possible in dry pleurisy. 
 
 In trismus painfulness and rigidity of the 
 muscles are also perceptible. An acute inflam- 
 mation of the maxillary joint or of the jawbone, 
 or an articular stricture following an acute pain- 
 ful affection of the oral cavity (wisdom tooth, 
 tongue, tonsils) or of the upper salivary glands 
 at times bear a strong resemblance to lockjaw 
 and render the differential diagnosis difficult, 
 particularly so in cases of periosteal abscess in 
 the upper maxilla due to an injury. If the 
 maxillary stricture sets in immediately after the 
 injury lockjaw is contraindicated, but if the 
 stricture persists while the abscess recedes true 
 trismus is affirmed. In some rare cases of acute 
 rheumatism of the temporalis muscle similar 
 conditions have been observed (Oppoher). 
 
 I recall two interesting cases of pseudotrismus 
 in two soldiers. One was that of a military 
 surgeon who attended a wounded man with 
 tetanus infection, the other was an infantryman 
 who lay in the bed next to that of a patient 
 afflicted with trismus and subsequent tetanus. 
 Within twenty-four hours both men were at-
 
 MUSCLES 383 
 
 tacked by trismus. They were unable to open 
 their mouths, the private soldier even showing 
 signs of hysteria. A clear proof of pseudo- 
 trismus caused by imitation neurosis. 
 
 In hysteria analogous phenomena have been 
 observed. A local trauma, e.g., a gunshot 
 wound in the face may produce an hysterical 
 maxillary stricture with synchronous analgesia 
 of the face. Under suggestion the trouble gen- 
 erally disappears. The diagnosis should not be 
 difficult if we pay attention to the other typical 
 signs of hysteria. 
 
 Trismus is frequently an early symptom of 
 tetanus. Here, too, the diagnosis is obvious on 
 the strength of the usual tetanic characteristics. 
 
 Epidemic and tuberculous meningitis as well 
 as epidemic encephalitis frequently present in 
 their incipient stages the clinical picture of tris- 
 mus, and in many cases of poisoning lockjaw 
 is an accompanying manifestation. If a patient 
 shows signs of trismus coupled with intensive 
 headache, pressure sensitiveness in the head or 
 cerebral vomiting we should more coftectly diag- 
 nose meningitis as the originating cause and not 
 trismus or tetanus. Lumbar puncture will fur- 
 nish additional proof. From a similar stand- 
 point we can also explain the occurrence of 
 trismus besides other cerebral symptoms in per- 
 nicious anemia of the cerebral type. 
 
 In other acute infections initial trismus may
 
 384 GENERALIZED PAIN 
 
 be the effect of the bacterial poisons on the brain, 
 e.g., in recurrent fever, in which disease the mus- 
 cles at times are so stiffened that a suspicion of 
 tetanus is pardonable. Diphtheria, erysipelas, 
 influenza, Weil's disease and ton$illar angina are 
 other pertinent instances. In typhoid fever 
 trismus is more common in the final stages. 
 When it occurs in any of these infectious dis- 
 eases it must be taken as a definite proof of very 
 severe bacterial intoxication and of great signifi- 
 cance for the prognosis, more so even than clonic 
 cramps in the masseters or grating of the teeth. 
 
 But it is not only general toxic conditions but 
 also strongly localized diseases of the brain from 
 which trismus may result that lasts for weeks, 
 months and even years, e.g., a tumor (tubercle) 
 in the posterior pons or a softening process from 
 sclerosis or a syphilitic endarteritis of the basilary 
 artery caused by an irritation of the motoric 
 trigeminus. We can in this manner explain the 
 occurrence of trismus and grating of the teeth 
 in meningitis and in pseudomeningitis for which 
 a basal posferior meningitis is responsible. 
 
 In some cases of tetany trismus is also de- 
 veloped. The differentiation between tetany and 
 tetanus is discussed elsewhere. 
 
 If trismus occurs in trichinosis it is of peri- 
 pheral and not central origin and a proof of 
 the presence of trichina? in the masseter muscles. 
 
 In endogenous poisoning trismus is likewise a
 
 MUSCLES 385 
 
 possibility. It may be a manifestation in part 
 of icterus, of cholemia or pellagra. Perhaps 
 more frequently and mostly coupled with other 
 cerebral symptoms it is an associate of certain 
 acute exogenous intoxications, chiefly blood poi- 
 soning (hydrocyanic acid, aniline, coal gas, coal 
 dust, hemlock, helvella, fly agaric, scorpion poi- 
 son). In acute atropin poisoning trismus may 
 occur in combination with loss of consciousness, 
 Argyll-Robertson sign, absolute dryness of the 
 mucous membrane of the mouth, erythema, etc. 
 Acute nicotinism belongs here, too. Yet, in all 
 these conditions trismus does not occupy a very 
 prominent position, if we except acute strych- 
 nine, opium and morphine poisoning, especially 
 in children. In these cases trismus may be an 
 isolated condition or, perhaps, a partial manifes- 
 tation of generalized tetanic convulsions. 
 
 True infectious tetanus is always primarily 
 suggested when the patient manifests sudden 
 attacks of painful convulsions in the masseter 
 or nuchal muscles. These paroxysms (local or 
 universal) come on spontaneously or may be 
 reactions of external causes, and are felt by the 
 patient like the thrust of a dagger generally in 
 the injured part of the body. They are, so to 
 speak, a kind of tetanic aura preceding the 
 general spastic attack. Nevertheless, they may 
 just as well constitute the solitary symptom of 
 a tetanus infection which persists as "local te-
 
 386 GENERALIZED PAIN 
 
 tanus" without development of a generalized 
 state of tetanus. I have given full details about 
 this subject in the chapter on "Pains in the 
 Extremities." 
 
 If the bacteriological examination of the 
 wound fails to show the presence of the tetanus 
 bacillus we must look for other morbid processes 
 which are known to produce analogous tetanic 
 convulsions. 
 
 Among these strychnine poisoning is the first 
 to be considered. Here we find spasms in the 
 extensor muscles of a tetanic nature with risus 
 sardonicus and yet unclouded mind, reflectoric 
 hyperexcitability of the patient, retention of 
 urine, dysuria, rising temperature and profuse 
 perspiration. If anamnetic data are wanting, 
 but we discover a wound or a scar on the body 
 of the patient, a differential diagnosis between 
 strychnine poisoning and tetanus will be impera- 
 tive. We can arrive at a proper recognition of 
 tetanus by jts gradual development. We first 
 witness trismus, then opisthotonos and after that 
 generalized extensor convulsions. In acute 
 strychnine poisoning, on the other hand, the 
 universal cramps set in all of a sudden, some- 
 times, it is true, after short precursory symptoms. 
 It stands to reason that in most instances we 
 are not able to observe these various stages. In 
 fact, it is most difficult to ascertain in the vast 
 majority of cases what has happened previous
 
 MUSCLES 387 
 
 to the real attack. Then we must lean on the 
 fact that in strychnine poisoning the muscles 
 relax during the intervals between the spastic 
 attacks. The patient is able to move freely, can 
 even stand on his feet without assistance; whilst 
 in tetanus the muscles remain rigid until recov- 
 ery ensues. And, again, tetanus is a long con- 
 tinued disease, while in strychnine poisoning the 
 cramps (chiefly) in the extremities especially 
 in the hands soon pass away. I do not know 
 whether in strychnine poisoning leucocytosis and 
 eosinophilia, so common in tetanus, are also 
 found. 
 
 Tonic, tetaniform convulsions, opisthotonos, 
 increased reflex action and also, it is claimed, 
 leucocytosis are also observed in hydrophrobia. 
 It is distinguished from tetanus and strychnine 
 poisoning by absence of trismus, by the fear of, 
 or inability to swallow water, fear of water, 
 psychic agitation and a feeling of anguish. Fur- 
 thermore, the anamnesis and the fact that in 
 rabies the muscles in general, but especially those 
 in the nape of the neck and of the masticatory 
 apparatus, relax in between the spasms, are an 
 additional help. Under the heading of dys- 
 phagia I speak of the differential diagnosis 
 between hydrophobic tetanus and hydrophobia. 
 I will, however, mention that in the former the 
 muscles of deglutition and those of the dia- 
 phragm are deeply involved.
 
 388 GENERALIZED PAIN 
 
 Hysteria also breeds sometimes painful, te- 
 taniform extensor cramps. I have, indeed, seen 
 myself a case of acute strychnine poisoning 
 which was erroneously labeled "hysteria." The 
 differential diagnosis must be built upon the 
 anamnesis, the presence of other symptoms char- 
 acteristic of hysteria and the course run by the 
 disease. Of course, it is always possible that 
 an individual with an hysterical taint and afflicted 
 with exaggeration mania may at any time ac- 
 quire a genuine attack of tetanus. 
 
 Similar spastic conditions especially in the 
 muscles of the nape of the neck, the back and 
 extremities^ follow sometimes in the wake of cere- 
 bral affections, but they are free from pain and 
 do not affect consciousness. Here we find mani- 
 festations of paresis or paralysis of the cerebral 
 nerves which might suggest tetanus of the hand, 
 unless traces of a local wound are wanting. We 
 also meet with bilateral BabinsM's toe phenome- 
 non and unilateral absence of abdominal wall 
 and cremaster reflexes. Moreover, lumbar punc- 
 ture yields a bloody-red or sanguinolent cere- 
 brospinal fluid containing diluted red blood 
 corpuscles without sendimentation a sure proof 
 of cerebral genesis. But I emphasize the fact 
 that an anemic condition of the blood is also 
 found when the puncture is made only sometime 
 after the cerebral hemorrhage has taken place. 
 If we are enabled to make the puncture soon
 
 MUSCLES 389 
 
 even within an hour after the injury, we are 
 likely to find perfect red corpuscles. After sedi- 
 mentation the cerebrospinal fluid may appear 
 tinged with blood should the needle have passed 
 through a meningeal vein. It is wise to watch 
 the fluid whilst it is being drawn and see if it 
 is evenly tinged with blood all throughout the 
 act of puncturing. As a rule the first portions 
 alone are tinged with blood or at any rate more 
 so than those that follow. If the patient has 
 been lying motionless for hours when we arrive, 
 we may well exclude tetanus and acute strych- 
 nine poisoning. 
 
 When extensor convulsions in the dorsal mus- 
 cles or in those of the extremities are found in 
 a patient who is not in a comatose state the 
 foregoing is of particular moment especially 
 when other positive or negative symptoms affect- 
 ing the central nervous system are present. 
 
 The differential diagnosis must be made from 
 the same angle in those rare cases of cerebro- 
 spinal meningitis (purulent epidemic or non- 
 epidemic, or tuberculous) which give rise to 
 tetanic extensor convulsions. The same applies 
 also to those rare cases of acute encephalitis 
 which may be observed after acute influenza and 
 likewise of saturnine encephalopathia which is 
 fully dealt with in the volume on "Abdominal 
 Pain" under the title of "chronic lead poisoning." 
 
 The severe form of arteriosclerosis of the cere-
 
 390 GENERALIZED PAIN 
 
 bred arteries is another harbinger of painful tonic 
 muscle clonus in the trunk and in the extremities 
 associated with mono- and hemiplegia, disturb- 
 ances of speech and slight apraxia. 
 
 Fatty embolism of the brain belongs to this 
 section also. It may happen in babies before 
 the foramen ovale has closed up or in persons of 
 old age and in heavy drinkers. Although this 
 disease is of minor interest to the internist I 
 deem it advisable to mention that we find here 
 cerebral irritations in the sense of trismus, opis- 
 thotonos and spastic attacks chiefly of an epilep- 
 tiform character, followed a few hours later by 
 dullness in the sensorium and a small, irregular 
 pulse. But the involvement of consciousness is 
 the master key to the diagnosis which might be 
 led into an error by the fact that in tetanus also 
 there is serious destruction in the tissues and 
 vessels. 
 
 Similar tonic spasms are often observed in 
 cerebellar tumors in which opisthotonos is not an 
 infrequent accompanying symptom. It would 
 be superfluous to discuss here the other typical 
 signs of these tumors. This refers with equal 
 force to tumors of the pons and of the medulla 
 oblongata in which every form of tonic spasms, 
 light convulsive tremor and slightly clouded 
 consciousness is of diagnostic import. 
 
 ftleningeal hemorrhages give rise to muscular 
 contractions which strongly resemble convulsions
 
 MUSCLES 391 
 
 so typical of strychnine poisoning. The behavior 
 of the sensorium and of the cerebral nerves and 
 lumbar puncture are generally sufficient to throw 
 the proper light on the situation. 
 
 Spasms of this tetanic character are, however, 
 quite common in a number of exogenous poison- 
 ings such as carbon dioxid, sewer gas, arsenic, 
 mercury, alcohol, dicyanogen, nitrobenzol iodo- 
 form. The coincidence of the cerebral manifesta- 
 tions, i.e., loss of consciousness and simultaneous 
 spasms, are the strongest differential-diagnostic 
 points in these cases. 
 
 Acute cases of opium or morphine intoxication 
 are to be included here, especially in children. 
 Trismus, opisthotonos and tonic spasms are al- 
 ways present. The diagnosis results from the 
 observation of the comatose state, the want of 
 reaction to light in the closed pupils, of brady- 
 cardia, bradypnea, fall of body temperature and 
 the presence of the drug in the saliva, the urine 
 and the gastric contents. 
 
 In ergot poisoning the tonic spasms do not 
 only affect the extremities but also the muscles 
 in the back, in the throat and in the diaphragm, 
 lasting continuously sometimes for days. The 
 diagnosis is materially assisted when gangrenous 
 spots in the skin are observed and when a pain- 
 ful creeping sensation has made itself felt all 
 over the body for some time previous to the 
 spastic onset.
 
 392 GENERALIZED PAIN 
 
 There are some cases of diphtherin poisoning 
 on record which are called "spasmogenous diph- 
 theria" in which tonic spasms are observed, but 
 I cannot speak from personal experience on this 
 matter. The symptoms are described as follows: 
 presence of bacillus diphtherias in nose and 
 throat, diphtheritic membranes, inefficiency of 
 antitetanus serum, reaction to diphtheritic anti- 
 toxin. 
 
 Escherich and v. Jacksch speak of pseudo- 
 tetanus, a condition of generalized tonic cramps 
 in the articular muscles of the jaws, the nape 
 of the neck and the back which continue for 
 months at a time and are caused by some infec- 
 tious disease. When it exists as an independent 
 disease the tonic spasms affect principally the 
 lower extremities; trismus sets in later on. It 
 yields to treatment. 
 
 Kollert describes tetanus-like conditions in 
 some severe cases of spotted typhus. In tropical 
 malaria cerebral symptoms such as delirium, 
 eclampsia and coma are not uncommon mani- 
 festations. 
 
 In uremia tonic as well as clonic spasms are 
 observed. The diagnosis can be made without 
 difficulty. 
 
 Painful muscular cramps in eclampsia and 
 epilepsy are sometimes erroneously taken for a 
 symptom of acute strychnine poisoning. But 
 the mistake can be easily prevented if proper
 
 MUSCLES 393 
 
 attention is given to the presence of edematous 
 conditions in the skin and of albuminuria so 
 typical of the former diseases, and the solitary 
 attack of convulsions and their clonic character, 
 the total loss of consciousness during the attack, 
 the involuntary discharge of urine and feces, 
 bites in the tongue, the want of pupillary re- 
 action and the anamensis in the case of strych- 
 nine poisoning. 
 
 There are likewise cases of tetany in which 
 the spasms involve the whole body with the pres- 
 ence of opisthotonos and trismus which may put 
 a mistaken diagnosis of tetanus within the range 
 of possibilities. But the want of reflex action 
 characteristic of tetanus, the presence of the 
 cardinal symptoms of tetany, the mechanical 
 overexcitation of the motoric nerves (the facial 
 phenomenon), the hyper-reaction of the motoric 
 nerves to the electric current (Erb's phenome- 
 non) and Trousseau's sign (the arrest of the 
 typical spastic attack by compression of the sul- 
 cus bicipitalis internus) should clearly establish 
 the differentiation. 
 
 A long continued exposure to heat, e.g., work- 
 ing in an overheated boiler room, i.e., collapse 
 from heat, provokes tetanic muscular spasms 
 with trismus, no doubt due to the enormous loss 
 of water in sweating. The same may be said of 
 sunstroke or heatstroke which, clinically speak- 
 ing, strongly resemble uremia: total loss of con-
 
 394 GENERALIZED PAIN 
 
 sciousness, pulse hardly perceptible, respiration 
 suspended, pale, cyanotic appearance of the 
 face, very high body temperature, tetanic mus- 
 cular contractions and trismus are the outstand- 
 ing features of this condition which is due to 
 abnormal over-exertion of the cardiac organs and 
 excessive action of the respiratory muscles.
 
 Pain in the Bones 
 
 When a patient complains of pain in a bone 
 and we find local changes and tenderness, the 
 diagnosis is simple enough. However, when the 
 complaint is of a rather vague nature, for in- 
 stance, of rheumatic, steady or variable or 
 intermittent pain now in the arm, then in the 
 leg, but with varying intensity, the thought of 
 a muscular affection will be uppermost in our 
 mind, and yet the originating cause may lie in 
 a morbid condition of the bones. A careful 
 search for local tenderness or swelling in the 
 osseal parts will soon correct our first impres- 
 sion. Many diseases of the bones can be readily 
 diagnosed in this manner. 
 
 I. Unilocular Pain in the Bones 
 
 If we find local sensitiveness on pressure or 
 percussion with or without anomalous configura- 
 tions we are confronted either by a purely 
 regional, local disease or with the manifestation 
 of a multilocular affection which is as yet, or 
 may be permanently localized in that spot. 
 
 In the first case we are dealing with the vari- 
 ous forms of osteoperiostitis as well as with the 
 local primary and metastatic neoplasms of the
 
 396 GENERALIZED PAIN 
 
 bones. These belong, in part at least, in the field 
 of internal medicine, but chiefly affect the sur- 
 geon. Those of interest to the internist will 
 engage our attention in the succeeding pages. 
 
 The first to speak of is syphilitic osteoperi- 
 ostitis together with that of tuberculous, actino- 
 mycotic and malleose genesis, and also acute as 
 well as chronic osteomyelitis. They will all be 
 discussed in separate paragraphs. But I must 
 add here various other divisions of secondary, 
 infectious osteoperiostitis which follow in the 
 wake of divers infectious diseases. Among 
 these I mention acute articular rheumatism (os- 
 teoperiostitis rheumatica and postrheumatica) 
 with demonstrable swellings sometimes of the 
 character of albuminous osteoperiostitis or with 
 limited sensitiveness in the bones, for instance 
 in the calcaneum; likewise purulent infections 
 and infections from the paratyphoid bacillus, 
 bacterium coli or dipplococcus (pyemia) ; fur- 
 ther, typhoid fever, smallpox, measles, scarlet 
 fever, influenza, bacilary dysentery and gonor- 
 rhea. 
 
 In many of the aforementioned infections 
 the morbid affection of the bones and the accom- 
 panying pains are merely a distinct expression 
 of the gradual development of the disease itself; 
 even though superficial reddening of the skin, 
 and swelling or enlargement of the bones are 
 not yet in evidence. Of course, we must not
 
 BONES 397 
 
 forget that, when the generalized infection has 
 been fully developed, the accompanying pain in 
 the bones may just as well be the expression of 
 the generalized infection itself although inflam- 
 matory neurotic changes in the bones are not 
 present at all. In that case we are not dealing 
 with one solitary local focus but with multiple 
 foci for the pain, especially so when these pains 
 are not spontaneous but only ensue from provo- 
 cation. 
 
 This painful focus in the bone, on the other 
 hand, may just as well be the first and only 
 spot where the disease is localized. This is the 
 case, e.g., in acute osteomyelitis, although this 
 disease is often enough localized in several places 
 either at the same time or in successive periods. 
 It happens also in actinomycotic, tuberculous or 
 syphilitic osteoperiostitis. In this the primary 
 port of entry of the infection is not always 
 apparent, a careful search may reveal it, but 
 often enough it remains an unsolved problem. 
 A similar dilemma faces us sometimes in other 
 forms of post-infectious osteoperiostitis in which 
 the generalized infection and the manifestation 
 of the local focus of the pains are often years 
 apart, for instance typhoid periostitis which may 
 set in on the orbital margin or on the skull even 
 during the first week of the disease. 
 
 These cases are very difficult to diagnose. 
 Only the widest search for every detail that
 
 398 GENERALIZED PAIN 
 
 might possibly be of use can clear the situation. 
 We may find, for instance, a sign of ostitis 
 (acute, chronic, purulent or plastic) on a rib, 
 on the sternum, on the tibia or on a vertebra 
 or even on the skull. There we have a sugges- 
 tion of lues or tuberculosis. We may hear of 
 an attack of typhoid fever, ten, fifteen or even 
 twenty years ago, when typhoid periostitis would 
 not be an improper guess, or we may be dealing 
 with a case of autointoxication of a chronic 
 typhoid bacillus carrier, due to some trouble of 
 the gallbladder. A bacteriological examination 
 of the contents of the lesion is very seldom at- 
 tainable, but the Gruber-Widal reaction, repeat- 
 edly made during the course of the disease, will 
 very likely give us the right clue, especially 
 when antisyphilitic treatment has proved ineffec- 
 tive. But even so, a positive Gruber-Widal 
 reaction or the anamnesis are not always abso- 
 lutely reliable indications. 
 
 I may mention also that the nocturnal habit 
 of the pains is not always a definite proof of 
 their syphilitic genesis. We find it also in ty- 
 phoid and posttyphoid osteoperiostitis, not to 
 speak of carcinomatous metastasis of the bones 
 and above all gouty pains in the bones. The 
 latter would, however, rather represent articular 
 pains owing to the presence of uric acid in the 
 articular ends of the bones. 
 
 At any rate in these complicated cases we
 
 BONES 399 
 
 shall derive much help from the local condition, 
 the X-ray, the serological examination and ten- 
 tative antisyphilitic treatment. 
 
 But there are very stubborn cases of syphilitic 
 ostitis which resist every form of specific thera- 
 peutic measure or at the utmost give only a 
 fleeting reaction. 
 
 The diagnosis of the other forms of osteoperi- 
 ostitis generally results from the anamnesis of 
 the causating acute infection. With regard to 
 gonorrhea I must add that this disease may, in 
 rare cases, give rise to an attack of osteoperi- 
 ostitis (e.g., in the clavicle or femur) of such 
 magnitude that an erroneous diagnosis of a sar- 
 coma may easily creep in. 
 
 There is a special lower form of periostitis 
 which is mostly of a localized, although at times 
 also of a multiple character, which deserves 
 special mention here, viz., angio-neurotic pseudo- 
 periostitis. Angio-neurotic processes provoke 
 very transient but ever recurring exudates in the 
 skin and mucous membranes and also in the 
 joints. We call them hydrops hypostrophos. But 
 similar conditions may also be observed on the 
 peristeum. We find swellings in certain parts 
 of the bones which come on suddenly, are of a 
 doughy consistence, spontaneously painful and 
 very sensitive. They generally localize in one 
 of the ribs or in the sternum. In the fleeting 
 character of these swellings, in their variability
 
 400 GENERALIZED PAIN 
 
 of localization, in the similarity of the symptoms 
 to those of hydrops hypostrophos we find the 
 key to the proper recognition of this disease. 
 Among the concomitant symptoms we count, 
 asthmatic attacks, mucous colitis, vasomotoric 
 rhinitis, urticaria and vasomotoric disorders of 
 the skin. All these manifestations are comprised 
 in the term "exudative diathesis" recently intro- 
 duced in medical literature. 
 
 In Sudek's atrophy of the bones active as well 
 as passive movements provoke serious pains in 
 the bones and are an important symptom of this 
 affection. As it is a surgical disease I cannot 
 claim personal knowledge of it, but the symp- 
 toms are described as follows. It sets in after 
 inflammatory processes in the cellular tissue 
 which are of simple, tuberculous, probably also 
 syphilitic and gonorrhoic origin, specifically also 
 after injuries to the bones. The distinguishing 
 symptoms are: a characteristically hard, doughy 
 edema of the subcutaneous cellular tissue, coupled 
 with malnutrition of the softer tissues, a shiny, 
 bluish-red skin, copious sweating and a feeling 
 of cold in the morbid section. The X-ray is 
 an important factor in the diagnosis. 
 
 In local processes caused by neoplasms the 
 diagnosis will not be difficult, if we find demon- 
 strable changes, such as thickening or enlarge- 
 ment of the bones, especially if the parchment 
 crackling sound is present. The X-ray should
 
 BONES 401 
 
 prove of great assistance, but in cases in which 
 it cannot be employed, mistakes are not always 
 avoidable. A sarcoma may be taken for osteo- 
 periostitis resp. osteomyelitis, for frequently the 
 fact is overlooked that in sarcoma also the skin 
 over the swelling feels hot and is very sensitive. 
 Let us remember that in primary neoplasms the 
 skin is distinctly interwoven with enlarged blood 
 vessels. 
 
 Metastatic neoplasms require the attention of 
 the internist as well as that of the surgeon, for 
 in many cases abnormal conditions, or even sensi- 
 tiveness in the bones cannot be detected. This 
 makes it very difficult to form an opinion 
 whether the painful sensation arises from an 
 affected bone or is due to some other cause. The 
 situation is improved if we can find the evidence 
 of a previous primary neoplasm, no matter how 
 large or little, for that might put us on the right 
 track in our search for the genesis of the pain. 
 We might be told, for instance, that five or ten 
 years ago a primary neoplasm was removed from 
 the mamma. It is exactly this kind of case in 
 which late metastases of the bones develop. 
 Another point worth mentioning is that primary 
 neoplasms generally are formed in just such 
 places where metastases of the bones prefer to 
 develop. I mean the mamma, the thyreoid gland, 
 the prostate, the adrenals (hypernephroma), the 
 ovaries, the male genitals (testicles), bronchi,
 
 402 GENERALIZED PAIN 
 
 stomach and sigmoid. Sometimes these primary 
 tumors escape our clinical observations because 
 they are so small and hardly palpable, when the 
 metastatic conditions in the bone marrow are 
 already provoking most painful sensations. This 
 is particularly the case in malignant primary 
 new growths of the thyreoid and prostate. The 
 spinal localization of the pains in any of these 
 parts is always a suspicious signal. When the 
 pains are localized near the head of the upper 
 arm or of the thigh, or in the pelvic region or 
 in the zone of a vertebra belonging to the lower 
 costal or to the lumbar spinal column, or in one 
 of the ribs or in the sternum, especially when 
 these thoracic pains are provoked by motation 
 or impair completely arrest the motor ic ac- 
 tion of the gait, and we cannot, on the other 
 hand, discover a demonstrable cause for these 
 manifestations, then we have sufficient ground 
 for suspecting the development of a metastatic 
 carcinoma of the bones. 
 
 Similar metastafic conditions are found in 
 simple, but not malignant colloid struma. They 
 are generally combined with other metastases in 
 the skin, mucous membranes, etc. 
 
 Pains localized in one bone only may be the 
 reflex action of a morbid process which is in the 
 initial or rudimentary stage of development in 
 other sections of the skeletal frame. I refei 
 particularly to Paget's ostitis deformans which
 
 BONES 403 
 
 may exist in only one leg for a number of years. 
 The diagnosis should offer no difficulty, espe- 
 cially when the characteristic thickening, soften- 
 ing and curvature of the tibia is in evidence. 
 The more so, when the patient is beyond the 
 forties and the pains are rather severe, neuralgi- 
 form and constant. Besides, the Roentgen-ray 
 should support the diagnosis. Syphilis, of course, 
 is the only other alternative, but the Wassermann 
 reaction and specific treatment are in this case 
 the distinguishing features, unless both diseases 
 co-exist. 
 
 When the cranial bones are the home of the 
 pains we are very likely confronted by diffuse 
 or tumorous hyperostosis. I shall speak of the 
 differential diagnosis later on. I will mention, 
 however, that, when the jaw bones are affected 
 we must differentiate between maxillary hyper- 
 ostosis and syphilis as well as neoplasms of the 
 bones, chiefly sarcoma. 
 
 Fibrous ostitis is in most cases a generalized 
 disease of the bones, but in the circumscribed 
 form it prefers the long bones for the place of 
 attack. Spontaneous fractures are frequently a 
 telling factor. The X-ray reveals their nature 
 (cyst formations). 
 
 There is a localized form of rachitis tarda of 
 which I shall speak later on. I will only men- 
 tion here so far as the diagnosis is concerned, 
 that the Roentgen-ray is the most reliable item.
 
 404 GENERALIZED PAIN 
 
 We should look for localized changes in the 
 bones of the leg and the spinal column (genu 
 valgum, pes valgus, kyphosis and scoliosis of 
 the spinal column, coxa vara in the adolescent). 
 Other symptoms are paleness of the face, ab- 
 normal fatigue and arrest of physical growth. 
 
 Other unilocular affections of the bones such 
 as syphilitic, actinomycotic or tuberculous ostitis, 
 and scleroma, will be discussed when we come 
 to the multilocular conditions. 
 
 Greater difficulties surround the diagnosis 
 when the pains are localized not only in one 
 place, but are spread over various portions of 
 the body. The patient locates them deep down 
 in the bones, or he may only complain of "rheu- 
 matic" sensations. We should resort to the 
 usual pressure and percussion methods. If we 
 find local sensitiveness we have several problems 
 to solve. The alternatives are: acromegaly with 
 pains of minor importance; multiple osteomye- 
 litis ; various forms of multilocular ostitis ( syphi- 
 lis and tuberculosis) ; osteomalacia ; osteoporosis; 
 rachitis tarda ; metastatic and primary neoplasms ; 
 Paget's ostitis; diffuse hyperostosis. 
 
 It may help the student of this book very 
 much if he ever keeps in mind that he is dealing 
 with a disease of the bones when the patient 
 complains of periodic, or constant pains, now of 
 a decidedly boring, tearing or shooting character, 
 or of a vague, indefinite, rheumatic nature.
 
 BONES 405 
 
 First in line is acromegdLy. The differential 
 diagnosis will be found at the end of this chapter, 
 and its initial symptoms have already been dis- 
 cussed in the chapter on "Pain in the Extremi- 
 ties." The diagnosis is not hard to make when 
 the disease is fully developed. The outstanding 
 signs are: the progressive enlargement of the 
 skull, the nose, the lower jaw, the lips and the 
 tongue, the hands and feet and of the overlying 
 parts. We also find marked spacing between 
 the teeth, sexual impotence, atrophy of the 
 genitals. Further, the enlargement of the hypo- 
 physis causes local symptoms such as, exoph- 
 thalmos, paralysis of the optic muscles, visual 
 impairment, bitemporal more frequently than 
 homonymous, morbid changes in the optic nerve 
 (reactions of the pupils, atrophy), cerebral pres- 
 sure symptoms (headache, dizziness, weak mem- 
 ory, apathy) , sleeplessness, moodiness, depression, 
 enlargement of the larynx, abnormally deep, 
 raucous voice, rigidity of the chest, kyphosis and 
 cuplike dullness over the upper sternum. The 
 X-ray will reveal the conditions in the sella 
 turcica (abnormal dimension in the sagittal di- 
 rection) . Diffuse hyperostosis and Paget's osti- 
 tis are closest in resemblance. 
 
 The differential diagnosis of osteomalacia will 
 be more fully discussed at the end of this chap- 
 ter. The pregnancy (puerperal) form is easy 
 to diagnose. When a pregnant or parturient
 
 406 GENEBALIZED PAIN 
 
 patient complains of rheumatic pains be on the 
 watch for a case of osteomalacia. 
 
 The characteristic symptoms are: the pains 
 are localized in the pelvic region near the last 
 vertebra and gradually extend into the trunk 
 and thighs, rarely into other extremities, scarcely 
 ever in the head, later on they increase in violence 
 during the menstrual flow and in subsequent 
 pregnancies; wattling gait, clumsy movement of 
 the body, spasms of the adductors, increased 
 patellar reflexes, tenderness in the bones, espe- 
 cially the ribs, abnormal flexibility of the bones 
 (feathering pelvis, feathering ribs, etc.), unusual 
 softness and deformities (osteomalacia pelvis, 
 kyphosis), indentation, especially of the lumbar 
 vertebras and subsequent shrinkage of stature, 
 the dimensions of the body are out of propor- 
 tion to the length of the legs, the costal arches 
 almost touch the upper pelvis, causing a deep 
 furrow in the waist line, lateral bending of the 
 ribs, arching of the sternum (chicken breast) or 
 depression of it, later on bow-leggedness, in- 
 fractions or fractures on impacts ever so light, 
 slightly brisk muscular action and surprising 
 fluctuations in the intensity of the morbid symp- 
 toms. 
 
 Tardive or senile osteomalacia occurs also in 
 men. It differs from the former in many ways, 
 viz., it chiefly begins in the bones of the trunk. 
 There are pains in the ribs and pains and
 
 BONES 407 
 
 formities in the vertebrae (arcuary kyphosis), 
 depression of the chest, sensitiveness of the spinal 
 column on pressure, a strong compression of 
 the thorax is painful, girdle sense, pains and 
 changes in the legs and thighs, the long bones 
 are flexible but do not break easily, muscular 
 contractions especially of the adductors, knees 
 and thighs are closely pressed together when 
 standing or walking (in decubitus contracture 
 of the adductors is not demonstrable) and shrink- 
 age of the body. Excruciating pains accom- 
 pany this tormenting disease through many 
 weary years. 
 
 Hunger-osteopathy presents pretty well the 
 same picture. 
 
 Senile osteomcdacia is easily mistaken for 
 osteoporosis. 
 
 In the latter the bones are very brittle and do 
 not bend. Spontaneous fractures of the femur, 
 the ribs, clavicles, sternum and spinal column 
 without conspicuous accompanying symptoms 
 are frequently found in Roentgengraphs. More- 
 over, osteoporosis as a rule involves the entire 
 skeletal system including the skull and maxillse, 
 but shrinkage of the body, waiste-furrow and 
 wattling gait are not found. 
 
 The differentiation, however, of senile osteo- 
 malacia from multiple tumors of the bones is 
 much more difficult. Here we have a true pic- 
 ture of "carcinomosteomalacia."
 
 408 GENERALIZED PAIN 
 
 In juvenile patients the question lies between 
 osteomalacia and rickets, if a differentiation be- 
 tween the two diseases is at all possible because 
 the pains in both diseases are almost identical. 
 
 Tardive rachitis runs its course from the 
 eighth year after birth till the time of puberty. 
 The pains are chiefly in the back and the legs 
 and there are rosary-like tuberosities on the 
 antero-external ridges of the bones and on the 
 epiphyses, and we observe scoliosis and genua 
 valga and vara very much the same as in osteo- 
 malacia. Differential points may be found in 
 several respects such as the juvenile age of the 
 patient, likelihood of infractions, absence of 
 shortening in the spinal column and in the thorax, 
 want of pressure sensitiveness in the chest and 
 pelvis excepting the extremities, pelvis normal 
 (not beaked, rostrated), involvement of the teeth, 
 retarded growth. The remaining requisites for 
 a positive diagnosis are the Roentgen ray and 
 urine and blood tests. 
 
 Pains in the bones, physical shrinkage and 
 spinal curvature have in recent years also been 
 observed in osteoporosis attended with chronic 
 bilious fistulce. 
 
 The differential diagnosis between senile and 
 carcinomatous osteomalacia, or more correctly 
 speaking multiple metastases of the bones, can 
 only be in doubt when there is no evidence of 
 an existing primary neoplasm. In that case
 
 BONES 409 
 
 pains, especially in the thoracic bones excerbated 
 by motation, are common factors. This refers 
 also to conditions which prevail in cases of osteo- 
 plastic neoplasms ( osteoplastic new growths are 
 recognized by the increase of body weight despite 
 progressive cachexia). We find brittleness of 
 the bones, deformities in the trunk due to colum- 
 nar kyphosis and also in the sternum, the ribs 
 and thighs, kyphosis in the lumbar portions, 
 changes in the formation of the pelvis and of 
 the proximal parts of the femur and shrinkage 
 of the body the same as in osteomalacia, infrac- 
 tions and fractures, remissions and intermissions 
 and a long protracted illness. But if we can feel 
 a protuberance even in one part of the bone only 
 and not of the nature of a callus the crista ilei, 
 the ribs and the skull (hypernephroma and car- 
 cinoma) are favorite spots the diagnosis points 
 to an existing tumor. When this sign is want- 
 ing, the Roentgen-ray and blood tests will prob- 
 ably furnish the required proofs. 
 
 In osteomalacia the blood test as a rule shows 
 only normal conditions. But in multiple meta- 
 stases there are signs of abnormal activity in the 
 bone marrow, i.e., leucocytosis in the form of 
 polynucleosis and myelocytosis, nuclear red blood 
 corpuscles. Later on regeneration of the mar- 
 row ceases, the marrow elements are wanting in 
 the blood, whole colonies of atypical marrow 
 cells are found in it. A careful X-ray exam-
 
 41U GENERALIZED PAIN 
 
 inafion of the whole bony framework should be 
 made in all cases. The differential diagnosis 
 will not be concerned with these points when 
 multiple osseous metastases are due to an or- 
 dinary, benign, adenomatous or insignificant 
 struma. But note, that a malignant struma may 
 manifest the clinicl symptoms of hyperthy- 
 reoidism. 
 
 The pains caused by these metastases are par- 
 ticularly distinguished by their fleeting, capric- 
 ious character: today they are felt in one place, 
 tomorrow in another; now they torment the 
 patient only to vanish again later on. This often 
 enough leads to the erroneous diagnosis of rheu- 
 matism, gout or hysteria, especially in cachectic 
 or nervous persons. Leucocytosis demonstrable 
 in the blood is of great help in the diagnosis, 
 although in many cases the blood picture is quite 
 normal. I again refer the reader to the neces- 
 sity of a studious X-ray examination of the 
 patient. 
 
 Sarcoma and principally hypernephroma are 
 further instigators of multiple metastases of the 
 bones with and without pain and pulsation. If 
 they are present they may even arrive before 
 the tumor becomes manifest. If a local swelling 
 already exists on the bone, the diagnosis is made 
 the easier, although mistakes are not always 
 avoidable. 
 
 In hypernephroma the metastases may again
 
 BONES 411 
 
 be of a truly fleeting character, rheumatic-like 
 as it were, changing their locality constantly, 
 before the clinician is enabled to recognize a 
 change in the bones or a primary tumor in the 
 kidney. Radiology is a conditio sine qua non 
 here also. 
 
 The presence of a tuberculous hearth in the 
 organism is also likely to mislead the attending 
 physician in his diagnosis, but let us remember 
 that it is very risky to believe that, because there 
 is a tuberculous condition in one organ, morbid 
 conditions in another organ of the same body 
 must of necessity also be of a tuberculous char- 
 acter. 
 
 There are other proliferations attributed by 
 some authorities to affections of the bones, by 
 others to systemic diseases, which cause pains, 
 similar to those described in the foregoing pages. 
 In most of these cases the complaint is of very 
 severe pains in the nape of the neck, in the chest, 
 the back and shoulders, sometimes also in the 
 limbs. They are sharpened by physical move- 
 ments and come on in periodic attacks. There 
 is local tenderness in the spinal column or in one 
 rib or another. Later on softness of the bones 
 sets in, deformities in the upper spine and in 
 the thorax generally, together with kyphosis are 
 found. The sternum becomes prominent owing 
 to angular curving of the ribs through multiple 
 spontaneous fractures. The chin is pushed down
 
 412 GENERALIZED PAIN 
 
 on the chest as in senile osteomalacia with which 
 multiple myeloma of the bones has so many 
 other conditions in common. This latter disease 
 chiefly affects the cranial bones but avoids those 
 of the pelvis and of the extremities. 
 
 The differentiation is not difficult so long as 
 protuberances on the affected bones, or multiple 
 tumors on the cranial bones (erroneously also 
 called atheroma) are in evidence. When these 
 are missing, doubts may arise. But the X-ray 
 and a test of the urine for Bence-Jones albumin 
 which is hardly ever present in osteomalacia, will 
 clear the situation. Moreover, in osteomalacia 
 the extremities are nearly always curved when 
 the trunk is markedly affected, whilst in mye- 
 loma the changes in the trunk and skull are much 
 less pronounced. If fever is present it speaks 
 for myeloma. 
 
 Whether we are confronted by a primary 
 myeloma or a secondary metastatic carcinoma 
 of the bones when we find a primary organic 
 neoplasm in the place mentioned before, the 
 diagnosis is self-evident. The presence of Bence- 
 Jones albumin points to myeloma although this 
 albumin is also found in multiple metastases of 
 the bones. When the pains are felt only in the 
 extremities or less markedly so than in the thor- 
 acic region we have little reason to think of 
 myeloma. The condition of the blood should 
 be of some help as in myeloma it generally
 
 BONES 413 
 
 shows only anemic, rarely leucemic conditions, 
 although myelocytes are sometimes found also. 
 It is further of importance to remember that, 
 clinically speaking, demonstrable metastases in 
 the internal organs, including the lymphatic 
 glands unless they are highly regional never 
 originate from myelomata. The presence of 
 such metastases, especially in the glands, con- 
 sequently favors the assumption of secondary 
 metastatic neoplasms. I do not wish to contend, 
 however, that a post mortem may not reveal 
 analogous growths in the bones in cases of mye- 
 loma. 
 
 On the other hand we come across, occasion- 
 ally, primary, multiple, benign or relatively be- 
 nign (osteoma, osteochondroma, echinococcus 
 cysts, or cysts in the bones in fibrous ostitis) 
 and malignant tumors of the bone marrow, e.g., 
 in the vertebras, ribs, thighs, upper arms, either 
 in the shape of osteosarcomata, lymphosarcomata 
 or giant cell sarcomata. They are all accom- 
 panied by pains in the bones and by anemia, 
 cachexia, if not by recurrent fever. The Bence- 
 Jones albumin may be found in this disease and 
 its presence be taken as a sign of myeloma. 
 
 Painful swellings are also found in typical 
 ieucemic lymphadenitis and thus simulate a mye- 
 loma. The clinical aspect and the condition of 
 the blood should suffice for a proper diagnosis. 
 
 Syphilitic or tuberculous multilocular osteo-
 
 414 GENERALIZED PAIN 
 
 periostitis are here within the reach of possi- 
 bilities. 
 
 In recent syphilitic periostitis and true gum- 
 matous osteoperiostitis we find new growths in 
 the form of painful, if not painless, round tumors 
 of various size. They are more or less hard, i.e., 
 of a fluctuating consistency and mostly situated 
 on those bones which are less protected by tissue, 
 I mean the skull, the forehead, the clavicles, the 
 sternum, the ribs and the inner side of the tibiae. 
 The diagnosis is not hard to make because the 
 usual symptoms of secondary syphilis are always 
 manifest, not to speak of their nocturnal char- 
 acter. And again, in recent cases of osteoperi- 
 ostitis we find very little, if any, local reddening 
 of the skin, unless it is due to some mechanical 
 irritation; we also can notice that the swellings 
 are flat in shape and gradually recede, while 
 in gummatous ostitis necrosis, ulceration and 
 subsequent scarification of the bones obtain. It 
 is worth while to remember that gummatous 
 periostitis manifests itself in the form of a 
 diffuse and not circumscribed infiltration which 
 breaks down in an ulcerous state. Minor flat 
 and far-reaching enlargements of the bones are 
 also demonstrable. Likewise that gummatous 
 ostitis, e.g., in the clavicles, or in the fingers or 
 forearm is apt to lead to spontaneous fractures 
 On the long bones and on the skull it may cause 
 proliferation and subsequent thickening of the
 
 BONES 415 
 
 bones, on the skull also hyperostosis or leontiasis 
 ossea. 
 
 Secondary syphilis does not as a rule cause 
 swellings in the bones, but rather transient, re- 
 current inflammations and moderate, not strictly 
 localized and wandering pains. The patient is 
 wont to call them "rheumatics." The fact that 
 they are sharper in the night time, other char- 
 acteristic symptoms and the Wassermann reac- 
 tion should influence the opinion. 
 
 In recent syphilitic osteoperiostitis we find the 
 same fluctuations in the body temperature that 
 are characteristic of secondary luetic conditions, 
 while in the gummatous form a normal degree 
 prevails unless pus cells are present. 
 
 If children are affected in this manner heredi- 
 tary syphilis suggests itself. In hereditaria 
 tarda the first four to five years in the patient's 
 life pass by without morbid symptoms. It is 
 at a later date, sometimes even beyond the stage 
 of puberty, that the characteristic manifesta- 
 tions on the bones make their appearance. The 
 history of the case, Hutcliimoris teeth, saddle 
 nose, remnants of former peranchymatous kera- 
 titis, partial deafness, chronic swellings of the 
 glands and knee joints, are all typical road signs, 
 especially if the Wassermann is not neglected. 
 
 Tuberculous ostitis and also osteomyelitis may 
 affect one or more bones at the same time. In 
 both rising temperature is usual.
 
 416 GENERALIZED PAIN 
 
 In the first named disease fever is moderate, 
 if not absent, although there is local tenderness, 
 the pains are not severe, but there are functional 
 disturbances, for instance, if it attacks one of 
 the lower extremities the patient is forced to 
 limp. Its tuberculous genesis may be recog- 
 nized from a tuberculous state seen in other 
 organs, from the nature of existing tumors 
 which are of a livid color, the thin, cheesy pus, 
 the slack, yellowish granulations of the fistulas, 
 and last but not least, from the Roentgen pic- 
 ture. It is of interest to know that this disease 
 has a preference for the small hollow bones such 
 as the metacarpal, metatarsal and phalangeal 
 bones (spina ventosa). In the larger bones it 
 settles rather in the diaphyses, rarely in the epi- 
 physes, which fact distinguishes it from acute 
 purulent osteomyelitis. 
 
 With the assistance of laboratory blood tests 
 and the Roentgen-ray the diagnosis of this dis- 
 ease can be made from the following symptoms: 
 the initial stages show chills and high fever, a 
 marked general indisposition, diarrhea, typhoid 
 state, soon to be followed by severe pains around 
 the heads of the affected bones (shin bone, thigh, 
 upper arm, sometimes the lower arm, clavicles, 
 ribs and the short hollow bones), local reddening 
 of the skin, higher local temperature, collateral 
 edema, later on septico-pyemic generalized in- 
 fection. While tuberculous ostitis may be of
 
 BONES 417 
 
 an acute character with high fever throughout 
 its course, purulent osteomyelitis is generally 
 subacute or chronic in its nature and the patient 
 suffers from rheumatoid pains in the affected 
 parts, and even from minor functional disturb- 
 ances, for many a year. When a differential 
 diagnosis from neoplasms, syphilis or tubercu- 
 losis tests will furnish the required information. 
 Marked leucocytosis points to osteomyelitis; in 
 tuberculous ostitis a mixed infection does not 
 exist. 
 
 Albuminous periostitis is, so to speak, an 
 intermediary disease between purulent osteomye- 
 litis and tuberculous ostitis. It sets in gradually 
 with little or no fever, is mostly chronic in char- 
 acter (sometimes acute in the beginning with 
 fever) and localized in the same bones as in 
 acute osteomyelitis and also at the ends of the 
 epiphyses, sometimes associated with osteomye- 
 litis in other bones, local, well defined, elastic, 
 fluctuating swellings which secret a stringy, al- 
 buminous, synovia-like fluid between the perios- 
 teum and the coating of the long bones showing 
 traces of tubercle bacilli or strepto- or staphy- 
 lococci. 
 
 I add two relatively rare forms of unilocular 
 or multiple acute or chronic osteoperiostitis, viz., 
 acute or chronic osteoperiostitis malleosa and 
 actinomycotica. The former is easy to recognize 
 if it occurs in a case of positive glanders, because
 
 418 GENERALIZED PAIN 
 
 it is merely a manifestation of pyemia of the 
 bones. In chronic farcy the diagnosis meets 
 with some difficulties. The salient features which 
 require consideration are: does the patient come 
 in contact with horses or other animals subject 
 to glanders, the presence of typical sores in the 
 nose and skin, of abscesses in the muscles or in 
 the periarticular tissue (a subacute or chronic- 
 exudative articular rheumatism might be simu- 
 lated by the latter condition), sub-febrile or 
 slightly febrile temperature, a positive diazo- 
 reaction and bacteriologic findings. 
 
 Actinomycotic osteoperiostitis or osteomyelitis 
 is mostly of a secondary character and arises 
 from a continuity in a vertebra, rib or in the 
 sternum, but it may also make its appearance 
 in a long bone, e.g., in the thigh after a trauma, 
 with local swelling and all the symptoms of an 
 acute osteomyelitis. When it runs an acute 
 course it is very likely of metastatic origin. 
 
 Typhoid osteoperiostitis generally sets in dur- 
 ing the period of convalescence from typhoid, 
 principally in the tibia, also in the ribs, the 
 sternum, clavicles, etc. It may be purulent, but 
 is as a rule reconstructive in character. The 
 etiologic diagnosis may meet with difficulties if 
 the symptoms have been overlooked or the pri- 
 mary infection is of very old standing. Blood 
 tests are necessary. 
 
 Malta fever may also produce suppuration of
 
 BONES 419 
 
 the bones and an abscess in a dependent part. 
 The diagnosis depends on the possibility of an 
 infection, the examination of the pus and the 
 presence of the micrococcus militensis. 
 
 Acute articular rheumatism may cause the 
 formation of various forms of periostitis, for 
 instance, the initial acute rheumatic form, in 
 which very severe pains, swelling, reddening of 
 the skin and high fever are noticed. 
 
 Paget's ostitis must again be mentioned. In 
 the beginning it is an individual disease of the 
 skull, or tibia, femur or spinal column, but has 
 also been observed on the clavicle and ribs. It 
 is a painful, sometimes, however, indolent affec- 
 tion of the bones which gradually involves the 
 whole thoracic frame if not also the pelvis. 
 
 The patient complains of rheumatoid pains in 
 the affected bones strongly influenced by weather 
 conditions, difficulty and clumsiness in walking. 
 The progress of the disease is assymmetric 
 throughout. The head grows larger and larger 
 and leans forward until the chin touches the 
 chest, the cervical and thoracic vertebrae become 
 kyphotic, the thorax looks shortened with the 
 lower part expanded and separated from the 
 abdomen by a deep furrow, the extremities are 
 curved, the knees approximate each other, and 
 the affected bones are abnormally thick, although 
 motation is seemingly little impaired. The 
 X-ray materially assists the diagnosis.
 
 420 GENERALIZED PAIN 
 
 We will now consider the differential diag- 
 nosis between acromegaLy, Paget's ostitis and 
 hyperostitis, since each of them involves the 
 enlargement of the head. 
 
 Acromegaly is distinguished not only by the 
 unusual expansion of the head, but also by the 
 symmetrical, uniform enlargement of the arms 
 and legs (bones and tissues as well) and ab- 
 normal bulkiness of the hypophyses. Mark the 
 symmetrical progress of the disease as against 
 the asymmetry prevailing in Paget's ostitis, and 
 again that in hyperostitis the distension of the 
 head is diffuse and not tumorlike. But when 
 it is tumorous the various growths are concati- 
 nated, but each prominence has its own indi- 
 vidual circumference; moreover, they attack in 
 the first line the bones of the face, whilst in 
 Paget's ostitis these remain unmolested or near- 
 ly so; furthermore, Paget's ostitis presents a 
 smooth surface all over the growth. Besides, 
 in hyperostitis we find exophthalmos and paral- 
 ysis of the cerebral nerves, which is not the 
 case in the other disease. But this latter nearly 
 always involves the bones of the lower extremi- 
 ties, quite an exception in hyperostitis, which, 
 moveover, occurs chiefly in youthful individuals 
 when Paget's ostitis prefers old age. 
 
 Gummatous ostitis may be confused with Pa- 
 get's ostitis because it also leads to scleroting 
 conditions which would enlarge the head con-
 
 BONES 421 
 
 siderably. If it is of syphilitic origin it can 
 easily be separated from Paget's ostitis by the 
 typical symptoms and the Wassermann reac- 
 tion, unless both are of a luetic character. 
 
 There is a peculiar aspect to Paget's ostitis, 
 viz., very often the neoplasms of different local- 
 ization, e.g., endothelioma of the pleura, gastric 
 or hepatic carcinoma, likewise neoplasms of the 
 bones, such as sarcoma of the tibia, enchondroma 
 of the pelvis, are associated with it. Thus we 
 may be tempted, when we see the patient only 
 in the last stadium of the disease, to ascribe the 
 whole symptom complex direct to the neoplasm 
 and its metastases. But the anamnesis and rela- 
 tively long duration of the affection, the well- 
 nourished physical appearance of the patient 
 and his fit condition, also the smooth surface of 
 the enlargement all over the head and the curves 
 in the lower extremities, together with the Roent- 
 gen picture should prove sufficient evidence in- 
 sofar as the diagnosis is concerned. 
 
 To differentiate Paget's ostitis from osteo- 
 malacia serulis is not always such an easy matter, 
 because in both very intensive pains are endured 
 and in both the body shrinks in height. But in 
 osteomalacia the thorax is principally involved, 
 while the head and the lower extremities, espe- 
 cially the long bones, remain intact, or if the 
 bones are at all affected the changes are sym- 
 metrical in form, while in ostitis the progress is
 
 422 GENERALIZED PAIN 
 
 irregular and asymmetrical in form and the 
 head is very much deformed. Here again the 
 X-ray shows the differentiation in a marked 
 fashion. 
 
 Furthermore, a differential diagnosis may 
 have to be made between fibrous ostitis (Reck- 
 linghausen's disease) and the two aforementioned 
 affections on account of the intensive "rheu- 
 matic" local pains and the bending of the bones. 
 In Recklinghausen's disease we can notice 
 fibrous changes in the bone marrow, with spongy 
 alterations in the bone tissue and the formation 
 of giant cell sarcomata and spindlelike swellings 
 around the metaphyses, along the long bones, 
 with parchment crackling and fluctuation, also 
 infractions, if not fractures, of the bones. We 
 must resort to the Roentgen-ray once more. 
 
 I must refer here to still another disease 
 which I have purposely avoided to mention thus 
 far because it is in reality not a primary affec- 
 tion. I mean "osteoarthropathie hypertrophi- 
 ante pneunuque" with drumstick fingers and its 
 intermediary form, i.e., Bamberger's disease 
 with osteoperiosteal enlargements of the long 
 bones, especially at their distal ends in the thighs 
 and forearms. 
 
 I confine myself to the two principal forms. 
 
 Bamberger's combination type is character- 
 ized by drumstick fingers and parrot-beak nails, 
 spontaneous and sensitive swellings in the distal
 
 BONES 423 
 
 zones of the forearms and the lower thigh bones. 
 Around the radius and malleolus we find dis- 
 tinct enlargement and the middle of the hand 
 appears plumper. The X-ray and anatomical 
 examination show still more changes in the 
 shape of inflammatory periosteal growths. 
 
 In osteoarthropathie hypertrophiante the fin- 
 gers are shaped like drumsticks whilst the hand 
 itself is shaped more in the form of a paw, the 
 feet are very much deformed, the whole distal 
 surroundings of the lower thigh and forearm 
 are swollen, and similar enlargement may be 
 observed in the sternum, the ribs, clavicles and 
 pelvis. Kyphoscoliosis also accedes in some 
 cases. 
 
 From this short sketch it will be seen that 
 osteoarthropathie hypertrophiante I shall speak 
 about its diagnostic importance later on pos- 
 sesses a certain resemblance to acromegaly. Yet 
 a mistake between these two diseases can be 
 easily prevented. I will not speak here of the 
 secondary nature of osteoarthropathie (see later 
 on about drumstick fingers), but only of other 
 phases which distinguish this disease from acro- 
 megaly. In the former the fingers are shaped 
 like drumsticks and the nails like a parrot's 
 beak; in acromegaly they are harmoniously en- 
 larged in every dimension, though the finger 
 nails are comparatively small. In osteoarthro- 
 pathie the hands and feet are misshapen like
 
 424 GENERALIZED PAIN 
 
 paws; in acromegaly they are enormously, but 
 symmetrically, enlarged, not deformed. The 
 bony deposits and protuberances on the distal 
 ends of the long bones so typical of osteoarthro- 
 pathie are missing in acromegaly. The swelling 
 of the overlying tissues, the enlargement of the 
 hypophyses an d a ll the other characteristic symp- 
 toms of acromegaly are missing in osteoarthro- 
 pathie. A combination of the two diseases has 
 been reported in one case. 
 
 There is a case of bone disease on record 
 which is ascribed to intestinal troubles. The 
 patient suffered since early childhood, but with 
 periodical interruptions, from diarrhea, appar- 
 ently due to a toxic decay of albumin in the 
 bowels. By avoiding meat and other albumin- 
 ous foodstuffs the patient was cured. What is 
 of interest from the clinical standpoint is the 
 fact that the symptoms had much in common 
 with acromegaly and Pagefs ostitis. At times 
 they simulated those of Marie's osteoarthropathie 
 hypertrophiante, or showed rachitic characteris- 
 tics. The patient complained of abnormal fa- 
 tigue, and at times of pains in the bones and 
 joints. Swellings, enlargements and deformi- 
 ties were also observed in the bones. 
 
 There are a few other affections of the bones 
 in which local pain is a prominent symptom. 
 As they are of minor significance for the differ- 
 ential diagnosis I will only mention them. Noth-
 
 BONES 425 
 
 nagel's lymphadenia ossium, is not as yet prop- 
 erly classified, although it seems to bear the 
 character of a leucemic lymphomatosis. Bruck's 
 disease is typified by enormous contortion in the 
 bones and frequent fractures thereof, also by 
 multiple ankylosis of the joints and by muscular 
 atrophy. Then there is Ziegler's osteotabes in- 
 fantum, and another childhood disease, i.e., os- 
 teogenesis imperfecta tarda, 
 
 Some of the morbid conditions mentioned in 
 the foregoing pages, such as acromegaly, are in 
 reality not primary affections of the bones; and 
 there is still a number of others belonging to 
 this category in which likewise pain in the bones 
 plays a significant role, although a primary 
 disease of the bones does not exist. Among 
 them are the following: 
 
 In degeneratio adiposo-genitatis arising from 
 hypopituitarism, periodic spontaneous pains in 
 the ribs and extremities are felt, although from 
 a diagnostic standpoint they are not of the same 
 importance as in acromegaly. 
 
 Such local spontaneous pains are not uncom- 
 mon in scurvy in the adult, when hemorrhages 
 set in between the bones and the periosteum, 
 and in Barlow's disease ( a combination of scurvy 
 and rickets). The children cry out loud upon 
 being merely touched. 
 
 If the patient complains of so-called "rheu- 
 matic" pains which increase in violence when he
 
 426 GENERALIZED PAIN 
 
 moves about or is dressing, it is a reminder of a 
 primary disease of the blood or of the blood- 
 producing organs, viz., acute or chronic myeloid 
 leucemia, aleucemia and myeloid chloroma, but 
 also (in a minor degree) lymphatic leucemia, in 
 which, as a rule, only sensitiveness on pressure 
 prevails in the bones. Pernicious anemia (ane- 
 mia aplastica, thrombopenia) and Jack's disease 
 (see "Articular Pains") deserve a place, too. 
 The subjective sensation is here restricted rather 
 to a dull sensitiveness in the bones similar to 
 that in some cases of chlorosis, but local pressure 
 or percussion of the bones elicit most intensive 
 pain. A combination of myeloid leucemia and 
 osteomalacia is on record. 
 
 Pains in the bones and accompanying swelling 
 of the lymphatic glands which occur in extirpa- 
 tion of the spleen are, no doubt, due to over- 
 activity forced upon the bone marrow by the 
 missing splenic function. 
 
 I will add here an observation from my own 
 practice which may interest the reader. I have 
 seen girl patients, before and during the stage 
 of puberty, who complained of abnormally quick 
 fatigue and also of pains in the joints or in the 
 tibia?, with pronounced tenderness on percussion 
 in the bones, and even in the thighs. I could 
 find no other explanation than an abnormally 
 quick development of the body. This physical 
 growth seemed to come on in regular spells,
 
 BONES 427 
 
 one after the other in quick succession, and with 
 each the pains in the bones would arrive, only 
 to disappear when nature had finished its task. 
 Noteworthy changes in the condition of the blood 
 I was never able to observe. 
 
 Pains in the bones, particularly in the frame 
 of the chest, and very hard to distinguish from 
 intercostal neuralgia, are often enough part of 
 the symptoms in the climacterium. If we con- 
 sider the age and sex of the patient, the waning 
 function of the ovaries, the general gynecologi- 
 cal conditions and other climacteric disorders, 
 above all vasomotoric disturbances (flushing of 
 the face, sweats, -paresthesias of the extremities, 
 swooning spells, palpitation of the heart, angi- 
 noid attacks), accumulation of adipose tissue, 
 Heberden"s nodes, etc., the diagnosis could not 
 go amiss, and yet it will be wise to keep a sharp 
 eye on the possible development of a tardy 
 osteomalacia. 
 
 The Wolhywan, or five days fever, which be- 
 came common during the World's War, requires 
 some attention here. Both names are badly 
 chosen, because it did not exactly originate in 
 Wolhynia, neither is it recurrent in five-day 
 periods; only in rare cases so. Still it has the 
 character of recurring four or five times at 
 irregular intervals, and is generally associated 
 with a tumor of the spleen, and also with osteo- 
 periosteal neuralgic pains.
 
 428 GENERALIZED PAIN 
 
 Tibial pains are observed in abdominal ty- 
 phoid, influenza and spotted typhus. They may 
 even degenerate into generalized pains of the 
 bones, as is also the case in paratyphoid and 
 recurrent fever, and sometimes in typhoid vac- 
 cination. When they occur in erythema nodo- 
 sum, a wrong diagnosis of osteomyelitis may 
 result. 
 
 If spontaneous pains arise in gout, they are 
 of a minor degree, but very severe on percussion, 
 especially on the condyles of the humerus, the 
 head of the radius, in the os calcaneum, and in 
 the small tarsal bones, but not more acute in 
 the night time. 
 
 Certain exogenous poisons may cause pains 
 in the bones. I do not refer to the phosphorous 
 necrosis of the lower jaw or of the nose caused 
 by chromic acid poisoning (the latter resembling 
 a syphilitic defect of the septum), but to acute 
 intoxications from arsenic and phosphorus. Al- 
 though the pains are rarely spontaneous, pres- 
 sure and percussion evince them sharply in 
 the bones, chiefly in the ribs, the vertebras and 
 the tibiffi, and according to my own experience, 
 constitute a frequent and diagnostically most 
 important symptom. They are, no doubt, due to 
 overactivity of the bone marrow which, in acute 
 poisoning from phosphorus, manifests itself in 
 the form of severe polycythemia and leucocy-
 
 BONES 429 
 
 tosis with an increase of the bone marrow 
 elements. 
 
 In mercurial poisoning similar pains are ob- 
 served. This is interesting from the standpoint 
 of the differential diagnosis in syphilis and mer- 
 cural intoxication. Chronic arsenic poisoning 
 belongs here, also. Lancinating pains in the 
 bones are not uncommon in tabes. 
 
 Pains which in their nature are not spontane- 
 ous, but provoked by pressure or percussion, are 
 of diagnostic value in a series of affections such 
 as: diseases of the blood, leucemia, aleucemia, 
 pernicious anemia, chlorosis, acute hemolytic 
 anemia, v. Jacksch's disease, various forms of 
 severe secondary anemia, especially after neo- 
 plasms (red bone marrow), some cases of 
 chronic osteomyelitis, and all the initial stages 
 of the aforementioned disorders. In some cases 
 of Basedow's disease I have been able to ob- 
 serve in the bones a very marked sensitiveness 
 on pressure or percussion when a demonstrable 
 anemia or overstimulated activity of the bone 
 marrow were not present, not even when a 
 complicating osteomalacia set in or signs of 
 abnormal softening of the bones were in evi- 
 dence. 
 
 In pulmonary emphysema the pains are of a 
 rheumatoid nature, especially in the bones of 
 the lower extremities. The tibiae are most sensi- 
 tive on pressure and percussion. The pains are
 
 430 GENERALIZED PAIN 
 
 unmistakably due to periostitic growths at the 
 distal ends of the tibiae, and remind one of the 
 osseous changes described by E. Bamberger. 
 
 In certain infectious diseases, sensitiveness on 
 pressure and percussion (sometimes rather vague 
 and quite indefinite), and also pain in the bones, 
 will be found a very valuable asset in the 
 diagnosis. This is particularly so in generalized 
 septic conditions (septic endocarditis) and in 
 scarlet fever. 
 
 Pains in the bones belong also to the promi- 
 nent prodromal symptoms of secondary syphilis, 
 even when the patient is not affected with luetic 
 periostitis. There are no local changes in the 
 bones and the pains disappear with the cure 
 of the exanthema. 
 
 If in abdominal typhoid pain and tenderness 
 in the bones are experienced, it may be the 
 expression of an existing acute osteomyelitis, 
 the more so when we find a local edema or vivid 
 coloring of the skin and lymphangoid striae. 
 
 In malaria pain and tenderness in the bones 
 are often very molesting symptoms. They pre- 
 vail in the long bones (tibise in particular), like- 
 wise in the cervical and upper thoracic vertebrae. 
 But they carry also another very important 
 message. We come across cases in which the 
 patient may have suffered from some kind of 
 fever, but to the best of his knowledge has never 
 had an attack of malaria before or has not dwelt
 
 BONES 431 
 
 in a malarial district, a fact, which would remove 
 the suspicion of a possible tumor in the spleen. 
 Moreover, we find no traces of other morbid 
 conditions (unless it be a minor, irregularly 
 recurring rise in the temperature) and no plas- 
 modia or pigment (but mononucleosis) in the 
 blood. But pressure and percussion elicit intense 
 pains in the bones, especially in the tibiae, and a 
 week or two later we are confronted by a typical 
 attack of fever, perhaps, superinduced by the 
 electric current, or a supervening cold or by 
 radiation of the spleen. In such a case we are 
 justified to assume that the plasmodia lay hidden 
 in the spleen and bone marrow and have only 
 now entered the blood. It is my firm conviction 
 that a definite cure of malaria can never be 
 claimed until every vestige of pressure pain in 
 the bones has disappeared. 
 
 A similar sensitiveness of the bones is also 
 demonstrable in malarial cachexia. It is due to 
 anemia and changes in the bone marrow. The 
 same conditions prevail in carcinomatous cach- 
 exia and in tuberculosis. 
 
 It should not be difficult to learn from the 
 foregoing dissertation that the differential diag- 
 nosis of "rheumatoid pains" leads us through a 
 very wide field of internal medicine. We must 
 not only take into consideration the rheumatic 
 and rhematoid pains of the muscles and joints, 
 the morbid conditions of the skin (adipositas
 
 432 GENERALIZED PAIN 
 
 dolorosa, neurofibromatosis, sclerodermia) , a 
 multitude of diseases and their localization in the 
 muscles, in the fascia and in the ligaments, in 
 the joints and in the bones (gout), affections of 
 the arteries and veins (sclerosis, arteritis, phle- 
 bectasis), neuralgic, chronic neuritic, neurotic 
 and lancinating pains and painful rheumatic 
 sensations which originate from diseases of in- 
 ternal organs, but also ailments of the skeletal 
 organism. 
 
 Acromegaly, primary and secondary neo- 
 plasms of the bones, myeloma, osteomalacia, 
 osteoporosis, fibrous ostitis, Paget's ostitis, de- 
 forming, recent syphilitic and gummatous ostitis, 
 chronic purulent osteomyelitis as well as Marie's 
 osteoarthropatie hypertrophiante pneumique in- 
 cluding Bamberger's subdivision, all are irritat- 
 ing factors of rheumatoid pains. 
 
 Osteopsathyrosis, the symptom of brittleness 
 of the bones, is observed in osteoporosis, osteo- 
 malacia and rickets, in primary and secondary 
 metastatic tumors of the bones (we must add 
 enchondroma, sarcoma, echinococcus cysts and 
 those of the bones), myeloma, deforming, fibrous 
 and gummatous ostitis and Bruck's disease. It 
 occurs also in rare cases of chronic osteomyelitis 
 and tuberculous ostitis. Diseases of the central 
 nervous system such as tabes, syringomyelia, 
 poliomyelitis, progressive paralysis and mental 
 disturbances may through minor traumatic con-
 
 BONES 433 
 
 ditions lead to spontaneous fractures. The inter- 
 mediary cause here would be some trophic dis- 
 turbance or a simple atrophy of the bone. Base- 
 dow's disease and old age are likewise causative 
 factors of osteopsathyrosis. But there is also an 
 independent form of this disease which is called 
 idiopathic osteopsathyrosis which is either con- 
 genital in its nature or at any rate acquired in 
 childhood. It may be hereditary (familial), 
 but there are also solitary cases on record. The 
 bones are of very soft consistence and frequent 
 fractures ensue which cause abnormal curvatures 
 and deformities. Hereditary cases are easy to 
 diagnose. In acquired cases we must look for 
 rickets or juvenile osteomalacia. Syphilitic af- 
 fections of the ephiphyses must also be consid- 
 ered. The absence of syphilitic symptoms and 
 the X-ray will determine the differential diag- 
 nosis, especially when the fractures are located 
 in the shaft of the bone between the epiphyses 
 and not where the diaphyses and epiphyses meet. 
 The X-ray also shows in syphilis a swelling of 
 the epiphyses, while in idiopathic osteopsathy- 
 rosis there is only an apparent thickening, a 
 proof that the epiphyses are normal. This thick- 
 ening is caused by an atrophy of the diaphyses 
 through pericostal dysplasia. 
 
 Localized isolated or multiple swellings of the 
 bones may be observed in various morbid condi- 
 tions, such as an ordinary callus, the different
 
 434 GENERALIZED PAIN 
 
 forms of acute or chronic infectious and non- 
 infectious osteoperiostitis (purulent or other- 
 wise), primary and metastatic plasmata, mye- 
 loma and tumorous hyperostosis. 
 
 Sporotrichosis is another malady which leads 
 to pericostal and osseal abscesses. It is not hard 
 to diagnose it. We find multiple papulous, or 
 vesiculous and pustulous manifestations in the 
 skin and mucous membrane, also muscular infil- 
 trations thus presenting very strongly the fea- 
 tures of tertiary syphilis or tuberculosis. The 
 microscopic examination of the pus showing 
 absence of bacteria and the agglutination test 
 will give ample proofs of Schenk-de Beurman's 
 sporotrichosis. Prompt reaction to iodide treat- 
 ment is another good test. 
 
 Chloroma is a disease which often causes the 
 formation of tumors of the bones, especially on 
 the cranium and on the sockets of the eyes. At 
 the present time it is recognized as a subspecies 
 of lymphatic myeloid leucemia and is distin- 
 guished by the green tint of the distended tissue. 
 We encounter chiefly subperiosteal growths com- 
 posed of lymphatic tissue especially on the skull 
 or in the orbita, sometimes in the temporal region 
 or around the cheek bones. Exophthalmos and 
 constriction of the optical nerve are frequent 
 complications when the tumor is localized near 
 the visual organs. The diagnosis must be based 
 upon the following symptoms: generally simul-
 
 BONES 435 
 
 taneous swelling of several lymphatic glands and 
 of the spleen ; regular, perceptible aggressiveness 
 of the tumor on the surrounding tissue (nerves 
 and muscles), penetrating even into the spinal 
 canal; the condition of the blood which strongly 
 resembles that in lymphatic or myeloid leucemia. 
 Myeloid leucemia may change into a myeloid 
 chloroma when the proliferations suddenly as- 
 sume an aggressive character and reach out from 
 the clavicullar fossa not only into the spinal 
 canal, but also into the face, the lower jaw and 
 the oral cavities. The tonsils, in fact, the entire 
 mucous lining of the mouth look as if they were 
 dyed a vivid green, even the blood serum shows 
 that color. 
 
 In rare cases of lepra swellings of the bones 
 (lepromata) are observed preferably on the 
 phalanges of the hands and feet. They are 
 spindleformed and strongly resemble the spina 
 ventosa in tuberculosis or syphilis. The diag- 
 nosis should result from the presence of the 
 lepra bacillus in the nodules of the skin, or from 
 the appearance of erythematous, hyperesthetic 
 areas on the skin, from the existing leprous neu- 
 ritis and the synchronous affection of the mucous 
 membranes of the nose, the mouth, the palate 
 and the porterior oral cavities. 
 
 When we see fingers formed like drum sticks, 
 or nails on hands and feet shaped like the beak 
 of a parrot, or like the crystal of a watch, we
 
 436 GENERALIZED PAIN 
 
 naturally ask the question: "What is the origi- 
 nating cause of these deformities?" The answer 
 to this question will also solve the problem 
 of the occurrence and clinical significance of 
 Marie's osteoarthropathie hypertrophiante and 
 Bamberger's disease because the etiologic genesis 
 is the same in these three affections. In the 
 majority of cases the underlying cause is a pro- 
 longed purulent condition of the respiratory 
 tract such as: cavernous tuberculosis, chronic 
 induration of the lungs with dilatation of the 
 bronchi, gangrenous pulmonary abscess, gan- 
 grene of the lung and empyema. Drum stick 
 fingers occur also in cystopyelonephritis and in 
 dysentery. For the differential diagnosis it is 
 worthy of mark that the deformity of the fingers 
 is of a specific type in tuberculous diseases. In 
 non-tuberculous affections, e.g., in bronchiectasy 
 the drum stick form is very conspicuous and 
 the ungual phalanges are short and thickened 
 and spherical, while in tuberculosis the latter 
 are longer, narrower and bent more like a hook. 
 But the difference is not always so pronounced. 
 
 Analogous misshapen fingers are also observed 
 in chronic actinomycosis of the lungs. A proper 
 diagnosis cannot fail to result from the bacte- 
 riologic examination of the sputum and the 
 likely discovery of a purulent tooth. 
 
 After pneumonia or non-purulent pleuritis 
 and also in influenza similar disfigurements of
 
 BONES 437 
 
 the fingers and nails may be seen, mainly in the 
 tissue and not so much in the bones. This is 
 also the case in chronic icterus, biliary cirrhosis, 
 chronic alcoholism, cholelithiasis, liver abscess, 
 congenital or protracted syphilis, recurrent ar- 
 ticular rheumatism, dilatation of the stomach, 
 tuberculous peritonitis or severe chronic dysen- 
 tery even without stenosis or intestinal stagna- 
 tion. 
 
 Diseases of the heart (especially congital de- 
 fects in children), acquired vascular affections 
 of this organ, chiefly in sclerosis of the pulmo- 
 nary artery, intrathoracic tumors (carcinoma or 
 sarcoma of the lungs), mediastinal tumors (lym- 
 phosarcoma or granuloma), rachitie deformities 
 in the thorax, tumors of the parotis or carcino- 
 mata in the posterior pharyngeal cavities belong 
 to this category. In some cases of intrathoracic 
 tumors, especially in aneurysm of the aorta or 
 of the subclavian artery the drum stick forma- 
 tion is noticeable only on one side. 
 
 Perhaps we are entitled to conclude that dis- 
 turbances of the venous circulation are the or- 
 iginating factors of these deforming processes 
 which in other diseases may also be caused by 
 neurogenous influences, for instance, in syringo- 
 myelia and neuritis. 
 
 Whether in myxedema the affection of the 
 thyreoid gland itself or the concomitant tuber- 
 culous condition of the lungs is the causative
 
 438 GENERALIZED PAIN 
 
 element of these changes in the fingers, is a 
 matter of speculation. I know of one case which 
 pointed to a glandular source. It was that of 
 a woman with an infantile uterus who suffered 
 from pains and swellings in the fingers at every 
 menstrual flow but only during this period. 
 
 I may add here also sporadic cases of senile 
 osteoporosis and primary polycythemia. In other 
 cases concomitant disfigurations of other parts 
 of the body have been observed, such as enlarge- 
 ments of the nose, of the shoulders or the lips, 
 also diastasis of the teeth, abnormal growth of 
 the hair of the head, glycosuria, polyuria and 
 polydypsia, also loss of the sexual powers. These 
 changes are possibly due to either an anatomical 
 or toxic affection of the hypophysis. The sub- 
 ject is worth further detailed study. 
 
 The peculiarly shaped finger nails mentioned 
 above may also be of hereditary origin, familial 
 landmarks as it were. 
 
 It is meet that I speak here of certain morbid 
 processes which do not take place primarily in 
 the skeletal system and yet have a certain affinity 
 to acromegaly because their symptoms are to 
 be found in the soft parts of the tissue. But 
 before doing so I will first mention a few an- 
 omalies which are also due to abnormal condi- 
 tions in the bones but entirely devoid of pain. 
 For the purpose of differential diagnosis this 
 might appear to be decisive were it not for the
 
 BONES 439 
 
 fact that certain cases of acromegaly develop 
 also without painful sensations or paresthesias. 
 
 I refer especially to physiological giantism. 
 The differentiation between this and acromegaly 
 offers no difficulty, because giantism is not a 
 disease but an abnormally large development of 
 all sections of the body in physiological propor- 
 tion. In acromegaly there are only certain parts 
 of the anatomy which are enlarged in an unduly 
 manner, i.e., out of proportion to the rest of the 
 body, by a slow process reaching back some- 
 times into the very period of childhood. In 
 many cases the X-ray does not show an enlarge- 
 ment of the pituitary body (small adenoma 
 of the hypophysis?). Aside from acromegalic 
 giants we find another kind, i.e., pathological 
 giants, persons afflicted with tumorlike hyper- 
 ostoses, abnormal curvatures of the bones, e.g., 
 in rachitis, or with hemihypertrophy of the face, 
 or who are disfigured by hereditary syphilis or 
 early in life by a tumor of the testicles. Rare 
 cases as they are, they can by no manner of 
 means offer difficulties in diagnosing. The same 
 may be said of partial giantism or hypertrophy 
 of particular parts of the body. The asymme- 
 trical and unilateral development of the morbid 
 condition and the complete absence of all acro- 
 megalic symptoms at once lead us to a positive 
 finding. 
 
 Pregnant women especially in the second
 
 440 GENERALIZED PAIN 
 
 half of the child-bearing period present some- 
 times a thickening in the bones of the face and 
 the arms which strongly resembles acromegaly 
 (pseudoacromegaly) . These swellings recede 
 again in the course of a year or so. We may 
 look upon them as an over-activity of the hypo- 
 physes superinduced by the altered function of 
 the female genital glands. 
 
 In abnormal growth of the hands acromegaly 
 is apt to be mistaken for syringomyelia. In the 
 latter, however, the hand or as the case may be, 
 both hands are really deformed, the skin is thick- 
 ened, the bones of the phalanges are enlarged, 
 differently though in each finger, the nails are 
 unusually small and shaped like claws. 
 
 Moreover, the skin of the palm of the hand 
 is abnormally thick, there are painless paro- 
 nychiae or scars or defects in the bones and 
 muscular atrophies together with sensibility dis- 
 turbances characteristic of syringomyelia are 
 present, while other prominent parts which un- 
 dergo changes in acromegaly remain intact. Of 
 course, a combination of the two diseases is not 
 among the impossibilities. 
 
 Abnormal lengthening of the fingers caused 
 by neurotic, apparently vasomotoric conditions 
 can easily be distinguished from acromegaly. 
 
 The condition called cranium progeneum in 
 which the lower set of teeth protrudes beyond 
 the upper row may be a partial symptom o
 
 BONES 441 
 
 acromegaly of the lower jaw. But it may also 
 be due to other morbid processes. It occurs in 
 cretinism, in mongolism, in degenerates, but 
 also in otherwise quite normal persons. The 
 differentiation from acromegaly should offer no 
 difficulties. 
 
 In the child cretinism may erroneously be 
 taken for acromegaly as both have many symp- 
 toms in common. But in cretinism the physical 
 anomalies are accompanied by mental defects 
 and irregularities of speech. Moreover, the 
 majority of these unfortunates have low fore- 
 heads, broad, flat noses, wrinkled faces, promi- 
 nent shoulder bones, deformed knees and legs, 
 pendulous arms, a wattling gait and very thick 
 skins like pachyderms. With the observation 
 of these symbols and the aid of the X-ray the 
 proper diagnosis can run no risk. 
 
 There is a certain similarity between myx- 
 edema and acromegaly, because in myxedema 
 the face is very much swollen and lumpy and 
 the hands and feet and the tongue are consider- 
 ably enlarged. The patient complains also of 
 pain in the bones. But it should not be hard to 
 separate the one disease from the other if we 
 consider that in myxedema the edematous nature 
 of the swellings is so palpable. Nevertheless, 
 I will enumerate here some of the distinguish- 
 ing features: the back of the hands looks like 
 upholstery, the eyelids are swollen, the cheeks
 
 442 GENERALIZED PAIN 
 
 are puffy and pendulous, the whole face has a 
 dull, sleepy expression, mental activity is re- 
 tarded, the voice is raucous, the skin dry and 
 scaly, the physical movements are clumsy, the 
 body temperature is low and the patient com- 
 plains of feeling cold and chilly, the hair falls 
 out, there is stubborn constipation, the thyreoid 
 gland is very small, if not missing altogether. 
 If anything else is required the Roentgen-ray 
 will supply the information. 
 
 The absence of osseous lesions in pachydermia 
 and elephantiasis makes a separation from acro- 
 megaly easy. So far as habitus scrophulosus is 
 concerned it is readily distinguished by the 
 swollen lips, nose and eyelids. In rachitis the 
 resemblance to acromegaly is perhaps more pro- 
 nounced, but there are so many characteristic 
 signs in this disease that a mistake is well nigh 
 impossible. 
 
 There is, however, a certain rudimentary form 
 of acromegaly in which "rheumatic" pains in 
 the bones manifest themselves and in conse- 
 quence should be mentioned here. I may be 
 permitted to call this condition "acromegaloid- 
 ism." The hands and feet and sometimes also 
 the nose, ears and the lower jaw appear very 
 much enlarged, in fact there is a general impres- 
 sion of acromegalic symptoms, the cerebral and 
 genital manifestations are missing. It is not 
 yet definitely known whether the underlying
 
 BONES 443 
 
 cause consists of small adenomata in the anterior 
 lobes of the hypophyses or whether we are deal- 
 ing simply with concomitant manifestations of 
 chronic bronchial affections. 
 
 A small, benign, hypophyseal tumor of this 
 kind may very well mask an attack of neuras- 
 thenia and be accepted as such. The patient 
 merely complains of unusual fatigue and in- 
 termittent, headaches. Ocular symptoms are 
 missing and the X-ray reveals no abnormal 
 conditions. But a very careful and painstaking 
 examination may yet disclose lesser enlargements 
 in the extremities, spacing between the teeth, 
 progressive impotence or cessation of the men- 
 strual function. 
 
 Further details of the differential diagnosis 
 of osteomalacia claim some space in the present 
 discussion, because up till now I have separated 
 this disease only from osteoporosis, myeloma, 
 rachitis and tumors of the bones. It is not neces- 
 sary to mention that osteomalacia may upon a 
 superficial examination be mistaken for muscular 
 or articular rheumatism, or for neuralgia and 
 even gout. More difficult is its differentiation 
 from arthritis deformans in both the hip joints, 
 for difficulty in walking and pain in lateral 
 abduction of the hip joints are common to both 
 diseases. But here again the Roentgen-ray will 
 promptly bring light. Nevertheless, I will say 
 that a careful, slow movement of the hip joint
 
 444 GENERALIZED PAIN 
 
 with the patient in a recumbent position will 
 prove free motility in cases of osteomalacia 
 while this is not so in arthritis def ormans. Treat- 
 ment with phosphoric drugs is also a promising 
 test, although good results with these same rem- 
 edies have likewise been obtained in deforming 
 arthritis. 
 
 Senile osteomalacia settles with preference in 
 the thoracic bony frame, chiefly in the spinal 
 column. In this case the differential diagnosis 
 is a question of arikylopoietic spondylarthritis. 
 The former is proved by painful sensations on 
 pressure in other bones apart from the articula- 
 tions of the thoracic frame and by the X-ray. 
 
 We may also be called upon to differentiate 
 between osteomalacia and multiple tertiary syph- 
 ilitic affections of the bones, especially when the 
 pains are both of a subjective and objective 
 nature, with adductor spasms, increased tendon 
 reflexes in the lower extremities, perhaps also 
 ileospasms, and wattling gait. The presence of 
 localized enlargements of the bones, nocturnal 
 pains, unilateral onset or asymmetry of the 
 manifestations, the Wassermann reaction, the 
 Roentgen picture and the effect of specific 
 therapeutic measures should prove determining 
 factors. 
 
 Diseases of the nervous system must also be 
 considered in this connection. Likewise affec- 
 tions of the spinal cord such as sclerosis of the
 
 BONES 445 
 
 local arteries. Initial paresthesias are common 
 property in these diseases as well as in osteo- 
 malacia, and so are local pain and increase of 
 the tendon reflexes. But the remaining symp- 
 toms such as tendon clonus, positive Babinski, 
 intermittent dysbasia, muscular atrophies and 
 bladder and rectal troubles always point to spinal 
 arteriosclerosis. 
 
 Spastic spinal paralysis or some other affec- 
 tion resembling it are not unlikely to be taken 
 for osteomalacia. But a careful observer knows 
 how to circumvent such a palpable error. 
 
 Hysterical pseudoosteomalacia on the other 
 hand offers greater difficulties. It requires some- 
 times long continued and close observation of 
 the patient before the contrast between the pains 
 and the motoric properties of the two diseases, 
 i.e., osteomalacia and hysterical pseudo-osteoma- 
 lacia, is recognized. Suggestion and phosphoric 
 treatment will solve the problem.
 
 Pain in the Joints 
 
 In the majority of cases the patient is able 
 to correctly localize an articular pain. But it 
 happens also that he will attribute pain to a 
 certain joint when the real seat of it is to be 
 found elsewhere, or he will experience a painful 
 sensation in a place somewhat removed from the 
 affected joint. 
 
 From local tenderness, impairment of the 
 articular motility and patent changes in the joint 
 the truth can be easily learned. 
 
 For the purpose of a clearer understanding 
 I divide the subject into two groups, viz.: acute 
 and chronic articular pain. 
 
 I. Acute Articular Pain 
 
 When a patient complains of sudden acute 
 pains in the joints our first suspicion is natu- 
 rally that of articular rheumatism. It will be 
 confirmed if we find the following symptoms: 
 pains in the small and large joints, distal as well 
 as proximal, as a rule symmetrical in those of 
 the extremities, possibly in those of the spinal 
 column, of the lower jaw, of the clavicle and 
 the symphyses, etc., often synchronously in sev- 
 eral joints bounding from one joint to another, 
 
 446
 
 JOINTS 447 
 
 enlargements in the joints, the superficial skin 
 has a reddish, shiny appearance and is feverish, 
 rising body temperature, definite reaction to 
 salicylic treatment, profuse, annoying and pecu- 
 liarly acid perspiration even before salicylic 
 drugs have been administered. Duration of the 
 disease three or four weeks, but sometimes re- 
 peated recurrent attacks in previously affected 
 joints. The heart, especially its serous coating, 
 may be implicated and at times initial signs of 
 a slight, transient angina are present. 
 
 In children we are able to discover sometimes 
 multiple nodules the size of a pinhead or pea 
 in the subcutaneous cellular tissue over the 
 affected joints of the extremities. These nodules 
 feel like soft cartilagenous matter and are more 
 or less tender upon pressure, the skin above 
 them appears quite normal, at the utmost only 
 a slight tinge of reddening is perceptible. Simi- 
 lar nodes may be found in the tendons or in 
 the tendon sheaths or in the periosteum, spinous 
 processes, sacrum or in the galea aponeurotica. 
 This condition is associated with endocarditis 
 and chorea. Perhaps an appropriate name for 
 it would be acute nodose rheumatism. 
 
 The necessity to differentiate between acute 
 articular rheumatism and septic polyarthritis on 
 the one hand and gonorrhoic arthritis on the 
 other is of common occurrence in every day 
 practice.
 
 448 GENERALIZED PAIN 
 
 In gonorrhoic arthritis we are confronted by 
 its monoarticular characteristics, i.e., that it set- 
 tles principally in the knee joint in women also 
 in the wrist and the contrast between the rela- 
 tively low degree of fever and the high intensity 
 of the pains. 
 
 However, there are cases in which these dif- 
 ferential symptoms fail. I have seen, not in- 
 frequently, polyarticular forms of this disease 
 in which several joints were progressively af- 
 fected. Much information came to me from 
 the discovery of a fresh gonorrheal infection in 
 the patient, and also from the rinding of gono- 
 cocci in the urethral, i.e., genital secretions; and 
 again, it is of importance to know that gonor- 
 rhoic articular rheumatism often develops only 
 after the abnormal secretions from the genital 
 organs have completely disappeared. It may 
 also be due to latent gonorrhea or to chronic 
 gonorrhoic prostatitis which has been overlooked. 
 Hidden gonococci discovered by manual pres- 
 sure furnish the evidence. If this prove a failure 
 we must consider the peculiarities of the articular 
 affection. 
 
 In the gonorrhoic form we miss the progres- 
 sive element which is characteristic of acute 
 articular rheumatism, but we find the distinctive, 
 periarticular, pasty edema extending far beyond 
 the articular limits. We also encounter endo- 
 articular swellings and periarticular muscular
 
 JOINTS 449 
 
 atrophy, intermittent fever and an early inclina- 
 tion to ankylosis. A trial puncture of the joint 
 shows a cloudy, serous, cytologic fluid consisting 
 chiefly of polynuclear leucocytes (later on also 
 mononuclear cells) and gonococci. Further- 
 more, the relatively long duration of the disease 
 is a speaking factor not to mention inefficacy of 
 salicylic treatment, local reaction to gonococcus 
 vaccine (arthigen). A concomitant disease of 
 the joints, foreign to acute articular rheumatism, 
 even an isolated affection, e.g., of the maxillary 
 arthrosis or of a sterno-clavicular articulation 
 must be taken as strong evidence of gonococcal 
 arthritis. An affection of the endocardium or 
 pericardium, of the pleura or peritoneum does 
 not exclude gonorrhea and in that case we are 
 dealing with a gonococcal septicopyemia. Pres- 
 ence of the gonococcus in the blood is positive 
 proof. 
 
 Acute septic polyarthritis is often erroneously 
 disguised as acute articular rheumatism. Of 
 course, this cannot happen in a classical case of 
 severe septicopyemia, but is not uncommon in 
 cases of endocarditis bacteritica or lenta in which 
 pains and swelling are of a lower quality and 
 of short duration. Likewise in cases of a gen- 
 eralized septic infection of a mitigated character. 
 In this condition the bacterial deposit in the 
 joints causes multiple local pains and swellings. 
 Mention must be made here of angina. In it
 
 450 GENERALIZED PAIN 
 
 as well as in articular rheumatism we meet the 
 same difficulty in deglutition and local pharyn- 
 geal affections either immediately before or with 
 the initial stages of the attack. The matter 
 may be further complicated by the fact that in 
 both diseases a ocncomittant infection of the 
 cardiac valves and abnormal sweating are in 
 evidence thus rendering an erroneous finding 
 still more plausible. 
 
 If the patient has been under our observation 
 early enough we must have noticed the lesions 
 in the pharynx and the painful swellings in the 
 lymphatic glands of the neck, a sure proof of 
 bacterial infection. In the later stages of septic 
 polyarthritis we must fall back upon the pro- 
 gressive nature of the disease, acute splenic 
 tumor, marked hyperhemocytosis and positive 
 diazo reaction. (I agree with R. Schmidt that 
 the diazo reaction is a positive contraindication 
 against primary as well as secondary infectious 
 articular rheumatism no matter of what genesis.) 
 Furthermore, I mention hemorrhages or white 
 spots in the retina, laboratory examination of 
 the articular serum, be it clear or cloudy, like- 
 wise of the blood and relative failure of salicylic 
 drugs. 
 
 Akin to those connected with septic poly- 
 arthritis are the initial and later on intermittent 
 articular pains caused by endocarditis lenta so 
 frequently mistaken for articular rheumatism
 
 JOINTS 451 
 
 with concomitant heart disease. The error is 
 not pardonable, for the symptoms are plain 
 enough. We have an intermittent, mostly long 
 continued morbid condition, a leaning to in- 
 farcts, a relatively hard, often painful tumor of 
 the spleen, pronounced leucocytosis, embolic 
 nephritis, all the symbols of a recent or recru- 
 descent endocarditis and the presence of the 
 streptococcus viridans in the blood. We have, 
 moreover, pus cells, gonococci, influenza bacillus, 
 and Weichselbaum's meningococcus, every one 
 of them a septic agent. The latter alone are 
 able to parade before us under the false face 
 of an acute febrile polyarthritis without display- 
 ing the characteristic symptoms of their own 
 isolated, classic disease. To make here a correct 
 diagnosis of a specific, septic polyarthritis is 
 only possible with the aid of a competent labo- 
 ratory examination of the blood and the articular 
 fluid, rarely through the port of entry, i.e., the 
 postnasal pharyngeal cavity. 
 
 A similar state exists in paratyphoid bacillosis 
 with gastro-intestinal symptoms. Bacteriologic 
 and serologic blood tests will make the diagnosis 
 positive. 
 
 Sepsis caused by the pneumonia diplococcus 
 requires mention here, too. The blood test will 
 make us recognize it as a true originator of 
 specific polyarthritis. Our attention will be 
 quickly invited by the unusual adherence of
 
 452 GENERALIZED PAIN 
 
 blood to the fibrin net and leucocytosis in the 
 absence of eosinophile cells. 
 
 Acute tuberculous articular rheumatism pre- 
 sents pretty well the same features as acute arti- 
 cular rheumatism. We have to distinguish here 
 between two forms. ( 1 ) The patient shows high 
 fever and multiple articular pains and swellings, 
 cough, cyanosis, dyspnea and cerebral compli- 
 cations, and dies within a week or two. The 
 postmortem reveals miliary tuberculosis impli- 
 cating the joints. The diagnosis in such a case 
 is rather difficult. Acute articular rheumatism 
 is, practically speaking, out of the question; 
 but cerebral rheumatism or miliary tuberculosis 
 involving the meninges might be considered, and 
 above all septic infection. The differential diag- 
 nosis is confined to miliary tuberculosis and 
 septic, infectious-chorioidal tubercles, dyspnea 
 and cyanosis with negative pulmonary findings, 
 rather soft tumor of the spleen, positive diazo 
 reaction, leucopenia with polynucleosis and pro- 
 gressive lymphopenia and monopenia in miliary 
 tuberculosis, hemorrhagie retinitis, cutaneous 
 hemorrhages, pain in the bones, leucocytosis 
 (only in severe cases of leucopenia), absence 
 of lymphocytosis (nearly always with lympho- 
 penia in sepsis). So far as special localization 
 in the joints is concerned the bacteriological find- 
 ings of the articular fluid and of the blood should 
 prove useful. Of the cytologic conditions of
 
 JOINTS 453 
 
 the articular contents we have no definite knowl- 
 edge. It is not unlikely that in these cases mul- 
 tiple articular swellings and an accumulation of 
 fluid in the abdominal cavity together with k)cal 
 tenderness are found. 
 
 (2) The second form approaches more closely 
 the clinical picture of articular rheumatism, but 
 similar conditions as under (1) prevail: pains in 
 the joints, likewise enlargements, high tempera- 
 ture, generally constant above 39 centigrade. 
 The differentiating points, however, are: we 
 observe, as a rule, no local reddening of the skin, 
 no characteristic, sour - smelling perspiration ; 
 witness the progress of the disease by bounding 
 into new joints, the absence of complicating 
 cardiac affections, the failure of salicylic treat- 
 ment except that it mitigates the pain and some- 
 what reduces the swellings, lymphocytosis of the 
 articular fluid and above all the local reaction 
 of tuberculin. Pulmonary tuberculosis and 
 other tuberculous phenomena may be concomit- 
 ant symptoms and materially assist in the diag- 
 nosis which will find another adjuvant in the 
 general course of the disease. 
 
 Multiple painful articular swellings and some- 
 times local reddening of the skin are not un- 
 usual in resorption of tuberculous serous exu- 
 dates, especially in the pleura. 
 
 Tuberculosis may also be the generator of 
 simple toxic multiple arthralgia. The same
 
 454 GENERALIZED PAIN 
 
 applies to syphiUs. On the ground that acute 
 articular rheumatism is able to provoke multiple 
 pains in the joints strongly resembling those 
 due to such arthralgias, a confusion in the diag- 
 nosis is likely to arise. But salicylic drugs 
 promptly clear up the situation. 
 
 This applies in the same measure to secondary 
 syphilis when the patient suffers from pains in 
 the joints that are accompanied by fever and 
 general indisposition, but not local changes. It 
 is different, however, when local reddening of 
 the skin is noticeable. The salicylic test is here 
 not adequate. We must watch closely the pro- 
 gressive nature of the pains, look out for tumors 
 in the spleen and make sure of the character of 
 the primary affection; search for the presence 
 of spirochetes and the Wassermann reaction 
 become a necessity. 
 
 A differential diagnosis between syphilitic 
 arthritis and gonorrhoic articular affections is 
 urged upon us when a chancre with purulent 
 discharge is discovered in the urethra. The 
 distinguishing features are easily recognized: in 
 syphilis the articular swellings are less painful, 
 or even painless altogether, whilst in articular 
 rheumatism we have multiple localization, evi- 
 dence of bacteriologic and serologic tests, and 
 extreme local painfulness, to which in gonor- 
 rhoic arthritis is also added affection of the 
 periarticular tissue.
 
 JOINTS 455 
 
 Late syphilis sets in years after the initial 
 attack has been overcome with or without fever 
 and even without swelling in any of the joints. 
 In such cases where doubt exists it is advisable 
 to resort to antirheumatic therapeutic measures. 
 With negative results we know that the disease 
 is not rheumatism but of a tuberculous or syphi- 
 litic nature. The Wassermann reaction and 
 antiluetic remedies will clear up the situation 
 still further. Remember also that tuberculosis 
 is indicated by the presence of a pronounced 
 splenic tumor. 
 
 There are other cases of indubitable aortic 
 insufficiency with slight dilatation of the heart 
 in which the anamnesis lays bare a pristine 
 attack of syphilis or acute articular rheumatism. 
 And again, I have seen individuals with unde- 
 niable gonorrhea who were suffering from pains 
 and swellings in several joints and yet they 
 proved to be cases of genuine syphilitic articular 
 rheumatism. 
 
 Multiple enlargements of the lymphatic glands 
 are of importance in the diagnosis not only of 
 syphilitic conditions but particularly so of acute 
 rheumatism in the joints. As a rule they are 
 strung together in chains or in groups around 
 the affected joint and are sensitive on pressure. 
 Both these qualities are helpful in differentiating 
 between syphilis and acute articular rheumatism.
 
 456 GENERALIZED PAIN 
 
 In the former the swellings are universal and 
 indolent, in the latter sensitive and regional. 
 
 In the Still-Chaufford disease of which we 
 have all seen so much during recent years, we 
 find multiple swellings of the lymphatic glands 
 with multiple affections of the joints, (also 
 accompanied by swelling and articular pain) in 
 every form of the ailment from the subacute to 
 the subchronic stage; sometimes also periodic 
 or else continuous subfebrile temperature. The 
 joints are painful and disfigured more in the 
 sense of multiple chronic articular rheumatism 
 without ankylosis , the glands are fused and 
 tumefied, those in the armpits may lie so deep 
 that they escape attention unless the patient is 
 examined in an upright posture (the histologic 
 examination of excised glands does not show 
 a distinctive pathological tissue form but only 
 the picture of a simple fibroadenitis). We 
 further find a moderately hard splenic tumor, 
 vasomotoric disturbances (cold hands), exoph- 
 thalmos, tachycardia and slightly raised temper- 
 ature. In some cases we may also observe a 
 slight tuberculous apex affection, or indurated 
 mediastinitis or a questionable pericardiac con- 
 cretion with the heart. In my experience I 
 have found on several occasions that the general 
 as well as the local reactions in the joints and 
 glands to bovine tuberculin were very much 
 stronger than to the human product, i.e., the
 
 JOINTS 457 
 
 curative qualities of the former were more strik- 
 ing and satisfactory, for which reason I took, 
 at any rate, several cases of this disease as a 
 specific form of bovine tuberculous articular 
 rheumatism. 
 
 In acute leucemia enlargements of the joints 
 and glands are by no means a rarity. 
 
 There is another form of typical chronic, 
 articular rheumatism, though not very common, 
 with strong pains, exudation in the joints and 
 ulnar position of both hands which we may 
 witness in young women. We shall find chronic 
 indolent lymphatic swellings in the armpit as 
 well as in the forearm, not a trace of tuber- 
 culous affection in the whole system, but evident 
 endocarditis of some standing and mitral sten- 
 osis and insufficiency. The genesis seems to be 
 not subject to doubt. 
 
 Among the infectious articular rheumatoids 
 or pseudo-rheumatisms I name here first scarla- 
 tinous polyarthritis, a polyarthritis which ap- 
 pears in the second or towards the end of the 
 fourth week of the disease. It is a serous, some- 
 times a purulent affection of various joints, 
 finger, hand, foot or knee, often accompanied 
 by pericarditis, more rarely by endocarditis. 
 When it follows on top of a purulent arthritis 
 it assumes a septic pyemic character. It differs 
 from the common form of articular rheumatism 
 insofar that it does not, like the latter spread
 
 458 GENERALIZED PAIN 
 
 by leaps, as it were, from one joint to others, 
 but persists in the affected parts to disappear 
 again after three or four days. The joints may 
 be similarly affected in smallpox, chickenpox, 
 erysipelas, possibly with endo-myocarditis, and 
 also in influenza, but with more frequency in 
 or after pneumonia. In other localized diplo- 
 coccus infections, e.g., ulcerating teeth or otitis, 
 generally only one joint, preferably the shoulder, 
 is involved unless streptococcic infection super- 
 sedes. It follows also in the wake of dysentery 
 (with stubborn persistence in a single joint), the 
 same as in ulcerous colitis complicated with 
 endocarditis. The attack survives the original 
 sickness for a considerable span of time and 
 sometimes only sets in as an aftereffect when 
 the characteristic intestinal manifestations have 
 already gone away. 
 
 Under the last named conditions pseudo-rheu- 
 matism in colitis may set in all of a sudden after 
 a chill, with high fever, intensive pains, immo- 
 bility and swelling of the joint with reddening 
 of the skin, to last for several months. Con- 
 siderable disfiguration and periarticular muscu- 
 lar atrophy are seen, and yet complete recovery 
 takes place, sometimes after cecostomy. 
 
 In sporadic instances of multiple articular 
 pain and swelling after dysentery we may have 
 to deal with a case of septic polyarthritis instead 
 of the aforementioned toxic pseudorheumatism
 
 JOINTS 459 
 
 when the blood becomes irritated by the invasion 
 of bacteria (e.g., streptococci) into the blood 
 from an intestinal ulcer. The blood test will 
 confirm this. Even in ordinary diarrhea enteric 
 polyarthritis may be observed. Although here 
 the local reddening of the skin, heat, sweating 
 and cardiac complications are not in evidence 
 and salicylic remedies prove ineffective, we often 
 find conjunctivitis and urethritis in company 
 with this disease. 
 
 Mono- and polyarthritic conditions are not so 
 common in epidemic cerebrospinal meningitis 
 (see "Sacralgia"), or in epidemic encephalitis, 
 in malaria,, (especially tropical malaria, and the 
 chronic type with intermittent articular swell- 
 ings) or in diphtheria, but are very rare in 
 measles, German measles, whooping cough, vari- 
 cella and spotted typhus, although in all these 
 diseases they are more in the nature of arthral- 
 gias of an infectious toxic origin. 
 
 A similar state exists in the initial stages of 
 tetanus. In leprosy very severe pains and swell- 
 ings in the joints with fever prevail analogous 
 to syphilitic polyarthritis and periarthritLs. 
 These arthralgias either accompany the incipient 
 stages of the infection or develop gradually dur- 
 ing its course. If the former is the case an 
 erroneous diagnosis of acute articular rheuma- 
 tism or a sepsis is not excluded, for instance, in 
 smallpox in which articular pains are often
 
 460 GENERALIZED PAIN 
 
 predominant. Here we must be guided by the 
 other early signs, namely pains in the sacrum, 
 prodromal exanthema, the eruption of papules 
 on the mucous membranes of the eyes, mouth 
 and throat, negative bacteriologic findings, cyto- 
 logic condition of the blood (in sepsis leucocyto- 
 sis, leucopenia with neutrophilia or lymphopenia, 
 in variola leucocytosis and monocytosis). In 
 influenza arthralgias are very common. 
 
 Serum injections frequently cause articular 
 swellings and local pain, also in lymphatic 
 glands, with high temperature and marked dis- 
 turbances in the general condition of the body; 
 even herpes and albuminuria may be concomit- 
 ant factors. After two or three days these 
 manifestations disappear again. The absorption 
 of any hydropic fluid, e.g., of a serous, tubercu- 
 lous pleural exudate, in the system has the same 
 effect, an anaphylactic manifestation, no doubt, 
 due to the influence of endogenous albumin. 
 
 In paroxysmal hemoglobinuria the pains in 
 the joints are not accompanied by swellings or 
 other articular changes and disappear with the 
 attack. 
 
 Very tenaceous pains go with recurrent fever, 
 especially in one or more of the larger joints, 
 but without swelling. Sometimes they are of 
 such a vicious character that they are easily 
 taken for articular rheumatism, but the tempera- 
 ture, the enlargement of the spleen and the
 
 JOINTS 461 
 
 presence of spirochetes in the blood will soon 
 bare the error. 
 
 In dengue fever pains and enlargements in 
 the joints, reddening of the skin, fever, affecting 
 one joint after another, are typical symptoms 
 of the disease. A false diagnosis of acute arti- 
 cular rheumatism or of acute influenza is not 
 among the impossibilities. The geographical 
 locality in which the disease occurs must be 
 considered. Generally speaking a close obser- 
 vation of the course taken by the malady will 
 secure a positive diagnosis, especially if one 
 bears in mind that besides the symptoms already 
 enumerated there exist also stiffness in the knee 
 and other joints, likewise in the vertebrae, loss 
 of appetite and a thickly coated tongue. The 
 fever is on the wane within three to seven days, 
 perspiration is copious, but a few days later 
 high temperature returns, the articular pains 
 come back and with them exanthema appears 
 in the face, on the hands and the forearms, simi- 
 lar to purpura or measles. The skin peels off 
 soon afterwards and a slow recovery ensues. 
 
 In Malta fever the patient suffers from mul- 
 tiple pain chiefly in the larger joints which set 
 in about two weeks after the beginning of this 
 pseudotyphoid disease. The principal symptoms 
 are gradual rise of temperature, chills, continu- 
 ous remittent or intermittent fever, frequent 
 heavy sweating, thickly coated tongue, nausea,
 
 462 GENERALIZED PAIN 
 
 vomiting, constipation, meteorism and acute 
 splenic tumor. The pains are of a rheumatic 
 nature affecting one or more of the joints. We 
 notice swellings and local reddening of the skin, 
 serous extravasations in the shoulder, hip or 
 knee joints for a month or so. When the acute 
 articular affections make their appearance at 
 the very beginning of the disease, as seems to 
 be the case sometimes, the differential diagnosis 
 from acute articular rheumatism is not so easy. 
 The agglutination test for micrococcus meliten- 
 sis and certain clinical signs such as painful 
 testicles should, however, positively distinguish 
 this disease from articular rheumatism as well 
 as from septic polyarthritis. This refers with 
 like force to those cases in which a metastatic 
 purulent arthritis results from Malta fever. 
 
 More difficult is the differentiation from ab- 
 dominal typhoid, especially arthrotyphoid. This, 
 of course, refers only to those cases in which 
 pains in several joints with swelling and redden- 
 ing accompany the symptoms of typhoid. The 
 resemblance to acute articular rheumatism may 
 here easily lead to some mistake. But when 
 we observe that the affection does not bound, 
 as it were, from one joint to various other joints, 
 that the characteristic perspiration is wanting 
 the diagnosis of abdominal typhoid should be 
 made positive, especially in the presence of a 
 tumor in the spleen, of bronchitis, of a diazo
 
 JOINTS 463 
 
 reaction (when urobilinogenuria is absent), of 
 leuco- and neutropenia with lymphocytosis and 
 eosinophilia, not to forget the bacteriological 
 blood test and the Gruber-Widal reaction. It 
 is worth while also to remember that in abdom- 
 inal typhoid fever secondary, mostly purulent 
 articular affections make at times their appear- 
 ance. They are of great importance for a cor- 
 rect etiologic diagnosis. Especially in children 
 localized pains in the cervical spine with wry- 
 neck have been observed which makes it advisable 
 to think of a possible typhoid infection when 
 dealing with a case of feverish torticollis. 
 
 That antityphoid serum may cause articular 
 pains has already been mentioned. But I will 
 add here that acute polyarthritis with light fever 
 and a septic aspect may originate in a typhoid 
 carrier by way of auto-intoxication thus pro- 
 ducing a typhoid badllary septicemia. 
 
 In paratyphoid articular pains and swellings 
 of an infectious toxic nature may also be ob- 
 . served. In fact the paratyphoid bacillus may in 
 some instances be the causative element of an 
 acute, purulent arthritis. In a like manner 
 multiple affections of the joints may be con- 
 ditioned by a coli infection, i.e., in severe cases 
 of enterocolitis. Or in the absence of a coli 
 infection the articular pains can just as well 
 be merely the expression of a coli bacillosis. 
 
 I have already mentioned in another place
 
 464 GENERALIZED PAIN 
 
 that in trichinosis a paratyphoid state combined 
 with articular pains is not an unusual occur- 
 rence. 
 
 While speaking of the differential diagnosis 
 between arihrotyphoid and articular rheumatism 
 I wish to call attention to another point of im- 
 portance. It is this: abdominal typhoid, like 
 many other infectious diesases, is apt to revive 
 a dormant articular rheumatism with all its pris- 
 tine pains and changes in the very joints which 
 were affected by the primary attack. In other 
 words every acute infectious disease that is cap- 
 able of producing morbid conditions in the joints 
 may be the connecting link between the infection 
 and genuine acute articular rheumatism. Ty- 
 phoid and gonorrhoic polyarthritis are by no 
 means an impossible combination. 
 
 Glanders (malleus) in the acute form bears 
 a stronger resemblance to septic pyemia than 
 to articular rheumatism. In the primary stages 
 of this disease we observe a painful infiltration 
 of the skin which rapidly develops boils typical 
 of farcy; the surrounding lymphatic glands and 
 vessels are inflamed; the nose is infected with 
 a specific form of rhinitis and sores form along 
 its margin and in the mucous membrane. But 
 when these typical symptoms are not present 
 we only gain the impression of a general severe 
 septic pyemia, the more so as towards the end 
 of the first week the eruption in the skin looks
 
 JOINTS 465 
 
 very much like a multiple, at first papular, then 
 pustular exanthema. Most conspicuous are the 
 multiple affections of the joints and muscles 
 by purulent exudates, the formation of pustules 
 on the skin and the mucous membranes, of ab- 
 scesses in the muscles and pus under the skin, 
 genuine guiding symptoms for a correct diag- 
 nosis, which may be further assisted by the 
 anamnesis (contact with animals), bacteriologic 
 examination of the pus, etc., for the presence 
 of the malleus bacillus. 
 
 The diagnosis, of course, will be more difficult 
 when an acute attack after several days of con- 
 tinuous fever with very severe pains suddenly 
 develops swelling of one or more joints, thus 
 simulating a multiple septic arthritis. But we 
 shall find safety from error if we consider the 
 following points. Malleus shows a distinct, 
 diffuse reddening of the skin of a deep hue as 
 in erysipelas, almost brownish red, a simulta- 
 neous infiltration of the skin which subsequently 
 reaches into the muscles, and cutaneous pustules 
 typically characteristic of malleus. 
 
 Farcy sometimes travels under the guise of 
 subacute disease. It is then somewhat difficult 
 to arrive at a proper conclusion. The main 
 points to keep in view are always: examination 
 of the blood, livid red coloration of the skin over 
 the affected joint, edema tous infiltration of the 
 surrounding parts, mild febrile conditions and
 
 466 GENERALIZED PAIN 
 
 general indisposition. I may add that chronic 
 malleus may persist for several months. 
 
 Sporotrichosis is likewise connected with arti- 
 cular pains and sometimes with hydrarthros. The 
 presence of subacute, gummatous nodes, fistulas, 
 resemblance to tertiary syphilis, and Beurmann's 
 sporotrichon should be sufficient evidence for 
 a correct diagnosis. 
 
 Periarteritis nodosa presents sometimes a sep- 
 tic aspect with sporadic pains and swellings in 
 several joints. The diagnosis is fully discussed 
 in "Abdominal Pain" and in the section on 
 "Muscular Pain," and will again be referred 
 to under "Typhoid Diseases." 
 
 Acute leucemia is apt to be ushered in by 
 multiple articular pains and changes thus lead- 
 ing to the false impression of articular rheuma- 
 tism or septic polyarthritis. To differentiate 
 look for signs of scurvy in the mouth, more 
 generalized glandular swellings, harder consis- 
 tence of the splenic tumor, progressive pallor 
 and tendency towards hemorrhages, and do not 
 neglect the blood test. Our present state of 
 knowledge does not in any way clear up the 
 relation of myeloid leucemia to streptococcic 
 sepsis, for we must remember that in sepsis both 
 myelocytes and lymphocytes may be found in 
 the blood. 
 
 In eri/sipeloid pain and bulging are observable 
 in the middle joints of the fingers. The color
 
 JOINTS 467 
 
 of the skin is of a bluish, violet tint and reaches 
 out in tongue-shaped extensions with pale spaces 
 between them. 
 
 Rheumatic peliosis with multiple articular 
 pains and prominences distinguishes itself from 
 articular rheumatism by periarticular hemor- 
 rhages especially on the minor surfaces of the 
 extremities. Still it is wise to bear in mind 
 that arthralgias are not an uncommon occurrence 
 in the beginning of purpura hemorrhagica and 
 likewise in scurvy. In the latter disease par- 
 ticularly severe pains are caused by hemorrhages 
 into the joints which become enormously en- 
 larged almost reaching the stage of an anky- 
 losis. 
 
 In hemophilia and hemophilic hemarthrosis 
 the hemorrhages into the joints cause exquisite 
 pain therein. If there is also high temperature 
 and we are not aware of the fact that the patient 
 is a bleeder, we may easily be led astray and 
 make a diagnosis of articular rheumatism or 
 even of acute monarthritis. A careful anam- 
 nesis is of paramount necessity in all such cases. 
 Additional adjuvants are found in the presence 
 of other hemorrhages, diminished coagulation of 
 the blood during the intervals which gradually 
 reaches the normal stage with the ensuing hemor- 
 rhage (extravascular coagulation), and concom- 
 itant lymphocytosis with a normal count of the 
 blood platelets. Hemarthros ends either in a
 
 468 GENERALIZED PAIN 
 
 slow recovery or degenerates into a chronic con- 
 dition with resulting ankylosis. 
 
 I will now speak of those articular diseases 
 which are not necessarily of a metastatic origin. 
 
 Foremost among these is gout, a constitutional 
 disease which is more frequently the causative 
 factor of monarthritis than of polyarthritis. If 
 it affects only one particular joint, for instance, 
 that of the big toe (podagra) or at any rate 
 only the distal joints of the lower extremities 
 we have a very fair proof of its monoarticular 
 nature. But gout may also attack the upper 
 extremities (chiragra, omagra) or some other 
 joint, or even quite a number of joints. In any 
 case it is always characterized by the fact that 
 the pains generally set in after midnight, or if 
 they do come on in the daytime they grow 
 worse during the night. The patient is slightly 
 feverish, the skin shows a velvety blush which 
 tapers into the normal of the surrounding parts, 
 is shiny, tense and hot, with tactile hyperesthesia 
 and hyperalgesia, is marked with lymphangitic 
 stria?, and the cutaneous veins are puffed up. 
 The attack generally lasts from three to four 
 days or a week. This differentiates it from 
 articular rheumatism. 
 
 I have already said on a previous occasion 
 that gout is one of the hereditary diseases, also 
 that it is characterized by the peculiar behavior 
 of the uric acid in the blood (hyperuricemia)
 
 JOINTS 469 
 
 and that an attack may be. provoked by the 
 consumption of nucleins. But I will add here 
 that a multiple acute articular affection which 
 makes its appearance for the first time after 
 the age of 50 should arouse the suspicion of a 
 possible gouty involvement. But it does not 
 always prove true. On the other hand persons 
 who have suffered in bygone days from articular 
 rheumatism are not immune from an attack of 
 genuine gout in later years in the very joint or 
 joints that were involved by the previous attack. 
 I will refer to the differential diagnosis between 
 gout and other articular affections later on when 
 speaking of the rudimentary development of 
 this ailment. 
 
 Although the chrome form of multiple arti- 
 cular rheumatism shows a strong resemblance 
 in its incipient stages to the acute attack, yet 
 there are certain definite signs by which the two 
 can be separated. First of all there is the course 
 of the disease itself, then there is the fact that 
 in chronic rheumatism it is particularly the 
 joints, especially the small ones of the upper 
 extremities that are involved, there is no recov- 
 ery in the joints once affected when the disease 
 leaps into others, characteristic sweating is ab- 
 sent, but there is a prompt response to salicylic 
 treatment. Consider also moderate rise of tem- 
 perature, the stubbornness of the disease and 
 the rare occurrence of complicating heart dis-
 
 470 GENERALIZED PAIN 
 
 eases. I am inclined to believe that the origi- 
 nating force is to be found in some primary 
 affections of the oral cavities, more likely than 
 not in the tonsils. 
 
 There are other acute diseases which do not 
 originate from the joints themselves but from 
 adjacent parts such as the epiphyses of the 
 bones, and in consequence are mistaken for 
 acute rheumatic or septic arthritis. In such 
 cases we should always think of the possibility 
 of an existing osteomyelitis or syphilitic ostitis. 
 If only one joint is involved a monarthritis may 
 be simulated, but generally several joints are 
 affected. In purulent osteomyelitis the joints 
 are swollen and their integument is reddened, 
 the patient complains of local pain (more acute 
 in motoric action), chills and fever. If upon 
 careful scrutiny we find that pain and tender- 
 ness are more acute in the adjacent osseous 
 parts than in the joint itself and that the swell- 
 ing extends beyond the capsule, the diagnosis 
 of osteomyelitis is correct. The X-ray can 
 easily confirm such a finding, doubly assured 
 by the development of an edema and the livid 
 coloring of the skin over the affected part, the 
 presence of lymphangitic stria3 and the cordlike 
 appearance of the superficial veins. I may add 
 that in osteomyelitis fever and pain precede the 
 swelling, while in arthritis they come at one 
 and the same time. This is important insofar
 
 JOINTS 471 
 
 as a purulent monarthritis of metastatic origin 
 may easily obscure the primary infection. 
 
 Luetic ostitis is mentioned here because in it 
 gummatous growths are formed in the bone 
 under the peristeum nearest to the joint which 
 may be taken for mon- or polyarthritic condi- 
 tions. Analogously we find in arthritis gummosa 
 intermittent or periodic fever as a concomitant 
 of the gummatous affections of internal organs. 
 The anamnesis, the typical symptoms of syphi- 
 lis, the Wassermann reaction, specific treatment 
 and the Roentgen-ray should not leave the diag- 
 nosis in doubt. 
 
 Jacksch's disease is another carrier of articular 
 pains. The patient is subject to irregular at- 
 tacks of fever and to pains in the joints or in 
 the extremities. A careful study of the disease 
 shows that the pain is really located in the bones 
 and not in the joints, for the Roentgen-ray 
 distinctly reveals a thickening of the periosteum. 
 Salicylic treatment is ineffective which at once 
 speaks against rheumatism. But if endocarditic 
 complications accede, which is often the case, 
 the diagnosis may meet with obstacles. Much 
 help is derived from the clinical examination of 
 the blood for an increased number of polynu- 
 clear or eosinophile leucocytes and, perhaps, also 
 myelocytes. I cannot speak from personal ex- 
 perience as I have never seen a case of this 
 ailment. I must admit this also of tetanus, for
 
 472 GENERALIZED PAIN 
 
 which it is claimed that during the so-called 
 latent period dragging pains in the extremities 
 are in evidence in addition to swelling and red- 
 dening of one or more joints, even eruptions 
 resembling purpura as an expression of vaso- 
 motortic disturbances. In Basedovo's disease and 
 arthrogryposis similar observations have been 
 made. In bronchiectasy and pulmonary emphy- 
 sema, both closely related to osteoarthropathy, 
 the articular changes are subject to many fluc- 
 tuations; they come and go to reappear again 
 during many weary months. 
 
 The acute, painful, articular swellings at the 
 beginning of a multiple insular sclerosis find 
 their explanation in the presence of other initial 
 symptoms of this disease, such as painful pares- 
 thesias of the extremities, intention-tremor, nys- 
 tagmus, missing abdominal reflex by increased 
 tendon reflex, visual disorders, headaches, ver- 
 tigo, disturbances of speech and bladder. 
 
 In acute polyneuritis acute articular swellings 
 coupled with sensibility and motility disturb- 
 ances in other parts of the body are bound to 
 interfere with proper diagnosing. I say pur- 
 posely "in other parts of the body," because if 
 these symptoms manifest themselves in the im- 
 mediate surroundings of the swollen joints the 
 priginating' cause may be found in a secondary 
 periarticular neuritis due to the primary affec- 
 tion of the joint. The differential diagnosis,
 
 JOINTS 473 
 
 i.e., whether we have before us a case of a pri- 
 mary neuritis with a secondary articular swell- 
 ing, or vice versa, may be a difficult problem 
 to solve, because motoric impairment is evident 
 in both cases. It, that is the diagnosis, can only 
 be based upon the fact that "neuritic changes" 
 may exist in places where no articular swelling 
 can be proved, and upon the X-ray. (See 
 "Shoulder Pains.") 
 
 An attack of acute polyneuritis may be mis- 
 taken for that of acute articular rheumatism in 
 the absence of swellings dependent on polyneu- 
 ritis. But this error can be quickly mended by 
 a careful search for tenderness ig the muscles 
 and nerves, enlargements in the latter, sensi- 
 bility and motoric disorders and anomalous 
 tendon reflexes, all of which defects are claimed 
 by polyneuritis. 
 
 Ischias may be taken for gonitis. In both 
 the patient complains only of pains in the knee- 
 joint or close to it. Observations of tendon 
 and skin reflexes, pressure points and the appur- 
 tenant signs of ischias should prevent the error. 
 
 During the incipient stages of acute polio- 
 myelitis in children we may observe similar con- 
 ditions as in acute articular rheumatism, i.e., 
 the patient lies motionless in bed and complains 
 of pains in the arms and legs and all the mem- 
 bers of the body which are aggravated by any 
 attempt to move. Only the most exacting ob-
 
 474 GENERALIZED PAIN 
 
 servation of the tendon reflexes, lumbar punc- 
 ture ( ?) and the epidemiologic moment will 
 bring light in the situation. 
 
 Besides the diseases referred to in the fore- 
 going pages there are certain other rudimentary 
 forms of articular rheumatism to which we must 
 advert in this place. In mitigated articular 
 rheumatism the pains and anatomical changes 
 are of a less virulent, milder type, the disease 
 develops only in one joint with less pain and 
 less noticeable swelling. 
 
 The diagnosis will find much assistance in 
 the fact that the attacks come by leaps and 
 bounds now in this, then suddenly in another 
 joint, there is tendency towards perspiring, 
 hardly any fever, if at all, localization in small 
 as well as in larger joints and a prompt reaction 
 to salicylic drugs. The anamnesis is most useful 
 insofar as it generally reveals the fact of a pre- 
 vious attack of typical fullblown articular rheu- 
 matism. 
 
 These low grade polyarthritic forms are often 
 symptomatic of some mild septic infection. If 
 a catarrhal angina preceded the attack, the diag- 
 nosis may be somewhat troublesome, but the 
 symptoms described above should suffice to re- 
 move the doubtful element. 
 
 During the menstrual period high tempera- 
 ture, pain and swelling in the joints, general 
 indisposition are common affairs. In some in-
 
 JOINTS 475 
 
 stances they might arouse the suspicion of some 
 latent tuberculous condition, and it is advisable 
 to make proper inquiries in this direction. In 
 most cases they are, no doubt, due to bacterial 
 septic or toxic influences. The cause may also 
 be found in some lesion of the mucous mem- 
 brane of the uterus caused during delivery or 
 by some other interference. 
 
 But there is also a very mild form of purulent 
 osteomyelitis in which the patient complains only 
 slightly of pain and functional impairment of 
 the joints. The clinical points already men- 
 tioned before and the Roentgen-ray should make 
 the diagnosis positive. 
 
 If the affection is confined to one joint only 
 the differential diagnosis must decide between 
 rheumatic (also monarthritis rheumatica nodosa) , 
 gonorrhoic, syphilitic and uratic monarthritis. 
 In acute monarthritis we must also bear in mind 
 pneumococcic infection. 
 
 Acute tuberculous monarthritis is sometimes 
 mistaken for the rheumatic form. The symp- 
 toms are: a sudden sharp (sometimes only slight) 
 articular pain in the finger or in the hand, the 
 joint is swollen and its movement gives pain, 
 the skin over it is hot and tense, although at 
 times there is no rise in the local temperature. 
 Now if we find that the swelling is of a doughy 
 consistence and assumes the form of a spina 
 ventosa and that the skin over the joint has a
 
 476 GENERALIZED PAIN 
 
 dull, glazy appearance we are warranted to 
 decide in favor of tuberculosis, especially if in 
 addition fistulous formations should come into 
 evidence. 
 
 It is important to remember that a uratic 
 arthritis not infrequently follows a local articu- 
 lar injury. There may have been a contusion 
 or a distortion or some other traumatic condi- 
 tion, or pressure from a narrow shoe or a cold 
 of some sort which primarily caused the swell- 
 ing and impaired the motility of the affected 
 joints and finally degenerated into arthritis 
 urica. 
 
 Acute hemarthrosis in hemophilia is our next 
 point of consideration. In this disease we find 
 the development of a painful swelling (in the 
 early stage the pains are frequently absent) in 
 a joint, chiefly the knee or elbow, not always 
 accompanied by fever. It generally comes on 
 after a cold and sometimes is preceded by a 
 slight traumatic condition. The joint becomes 
 stiff and immovable, the hemorrhage in the joint 
 finds extension into one or two more and we 
 soon get the impression of an acute articular 
 rheumatism. If, however, lateral hemorrhages 
 appear in the skin and in the mucous membrane, 
 the diagnosis is soon turned in the right direc- 
 tion. When these dermal signs are missing the 
 only means to fall back on will be the anamnesis : 
 is there inclination to bleeding in other parts
 
 JOINTS 477 
 
 of the body; if so, is it a familial charasteristic ; 
 is the patient a male, his age there are cases 
 of hemophilia in females, but not many pres- 
 ence of lymphocytosis, reduced vascular coagu- 
 lability of the blood during the hemophilic hem- 
 orrhages while the extra-vascular coagulability 
 in the intervals between the fluxes is diminished? 
 Gradual return to normalcy during the course 
 of the disease. 
 
 Multiple articular pain without hemorrhage 
 in the joints is not a rarity in hemophilia, in 
 fact in every form of hemorrhagic diathesis 
 (scarlet fever, scurvy). 
 
 The pains in the joints or their swellings that 
 accompany hemorrhages into one or successively 
 into several joints may originate from other 
 causes, such as a spontaneous fracture of the 
 bones themselves, e.g., the neck of the humerus 
 or femur through a local neoplasm, e.g., mye- 
 loma or neoplasmatic metastasis. If motoric 
 impairment and crackling sounds accede, a false 
 diagnosis of acute mon- or polyarthritis may 
 result. A careful palpation, however, for pro- 
 tuberances either at the injured or any other 
 part of the affected bones and the Roentgen- 
 ray should forestall the mistake. 
 
 Acute arthropathy is only mentioned here as 
 a possible source of the pains described in this 
 department, but it will receive more detailed 
 attention in the following chapter.
 
 478 GENEEALIZED PAIN 
 
 II. Chronic Articular Pains 
 
 Many of the acute diseases described in the 
 preceding pages often become chronic in their 
 character in which state they manifest the same 
 morbid conditions and localized pains, for in- 
 stance, gonorrhea, tuberculosis, articular syphi- 
 litic affections, hemarthrosis in hemophilia and 
 scurvy. This refers principally to those lasting 
 changes (leading eventually to ankylosis) in 
 one joint only succeeding an attack of gonor- 
 rhoic or tuberculous articular rheumatism or else 
 of hemarthrosis, a rather important symptom in 
 these affections of the joints. 
 
 Gummatous arthritis is apt to show similar 
 results, for here, too, we come across swellings 
 of the smaller as well as the larger joints often 
 involving the entire head of the bone. Deform- 
 ing arthritis in tertiary syphilis of joints must 
 also be considered here. In most cases chronic 
 gummatous arthritis is monoarticular in its char- 
 acter. In both cases we shall find light in the 
 very conspicuous colateral affection of the epi- 
 physis and periosteum, in the anamnesis (prema- 
 ture births, abortions), in the nocturnity of the 
 pains, serologic blood test and the results of 
 specific treatment. In congenital syphilis, which 
 may cause likewise various chronic articular 
 conditions, the picture is often that of osteo-
 
 JOINTS 479 
 
 chondritis, or a simple sinovitis or arthritis 
 deformans. 
 
 Gout requires special attention in this place. 
 After one, chiefly after repeated typical attacks 
 we find a series of weaker attacks, but of longer 
 duration, with strongly marked exudates in one 
 joint; the painless intervals come to a stop, 
 deposits of uric acid begin to show up and a 
 crunching sound may be heard in the affected 
 joint; there is increasing stiffness, motoric inhi- 
 bition and subsequent deformity and ankylosis. 
 Hereditary gout will be dealt with in another 
 place. I will only mention here that the diag- 
 nosis in chronic gouty changes of one or more 
 joints is much assisted by the evidence of pre- 
 vious gouty attacks. 
 
 Chronic hy drops of one, chiefly the knee joint 
 it matters not whether a multiple articular 
 affection has preceded it or not should at once 
 remind us of a tuberculous if not a syphilitic 
 (congenital or acquired) or gonorrhoic condi- 
 tion, or of sporotrichosis, or of a chronic osteo- 
 myelitic, para-articular disease of the bones. In 
 hemophilia the appearance of a joint may be 
 changed by hemorrhage into it until it resembles 
 a chronic hydrops. This is particularly the case 
 in an affected knee joint. The differential diag- 
 nosis in all these processes is surrounded by great 
 difficulties. In case the anamnesis, the sero- 
 logic test and an attempted diagnosis ex ju-
 
 480 GENERALIZED PAIN 
 
 vantibus (anti-syphilitic treatment) lead to no 
 results, the cytologic and bacteriologic examina- 
 tion of the articular fluid, or in some instances 
 the X-ray examination of the joint itself may 
 prove successful. But there are cases in which 
 even the knife does not furnish unmistakable 
 proof of the nature of this disease. 
 
 There are other forms of chronic articular 
 infections with permanent pains of varying 
 intensity, and connected with inhibitory motoric 
 action, enlargements, changes in the outlines, 
 and certain anomalous conditions revealed by 
 the X-ray within the joints. Diplococci, staphy- 
 lococci, after-effects of diphtheria, scarlet fever, 
 influenza, etc., may be the provoking causes of 
 this acute infectious pseudorheumatism which 
 itself has borne from the very beginning the 
 character of a chronic evil or else degenerated 
 from the acute into the chronic state during the 
 course of the disease. If the latter was the 
 case, the diagnosis would be apparent, especially 
 when supported by bacteriological evidence. 
 
 Of the commoner forms of chronic articular 
 infections that are here concerned it is as yet not 
 possible to give a satisfactory survey because 
 the opinions of the present day clinicians vary 
 so much as to their classification and even no- 
 menclature. I prefer to adhere to the older 
 system which looks upon chronic rheumatism of 
 the joints as an atrophic process established by
 
 JOINTS 481 
 
 the Roentgen-ray, and keeps it separate from 
 chronic deforming arthritis which it considers in 
 the light of a degenerative hyperplastic articular 
 condition. By this system the first named affec- 
 tion is divided again into two subsections, viz., 
 primary and secondary chronic articular rheu- 
 matism. 
 
 The primary form which today is called 
 "primary chronic progressive polyarthritis," is 
 characterized by a slow creeping, sometimes sub- 
 febrile, but mostly fevereless beginning. It 
 progresses symmetrically from the small joints 
 of the fingers, toes and wrists. It has a chronic 
 course with many intervening remissions marked 
 with periods of increased virulence and tempera- 
 ture. The affected joints, especially the meta- 
 carpophalangeal ones, are swollen and nodose, 
 and thickened with spinous protuberances owing 
 to the enlargement of the caps of the bones or 
 in some rare cases through articular exudates. 
 The pain is, as a rule, sharper at the beginning 
 of the movement of the joints which themselves 
 are impeded in their actions if not rendered 
 helpless altogether. Quick motions are intensely 
 painful because the synovial villi are constricted. 
 
 The most characteristic criterion, however, is 
 the contorted shape of the finger- j oints. The 
 ungual phalanx is bent to one side, the meta- 
 carpophalangeal joint is abducted towards the 
 ulna, the wrist is enlarged, the distal end of the
 
 482 GENERALIZED PAIN 
 
 forearm is cylindrically thickened. The toes 
 also undergo changes. The big toe is, as a rule, 
 drawn away from or under the other toes. The 
 skin over the affected parts has generally a paler 
 tint and is of a doughy consistence, but grows 
 gradually very thin as the illness progresses, 
 seldom sclerodermic. Gradually the process 
 finds its way into the elbow and knee joints. 
 Ankylosis is one of the later symptoms. But 
 I have seen cases in which this affection, eschew- 
 ing slowness, settled with savage rapidity and 
 sudden feverish attacks simultaneously in sev- 
 eral of the small joints. 
 
 In the secondary I comprise every other form 
 of chronic articular rheumatism which had for 
 a precursor an attack of undoubted, typical 
 acute rheumatic polyarthritis. This secondary 
 form does often present the manifestations de- 
 scribed in the previous paragraph. More fre- 
 quently, however, the result is a chronic fibrous 
 ankylosed rheumatism, i.e., in one or more joints 
 enlargements of the caps appear, also of the 
 lateral ligaments of the joints and their ten- 
 dons until a complete fusion into one solitary 
 fibrous mass is formed causing complete rigidity 
 and ankylosis. This transformation may con- 
 tinue after the symptoms of acute rheumatism 
 have already disappeared if it has not completed 
 its course during the progress of the disease. 
 
 The differentiation between the secondary and
 
 JOINTS 483 
 
 primary form rests principally on the history 
 of the case and the nature of the articular 
 changes which are distinctly characteristic for 
 both affections. It is well to remember that 
 after an attack of acute articular rheumatism 
 pains will reappear in the affected joints from 
 time to time often for years influenced gen- 
 erally by metoreological conditions, likewise 
 painful minor swellings and stiffness which may 
 put the joint temporarily out of commission 
 until the normal state is gradually reached again. 
 
 The second form of classical chronic affections 
 of the joints is hypertrophic arthritis, more accu- 
 rately called deforming osteoarthritis. It runs 
 a slow, sneaking course, is not very painful and 
 does not interfere much with the motility of the 
 joints until later on in life. It may be also 
 polyarticular in its nature and attack the smaller 
 joints (especially in the spine). As a rule, it 
 affects at first only one of the larger joints, 
 the hip, shoulder, knee or the big toe, but sprouts 
 out from there into the other larger joints. 
 Anatomical as well as radiological examination 
 shows onion formations, which naturally affect 
 the motoric faculties of the joints more and more 
 until the latter become quite immovable and 
 very much deformed. Cardiac complications 
 are rare whilst in chronic rheumatism they are 
 ever plentiful. 
 
 There is another distinguishing sign to which
 
 484 GENERALIZED PAIN 
 
 I desire to call attention. In both the afore- 
 mentioned principal forms of chronic articular 
 disease the pains are generally aggravated by 
 any movement of the affected joint, whilst in 
 the initial stages of chronic articular rheumatism 
 and of deforming arthritis the pains, as a rule, 
 start with the transition from rest into activity 
 of the joint, is most acute during the first few 
 movements but declines in virulence or disap- 
 pears altogether with continued exercise. An- 
 other important sign in deforming arthritis 
 in fact in every painful anatomical joint disease 
 is this: a knock or a stroke on the elbow 
 produces pain in the corresponding shoulder; in 
 deforming omarthritis a kick on the heel or a 
 slap on the sole of the foot or on the bent knee 
 elicits a similar pain in the hip joint. This same 
 distinguishing sign is also found when in de- 
 forming arthritis the pain radiates into the entire 
 extremity with demonstrable tenderness on pres- 
 sure of the nerve roots thus simulating an ischio- 
 or brachial neuralgia. The decision should not 
 be hard to make for it is easy to see that this 
 overlapping painful zone really emanates from 
 the joint. Moreover in neuralgia the joint can 
 still be used although with discretion. 
 
 Chronic articular rheumatism due to ochrono- 
 sus deserves special mention. The presence of 
 homogentisic acid is the cause of this trouble 
 as well as of chronic endocarditis which so fre-
 
 JOINTS 485 
 
 quently accompanies it. The evidence of exist- 
 ing alcaptonuria and dysuria facilitates the 
 diagnosis. 
 
 Gout must be our next subject of considera- 
 tion. The chronic condition of this disease 
 evolves from one or more preceding acute at- 
 tacks, a fact upon which the positive diagnosis 
 must rest. In both forms we should look for 
 crepitant rales in the affected joints, especially 
 the knee-joint, for chronic inflammatory changes 
 in the joints due to deposits of uric acid, and 
 to subsequent deformities, structural anomalies 
 and ankylosed conditions. Uratic deposits in 
 the softer parts around the joints (tophi) are 
 often the causative factor of these changes. The 
 fingers appear swollen or thickened in certain 
 parts and twisted out of shape, the wrists ulnad. 
 The toes, especially the metatarsophalangeal 
 joint of the big toe, are bent in a devious man- 
 ner under the other toes, thus forming, as it 
 were, a foundation for them. This abnormal 
 position may, however, be due to chronic articu- 
 lar rheumatism or to ill-fitting shoes. The pres- 
 ence of gouty nodes would be clinical evidence. 
 
 These nodes are often found on the helix of 
 the ear, but chiefly around the joints, with pref- 
 erence about the olecranon. They rise from 
 the subcutaneous tissue, from the synovial sacs, 
 rarely from the periosteum or the nerve proc- 
 esses and develop gradually but without causing
 
 486 GENERALIZED PAIN 
 
 pain. If their origin is derived from any other 
 source they may be recognized by sliding them 
 about over the bone. Otherwise the diagnosis 
 can be made from their soft, doughy feeling 
 and by needling a young tophus when a white, 
 chalky, mushy mass exudes which consists essen- 
 tially of uric acid and its salts. This is also the 
 case when this exudation breaks spontaneously 
 through the skin leaving a scar in the place of 
 the former fistula. Beneath the scar prickly 
 points or horns may be felt. 
 
 If the nodes are stony hard the diagnosis may 
 be rather difficult to make owing to the fact that 
 such protuberances are also observed in chronic 
 articular rheumatism. (The differentiation be- 
 tween these and Heberden's nodes will be dis- 
 cussed later on.) In such a case it is wise to 
 fall back on the Roentgenogram, the blood test 
 for uric acid after a purin-free diet. 
 
 Notice also that the morbid conditions of the 
 joints in chronic gout are quite abnormal and 
 so different from those prevailing in chronic 
 rheumatism: in the latter, simultaneous and sym- 
 metrical attacks and an even disfiguration of 
 several joints, in gout, asymmetry of the joints, 
 affection of one joint only, perhaps nodes on 
 only one joint thus making the asymmetrical 
 appearance of the various joints more drastic. 
 
 In gout the crepitus (especially in the knee- 
 joint) is more like the crackling sound over the
 
 JOINTS 487 
 
 lungs, while in chronic articular rheumatism it 
 is of a coarser character and sounds more like 
 friction or large bubbles exploding. This is 
 particularly the case in deforming arthritis. If 
 the pains are felt more acutely during the night 
 time and begin to tone down towards morning 
 it speaks rather for gout, because in chronic 
 rheumatism the painfulness awakens with the 
 sleeper's first movements as he tries to rise from 
 the couch. Nevertheless these conditions are 
 sometimes reversed in different patients. 
 
 Of course these are clinical points which estab- 
 lish the genesis of a gouty affection: such as 
 hereditary conditions, the life led by the patient, 
 preceding or concomitant manifestations of 
 chronic gout, chronic-uratic diathesis, the patient 
 is subject to catarrh in the air passages or to 
 asthmatic attacks, to iritic or sclerotic affections, 
 dyspeptic or neuralgic troubles, localized pains, 
 e.g., achillodynia or tarsalgia, cramps in the 
 calves, eczema, hemorrhoids, glycosuria, con- 
 tracted kidney and nephrolithiasis, likewise in- 
 creased uric acid content in the venous blood 
 even with a purin-free diet. 
 
 The assumption that severe pains in the big 
 toe point to a gouty affection often enough leads 
 to a mistaken diagnosis and wrong therapeutic 
 measures. Frequently what is taken for gout is 
 only a case of chronic arthritis caused by the 
 (wearing of shoes which are too narrow or pointed
 
 488 GENERALIZED PAIN 
 
 at the toes more often observed in women. 
 The tightly fitting footwear forces the big toe 
 into a valgus position, the metatarso-phalangeal 
 joint is misshapen and the synovial villus is 
 badly squeezed in. The resulting pains strongly 
 resemble those caused by gout, and yet a narrow 
 boot may arouse a gouty attack from its slum- 
 bers. 
 
 That periarticular gouty tophi are apt to be 
 mistaken for Heberden's nodes is only men- 
 tioned here. The subject will be discussed more 
 fully later on. To take a cutaneous tophus 
 erroneously for a cystic growth or a small ab- 
 scess or a milium, or else for a ganglion if seated 
 in a synovial sac, seems to me well nigh impos- 
 sible if a careful inspection is made. The error 
 might be pardoned when concretions on the 
 helix are observed which may be a congenital 
 malformation on the ear, or a cartilagenous 
 defect caused by frostbite resembling a patho- 
 logical condition. The microscopic examination 
 of the tissue and the anamnesis should remove 
 any false impression. 
 
 Sebaceous cysts form sometimes on the car- 
 tilage of the ear and may be misinterpreted for 
 gouty nodules, but it is easy to distinguish be- 
 tween them as the former are softer to the touch 
 and are seated in the subcutaneous cellular tissue, 
 while the gouty formations are harder and sprout 
 from the cartilage with which they even coalesce
 
 JOINTS 489 
 
 as they grow older. On palpation, it seems to 
 me, the sebaceous cyst presents a hard but uni- 
 formly smooth surface whilst the gouty tophi 
 have more of a sandy feel in them. If in doubt 
 the chemical test will decide the presence of 
 uratic contents. 
 
 There are cases in which we find a combina- 
 tion of both diseases, viz., chronic gout and 
 chronic rheumatism of the joints. In these 
 cases the gouty affections generally select those 
 joints in which the rheumatic virus has already 
 settled. An early uratic diathesis often lays 
 the foundation for chronic articular rheumatism 
 or gout in later years. When I use here the 
 expression "chronic articular rheumatism" I 
 mean only that affection which is entirely free 
 from gouty symptoms and presents purely the 
 typical features of the disease. In many cases 
 of this kind I could find no therapeutic results 
 whatever from the administration of antiuratic 
 remedies, whilst they reacted promptly to the 
 measures which it is customaiy to apply in 
 chronic rheumatism. 
 
 It is by no means an uncommon occurrence 
 in every day practice to come across cases of 
 chronic uratic diathesis in which complaints of 
 chronic pains in almost any possible joint are 
 ripe. And yet a most careful scrutiny discloses 
 no crepitus or deformity, not to speak of gouty 
 tophi. Here it is wise to be guided by the hered-
 
 490 GENERALIZED PAIN 
 
 itary and constitutional idiosyncrasies of these 
 chronic sufferers. The diagnosis must depend 
 rather upon a reliable blood test than the cus- 
 tomary overestimated examination of the urine 
 which from the standpoint of present day science 
 is of a minor significance in these cases. Copious 
 residue of the largest possible amount of uric 
 acid and diminished Zerner's coefficient can at 
 the very best only suggest the thought of gout. 
 
 Basedow's disease, hyperthyreoidism will in 
 some rare instances be found associated with 
 typical chronic progressive polyarthritis with 
 exudations in the joints and must be looked 
 upon as a thyreoprival affection which compli- 
 cates the disease but not the diagnosis. 
 
 Gout may be, according to some authors, 
 associated with a second metabolic anomaly, viz., 
 oxalemia and oxdluria. They also combine with 
 diabetes mellitus and obesity. The clinical signs 
 are claimed to be abnormal fatigue, chronic dys- 
 peptic and neurasthenic troubles, kidney colics, 
 albuminuria, hematuria and chronic pains in the 
 joints. The proof for its existence is to be 
 found in the exaggerated amount of oxalic acid 
 in the blood equal to from three up to ten times 
 above the normal content which is at the utmost 
 1 eg. in 1000 ccm. 
 
 Chronic articular affections are often com- 
 bined with psoriasis (arthropathia psoriatica) . 
 (This does not refer, however, to isolated pains
 
 JOINTS 491 
 
 in the joints in the shape of mere acute after- 
 effects.) I am not able to give a correct classi- 
 fication of this subdivision of articular affections. 
 
 Chronic swellings in the joints come under 
 our observation sometimes during the course of 
 scleroderrma. Patients afflicted with myxedema 
 (thyreoprival articular rheumatism) complain 
 of chronic pain in the joints of the hands and 
 feet. We find the same condition also in adre- 
 nal affections (Addison's disease ~, tumors). Ar- 
 ticular changes have also been reported in 
 myositis ossificans, in osteopsatyrosis and in 
 Paget's ostitis. Their genesis has never been 
 properly cleared up and I myself cannot speak 
 from personal experience regarding them. 
 
 On the other hand chrome tuberculous articu- 
 lar diseases are of greater importance. The 
 diagnosis will find much help in the considera- 
 tion of the regular tuberculous symptoms such 
 as the usual manifestations, swelling in the 
 glands, anal fistulae, comptodactylia in the ring- 
 finger, reaction to tuberculin and perhaps a 
 complementary restringent reaction. There is 
 a distinct difference between this and the com- 
 mon chronic articular rheumatism. The former 
 begins, as a rule, in the larger joints, the knees 
 and the hips, but when it reaches the finger 
 joints the spindle formed swellings make their 
 appearance rather in the joint between the 
 middle and ungual phalanx, whilst in ordinary
 
 492 GENERALIZED PAIN 
 
 chronic articular rheumatism the joint between 
 the proximal and middle phalanx is affected. 
 And again, in the tuberculous form the promi- 
 nence comes into view in only one finger, when 
 in the other several or all the fingers are simul- 
 taneously attacked. The Roentgen picture 
 shows highly marked differences between the 
 two. Chronic syphilitic articular rheumatism 
 (pseudotumor albus lueticus) is another possi- 
 bility that requires our attention in this connec- 
 tion. 
 
 Nervous Affections of the Joints 
 
 Patients troubled with hemiplegia are wont 
 to complain of pains which come on either spon- 
 taneously or by passive movements mainly in 
 the shoulder joints. They are, no doubt, due 
 to a tension of the capsular ligaments caused 
 by the dead weight of the paralyzed arm, for 
 they disappear when the arm is properly sup- 
 ported. 
 
 Analogous pains are felt in the spinal cord 
 in poliomyelitis, but in tabes and syringomyeUa 
 the pains are of a different kind. Here they 
 settle with special viciousness principally in the 
 joints of the larger extremities. The diagnosis 
 is rendered more difficult by the fact that these 
 pains, like all lancinating pains are largely in- 
 fluenced by weather conditions, damp, clammy 
 days being the worst offenders. The conven-
 
 JOINTS 493 
 
 tional symptoms of myelonal affections should, 
 however, correct any possible error as to their 
 true nature. 
 
 Cerebral diseases of a hemiplegic character 
 are also guilty of producing articular pains 
 which are felt along the lines of the nerve paths 
 in the corresponding half of the body or its 
 extremities. Sometimes they are continuous, 
 sometimes intermittent, neuralgiform in char- 
 acter. Sometimes they are precursors or com- 
 panions of locomotor paresis and at other times 
 they follow in the wake of it. The diagnosis 
 is fully given in the chapter on "Pains in the 
 Extremities." In spastic hemiplegia the pains 
 may also be due to a change in the static ele- 
 ment of the joint caused by the increased 
 muscular tonus. 
 
 In chronically diminishing muscle tonus (atro- 
 phies and tabes) articular changes and pains 
 develop in a similar manner. 
 
 The trophic disturbances in the joints which 
 manifest themselves in arthropathies, in tabes 
 and syringomyelia are the natural progeny of 
 other diseases in the central nervous system. 
 Their resemblance to deforming osteo-arthritis 
 and to chronic articular rheumatism, especially 
 in syringomyelia, is so pronounced that even 
 prominent neuropathalogists are at times misled 
 into a false diagnosis. This is principally due 
 to the fact that the arthropathy whose seat is
 
 494 GENERALIZED PAIN 
 
 as a rule in the upper extremities, i.e., shoulder 
 and elbow joints, does not come on suddenly 
 but very slowly and is one of the first symptoms 
 of the disease and at a time when the sensibility 
 of the joints is still unimpaired. The patient 
 complains of pain in the affected parts while 
 arthropathy is still in the hypertrophic stage in 
 which the swelling of the joint terminals and 
 the osseous new growths in the articular capsules 
 are only beginning and even exostosis on the 
 diaphyses is forming. 
 
 On the other hand there is always the risk 
 of mistaking the swellings in the finger joints 
 due to syringomyelia for a symptom of chronic 
 articular rheumatism. To avoid this error we 
 must look closely for muscular atrophies, trophic 
 conditions in the fingers, painless whitlows, 
 scoliosis, spastic paresis in the lower legs, and 
 bulbar symptoms the most important of which 
 is dissociated insensibility to pain. 
 
 It is much easier to differentiate between 
 tabetic arthropathy and deforming arthritis. The 
 former comes on suddenly with large, painless 
 swellings in the joints that may extend over the 
 whole extremity. It may also follow on the 
 heels of paresthesias in the articular region or 
 in the joints themselves. The presence of free 
 bodies in the joints unaccompanied by pain, 
 grating on motion and crackling sounds are 
 characteristics. The lower limbs are the favorite
 
 JOINTS 495 
 
 site for attack in tabetic arthropathy, i.e., the 
 knee, foot and hip joints, but when the shoulder 
 is also involved tabes superior is rather indicated. 
 The X-ray and the usual typical symptoms are 
 the proper aids for a good diagnosis. Sponta- 
 neous fractures or infractions should not be 
 overlooked. 
 
 It may be of interest to mention here that 
 loose joints are often the consequence of acute 
 articular rheumatism and mongolism, undoubt- 
 edly due to an anomalous development of the 
 articular cartilages. 
 
 Diseases of the nervous system not only lead 
 to anatomical changes in the joints but also to 
 arihralgias and multiple sclerosis. 
 
 In neurasthenia the pain is, as a rule, less 
 intensive but rather of a dragging, pressing, 
 or burning kind. Often it consists simply of 
 an aching tired feeling. Bodily motion softens 
 or suppresses it altogether, whilst in chronic 
 articular rheumatism the pain is sharpened 
 thereby, although I must admit that here, too, 
 the change from rest into activity in the latter 
 case only awakens the pain sometimes which 
 tones down again and gradually disappears 
 under continued exercise. Of course, it goes 
 without saying that radiological articular changes 
 are not observed in neurasthenia. 
 
 The epileptic patient suffers also from pains 
 in the joints during the interparoxysmal period.
 
 4?96 GENERALIZED PAIN 
 
 Hysteria is another fertile ground for these 
 pains, with preference in the lower extremities 
 and more often due to some slight traumatic 
 influence. If the attacks continue for some time 
 a permanent fixation of the affected joint may 
 be the result, atrophy of the surrounding mus- 
 cles may also set in with secondary, trophic, 
 anatomical changes in the articular portion. 
 This makes it rather difficult to differentiate it 
 from organic articular affections. But the fol- 
 lowing points will be of great assistance: the 
 skin over the affected part has an hyperalgesic 
 appearance, the sense of pain is reduced by 
 distraction, the latter also allows of motions 
 which seemed impossible before, the pains are 
 sharpened when sympathy is shown the patient, 
 if the head of the joint is pressed firmly against 
 the acetabulum no pain is felt, but a slight 
 touch of the skin over it is exceedingly painful. 
 Naturally the X-ray is a great help in the 
 diagnosis of these cases. Still we must never 
 lose sight of the fact that even hysterical persons 
 may be afflicted with anatomical lesions of the 
 joints. 
 
 In some cases these articular pains without 
 manifest hysterical or neurasthenic stamp appear 
 as true articular neuralgias, that are sometimes 
 accompanied by vasomotoric changes in the 
 joints. One patient complains of pains in the 
 joints when he is walking, another claims that
 
 JOINTS 497 
 
 the pains disappear when he is moving about. 
 Of importance for the diagnosis of such cases 
 is the finding of pressure points and hyperes- 
 thesia of the skin over the articulation, espe- 
 cially when symptoms of an angioneuritic char- 
 acter, or fever articular inflammation or gout 
 are present. 
 
 In tabes dorsalis arthralgias may also be 
 observed, quite independently of arthropathy. 
 They arrive in sudden attacks, persist for sev- 
 eral days, sometimes for a whole week, are 
 located in the joints of the big toe but radiate 
 thence into other joints, and the affected parts 
 feel hot, so to speak, a veritable "tabetic pseudo- 
 gout." True gout generally comes on after 
 midnight, but these tabetic arthropathies seem 
 to prefer the time before or close to that period. 
 Objective tabetic symptoms should clear up the 
 situation. 
 
 Similar chronic arthralgias with local hyper- 
 esthesia of the skin may also follow in the wake 
 of chronic obstipation (autointoxication). Re- 
 move the cause and the symptoms will disappear. 
 
 The case is different in articular pains, espe- 
 cially in the hip or knee, which arises from 
 affections in the small pelvis or in the abdomen 
 nearest the hip such as hemorrhoids, diseases of 
 the rectum, the uterus, the bladder, the prostate 
 or in chronic appendicitis, and are felt in walking 
 or other bodily exercises, sometimes also during
 
 498 GENERALIZED PAIN 
 
 the night or when resting. Objective changes 
 in the joints are rarely found, but sometimes a 
 slight congestion or a crunching sound in the 
 joint may be noticed. However, muscular fixa- 
 tion, sensitiveness to pressure, an exquisite ten- 
 derness of the skin just over the affected joint, 
 in fact in the whole field of the morbid segment 
 and its corresponding nerve complex (n. ischia- 
 dicus, cruralis, saphenus) as well as paresthesias 
 may be expected. 
 
 Certain arthralgias may also parade as masked 
 malaria, while other recidivous forms spring 
 from a chronic osteomyelitic focus near to the 
 affected joint. In rachitis tar da we likewise 
 hear complaints of articular pains coupled with 
 unusual fatigue. Proof of hyperostosis (rosary 
 formation) on the ribs, of genu valgum (both, 
 however, of recent origin only), skiagrams of 
 the bones, also the examination of lime balance 
 should be winning features when forming the 
 diagnosis. 
 
 Of great importance is the fact that arthral- 
 gias are a prominent symptom of lead poisoning. 
 The blue line, clonus, the punctated erythrocytes, 
 etc., are the residual signs. 
 
 Lead is a strong factor in many severe arti- 
 cular changes, e.g., lead gout, gouty tophi, gouty 
 kidney. 
 
 A predisposition to gout is often the road 
 that leads to arthralgias, or rather to articular
 
 JOINTS 499 
 
 pain even though demonstrable and definable 
 changes in the joints themselves are not appar- 
 ent. Long before the real attack comes on, 
 even before clear clinical signs of gout are ob- 
 served, these cases will complain of transient, 
 recurrent pains, lasting sometimes for days, in 
 various joints or in one only, especially during 
 changes in the weather. Purin tests, hereditary 
 familial traits, observation of habitus in eating 
 and living should be guiding points. 
 
 Arthralgias (toxic) as accompanying symp- 
 toms in chronic uremia are of rare occurrence. 
 Objective sensitiveness upon pressure on the 
 joints may prevail it may also be absent. The 
 seat of the pains (often intermittent) may be 
 paraarticular. Whether there is an anatomical 
 subtratum for these arthralgias I am not pre- 
 pared to claim. But I can say this, that in 
 none of my cases the articular pains were in 
 the foreground, they were always surpassed by 
 the other morbid sufferings and in consequence 
 never an obstacle to the diagnosis. 
 
 Strictly distinct from these are the cases of 
 true articular gout due to the retention of uric 
 acid due to a preexisting primary or secondary 
 granulation of the kidney. The differential 
 diagnosis is selfevident. 
 
 Articular pains come also to the surface dur- 
 ing the climacterium and in the adolescent period 
 in girls.
 
 500 GENERALIZED PAIN 
 
 In adiposis dolorosa they often make move- 
 ment painful owing to the fatty deposits in the 
 joints which are also very sensitive to pressure. 
 
 In insufficiency of the thyreoid the articular 
 pains are outstripped by the other clinical signs. 
 
 Acute arthralgias are common in a whole 
 series of acute infectious diseases, especially in 
 their incipient stages, in all infectious pseudo- 
 rheumatisms and in the Wolhynian fever. 
 
 Intermittent articular hydrops deserves men- 
 tion here. It is partially due to nervous influ- 
 ences but also connected with acute swelling in 
 the affected joint or joints. As a partial symp- 
 tom of hydrops hypostrophos (Quinke's angio- 
 neurotic edema) (probably due to regional 
 venous cramps), it appears at times in exchange 
 with other manifestations of "exudative dia- 
 thesis" .asthma, urticaria, mucous colic, vaso- 
 motoric rhinitis, etc.), sometimes also as an 
 isolated condition, but principally in one of the 
 kneejoints or in both (hydrops genus intermit- 
 tens), or in some instances in one knee joint and 
 one or more joints in different parts of the body. 
 Fever or chills are rarely present, but often a 
 sudden and considerable infiltration in the af- 
 fected parts may be observed. This may not 
 be inhibiting movement and quite painless, 
 while in some cases the pains are very severe; 
 and again, whilst in some cases there is a rise 
 in temperature and the skin over the affected
 
 JOINTS 501 
 
 joint is reddened, in other cases it does not lose 
 its normal aspect. The course of the disease 
 is about 8 days. In some women it sets in 
 regularly before every menstrual flux; in other 
 patients it appears with regular periodicity. 
 The symptoms should be ample for the diagnosis. 
 
 But we must not forget that a hydrops chro- 
 nicus articulorum and not any the less an inter- 
 mittent hydrops articularis (the latter is also, 
 as a rule, the manifestation of an idiopathic 
 vasomotoric neurosis) may sometimes be only 
 a deuteropathic disease. It is found, though 
 rarely, in company with arthropathies in tabes 
 and syringomyelia, with Easedow's disease and 
 polycythemia, but may also be (but only when 
 in an independent state) the expression of a 
 tuberculous or heredo-syphilitic, more frequently 
 of a gonorrhoic affection. Hydrops artic. inter- 
 mittens of a joint, e.g., in the knee, may also 
 be caused and sustained by a chronic osteo- 
 myelitis. The fact that in every instance only 
 one joint is affected and the X-ray should be 
 sufficient for proper recognition. In neurotic 
 hydrops the affection settles now in this, but the 
 next time in the contralateral joint. 
 
 Heberden's nodes, about the size of a small 
 pea, are always connected with chronic arthritis 
 or chronic gout. They develop on the proximal 
 extremity of the ungual phalanx on the dorsal 
 side of the finger, preferably the little finger,
 
 502 GENERALIZED PAIN 
 
 either on one or both sides, are not always soft 
 but of different degrees of hardness, rather 
 painful and tending to become paresthetic. 
 Their presence impairs the motility and gradu- 
 ally bends them in a solar or radial direction. 
 As companions of gout or chronic arthritis they 
 are common enough, but there is an intimate 
 connection between them and an impairment 
 of the genital functions such as the climacterium 
 or the surgical removal of some internal genital 
 organ. 
 
 The differentiation between Heberden's nodes 
 and periarticular gouty nodes is not difficult, 
 unless the latter grow out from the periosteum 
 or the tendon roots in which case there is patent 
 motility in the bones while in the Heberden's 
 nodes there is none. In gouty nodes consistence 
 and touch are telling signs; they have an elastic 
 hardness of a granular, gravelly, warty, prickly 
 quality, while the hardness in Heberden's nodes 
 has a more even smoothness especially when 
 they get older. 
 
 The seat of the affection differs strongly in 
 both. Heberden's nodes choose the ungual pla- 
 lanx particularly of the little finger; the gouty 
 nodes and other articular affections prefer the 
 pedal extremities, with predilection the big toe. 
 In chronic gout or after acute gouty attacks 
 these nodes are formed but not exclusively 
 on the big toe, as they appear in other joints
 
 JOINTS 503 
 
 of the lower extremities as well. The X-ray 
 plainly shows a marked difference between the 
 kinds of nodes. It is my experience also that 
 Heberden's nodes which stand in causative con- 
 nection with gout and arthritis are, forsooth, 
 much more painful in themselves as well as 
 sensitive to pressure, than those which follow 
 upon impaired genital function. 
 
 Chronic arthritis of a very painful character 
 is quite common in stout, fat women of the 
 climacteric age. 
 
 Observe also that in this disease nodular for- 
 mations resembling the gouty nodes will appear 
 under the skin. The X-ray will plainly show 
 the difference between them. (Rheumatismus 
 articulorum nodosus ckromcus as against rheu- 
 matismus artic. nodos. acut.) Spontaneous pain 
 speaks for gouty and against rheumatic nodes. 
 
 A similar affection is comptodactylia. It con- 
 sists of excrescences on the side of the bones of 
 the medial phalanx, only at times painful. They 
 assume sometimes spindle-shaped figures around 
 the medial phalanx and seem to come into evi- 
 dence with disturbances in the intestinal canal 
 only to disappear again when the cause has been 
 removed. I have never seen a case myself. 
 
 A disease of the central nervous system which 
 is often erroneously taken for chronic arthritis, 
 in fact, at the first glance strongly resembles it, 
 is paralysis agitans. The fingers frequently
 
 504 GENERALIZED PAIN 
 
 show the same position to the hand in both dis- 
 eases, i.e., turned towards the ulna. Moreover, 
 the patient not seldom complains in paralysis 
 agitans of rheumatic pains in the extremities, 
 and in both affections the .tendon reflex is in- 
 creased. These circumstances make allowance 
 for the error. But in paralysis agitans we fail 
 to find those changes in the configurations of 
 the joints which are such salient features in 
 chronic arthritis. We miss the swelling, the 
 impaired motility of the joints between the 
 ungual and middle, and also between the middle 
 and metacarpal phalanges so characteristic in 
 chronic arthritis. 
 
 As for the rest the special symptoms of par- 
 alysis agitans should be a sure basis for the 
 diagnosis, viz., ague, muscular rigidity and the 
 bodily posture of the patient. Put there are 
 cases in which both diseases may simultaneously 
 exist. 
 
 It is easier to avoid another error. The pa- 
 tient complains of stiffness in the joints and 
 difficulty in moving them. "Chronic arthritis" 
 is the first thought. But the real cause will be 
 found in the skin which is drawn taut by sclero- 
 dermia, has lost its softness and pliability, in 
 fact feels as if it were not long enough. Never- 
 theless sclerodermia may lead to arthritis. 
 
 To mistake chronic arthritis osteoarthritis 
 deformans for osteoarthropatMe hypertrophi-
 
 JOINTS 505 
 
 ante pneumique Marie, seems to me impossible. 
 I admit that the diagnosis may offer some diffi- 
 culty when the latter affection is associated with 
 articular troubles. But the clinical signs char- 
 acteristic of the disease together with the Roent- 
 gen picture ought to be sufficient criteria. Still 
 the error might be pardoned in the incipient 
 stages of osteorarthropathy when the changes 
 in the bones have just barely reached the car- 
 tilage in the joint caps with resultant pains and 
 impaired motility in the joints. 
 
 Under "Pains in the Bones" I have already 
 mentioned how an arthritis deformans may erro- 
 neously be diagnosed in senile osteomalacia, or 
 osteoporosis. 
 
 A relatively rapid, subacute arthritis defor- 
 mans with well-defined disfiguration and en- 
 largement of the joint may be readily simulated 
 by a primary, malignant neoplasm in the bone 
 or by an epiphyseal or juxtaphyseal sarcoma 
 of the bone-marrow, for we find here enormous 
 swellings in the articular region, the articular 
 outlines disappear almost entirely and the skin 
 has a reddish, or rather bluish red appearance 
 and is feverish, no doubt owing to venous stasis. 
 But the fact that the motility of the joint 
 remains unimpaired, even though pain (mostly 
 slight) does exist, and the evidence of deformi- 
 ties in the bones, of ectatic veins in the skin of 
 the affected part, together with the X-ray should
 
 506 GENERALIZED PAIN 
 
 be the guiding points in the diagnosis. Only 
 a tub erculo- fungoid or perhaps a chronic syphi- 
 litic (pseudo-tumor albus lueticus) articular 
 affection or an arihropaihy might become a 
 disturbing element. 
 
 The differential diagnosis between an arthro- 
 pathy and an arthritis deformans may always 
 be based on the following lines: in arthritis 
 deformans the beginning is slow, in arthropathy 
 the attack is sudden and acute; in arthritis de- 
 formans the articular processes are impaired, 
 impeded, in arthropathy they are enlarged (loose 
 joints) ; in arthritis deformans the disfiguration 
 is confined to the joint, in arthropathy it extends 
 beyond; in the former there is pain in the joint, 
 in the latter, as a rule, none. 
 
 In subacute or chronic, mostly exudative mon- 
 arthritis, for instance, in the knee joint, we must 
 always think of a subacute or chronic osteomye- 
 litis as the provocative cause. This is generally 
 located in the part of the bone nearest to the 
 joint affected. Articular tuberculosis or articu- 
 lar neuralgia is very often the erroneous diag- 
 nosis in these cases. The seat of the trouble is 
 centered in some purulent condition in the lungs 
 or pleura. Roentgenographic evidence will as- 
 sist the diagnosis. 
 
 When we hear of pains in the knee or hip 
 joints we should not only think of local affec- 
 tions, among them genu valgum, varum, flexum,
 
 JOINTS 507 
 
 recurvatum, but we must likewise give attention 
 to reflex pains due to flat foot. 
 
 Coxitis shows pains in one kneejoint, a sign 
 of importance not only for the surgeon, but also 
 for the internist because the same conditions ap- 
 ply in osteoarthritis deformans of the hip as 
 they do in coxitis. The examination should be 
 based on the proof that when standing up the 
 patient cannot properly abduct the femur in its 
 joint. The X-ray will show the existence of 
 an arthritis deformans in the hip joint when 
 the knee joint is normal. 
 
 Sometimes it will be difficult to differentiate 
 between omarihritis and brackial neuritis. (Cf. 
 chapter "Pains in the Shoulders.") Here it is 
 wise to make a thorough examination of the 
 legs, especially the vascular regions. We may 
 find then whether we have before us a case of 
 arthritis of the hip joint or an acute osteomye- 
 litis of the head of the femur or of the iliac 
 section, or an arthritis of the sacro-iliac articu- 
 lation or a rheumatism of the gluteal muscles. 
 The latter will be recognized by the presence 
 of pressure points (not always in evidence), 
 accentuated pain in abdominal exertion, and the 
 sciatic phenomenon. If we find that the sacro- 
 iliac region is especially tender to pressure, that 
 a quick and full lateral pressure of the pelvis 
 sharpens the pain, we are dealing with arthritis 
 of the articulation belonging to that region. In
 
 508 GENERALIZED PAIN 
 
 arthritis of the hip joint the salient features are: 
 deep seated pain, throbbing sensation in the 
 major trochanter, the impossibility to hyper- 
 extend the hip joint to twenty-five or thirty 
 degrees when the patient is lying on his stomach 
 always possible in normal individuals, but 
 impossible also in spondylitis with abscess in a 
 dependent part as well as in all forms of psoitis, 
 likewise in retro - cecal appendicitis, impaired 
 motility in the sense of abduction, especially in 
 the standing posture, the disappearance of pain 
 when lying prone (except in sciatica when pain 
 is always present). Much may be learned from 
 the Roentgen-ray picture. The constancy of 
 the pains, leucocytosis and the fact that even 
 cautious movement in the hip joint is not pos- 
 sible, speak for osteomyelitis and against arti- 
 cular affections. In rheumatism of the gluteal 
 muscles a rather rare disease the spontaneous 
 and pressure pains are diffuse, not only exacer- 
 bated by movements of the lower extremity, but 
 also by simple, active contraction of the gluteal 
 muscular plexus without locomotion of the ex- 
 tremity.
 
 Headache (Cephalea, Cephalalgia) 
 
 The causes of headache are as numerous as 
 the complaints thereof. To recognize headache 
 properly and make a fitting etiologic diagnosis 
 without the latter there is no efficient therapy 
 we must always be alive to the fact that this 
 affection is primarily located within or without 
 the cranial sphere, but that the originating cause 
 may be centered in a local, or distant part of 
 the anatomy or may be quite general in its 
 nature. 
 
 It is my experience that those headaches which 
 are due to changes in the cranial shell are most 
 frequently overlooked, because an important 
 rule which I earnestly advise my readers to keep 
 always before them, is so often overlooked, viz., 
 "In complaints of headache make a thorough 
 inspection and palpation of the cranium." 
 
 If you observe this rule carefully you will 
 soon learn that headaches may have their origin 
 in the scalp. Wounds, sores, inflammation, 
 phlegmons concern the surgeon. To the inter- 
 nist of interest is erysipelas of the scalp. I do 
 not mean the form which is so often an exten- 
 sion of facial erysipelas, but that affection which 
 originates directly in the scalp itself from a 
 
 609
 
 510 GENERALIZED PAIN 
 
 scratch or a fissure in the skin, with a dragging, 
 drawing pain. Only a very painstaking search 
 for such a scarcely noticeable lesion will lead to 
 a happy diagnosis. Mark the localized redden- 
 ing of the skin and the inflammatory areola 
 neither of these signs ever appear so distinctly 
 marked in erysipelas of the scalp because the 
 skin in this affection is drawn too tight the 
 localized pressure sensibility, glandular swellings 
 and the symptoms of a general infection. The 
 diagnosis is beset with difficulty in individuals 
 of advanced age because in them the general 
 manifestations, especially in the temperature are 
 no longer so pronounced. 
 
 That form of headache which is called clavus 
 hystericus, (hysterical hair ache) is basic in a 
 hyperesthesia of the scalp. The patient feels a 
 sensation as if a nail were being driven into the 
 head, or as if there were a wound, a sore on the 
 aching spot. Sometimes the pain is quite diffuse, 
 or centered in the very vertex, and the hair is 
 sensitive to touch. When a woman pulls the hair 
 upwards in combing there is pain in the scalp 
 similar to toothache, especially on the top of the 
 head. 
 
 Painful sensitiveness on pressure is a promi- 
 nent symptom of neuralgic headache. But here 
 the pain is confined to the zone in which the 
 affected nerves are located. It generally follows 
 two distinct lines, either along the trigeminus or
 
 HEAD 511 
 
 the nervus occipitalis, both major and minor. 
 In consequence the local sensitiveness to pres- 
 sure pain in supraorbital neuralgia corresponds 
 with the supraorbital nerve process from the 
 supraorbital foramen, in neuralgia of the nervus 
 occipitalis to about the middle of a connecting 
 line between the mastoid and spinous process. 
 
 In both a proper etiologic distinction between 
 genuine and deuteropathic neuralgia must be 
 made. If the latter is the case and supraorbital 
 neuralgia is present, we must direct our mind 
 to affections of the osseous surroundings of the 
 n. supraorbitalis, to arteriosclerosis of the vasa 
 vasorum of the nerves, diseases of the oral cavi- 
 ties, the eye, the nose and its cavities, the ear, 
 the brain (tumors of any kind, also tuberculosis, 
 gummata, multiple sclerosis, etc.), all of which 
 are causative elements, especially preceding in- 
 fectious diseases, principally malaria and syphilis, 
 existing metabolic disturbances (gout, diabetes 
 mellitus), colds and constipation. 
 
 In cervico-occipital neuralgia similar condi- 
 tions prevail, but in addition we should look 
 for affections of the cervical vertebrae, especially 
 the first and second, also the spinal cord, but 
 particularly for syphilitic cervical hypertrophic 
 pachymeningitis in which pains also occur in the 
 arms, and, in exceptional cases, for pains in the 
 occiput. Neither must we forget localized affec- 
 tions in the posterior section of the head (cere-
 
 512 GENERALIZED PAIN 
 
 bellum, medulla oblongata), radiations of pain 
 along the neck into the shoulders and arms, 
 diseases of the sphenoid sinus and all possible 
 affections in the retromediastinal space (see 
 chapter on "Pains in the Neck"). Only a care- 
 ful scrutiny of all these conditions can assure 
 us of a correct diagnosis. 
 
 If a patient complains of intense pains in the 
 head which come on in sudden periodical attacks, 
 last sometimes for two or three weeks on a 
 stretch and are of a neuralgiform, shooting and 
 piercing character, we should promptly suspect 
 a case of lancinating pains in tabes cerebralis. 
 Beyond the customary symptoms we may expect 
 no nervous sensitiveness to pressure pain, no 
 nervous pressure points, but rather objective 
 sensibility disturbances in the sense of hypo- or 
 anesthesia, resp. analgesia. 
 
 Headache of a neuralgic character may be a 
 manifestation of a local lesion in any part of 
 the trigeminal plexus or of any other encroach- 
 ment in the frontal region. Circumscribed, 
 chronic, local meningitides, basilar cranial and 
 cerebral tumors and those of the angle of the 
 cerebellar pons will surely give rise to neuralgi- 
 form headaches. The diagnosis results from 
 the local and general symptoms. 
 
 Myalgia capitis is rheumatism of the scalp 
 and the cause of acute, continuous, exacerbated 
 attacks of headache. The diagnosis is guided
 
 HEAD 513 
 
 by the presence of hard, painful, lumpy indura- 
 tions along the linea semicircularis where the 
 muscles are attached to the cranium, especially 
 the splenicus and m. cucullaris, also the sterno- 
 cleidomastoid and scalenus. Very sensitive no- 
 dules in the panniculus cavernosus of the occiput 
 and of the nape of the neck may also be felt. 
 There is pressure pain in the periostea of the 
 superior vertebrae, especially in the transverse 
 processes. 
 
 The patient complains of a tearing pain in 
 the head, exacerbated when chewing or speaking 
 (also a symptom in neuralgia of the trigeminus), 
 or by the pressure of a hard hat, or by combing 
 the hair. The pain is sometimes relieved by a 
 brisk movement of the head, but it may be also 
 aggrevated by it. 
 
 In bald-headed people myalgia capitis is not 
 uncommon, likewise in women who contract a 
 cold from washing the hair, or when the hair 
 gets wet through some accidental cause, going 
 from a warm room into a colder atmosphere, or 
 exposure to drafts or cold winds. The pain 
 prevails chiefly in the back part of the head, 
 rarely in the temples or forehead. A dose of a 
 salicylic preparation, massage and wet bandages 
 frequently bring relief. 
 
 The crural part of the cranium may be a 
 source of headache. I mention here syphilis of 
 the bones or of the periosteum. When osten-
 
 514 GENERALIZED PAIN 
 
 sible gummata exist, the diagnosis offers no diffi- 
 culties. But when these are not in evidence, we 
 should look for the nocturnal appearance or 
 aggravation of the pains especially before or 
 around the midnight hour always a strong hint 
 for the syphilitic genesis of the aches (but not 
 pathognomonic) . 
 
 Such headaches with nocturnal habits are also 
 found in tumors of the brain, especially in aneu- 
 rysms of the vertebral and basilar arteries, in 
 uremia, arterial hypertension, dental affections 
 (caries), glaucoma, and also in diabetes, hysteria 
 and migraine, not to speak of patients who work 
 in the night time. Their nocturnal character 
 together with the complementary corrective re- 
 action and the results obtained from therapeutic 
 measures should easily put upon them the stamp 
 of dolores osteocopi luetici. 
 
 Osteocopic pains mature also in other morbid 
 conditions of the osseous portion of the cranium, 
 viz., hyperostosis (leontiasis ossea), in neoplasms 
 (chloroma, carcinoma, sarcoma), myeloma, fam- 
 ine osteopathy (sensation of hammering in the 
 skull). The pains are generally in the shape of 
 attacks of an intermittent character, while in 
 some cases they do not appear at all. Caries of 
 the cranial bones and cold abscess also belong 
 here. 
 
 Pyrgocephalus is only mentioned here casu- 
 ally. Fuller details will be given later on, be-
 
 515 
 
 cause the pains in it are more in the form of 
 migraine. , 
 
 That in traumatic periostitis headaches prevail 
 is self-evident, for in it impressions of the os- 
 seous cranium can be easily demonstrated by 
 radiology. The cause of headache in cranial 
 trauma is frequently focused in intracranial 
 conditions. In some cases these pains pass away 
 quickly and may be attributed to a transient 
 minor circulatory disturbance or to some cellular 
 encapsulation. In other cases the root of the 
 evil may be traced to cerebral commotion, com- 
 pression or contusion or to some hematoma of 
 the dura or a traumatic rupture of the median 
 meningeal artery, an intermeningeal hemorrhage 
 or an abscess in the brain or a traumatic neu- 
 rosis. The diagnosis is irrelevant in this place. 
 
 What is of interest to the internist is the fact 
 that headaches with giddiness especially when 
 stooping down nausea, abnormal irritability or 
 fainting, also loss of consciousness and intoler- 
 ance for alcohol are the inevitable after-effects 
 of a previous concussion of the brain. This 
 knowledge would forestall an erroneous diagnosis 
 of "simple" traumatic neurosis in many cases. 
 Headache with increasing lumbar pressure indi- 
 cates very often chronic serous posttyaumatic 
 meningitis, even if only as a localized condition. 
 An important symptom in all these cranial af- 
 fections is a persistent hypersensitive pressure
 
 516 GENERALIZED PAIN 
 
 zone endowed with the sensation of a hot sponge 
 wiping over it. 
 
 We now pass over to that chain of inter- 
 cranial affections without trauma which may be 
 the source of headaches. With the exception of 
 cerebral atrophy all other diseases that occur in 
 the cranial cavity, of whatever nature, are here 
 included. We shall only deal now with those 
 endocranial headaches that are determining diag- 
 nostic factors. 
 
 The diagnosis of chronic periostitis can be 
 made absolute by the X-rays, unless there are 
 external perceptible signs of osseous changes or 
 some definite symptoms of a cerebromeningeal 
 lesion. The same may be said of intracranial 
 osteoperiostitis. In fact it is the only means at 
 our command whereby we may obtain undoubted 
 results, for a differential diagnosis between 
 syphilitic ostitis, between the dura and the roof 
 of the cranium on the one hand, and pachy- or 
 gummatous leptomeningitis on the other can 
 hardly be established. 
 
 The diagnosis of internal hemorrhagic pachy- 
 meningitis is beset with many difficulties. It 
 occurs in marantic individuals, in nephrosclerosis, 
 in heavy drinkers and in old people. Apart from 
 the conditions mentioned above we find the fol- 
 lowing: the patient complains of headache, peri- 
 odical vomiting, befogged consciousness, paretic 
 conditions of certain cerebral nerves, pupillary
 
 HEAD 517 
 
 differences and disturbances in speech. The 
 body temperature remains unchanged. Impor- 
 tant for the diagnosis, especially for the differen- 
 tiation from an intracerebral affection is the fact 
 that there is a marked contrast between the cere- 
 bral paresis or paralysis of the extremities and 
 that of the respiratory muscles of the thorax, 
 and that the patient breathes with more ease on 
 the affected side. 
 
 Of course, this does not establish a differentia- 
 tion from a convexity leptomeningitis which runs 
 a course similar to pachymeningitis. But wor- 
 thy of note is that internal hemorrhagic pachy- 
 meningitis has a partiality for clinically one-sided 
 external, irritating symptoms, whilst in the other 
 forms of convexity meningitis these manifesta- 
 tions bear a much more generalized character. 
 Hemorrhages do not always occur in any of 
 these varieties, especially not in the earlier stages 
 of the diseases. Then there is the diffuse form 
 with a limited partial symptom complex, basic 
 in a stronger, unilateral meningeal progression 
 or also in a partial encephalitis or vascular lesion 
 ( thromboarthritis ) . 
 
 Still more distressing are the cephalic pains in 
 all forms of leptomeningitis. The accession of 
 throbbing pains is a telling symptom. 
 
 Cephalalgia is a frequent initial symptom in 
 acute (epidemic) encephalitis and one of its 
 after-effects.
 
 518 GENERALIZED PAIN 
 
 In multiple sclerosis the pains come in recur- 
 rent attacks, now from a frontal, now from a 
 vertical, or again from an occipital direction. 
 At times they are of a very intensive character 
 and accompanied by vomiting and giddiness. 
 
 The acme of pain in the head is reached in 
 three other intracranial morbid processes, viz., 
 in tumor of the brain (including cysticercus and 
 pseudotumors), in chronic abscess of the brain 
 and in chronic serous meningitis. When the 
 intracranial pressure, which is generally asso- 
 ciated in a violent form with these ailments, is, 
 however, of a more moderate character, the pains 
 will also be lighter in proportion. This puts the 
 stamp of a weighty symptom on the initial head- 
 aches in acromegaly. It assumes here mostly 
 the form of a dull pain in the frontal region, 
 perhaps only on one side, whilst in other hypo- 
 physeal diseases the occipital portion is rather 
 involved. 
 
 Cerebral vomiting frequently occurs in all 
 these affections and is a stereotyped signal for 
 the diagnosis. The pain is aggravated by other 
 accompanying symptoms such as muscular exer- 
 tion in coughing, sneezing, defecation or stoop- 
 ing down, all of which tend to increased pressure 
 on the cranium from within. Another source of 
 irritation is the intake of alcoholic stimulants. 
 In chronic serous meningitis the pain is more 
 diffused, whilst in cerebral tumors it either
 
 HEAD 519 
 
 spreads over the entire cranium, or at any rate, 
 if localized, is more intensely punctuated in a 
 certain spot, in which case, however, it must not 
 be accepted as an indication of the real seat of 
 the tumor. Even a neuralgiform pain in the 
 trigeminal zone is not an unconditional local 
 symptom. In cerebral abscess the site of the 
 pain corresponds with the local suppuration 
 thus pointing out the seat of the disease, but not 
 invariably. In both, tumor as well as abscess of 
 the brain, the pains are nearly always of the 
 deepest intensity when located in the posterior 
 portion of the cranial cavity they encroach on 
 the circulation of the vena magna Galeni and 
 in the aqueduct of Silvius. Magendie's foramen 
 being occluded a similar effect results in men- 
 ingitis. 
 
 The impairment of the venous circulation, 
 often of diagnostic significance, in tumors of 
 the brain, only partially explains why the pains 
 are aggravated when the head is held in a certain 
 position. This is particularly so in cerebellar 
 tumors. When the patient rests the head on the 
 affected side the pains set in, at least in the 
 beginning of the sickness. This is also the case 
 in cysticercus of the fourth ventricle. The pa- 
 tient gives his head a forced position, sometimes 
 to the right or left, sometimes forward or back- 
 ward, in order to make the pain more tolerable. 
 The same happens also in renal headaches.
 
 520 GENERALIZED PAIN 
 
 When, however, an occipital pain is very much 
 exaggerated by a forward inclination of the 
 head, when the patient has the sensation as if 
 the skull would burst, we must look for another 
 cause. We should be prepared to find a com- 
 pression of the aqueduct of Silvius or an acute 
 hydrocephalus of the fourth ventricle. 
 
 A point of value for the diagnostician is the 
 observation that in some rare cases the pains 
 are of a strongly remittent even intermittent 
 character. An erroneous diagnosis of neurosis 
 is here not excluded. 
 
 There are many cases of this kind which are 
 very difficult to diagnose. We should never be 
 rash in diagnosing neurosis from remittent or 
 intermittent violent attacks of headache persist- 
 ing for days or weeks, but rather direct our 
 thoughts to serous meningitis or brain tumor 
 or cerebral chronic abscess, even when the ail- 
 ment drags through several years. The same 
 idea should be followed when an undoubted 
 trauma has preceded the apparently "neurotic" 
 symptom complex. Every practitioner with 
 some clinical experience has seen cases in which 
 chronic serous meningitis followed on the heels 
 of some cranial traumatic affection running its 
 course exclusively under neurasthenic conditions 
 such as persistent or else periodic headache, back- 
 ache, giddiness, abnormal irritability and psychic 
 emotions. And does that not happen also in
 
 HEAD 521 
 
 chronic post-traumatic abscess of the brain? 
 Even light, continued headaches may constitute 
 the solitary symptom of a hitherto latent cere- 
 bral abscess. 
 
 There are other forms of periodic headaches 
 which build up from ascending intracranial pres- 
 sure. More about this when we are dealing with 
 infectious diseases. In passing I will only men- 
 tion here that in an analogous manner certain 
 cephalalgic attacks in chronic alcoholism may 
 be explained, especially when they are associated 
 with tinnitus, stupor, nystagmus, amblyopia 
 without ophthalmic conditions at times aggra- 
 vated by coughing or sneezing. They yield, as 
 a rule, to lumbar puncture. The etiologic diag- 
 nosis is made positive when tremor of the hands 
 and tongue, sleeplessness and morning sickness 
 present themselves. 
 
 Headache in hysteria or neurasthenia cannot 
 be accepted as a pathognomonic manifestation 
 per se. In the majority of these cases the pain 
 is nothing more than an indefinite cephalic pres- 
 sure covering either the whole circumference or 
 only portions of the skull (forehead, temples or 
 occiput), although in neurasthenia some patients 
 complain of external constraint such as might 
 be caused by a hard hat, or a vice or a circular 
 band, while in hysteria the feeling is more as 
 if the head would burst from within; there is 
 also hyperesthesia of the scalp and hairache.
 
 522 GENERALIZED PAIN 
 
 Hysterical headaches may also assume the form 
 of clavus a sign which is unknown in neuras- 
 thenia aroused sometimes by the rays of a 
 glaring light or some loud noise. 
 
 But there are cases of hysteria in which the 
 headache simulates the character of a neuralgia 
 by running along the nerves of the cranial roof 
 into those of the occiput and branching out even 
 as far as the nape of the neck or else into the 
 frontal section and the face itself. The differen- 
 tial diagnosis may be drawn from the fact that 
 the headache is not confined to the path of the 
 nerves but radiates into adjacent ground, that 
 the head feels as if ready to burst in two from 
 within and that classical pressure points are 
 missing all characteristic symptoms of hysteri- 
 cal and non-neuralgic conditions. 
 
 Neurasthenic headache sometimes attended 
 with slight excitability or weariness or wakeful- 
 ness is not uncommonly the sole symptom of 
 neurasthenia. But there are other signs which 
 may help in the diagnosis, viz., mental overex- 
 ertion, psychic or sexual hyperexcitement, late 
 hours, and changeable weather conditions, more 
 acute in the early hours of the day; also the fact 
 that unlike constitutional forms of headache, e.g., 
 migraine or brain tumors, it is improved by or 
 disappears altogether with open air exercise or 
 walking or riding bareheaded. 
 
 Hysteroneurasthenia should not be overlooked
 
 HEAD 523 
 
 in this connection. Arteriosclerosis of the cere- 
 bral vessels presents not only headache but also 
 other cerebral symptoms which are analogous 
 to neurasthenia. The headache is chiefly local- 
 ized in the frontal region and is of a piercing, 
 boring, shooting, dull character, accompanied by 
 giddiness, loss of memory, sleeplessness, irri- 
 tability and fatigue. In all these qualities it 
 strongly resembles neurasthenia, a circumstance 
 that makes the diagnosis difficult. The minor 
 symptoms such as dizziness, paresthesia of the 
 extremities, inhibition of speech, changes in the 
 handwriting, vivaciousness, relate rather to arte- 
 riosclerosis, although they are not foreign to 
 neurasthenia. Arteriosclerotic headache may 
 easily be caused by a physical strain in cough- 
 ing, sneezing or during defecation, that is to say 
 by every form of increased blood pressure, while 
 on the other hand this does not seem to be the 
 case in neurasthenia. 
 
 Other distinguishing signs are: it mostly comes 
 on in the early morning hours, starting the pa- 
 tient out of his sleep, like a thunderbolt, some- 
 times it bears the character of migraine. In spite 
 of all this, I mean to say that the determining 
 factor will always be found in the etiology of 
 the case, especially in face of the fact that the 
 presence or absence of peripheral arteriosclerosis 
 does neither prove nor gainsay the existence of 
 a sclerosis in the cerebral vssels. If we fail to
 
 524 GENERALIZED PAIN 
 
 discover the causative force of the apparently 
 neurasthenic conditions (mental overstrain, psy- 
 chic emotions), and if the patient is advanced 
 in years (beyond the fifties), I should be in 
 favor of diagnosing pseudoneurasthenia basic in 
 arteriosclerosis resp. pseudoneurasthenic head- 
 ache. Nevertheless, arteriosclerosis has been 
 observed in younger persons, especially after 
 some preceding infectious disease such as syphi- 
 lis, malaria and toxic conditions (lead poison- 
 ing). Neither must we overlook the fact that 
 a genuine attack of neurasthenia may spring 
 from a preexisting demonstrable arteriosclerosis 
 of the afferent vessels. Still the diagnosis of 
 such a combination would not be justified unless 
 there is unmistakable proof of the provocative 
 cause. 
 
 If the patient begins to complain of headache 
 we must consider the likelihood of an additional 
 cerebral complication such as thrombosis of the 
 cerebral arteries or cerebral hemorrhage. Either 
 of these may occur in older persons with a con- 
 tracted kidney, and in younger individuals with 
 arterial calcification. Such headaches are, more- 
 over, a valuable symptom for the differential 
 diagnosis between thrombotic softening of the 
 brain and cerebral hemorrhage. If the pains 
 have prevailed for hours or days before the 
 attack of cerebral hemiplegia set in, they point 
 to thrombotic softening of the brain. In arterio-
 
 HEAD 525 
 
 sclerosis the headache does not always bear the 
 neurasthenic character but rather assumes that 
 of a boring, shooting or stitching sensation, espe- 
 cially after psychic emotions. 
 
 Similar manifestations are observed in the 
 incipient stages of syphilitic endarteritis of the 
 brain; likewise in progressive paralysis, the 
 earlier epochs of organic tuberculosis chiefly 
 pulmonary in Addison's disease, contracted 
 kidney or in some of the toxic affections. The 
 pains may mimic neurasthenia and thus create 
 a pseudoneurasthenic symptom complex. 
 
 Sclerosis of the cerebral arteries frequently 
 opens the road to the formation of aneurysms, 
 especially in the sphere of the basal vessels. The 
 evidence of combined general pressure and local 
 compression symptoms (e.g., in aneurysm of 
 the vertebral or basilar artery of bulbar symp- 
 toms) is of great value for the diagnosis. If 
 blood or clods are found in the fluid obtained by 
 lumbar puncture the diagnosis is absolute. 
 
 Dementia precox, progressive paralysis and 
 other mental affections are capable of creating 
 a "pseudoneurasthenic" symptom complex with 
 distressing headaches. It is often clinically diffi- 
 cult to distinguish between neurasthenia and an 
 early progressive paralysis. The character of 
 the headache may here be a determining factor. 
 In neurasthenia the pain is rather in the form 
 of pressure, although psychic emotions or fatigue
 
 526 GENERALIZED PAIN 
 
 may give it the nature of a real ache; it is 
 sharper in the morning, tapers down as the hours 
 pass by and vanishes with the setting sun; it 
 obsesses the patient with the fear of "going 
 mad." 
 
 In paralysis the pressure in the head is not 
 so predominant, but we find rather a progres- 
 sive weakening of memory and striking changes 
 in the personality of the patient. And yet, 
 progressive paralysis may wear the mask of a 
 cerebral asthenia and may be accompanied by 
 sleeplessness and very severe pains in the head. 
 But etiology and the somatic symptoms should 
 here help us out, viz., change in the pupils, the 
 missing light and pain reaction, weakening of 
 the patellar reflexes, trembling of the lips, an- 
 omalies of speech, change in the hand-writing, 
 not to forget lumbar puncture. Nonne-Appelt, 
 Wassermann, plyocytosis, all positive. Never- 
 theless a positive Wassermann reaction should 
 be accepted with caution, for syphilitic patients 
 are frequently neurasthenic. 
 
 In dementia precox there is more pressure, a 
 fullness of the head, than direct pain. Abnormal 
 fatigue, impaired capacity for work, noticeable 
 deterioration of the mental faculties, are im- 
 portant points to watch. The anomalous hyper- 
 excitability of the neurasthenic is lacking. While 
 in neurasthenia nervosity runs parallel with 
 external stimulation, the nervous spells in de-
 
 HEAD 527 
 
 mentia precox come on like explosions to make 
 room immediately after for dull inactivity. 
 
 Of course, all melancholic and depressing 
 psychoses carry parasitic headaches. 
 
 Anemia, no matter what its genesis may be, 
 and hyperemia of the brain arouse pains in the 
 head. In anemia the pains are not often of a 
 very intensive character, but may appear in 
 different localities, and in company with other 
 manifestations such as vertigo, fainting fits, 
 tinnitus aurium, nausea, especially when the 
 patient suddenly sits up. They are aggravated 
 when the head is held erect or when the abdom- 
 inal muscles undergo a strain, but soften down 
 with a horizontal position or deep inclination of 
 the head. In anemic women this headache is a 
 steady visitor during the catamenial period. 
 This is important for the reason that such a 
 pain, localized as it is in the occipital region and 
 associated with the other symptoms already enu- 
 merated, may very well point to some internal 
 hemorrhage. 
 
 If we find, however, very severe headaches in 
 the anemic patient we should at once suspect 
 higher pressure in the cerebrospinal fluid, or 
 some complication such as thrombosis of the 
 cerebral sinus especially when other symptoms, 
 impaired consciousness, fainting fits, accede. 
 
 A special form of cerebral anemia with head- 
 ache is caused by insufficiency of the aorta. The
 
 528 GENERALIZED PAIN 
 
 quick pulse of the cerebral arteries, the in- and 
 outflow of the cerebral blood produce the sensa- 
 tion of pressure simulating neurasthenic pains 
 in the head which are of a throbbing and very 
 distressing character, very much in the nature 
 of similar throbbing epigastralgias in failure of 
 the cardiac valves. Since the patients afflicted 
 with the latter diseases are likewise abnormally 
 excitable and suffer from sleeplessness, we have 
 again a pseudoneurasthenic symptomatic picture 
 before us. 
 
 Anemia of the brain need not necessarily be 
 a partial manifestation of a general anemia, nor 
 the result of defective organic circulation, but 
 may result from local vesicular changes. A 
 considerable contraction of the os art. anonymce 
 or of the carotis sin. either due to sclerosis of 
 the aorta, syphilitic arteritis or complete throm- 
 bosis of these arteries, will surely lead to anemic 
 headache with vertigo. 
 
 Hyperemia of the brain is another source of 
 headache, but only in those cases in which there 
 is polycyihemia rubra. The patients complain 
 of pressure and fullness in the head, the pains 
 are sometimes very severe, sometimes migraine- 
 like, or of a throbbing character, often there 
 are congestions combined with scintilating sco- 
 toma, tinnitus aurium, giddiness, sleeplessness, 
 abnormal excitability, in other words all the 
 "pseudoneurasthenic" symptoms again as men-
 
 HEAD 529 
 
 tioned before. Blood test and a proper clinical 
 examination should make the diagnosis clear. 
 
 The situation is very much the same when 
 there have been reiterated ruptures of bloodves- 
 sels followed by pain and dullness in the head 
 and clumsiness in the performance of the daily 
 tasks. We find it frequently in patients suffer- 
 ing from hemorrhoids. A good hemorrhage 
 from the piles gives relief all around and clears 
 the head of painful conditions. 
 
 Passive hyperemia of the skull can only then 
 be considered a cause for giddy headache when 
 it is of a chronic character. The pain as a rule 
 is light, but may become bothersome when it 
 spreads over a larger area which is really the 
 case in venous hyperemia owing to insufficiency 
 of the right ventricle. In other words we are 
 dealing here with a high grade cardial congestive 
 cyanosis of the brain, mainly by relative insuffi- 
 ciency of the tricuspid valve and by direct 
 restriction in the circulation of the vena cava 
 superior, no matter whether this restriction is 
 caused by pressure from a mediastinal tumor or 
 a chronic mediastinitis or a thrombosis of the 
 vein or of the right vestibule. The remaining 
 symptoms of the congestion of the vena cava 
 sup. (see Cyanosis and Edema), the direct 
 mediastinal manifestations, the Oliver-Cardarelli 
 symptom and the Roentgen-ray should suffice 
 to trace the real cause of the headache.
 
 530 GENERALIZED PAIN 
 
 It is not hard to understand how a steadily 
 rising pressure in the brain, i.e., increased venous 
 stasis (abdominal pressure, coughing, inclining 
 the head forward, or stooping, etc.) aggravates 
 the pain sometimes to a point where the patient 
 feels as if the head would split. We can observe 
 this in every cerebral cephalalgia, in arterioscle- 
 rosis in chronic alcoholism, in vasomotoric affec- 
 tions, in cerebral arteriosclerosis, in affections of 
 the nasal cavities, pressure in the cerebrospinal 
 fluid or in the arteries or in cerebral hyperemia. 
 In conditions due to visual refraction these pains 
 do not seem to occur. 
 
 Men who wear high collars, too narrow around 
 the neck, and women who lace too tightly are 
 likely to suffer from headaches owing to re- 
 stricted venous circulation. 
 
 In acute venous cerebral congestion headaches 
 do not, as a rule, play a prominent part. The 
 complaint is more of pressure and dullness than 
 a veritable pain. 
 
 But in phlebitis and thrombosis of any parti- 
 cular cerebral sinus severe headaches are symp- 
 tomatic, for here we are confronted in nearly 
 all cases by pseudomeningitic conditions. The 
 diagnosis is greatly assisted when we find a 
 collateral edema on the outside of the skull 
 in thrombosis of the longitudinal sinus a swelling 
 of the veins at the roof of the skull, in throm- 
 bosis of the cavernous sinus an edema of the
 
 HEAD 531 
 
 ! 
 eyelids, in thrombosis of the sigmoid sinus an 
 
 edema of the mastoid process and when we 
 give due consideration to the appurtenant eti- 
 ologic factors (nasal and aural and accessory 
 cavities, erysipelas of the scalp, marantic, anemic 
 thrombosis ) . 
 
 Periodic fluctuations in the blood stream give 
 rise to vasomotoric headache. In the vasopara- 
 lytic form it assumes the nature of rushes to the 
 head caused by certain acute intoxications, alco- 
 hol, chloroform, nitrites, especially amyl nitrite, 
 and chronic theism. Furthermore there are other 
 morbid conditions in which vasomotoric changes 
 are liable to occur, viz., neurosis in both sexes, 
 especially the climacteric form in woman, neu- 
 rathenia, hysteria, traumatic neurosis, Base- 
 dow's disease, chlorosis, etc. The pain in these 
 cases generally concentrates in the region of 
 the vertex and is accompanied by various vaso- 
 motoric manifestations (erythema, dermograph- 
 ism, red streaks where the garments pinch the 
 skin, changes in the complexion), cold hands 
 and feet, chilliness, heat, inclement weather con- 
 ditions. The vasomotoric hyperirritability of the 
 skin accompanying these headaches is also pecu- 
 liar to serous meningitis. 
 
 The climacteric headache is generally local- 
 ized in the occipital area. Its true signs are 
 easily recognized: its seasonable advent (some- 
 times months or years before the cessation of
 
 532 GENERALIZED PAIN 
 
 the menses sets in), congestion, rush of blood to 
 the face and head, unprovoked breaking out of 
 profuse perspiration, irritability, anxiety, worry 
 and general depression. Quasi climacteric neu- 
 roses may also occur in the male. 
 
 There is also a vasoconstrictor headache of an 
 acute (mainly pressure in the head) as well as 
 chronic character, e.g., nicotinism. No doubt, 
 some of the passing symptoms of cerebral arte- 
 riosclerosis may very well be reduced to some 
 vasoconstriction. We all know that in arterio- 
 sclerosis the nerves of the vessels, especially the 
 vasoconstrictors, are much easier stimulated than 
 is normally the case, and that functional hyper- 
 irritation is often a prominent feature in an 
 anatomical affection of the vessels. Vertigo and 
 periodic headache are part of the symptoms of 
 cerebral arteriosclerosis which manifest them- 
 selves in the union of these two factors. This 
 explains also the fact that in abnormal vaso- 
 motoric conditions both vasoparalysis and vaso- 
 constriction may give rise to the same manifes- 
 tations of headache. That vasoconstriction is 
 the provoking cause is proved by the fact that 
 fainting is often associated with it. 
 
 Abnormal innervation of the vessels, abnormal 
 distribution of the blood either due to anemia 
 or hyperemia of the cerebral arteries, are indu- 
 bitably the originating factors of that headache 
 which is so common in overworked men and
 
 HEAD 533 
 
 women in whom no anatomical affection exists. 
 The slightest excess, even a small dose of alcohol, 
 or a pipeful of tobacco may bring on the head- 
 ache in such people. 
 
 Vasomotoric disturbance is the excitant of 
 headaches in menstruating women, but the char- 
 acteristics of a concomitant migraine are not 
 present in these cases. We observe the same 
 in young girls at the time of pubescence, when 
 vicarious bleeding from the nose is coupled with 
 the pains in the head before the menses have 
 assumed their proper rhythm. Nausea, vomit- 
 ing, giddiness come along with the headache and 
 disappear with the epistaxis. 
 
 An anatomical lesion in the sympatliicus is 
 another originator of vasomotoric pains in the 
 head. If the complaint is on the right side of 
 the head and is combined with pains in the right 
 arm and hypodrosis in the right axilla, then in 
 a case of aortic aneurysm it can only be due to 
 pressure on the marginal trunk of the right 
 sympathicus or to perineuritis of the sympathi- 
 cus arising from periaortitis. 
 
 In a case of ulcus ventriculi I had occasion 
 to observe the following symptoms. The ulcer- 
 ous attack, came on year after year with increas- 
 ing virulence ; with them pains in the right inside 
 of the head set in, but disappeared with the 
 removal of the intestinal trouble by gastro- 
 enterostomy.
 
 534 GENERALIZED PAIN 
 
 Some patients who suffer from muriatic an- 
 acidity are subject to headaches when the stom- 
 ach is empty. It goes away with the intake of 
 food. 
 
 Still another cause for headache we find in 
 arterial hypertension and in all morbid processes 
 that lead to it no matter whether the hyper- 
 tension itself is essential or deuteropathic, pain- 
 ful or painless in its nature. The seat of the 
 pains in the head may vary according to circum- 
 stances. If they are connected with a protracted 
 case of arterial hypertension they are wont to 
 set in after midnight, i.e., in the early morning 
 hours or at awakening. In some cases they are 
 the only sign of the existing disease, but in 
 others they are associated with sleeplessness, 
 dyspnea, precordial pains (pressure, anginoid 
 troubles, polyuria). 
 
 Headache in arterial hypotension combined 
 with weak heart action or venous congestion 
 I have never been able to observe. 
 
 If, what is today called "pseudouremia" com- 
 prises also the vessel crises described above, then 
 it includes also the same list of symptoms (head- 
 ache, giddiness, transitory amaurosis, aphasia, 
 strokes, cramps, Cheyne-Stokes' respiration, 
 mental disturbances), and also increased cere- 
 bral pressure owing to edema (chloremia) which 
 may be spotted by lumbar pressure. 
 
 Needless to say headache is a steady com-
 
 HEAD 535 
 
 panion of epilepsy. It comes at times in the 
 shape of a sudden stroke on the head, and travels 
 in company with dizziness, nausea, vomiting, 
 temporary loss of consciousness. Without these 
 symptoms we have rather a case of petit mat 
 before us. The pains in the head, as a rule, go 
 away after the epileptic seizure. I may point 
 out here the fact that cocaine is contraindicated 
 as its administration may provoke an epileptic 
 fit or at any rate an epileptic aura including 
 giddiness, nausea, vomiting, palpitation of the 
 heart, dyspnea, tremor and sever headache. 
 
 Pain, especially in the occipital and vertex 
 region, is a frequent and lasting complaint dur- 
 ing the whole time of mental stupor in mycc- 
 edema. The evidence of psychic and cutaneous 
 changes, hypothermia, the thickened tongue and 
 the effects of thyreoid extract should clear the 
 situation without much delay. 
 
 The same holds good in cases of hypothyreoid- 
 ism which often simulates neurasthenia or ane- 
 mia. Dryness and roughness of the skin, trophic 
 disturbances in the hair and the nails, lassitude, 
 hypothermia, insufficient perspiration, moodi- 
 ness, and treatment with thyreoid extract, apply 
 here also. 
 
 Adrenal insufficiency and its substitute Addi- 
 son's disease, follow in line. In both diseases 
 headache is of a very severe, piercing character 
 not only during the whole course of the disease
 
 536 GENERALIZED PAIN 
 
 but especially also in the "pseudomeningitic" 
 final stadium. 
 
 True (functional) orthototic albuminuria in 
 youthful persons lays claim to headache, early 
 fatigue, despondency, giddiness and proneness 
 to fainting. The headache in these cases may 
 have in part a vasomotoric basis, but it seems 
 to me rather due to some abnormal, constitu- 
 tional, degenerative condition. The diagnosis is 
 extremely easy to make, but according to my 
 own experience it is rarely made. If a differ- 
 entiation is to be made between the lesional and 
 merely functional forms of the disease we should 
 look for granulated or epithelial cylindroids, 
 large numbers of erythrocytes and a typical 
 chondritis. 
 
 Headache Due to Distant Causes 
 
 Headaches due to ocular conditions. Over- 
 strained accommodation in refraction anomalies, 
 in hypermetropia and astigmatism, abnormal 
 convergent straining (exophoria), inflammatory 
 affections of the eyes, especially glaucoma, work- 
 ing by bad light, all these are possible causes of 
 pains in the head. In arthenopia the patient 
 complains also of pains in and above the eyes, 
 also in the forehead, that the headache is ag- 
 gravated by prolonged work, stops during the 
 night time, and when present resembles a supra- 
 orbital neuralgia. When in glaucoma vomiting
 
 HEAD 537 
 
 is witnessed the erroneous diagnosis of intra- 
 cranial disease with increased cerebral pressure 
 is apt to creep in much to the detriment of the 
 patient. It is not unlikely that some cases of 
 adolescence and puberty headache are attribu- 
 table to overstrain of the visual apparatus. 
 
 The same as in eye troubles, so the pains are 
 located in the forehead when the frontal sinus 
 is implicated either in a suppurative or inflam- 
 matory process. They are apt to create the 
 impression of a supraorbital neuralgia and are 
 of a diffuse character, generally felt at the root 
 of the nose between the eyebrows, chiefly in the 
 early morning hours. We shall not go astray 
 in the diagnosis if we keep a careful watch on 
 the following points: not only the nerve along 
 its course is tender to pressure, but the whole 
 frontal area is sensitive on percussion, the pa- 
 tient complains of a raging, throbbing pain in 
 the forehead at large, the nose is obstructed, 
 previous or parallel affections of the nasal cavi- 
 ties (acute or chronic rhinitis, the usual secre- 
 tions are hardened, polypus, spurs, spikes or 
 other deformities of the septum or bones). 
 Adrenalin or cocaine give relief. Thorough 
 examination of the nasal cavities and transillu- 
 mination of the frontal sinus are prerequisites. 
 
 All this applies with like force to acute as well 
 as chronic diseases of the sphenoid and the tur- 
 binated bones, also to any affections of the
 
 538 GENERALIZED PAIN 
 
 accessory nasal cavities. In catarrhal inflam- 
 matory conditions the pains are sometimes very 
 severe and distressing. Influenza is especially 
 marked by dull pains in the vertex region when 
 they are due to ethmoiditis, but when arising 
 from the sphenoid sinus they settle behind the 
 eyes and are made worse by mental work or 
 physical exertion. 
 
 Pains in the anthrum of Highmore radiating 
 to the head are likely due to some suppurative 
 process in the maxillary sinus giving rise to 
 meningeal or phlebitic complications. 
 
 Diseases of the outer or the inner ear (furun- 
 culosis, foreign bodies) always afflict the patient 
 with pains in the head. Sometimes they are only 
 of local signficance within the radius of the 
 affected part of the ear, but, as a rule, they 
 permeate the whole of the corresponding side of 
 the head. If of a diffuse nature they settle also 
 in the occiput, rarely involving the entire cranial 
 cavity. And again, they attack the region of 
 the visual organs with local pressure and deli- 
 cacy to percussion around the ear, especially 
 above the mastoid process in inner affections. 
 In acute, and more so, in chronic lesions of the 
 middle ear (cholesteoma, suppuration of the 
 bones of the ear) they involve the brain, and 
 form, perhaps, the primary symptom of a sinus 
 phlebitis, cerebral abscess, or purulent menin- 
 gitis. Lumbar puncture, or eventually trephin-
 
 HEAD 589 
 
 ing, often stop these very distressing headaches 
 efficiently. 
 
 Malignant growths and other affections in 
 the larynx or pharynx are also originators of 
 bothersome cephalalgias. 
 
 Retronasal angina and morbid conditions of 
 the tonsils and of the teeth belong here. Acute 
 occipital neuralgia with pains ranging from the 
 nape of the neck to the occiput point to acute 
 angina. Chronic pharyngeal affections (ade- 
 noids, tuberculosis or carcinoma of the pharyn- 
 geal wall) give room to chronic pains in the 
 occipital or frontal regions. Headaches arising 
 from sick teeth, especially from caries of the 
 molars or the difficult passage of a wisdom 
 tooth, are generally localized in the temporal 
 area, but may also be in the ear itself (simulat- 
 ing an attack of otitis) or in front of the ear 
 with irradiations into the corresponding cheek, 
 and often supersede in violence the toothache 
 itself. 
 
 Among the affections of the oral cavities I 
 wish to mention chronic infectious conditions 
 such as chronic purulent tonsilitis, chronic den- 
 tal stasis, all of which may lead to chronic sepsis, 
 loss of appetite, pallor, subfebrile temperature, 
 chills, sweats, and a general feeling of indis- 
 position and in consequence to toxico-septic 
 headaches which disappear with the removal of 
 the originating cause.
 
 540 GENERALIZED PAIN 
 
 Another focus from which headaches derive 
 their origin we find in the internal organs, espe- 
 cially those in which urinalysis is demanded. 
 
 In kidney affections headache easily proves 
 the distinguishing sign of uremia, pointing often 
 to the probability of an existing cerebral edema 
 running a parallel course with the edematous 
 condition (nephrosis), or of cerebral arterio- 
 sclerosis (pseudouremia) or of azotemia. The 
 occiput is the habitat of uremic headache which, 
 like all the other symptoms of uremia, is asso- 
 ciated with vomiting, and generally comes on 
 in the morning. That is the reason why it is 
 so frequently mistaken for idiopathic migraine. 
 A proper consideration of the other uremic 
 symptoms, urine, blood (residuary nitrogen) 
 and blood pressure tests should obviate all er- 
 rors. For quite some time I have held the 
 opinion that headache in chronic nephritis is of 
 toxic origin. No doubt a good deal of it is 
 due to high pressure tension. Moreover, in 
 nephritis with or without uremia there are many 
 complications which may give rise to pain in 
 the head, such as uremic meningitis, uremic cere- 
 bral edema, cerebral hemorrhage, the possibility 
 of encephalomalacia of thrombotic or embolic 
 origin, inclination to internal hemorrhagic pachy- 
 meningitis. Headache may also set in at the 
 incipient stages of acute glomerulonephritis as 
 a manifestation of acute infection.
 
 HEAD 541 
 
 Headache will also occur as an "anaphylactic" 
 phenomenon in the rapid resorption of hydropic 
 fluid in edemata and in hepatic insufficiency 
 (hepatargia, anhepathia). In the latter case, 
 however, they are, according to my own expe- 
 rience, more of secondary importance than in the 
 other cerebral disturbances (numbness, cramps) 
 and in the manifestations of hemorrhagic dia- 
 thesis. 
 
 In every kind of gravidity toacicosis headaches 
 will be present. They are complementary symp- 
 toms in hyperemesis gravidarum, and still more 
 so in eclampsia gravidarum and atypical toxi- 
 coses in the pregnant. The latter, as a rule, 
 starts in with cerebral symptoms, with icterus, 
 oliguria, even anuria and also hematuria, nearly 
 always accompanied by albuminuria and cylin- 
 druria and in contradistinction to eclampsia 
 without spasms leading to coma. But I have 
 my doubts whether these headaches which mani- 
 fest themselves in some women at the beginning 
 of every pregnancy, can be always reduced to 
 toxic origin. 
 
 In diabetes melUtus some patients suffer from 
 headache. Sometimes it is a generalized pres- 
 sure in the head, but frequently it assumes the 
 character of a well defined pain, mostly in the 
 frontal region, often enough, indeed, in the very 
 center of the cranium. At times it resembles 
 neuralgic pain all diabetics are inclined to neu-
 
 542 GENERALIZED PAIN 
 
 ralgia. This is mainly an expression of the 
 existing acidosis often making its appearance 
 only in the night time or at any rate with more 
 pronounced severity at that period. It is worthy 
 of note that very severe, at times, insufferable 
 pain in the head in the course of diabetes melli- 
 tus is often the forerunner or admonitory sign 
 of a diabetic coma. The diagnosis will be guided 
 by the concurrent clouding of consciousness, by 
 epigastralgia diabetica, meteorism, deep, re- 
 tarded breathing and above all, by a correct 
 urinalysis showing the presence of acid intoxica- 
 tion of the organism (acetic acid, oxybutyric 
 acid, increased ammonia content). 
 
 The situation may become more complicated 
 when the coma is compensated by an acute 
 affection which alone gives rise to headache. I 
 remember a patient who had been suffering from 
 diabetes mellitus of long standing and who sud- 
 denly became feverish owing to an acute peri- 
 ostitis in an upper molar. The second day he 
 complained of violent pain in the head attribut- 
 ing it to the diseased tooth. But a careful 
 clinical observation soon showed that the real 
 cause was a coma which developed during the 
 next twenty-four hours. On the other hand an 
 internal hemorrhagic pachymeningitis or a tu- 
 berculous meningitis may be the inciting element 
 of terminal headaches in diabetics. 
 
 Chronic obstipation is another source from
 
 HEAD 
 
 which pain in the head may spring in the shape 
 of a feeling of pressure, neuralgiform or real, 
 violent neuralgic pain either in the trigeminal 
 or in the occipital region. Many of these obsti- 
 nate cases yield to an efficient rigorous cathartic 
 treatment. 
 
 In cases where obstipation is in the main only 
 coupled with pressure in the head a diagnosis 
 for intestinal auto-intoxication is in my opinion 
 not warranted. I would rather seek the cause 
 in an existing neurosis, which would also explain 
 the complaints of lassitude, dizziness, restless 
 nights, etc. 
 
 Retention of flatus, intestinal flatulent dys- 
 pepsia following chronic intestinal catarrh are 
 apt to produce pain in the occipital region. 
 Diagnosis is rendered easy by means of adju- 
 vants. 
 
 Gout, resp. uratic diathesis, is not of great 
 moment in this connection. In my own prac- 
 tice I have not been able to substantiate the 
 existence of specific gouty headaches or neural- 
 gias either in the occipital or trigeminal region. 
 When headache and gout run concurrently I 
 should prefer to attribute the headache rather 
 to neurasthenia which thrives in gouty subjects, 
 or to arteriosclerosis of the cerebral vessels, or 
 to disturbances in the intestinal canal, to arterial 
 hypertension or insufficiency of the kidneys, 
 unless other causes (alcohol, nicotine, etc.) are
 
 544 GENERALIZED PAIN 
 
 in evidence, barring, however, headaches which 
 are the forerunners or companions of acute arti- 
 cular gouty attacks (podagra). 
 
 Headache is also conditioned by not a few of 
 the exogenous toxins (coffee, tea, nicotine, lead, 
 arsenic). All poisons which produce cerebral 
 morbid symptoms will also cause headaches (nar- 
 cotics, carbonic oxid, botulism, etc.). Similar 
 excitants of the so-called vasoparalytic headache, 
 are alcohol, chloroform, amylnitrate, nicotine. 
 The prolonged use or misuse of certain toxic 
 substances may lead to headaches (tea, coffee). 
 They all are the producers of pseudoneuras- 
 thenic troubles, i.e., pain in the occipital region, 
 pressure in the head, dizziness, anginoid attacks, 
 fainting fits, profuse perspiration, gastralgic 
 crises, pallor, emacition, obstipation, aphasia, 
 hemiparesthesia, etc. Presence of tremor, dis- 
 like for tobacco, etc., should assist the diagnosis. 
 (That first smoke!) 
 
 Excess in the use of the weed may also be 
 the father of other pains in the head such as 
 migraine, neurasthenic, hysterical or arterioscle- 
 rotic pains, likewise of headaches caused by cere- 
 bral affections, e.g., meningitis serosa. 
 
 Chronic lead poisoning may easily be mistaken 
 for some kind of neurasthenia as both have in 
 common the manifestations of slight pressure in 
 the head, sensation of oppression, weakening of 
 memory and general lassitude. This error will
 
 HEAD 545 
 
 creep in when the possible cause of chronic lead 
 poisoning is far removed from the minds of 
 patient and physician as well, for in many trades 
 lead is only used in small quantities, for instance, 
 in cosmetics. But findings of the blue line, 
 pallor, presence of punctuated erythrocytes, of 
 colicky pains in the bowels or of arthralgia, like- 
 wise muscular weakness in the radial region 
 should decide the correct diagnosis. These 
 symptoms must also be watched when saturnine 
 encephalopathy lies in the wake of plumbism. 
 In the differential diagnosis between lead poison- 
 ing and leptomeningitic headache is of little 
 moment, but in progressive paralysis (alcohol 
 paralysis) it becomes a determining factor, 
 viz., presence of pseudoneurasthenic, moderately 
 acute pressure in the head, as against most vio- 
 lent headaches in the former. 
 
 Arsenic poisoning, especially with arsenous 
 hydrogen, is also associated with headaches, espe- 
 cially in the forehead, with lassitude, dizziness, 
 sleeplessness and loss of appetite. The presence 
 of inflammatory lesions of the conjunctiva and 
 respiratory mucous membrane, gastrointestinal 
 symptoms, neuritic manifestations preferably in 
 the lower extremities, with well-defined strong 
 pains and trophic disturbances in the skin, and 
 dermoid formations, and in herpes zoster awaken 
 the thought of arsenic poisoning. Laboratory 
 tests of feces and urine furnish the final proof.
 
 546 GENERALIZED PAIN 
 
 I remember the case of a patient who was 
 afflicted with severe arteriosclerosis and a granu- 
 lar kidney and strong arterial hypertension. 
 Periodically he suffered for weeks from want 
 of appetite, nausea, vomiting, headaches, cramps 
 in the calves, a peculiar sweetish taste in the 
 mouth. The patient who possessed unusual in- 
 telligence suggested arsenic poisoning. I myself 
 diagnosed chronic uremia because the patient's 
 breath had the characteristic uremic odor. The 
 laboratory tests showed traces of arsenic in feces 
 and urine. Upon closer investigation the real 
 cause of the trouble was discovered. He had a 
 number of stuffed birds and also upholstered 
 chairs in his room all of which contained arsenic 
 as a protection against moths. Still I adhered 
 to my diagnosis of chronic uremia but compli- 
 cated with arsenic poisoning. 
 
 Mention must be made here of nitrobenzene 
 poisoning (an imitation oil of bitter almonds, 
 also called essence of mirbane, used in the manu- 
 facture of perfumes). Predominant signs are: 
 headache, transitory disturbances in the central 
 nervous system and manifestation of hemolysis 
 (icterus). 
 
 Very stubborn headaches will be encountered 
 in workers with vanilla, carbon disulphid and 
 quicksilver. 
 
 Raging headaches will at times follow spinal
 
 HEAD 547 
 
 anesthesia, generally accompanied by sleepless- 
 ness and delirious or pseudomeningitic affects. 
 
 It is proper to mention here also poisoning by 
 carbonic monoxid gas. It develops from leaky 
 gas pipes in the gas works (for heat or light). 
 The symptoms are: headache, dizziness, lassi- 
 tude, sleeplessness, numbness, epileptoid attack, 
 and also glycosuria. It is of value to know 
 that the pains in the head endure in the winter, 
 but disappear in the summer time. Spectro- 
 scopic examination of the blood it need not be 
 positive will confirm the finding. Similar con- 
 ditions will be encountered in laundries where 
 gas is used. 
 
 Reverting to the internal organs again, head- 
 aches will be prominent in acute and chronic 
 dyspepsia or in gastritis. In constant or only 
 sporadic dilatation of the stomach the pains are 
 by preference localized in the forehead; by 
 icterus (no matter of what origin) they consist 
 more of pressure in the head. It is selfevident 
 that in dyspepsia and gastritis they possess no 
 differential diagnostic significance so far as 
 neurosis of the stomach is concerned, because 
 headache and pains in the lumbo-sacral region 
 are common companions in all kinds of organic 
 neurosis. 
 
 Chronic cholelithiasis (gallstone in the gall- 
 bladder) deserves special mention here. It ap- 
 pears often in the frame of a chronic dyspepsia.
 
 548 GENERALIZED PAIN 
 
 There is a feeling of pressure in the stomach, 
 generally one-half to one hour after meals, espe- 
 cially after a heavy banquet, of surfeit, followed 
 by belching, ructus, oppression and headache, 
 dizziness and the sensation of cold pervading 
 the body, and chronic obstipation. (Particulars 
 will be found in my book "Abdominal Pain," 
 Rebman Company, New York.) The same 
 may be the case in relapsing cholecystitis. 
 
 Intestinal parasites (tenia, trichocephalus, 
 ascarides, oxyuris) also cause chronic dyspeptic 
 troubles (loss of appetite, bulemia, hungerpains, 
 vomiting, diarrhea) with accompanying pseudo- 
 neurasthenic manifestations, principally head- 
 aches, also vertigo, palpitation and emaciation. 
 Repeated tests of the feces for the eggs of the 
 parasites will clear the situation. 
 
 Headaches play a prominent role in the inter- 
 mittent flow of gastric juice (intermittent hyper- 
 acidity of the stomach) called by Rossbach 
 "nervous gastroxynsis." Violent headaches, se- 
 vere gastralgias, copious vomiting of hyperacid 
 stomach contents are the principal symptoms. 
 Some of these cases, it seems to me, are only 
 a migraine with prominent gastric manifesta- 
 tions, whilst others rather possess the dignity of 
 gastric crises (for instance in tabes) pointing 
 ultimately to some functional or anatomical dis- 
 order. 
 
 In affections of the respiratory tract headaches
 
 HEAD 549 
 
 are not of frequent occurrence. If present they 
 are very likely due to some vascular stasis con- 
 ditioned by repeated fits of coughing, defective 
 pulmonary ventilation or by insufficiency in the 
 right heart. 
 
 If headaches make a sudden appearance in 
 bronchiectasy, or in chronic interstitial pneu- 
 monia, or perhaps also in cladothrix, they will 
 remind us of possible complications with an 
 abscess in the brain, chiefly in the cerebellum. 
 
 Angina pectoris also brings about headaches, 
 chiefly in the left hemisphere. The fact that 
 they nearly always emanate from the retroster- 
 nal pain center spreading thence over nape and 
 neck into the occiput will render the diagnosis 
 easy. Unilateral headaches will also be observed 
 in vasomotoric angina pectoris. Cf. chapter on 
 "Pains in the Heart." 
 
 Headaches coming in successive attacks should 
 direct our thought to cardiac dissociation. But 
 if we are confronted by a functional disturbance 
 of the heart which may also lead to similar cere- 
 bral symptoms such as heartblock (see "Disturb- 
 ances of the Heart Rhythm"), then headaches 
 accompanied by dizziness, befogged conscious- 
 ness and nausea may constitute the sole sign of 
 a cardiac affection. They would then be due 
 to a defect in the blood supply of the brain, 
 i.e., a periodical cerebral anemia. It is acute 
 ischemia of the brain that produces the pain.
 
 550 GENERALIZED PAIN 
 
 Headache, particularly in the occipital region, 
 sometimes only in the form of a feeling of pres- 
 sure in the back of the head, often coupled with 
 dizziness, tinnitus and fainting fits, may be the 
 initial sign of incipient chronic insufficiency of 
 the heart. (Cf. under that heading.) 
 
 Headaches during the period of pubescence, 
 cephalea adolescentium, chiefly in the male, are 
 principally located in the frontal region, milder 
 in the morning but more acute in the evening, 
 very bothersome and interfering with even light 
 mental work. They may originate from ade- 
 noids. Otherwise we must consider age, abnor- 
 mally quick physical growth, disturbances in the 
 heart (cardiac debility, palpitation, small caliber 
 of the arteries) and vascular innervation, dizzi- 
 ness, epistaxis, early fatigue in bodily exercise, 
 orthotic albuminuria, in some cases asthenopia, 
 in others insufficient arterial circulation in the 
 brain, retarded cerebral development. All these 
 conditions may be the active cause of "pseudo- 
 neurasthenic" cephalic pains. They are called 
 school headaches and may persist during the 
 whole scholastic life. This "school anemia," as 
 it is also called, is, no doubt, due to an abnormal 
 rigidity of the arteries originating from an 
 increased vascular muscle tonus. Palpation of 
 the radial arteries will prove this. These pains 
 are also accompanied by other vasomotoric dis- 
 turbances, among them cold feet and hands,
 
 HEAD 551 
 
 palpitation of the heart, cardiac pains and faint- 
 ing spells, even anginoid troubles. In overexer- 
 tion of the mental faculties a peculiar pain will 
 be sometimes observed. The cause for this may 
 be found in the developing process of the cranial 
 sutures and may assume the form of a high 
 grade pressure sensibility (sutured neuralgia). 
 
 Headaches in childhood may be caused by any 
 of the following conditions, viz., defective hy- 
 gienic conditions, badly ventilated dormitories 
 or bedrooms or classrooms, sitting too near the 
 heating apparatus, too early rising in the morn- 
 ing, insufficient sleep, underfeeding at the break- 
 fast table or going away with an empty stomach, 
 and last but not least to overstrain of the eyes 
 in reading. These conditions may have the same 
 effect even on grown up people. 
 
 Persons who work by artificial light especially 
 when the gas jet or the electric bulb is too near 
 the crown of the head very often complain of 
 headaches. These pains belong to the same 
 category as sunstroke or heatstroke and are 
 frequently accompanied by the same symptoms, 
 dizziness, tinnitus aurium, vomiting, trembling 
 of the hands, fibrillary muscular contractions or 
 twitchings, even convulsions, subsequent retarded 
 pulse, unconsciousness, stertorous breathing, de- 
 lirium. Solar dermatitis is not excluded. 
 
 Violent hammering in the cranium and a feel- 
 ing of pressure in the head are concomitant
 
 552 GENERALIZED PAIN 
 
 symptoms of heatstroke together with dryness in 
 the mouth, physical debility, mental fatigue, 
 mental numbness, indifference to surroundings, 
 rise in body temperature, unsteady gait, bluish 
 tint in a puffed face and hot, dripping skin. 
 Sudden coma and utter collapse, spasmodic 
 muscular movements, anuria, arrest of perspira- 
 tion, feint, thready, finally disappearing pulse, 
 suppressed breathing, vomiting, diarrhea and 
 general convulsions. Persons who recover from 
 an attack of sunstroke frequently complain for 
 a long time afterwards of headaches and nervous 
 ( pseudohy sterical ) disorders. 
 
 Reflex actions from the sexual sphere may 
 also cause headaches. Acute and chronic infec- 
 tious diseases are often accompanied by head- 
 aches which are very intensive in some of these 
 affections, e.g., in pernicious or tropical malaria, 
 plague, yellow fever, blackwater fever, recur- 
 rent fever, exanthematous fever. In the last 
 named disease the pain is at times so severe 
 that the patient complains about nothing else 
 than that "terrible pain in head" especially in 
 the top and the frontal region. These pains are 
 at times coupled with vertigo and broadcast into 
 the lumbar and sacral regions, into the calves 
 and articular sections. 
 
 Infectious cerebral and spinal diseases, ery- 
 sipelas, smallpox, epidemic parotitis, Wolhy- 
 nian fever, abdominal typhoid, paratyphoid and
 
 HEAD 553 
 
 influenza, all are originators of headaches. In 
 typhoid and influenza the pains in the head set 
 in with the incipient stages of the disease in 
 typhoid they affect also the hearing and are of 
 a purely toxic infectious character. Recent 
 research ascribes them to hypertension of the 
 cerebrospinal fluid. In consequence they are 
 much ameliorated by lumbar puncture, but they 
 continue with the progressing infection until the 
 clouding of the sensorium renders the patient 
 less susceptible to pain. But if the patient 
 despite this numbness of the sensorium continues 
 to complain of steadily increasing headaches it 
 will be advisable to look for complications in the 
 cranial sphere. Influenzal cephalalgia bears the 
 character of inflammatory pain due to infectious 
 lesions in the nasal cavities, or that of neuralgic 
 pain. 
 
 The differential diagnosis between influenza 
 and hay fever depends upon the consideration 
 of the pain in the head. Quite true, the hay 
 fever patient also complains about dullness and 
 pain, mainly in the forehead, severely exacer- 
 bated by the typical attacks of sneezing. But 
 they are surpassed by the initial burning and 
 itching in the eyes and nose, whilst in influenza 
 the headache together with the rhinitic symptoms 
 will be found among the predominant manifesta- 
 tions. 
 
 In Pappataci fever, which also may be mis-
 
 554 GENERALIZED PAIN 
 
 taken for the grippe, the streaky injection of the 
 conjunctiva, congestion of the face, leucopenia 
 and the local conditions will facilitate the diag- 
 nosis. 
 
 Infectious meningitis is another source of 
 headaches. In the abortive forms of epidemic 
 meningitis mild headaches are about the only com- 
 plaint made by the victim. That circumstance 
 renders the diagnosis rather difficult, particularly 
 so when the existence of such an epidemic has 
 not yet been established. Nevertheless, it remains 
 an important sign. 
 
 In these cases it is well to watch the other 
 symptoms even though they also be developed 
 in a rudimentary form only. Among them: a 
 slight hammering in the cranium, stiffness in 
 the neck, a touch of pain in the scruff, indica- 
 tion of Kernig's signs, percussion in the spinal 
 column, leucocytosis, slight angina, bronchitic 
 or gastric disturbances. Our suspicions will be 
 confirmed by bacterial examination of the nasal 
 and faucial secretions and lumbar puncture 
 (increased lumbar pressure, turbidity in the 
 spinal fluid, intracellular meningococci). But 
 we must not overlook the fact that in these very 
 cases the meningococcus is generally not present 
 at all or at least not in its characteristic form 
 and that the lumbar fluid, though rich in albu- 
 min, is quite clear in appearance. The final 
 diagnosis must be made at the bedside.
 
 HEAD 555 
 
 The recurrence of intensive pains in the head 
 during the time of an epidemic of meningitis 
 points to the development of hydrocephalus, or, 
 let us say, to that of a serous chronic meningitis 
 as a sequel to acute epidemic meningitis. 
 
 There are other infectious diseases in which 
 headache is one of the foremost typical manifes- 
 tations, for instance, walking typhoid. Many 
 of these cases are at first diagnosed as influenza 
 or lobular pulmonary catarrh, until a severe 
 ambulant melena throws the patient upon the 
 sick bed or even into a premature grave. We 
 shall do well if in such doubtful cases we keep 
 our eyes open for initial nosebleeds, obvious 
 bradycardia, a possible minor splenic tumor, 
 positive diazo reaction, a rapidly developing 
 leucopenia, a positive WidaL serum test and the 
 necessary bacteriological examination of the 
 blood. It is my opinion that a stubborn, con- 
 spicuous, severe headache devoid of definite 
 signs of infection should always remind us of 
 a possible underlying typhoid condition. 
 
 We find these mild cases among the persons 
 who have been vaccinated with typhoid serum. 
 But the vaccination itself is often enough con- 
 nected with fever during the first week, articular 
 pains, lassitude, slight enlargement of the spleen, 
 leucopenia, sometimes a light attack of bron- 
 chitis and very often severe pains in the head. 
 
 What has been said of typhoid refers in the
 
 556 GENERALIZED PAIN 
 
 same measure to paratyphoid, in fact to every 
 kind of septic infection in the widest sense of 
 the term. Every disease kindred to typhoid is 
 accompanied by headache. Mild forms of chronic 
 sepsis so frequently met with in chronic infec- 
 tions of the tonsils or other organs of the oral 
 cavities belong here. Likewise Malta fever and 
 miliary tuberculosis. In the latter initial head- 
 aches are frequently present even though the 
 meninges do not participate in any way in the 
 tuberculous process. Epizootic and malignant 
 pustule must be mentioned in this place. In 
 epizootic the headache is generally localized in 
 the lateral region of the cranium. Anthrax may 
 set in with very severe pains in the head even 
 then when the meninges are either not at all, 
 or at any rate, but slightly implicated (capillary 
 embolism, hemorrhages). 
 
 Spotted typhus as the World War has 
 taught us may also occur in the "walking" 
 form, the affection being centered in very severe 
 headaches. The sudden rise in the body temper- 
 ature mainly due to intermittent chills (ague), 
 inflammation of the conjunctiva or of the mucous 
 membranes of the respiratory organs (laryngitis, 
 bronchitis) or of the intestines (diarrhea), intu- 
 mescence of liver or spleen, meningeal irritations 
 and epidermological conditions will demand an 
 early Weil-Felix agglutination test (which need
 
 HEAD 557 
 
 not be always positive) in order to establish a 
 correct diagnosis. 
 
 In malaria nearly every attack is accompanied 
 by headache. In fact it is in my opinion even 
 with only a slight rise in the temperature the 
 most salient feature of this infection which in 
 its chronic form is often the originating cause 
 of typical, periodic, cranial neuralgias. 
 
 Syphilis in the secondary as well as in the 
 tertiary stage frequently gives rise to severe, at 
 times also nocturnal, headaches. On account of 
 the accompanying articular pains and fever it 
 is sometimes mistaken for influenza. I call at- 
 tention here to the differential diagnosis between 
 typhoid and secondary syphilis described in the 
 section on typhoid fever. 
 
 In occult syphilis the intermittent headaches, 
 frequently setting in towards evening or during 
 the night are an important symptom, no matter 
 whether they are due to some specific disease of 
 the bones, to meningeal infiltrations or to some 
 vascular disorder. Emaciation, pallor, sleep- 
 lessness, splenic tumor, nervous disturbances 
 together with the anamnesis and a positive Was- 
 sermann reaction mould a safe diagnosis. 
 
 That long list of "pseudotyphoid" diseases is 
 in every instance associated with headache, some- 
 times of an almost unbearable nature, e.g., in 
 acute leucemia. 
 
 Headaches are also the companions of all
 
 558 GENERALIZED PAIN 
 
 those infectious disorders which bear the stamp 
 of meningism. They are apparently due to 
 increased pressure of the cerebrospinal fluid. 
 Lobar pneumonia (simulating symptomatically 
 meningitis) and acute articular rheumatism be- 
 long to this category. In the form of cerebral 
 rheumatism the latter produces most violent 
 headaches and hyperpyrexia, followed by cere- 
 bral excitation and coma. In lumbar puncture 
 performed in this connection no pathological 
 conditions have as yet, so far as I am aware, 
 been found. 
 
 In pulmonary tuberculosis headache seems to 
 be of minor import, unless there are further 
 complications present, for instance cerebral con- 
 ditions, tubercle, meningitis, pachymeningitis, 
 sinus phlebitis or caries, i.e., conditions which in 
 themselves lead to headaches (heart, kidney), 
 or violent fits of coughing. Still an initial pul- 
 monary tuberculosis may creep in with headache, 
 dizziness, lassitude, all of which are symptoms 
 of toxic origin and constitute, as it were, a clini- 
 cal fact, when we take into consideration that 
 frequently we are called upon to differentiate 
 between chlorosis and incipient lobar or glandu- 
 lar tuberculosis. On the other hand these head- 
 aches in pulmonary phthisis are often enough 
 caused by a chronic serous meningitis of tuber- 
 culo-toxic origin. Lumbar puncture will furnish 
 the proof.
 
 HEAD 559 
 
 In pellagra intensive pain in the head, but 
 variable in its location, is, in close connection 
 with pains in the back and paresthesias in the 
 extremities, the primary symptom, showing how 
 the nervous system is implicated even in the 
 earliest stages of the disease. 
 
 We now come to the hereditary headaches, 
 the familial or family headaches handed down by 
 the parents or ancestors who suffered or still 
 suffer from headaches or migraine basic some- 
 times in chronic alcoholism or lead poisoning, 
 to the offspring. They make their appearance 
 in early childhood or at the time of puberty and 
 are kindred to migraine (hemicrania). The 
 characteristic sign of these pains is that they 
 generally occupy only one side of the head; but 
 they may be also bilateral in the sense that they 
 move from one side to the other. In some cases 
 they affect both sides simultaneously, more pro- 
 nounced on one side or of equal severity in both. 
 
 They are of a boring quality, chiefly in the 
 temporal, more rarely in the frontal or occipital 
 region, spreading at times over the whole hemi- 
 sphere, accompanied also by flittering scotoma 
 or teichopsia or facial disturbances. In some 
 rare cases there is paraesthesia in the extremities. 
 They set in at the early awakening, steadily 
 increase in violence and cause the sufferer to 
 avoid all bodily motion, he feels ill and jaded. 
 Hyperesthesia of the visual and auditory organs
 
 560 GENERALIZED PAIN 
 
 accompanies the pains. Marked irritability, 
 moodiness, dislike of or even unfitness for work, 
 vasomotoric manifestations in the face (pallor, 
 flushing), commonly go with the attack. As a 
 rule, the patient recovers quickly after an attack 
 of vomiting or purging. 
 
 Of importance for the diagnosis is the fact 
 that migraine predominates in the female sex 
 and often sets in with the menstrual period. In 
 many cases it disappears spontaneously in the 
 climacteric stage or, at any rate, loses much of 
 its virulence. In pregnancy mainly after the 
 second month and during lactation it generally 
 ceases altogether. Migraine is an inherited evil 
 and crops up in early youth. If it makes its 
 appearance only at an advanced age beyond 
 the forties it is not a true, but rather a symp- 
 tomatic migraine. 
 
 I have mentioned above that migraine pre- 
 vails among the gentler sex and often accom- 
 panies the menstrual flow. Valuable though this 
 knowledge be, we should not lay too much 
 stress upon this fact. There are other conditions 
 which produce headaches and at the very time 
 of menstruation. I refer to what I have said 
 about headaches in chronic serous meningitis and 
 in abscess of the brain. 
 
 There are other affections which show similar 
 symptoms and are often very misleading. The 
 uremic or urotoxic headache is also onesided,
 
 HEAD 561 
 
 the same as in migraine; it is also accompanied 
 by vomiting and has the habit of starting in the 
 morning. Of course, when we have unmistak- 
 able proof of a kidney disease through urinalysis 
 in cases where this pseudo-migraine makes its 
 appearance in advanced age only, the diagnosis 
 cannot go wrong. But in the abscence of albu- 
 minuria mistakes will be made. A correct diag- 
 nosis cannot be missed if the following factors 
 are carefully weighed: evidence of permanent 
 polyuria (this may also be present in true mi- 
 graine, but only in a transient form), pollaki- 
 uria, nycturia, examination of the fundus oculi, 
 accentuation of the second aorta tonus, condition 
 of the peripheral arteries, intensity of the blood- 
 pressure, uremic habitus, and all the other symp- 
 toms of the so-called "minor uremia," cramps 
 in the calves, Raynaud's disease, loss of appetite, 
 itching of the skin, thorough test of the renal 
 functions. This "uremic" migraine occurs not 
 only in nephritis but in every kind of renal 
 insufficiency; it is preeminently an early symp- 
 tom in all urinary intoxications caused by chronic 
 congestion in the urinary tract, e.g., in strictures. 
 Exogenous toxins may occasion recurrent uni- 
 lateral headaches strongly resembling migraine, 
 chiefly chronic nicotinism. The diagnosis should 
 offer no difficulties when proper attention is paid 
 to the other symptoms: cardiac disorders (palpi- 
 tation, arhythmia, anginose troubles), disturb-
 
 562 GENERALIZED PAIN 
 
 ances in the visual organs (impaired visual acuity 
 with central scotoma for red or green, tobacco 
 amblyopia, retrobulbar neuritis), brown discol- 
 oration of the teeth and fingers (cigarettes), 
 chronic laryngeal, pharyngeal, bronchial catarrh, 
 disturbances of the nervous system (generalized 
 and neuritic). 
 
 Chronic especially spastic obstipation of toxic 
 origin may also cause migraine-like pains in the 
 head. It is not often confined to the lateral 
 region, however. But a true migraine may often 
 enough go hand in hand with headache in such 
 cases, and it will be our task to differentiate 
 between the two. This may be the proper place 
 to point again to the fact that a genuine mi- 
 graine is sometimes eased, if not entirely stopped, 
 by therapeutic means such as purging, or scour- 
 ing. The differential diagnosis should not meet 
 with obstacles when we keep before us the her- 
 editary and familial moment, the concomitant 
 symptoms (vomiting, hyperesthesia), the matu- 
 tinal or nocturnal beginning of the attack, and 
 the duty of adopting therapeutic measures for 
 relieving the headache due to chronic obstipation. 
 
 Neither must we neglect to remember that 
 such headaches might be traced to intestinal 
 parasites. Hence the necessity of proper exam- 
 ination of the stools. 
 
 Nervous gastroxynsis (Rossbach) in connec- 
 tion with migraine has already been mentioned.
 
 HEAD 563 
 
 Pains in the frontal sinus, in the nasal cavities 
 and toothache belong here also. Sometimes even 
 a casual examination will determine the differen- 
 tial diagnosis between these aches and migraine 
 in many cases. The absence of visual symptoms, 
 of vomiting and of hereditary idiosyncrasies, the 
 fact that migraine will persist sometimes through 
 weeks or crop up only at intervals as isolated 
 attacks, should make the diagnosis obvious irre- 
 spective of local conditions. Similar observa- 
 tions may also be made in affections of the nasal 
 organs especially in women during the menstrual 
 period. But in these cases the seat of the pain 
 is rather in the root of the nose or in the eye. 
 
 To misjudge a neuralgia of the trigeminus or 
 of the occipitalis for a migraine seems to me 
 well nigh impossible. The very fact that in this 
 case the typical pressure points are present, but 
 never vomiting, should guarantee a correct diag- 
 nosis. 
 
 Unilateral headaches, perhaps with giddiness 
 and nausea and a solitary or repeated attack of 
 vomiting should always point to the existence of 
 an arteriosclerosis in the plexus of the cerebral 
 arteries. If the headaches are of an intermittent 
 character we may give thought to an intermittent 
 angiospasm of the arteries which have already 
 been impaired by arteriosclerosis. If the pains 
 continue for days or weeks they are a sign of 
 thrombosis in a cerebral artery. Visual and
 
 564 GENERALIZED PAIN 
 
 skin reflexes (exacerbation of the former, ab- 
 sence of the latter), the Babinski toe pheno- 
 menon, hypersensitiveness of the sensory and 
 motoric faculties (paresthesias, pains), muscular 
 contractions in the extremities contralateral to 
 the lesion, or manifestations of minor defects 
 should be auxiliaries of the diagnosis. In many 
 cases this can be made merely on the ground 
 of the age of the patient, symptoms of arterio- 
 sclerosis of the cerebral or other arterial regions. 
 Sufferers from migraine may also become the 
 victims of cerebral arteriosclerosis at a later time 
 in life. The anamnesis, the periodical succession 
 of the manifestations, the point that migraine, 
 with exceptions, of course, generally lapses into 
 desuetude with the advent of the climacterium, 
 i.e., to put it rudely, the season for cerebral 
 arteriosclerosis, aught without default invariably 
 clear up the situation. 
 
 An acute glaucoma has often enough been 
 mistaken for migraine. Both have in common 
 unilateral recurrent headache, pain in the eye 
 which lies in front of the headache, subjective 
 disturbances in the visual apparatus, and like- 
 wise vomiting. If in the bargain the patient 
 suffers from migraine already, the error becomes 
 still more excusable. Only a thorough test of 
 the bulbar tension, in other words a careful 
 ophthalmoscopic examination will remove any 
 doubts that may exist.
 
 HEAD 565 
 
 Pronounced unilateral headache with vomiting 
 and strongly resembling migraine occurs also in 
 another combination; I refer to the so-called 
 periodic oculomotor paralysis. It makes its ap- 
 pearance either before or simultaneously with 
 the attack. In its pre- or coexistence and in 
 the anamnesis (appearance in childhood or early 
 youth) we may find the key to the diagnosis. 
 
 Myalgia capitis is at times erroneously taken 
 for migraine because it also is associated with 
 severe headaches although they generally de- 
 velop on both sides of the head. But the fact 
 that the pains in myalgia are continuous, though 
 at times of a milder character, should be the 
 determining element, especially if the symptoms 
 typical for each of these two affections are care- 
 fully considered. 
 
 If in migraine a so-called status Tiemicranicus 
 results from cumulative attacks, the differential 
 diagnosis will be surrounded by difficulties. One 
 attack follows the other with intervals of a pos- 
 sible restful night. Sometimes the patient is 
 distracted by continuous pain for six or seven 
 days on a stretch. Visual symptoms and vomit- 
 ing are not always present. In such cases the 
 diagnosis must rest entirely on the anamnesis. 
 
 When the diagnosis of migraine has been 
 firmly established it will yet be necessary to 
 remember, that not all cases of a true migraine 
 are a protopathic vasomotoric neurosis. They
 
 566 GENERALIZED PAIN 
 
 may be of a secondary nature, especially when 
 the first attacks arrive only at an advanced age 
 and bear no signs of familial or hereditary origin. 
 A migraine accompanied by visual symptoms, 
 migraine ophihalmique, a combination of uni- 
 lateral headaches and a clouding of the visual 
 field, should always remind us of a localized 
 affection of the brain, chiefly of the hypophysis 
 or the occipital cranial fossa, a cerebral tumor, 
 also of acute or chronic serous meningitis, aneu- 
 rysm of the cerebral arteries, progressive par- 
 alysis, taboparalysis, syphilis of the brain, mul- 
 tiple insular sclerosis or tuberculous headache. 
 The ophthalmic form offers difficulties before 
 the typical symptoms have been fully developed. 
 
 Useful points to remember are: in migraine 
 vomiting brings relief, often the end of the 
 attack; in tumor, resp. meningitis the patient 
 feels weak, has a jaded look after vomiting. In 
 migraine absolute rest, the exclusion of light and 
 noise have a soothing effect; but not in tumor, 
 at least not to any extent. The tumor patient 
 is indifferent to his surroundings, mentally be- 
 numbed, but not so in migraine. But migraine 
 may also in due time develop a cerebral lesion. 
 
 In pyrgocephalus we frequently find mi- 
 grainic conditions. The characteristic formation 
 of the head, the bulbar protusion, atrophy of 
 the optic nerve, the Roentgenogram are typical 
 enough for diagnostic purposes.
 
 HEAD 567 
 
 Epileptic migraine is not always so easily 
 recognized. An epileptic coma may very 
 strongly resemble migraine. Even an atypical 
 attack of epilepsy may have many symptoms in 
 common with a migraine such as headache, par- 
 esthesia in the arms and optic disturbances. But 
 we shall find a strong hold in the contemplation 
 of the hereditary conditions, of the convulsive 
 muscular reactions, the rotation of rudimentary 
 attacks and genuine epileptic fits, and also occa- 
 sional enuresis. 
 
 A deuteropathic status hemicranicus may also 
 be observed in another form of neurosis, I mean 
 cyclothymia. If depressing moodiness is strongly 
 marked, the diagnosis will be easy. But when, 
 as will happen, the migrainic attacks are asso- 
 ciated with a scintilating scotoma and other 
 somatic disturbances, such as periodic sleepless- 
 ness, dyspepsia, diarrhea and urticaria, then only 
 a competent psychanalysis will uncover the true 
 state of affairs. 
 
 Quincke's edema ( hy drops hypostrophos) may 
 likewise lead to a secondary migraine coupled 
 even with external opthalmoplegia (abducens 
 oculomotorius). Such cases are so obvious, how- 
 ever, that they leave no room for doubt. 
 
 The same may be said of erythromelalgia. 
 
 Uratic migraine has been mentioned by some 
 French authors in this connection, not only in 
 the sense that migraine may be basic in gout,
 
 568 GENERALIZED PAIN 
 
 but also that an acute attack of gout might be 
 substituted by an attack of migraine. I have 
 never been convinced of this. Yet it strikes me 
 that migraine, not unlike neurasthenia, finds in 
 gouty conditions rather a fertile ground. Quite 
 recently the opinion of our French colleagues 
 has been maintained by several specialists who 
 are well-recognized authorities on this subject. 
 
 Polycythemia rubra may also give rise to 
 migraine-like headaches. 
 
 The same may be said of essential arterial 
 hypertension. 
 
 Hysteria may also simulate migraine. Even 
 typical hysterical stigmata do not definitely 
 exclude a state of genuine migraine, for both 
 diseases may very well co-exist. The presence 
 of a scintilating scotoma and hereditary taint 
 should furnish the final proof. 
 
 From what I have placed before my readers 
 it will be clear that a definite localization of 
 headache cannot be reduced to a definite genesis. 
 But the following auxiliary deductions may be 
 garnered from the perusal of the foregoing 
 pages: pain in the occipital region points to 
 induration headache as the originating cause or 
 to occipital migraine or uremic cephalea or an 
 affection of the heart or the fauces. A circum- 
 scribed headache in the frontal region may arise 
 from an optic disorder, from the nose or from 
 the frontal sinus. Strictly defined pain in the
 
 HEAD 569 
 
 vertex directs our attention to hysterical etiol- 
 ogy. Benumbing pain in the vertex leads to 
 ethmoiditis and pain in the temporal region 
 around the ear to otological conditions or affec- 
 tions of the teeth as the causal factors. For the 
 local diagnosis of a cerebral tumor headache is 
 one of the strongest indications, especially when 
 it is accompanied by the sensation of humming 
 in the cranium and tympanitic percussion sound 
 in this region with bruit de pot fele.
 
 INDEX 
 
 Abdomen, diseases of, arthral- 
 gia in, 497 
 
 pendulous, sacral pain, 76 
 Abdominal diseases, pain in 
 
 shoulder, 123, 134 
 Abdominal muscles, diseases of, 
 
 pain in chest, 216 
 Abdominal tumor, pain in ex- 
 tremities, lancinating, 362 
 
 sacral pain, 76 
 
 Abscess, peripleuritic, pains in 
 chest, 197 
 
 subcutaneous, or empyema 
 necessitatis, 196 
 
 subcutaneous, or perforation 
 of a pulmonary cavern 
 through the pectoral wall, 
 197 
 
 bubpectoral, pains in chest, 
 209 
 
 eubphrenic, or pleurodynia, 
 236 
 
 subphrenic, pains in shoulder, 
 
 116 
 Achillodynia or dysbasia, 306 
 
 pains in extremities, 306, 342 
 Acroasphyxia, chronic hypertro- 
 phic, paresthesia in extrem- 
 ities, 272 
 Acromegaly, headache, 518 
 
 or cranium progenium, 440 
 
 or cretinism, 441 
 
 or elephantiasis, 442 
 
 or giantism, 440 
 
 or habitus scrophulosus, 442 
 
 or myxedema, 441 
 
 or neurasthenia, 443 
 
 or osteoarthropathic hyper- 
 trophiante pneumique, 423 
 
 or pachydermia, 442 
 
 or Paget's ostitis, 420 
 
 or pseudoacromegaly in preg- 
 nancy, 440 
 
 or syringomyelia, 440 
 
 671 
 
 Acromegaly, or vasomotoric 
 
 elongation of fingers, 441 
 pain in back, 155 
 pain in bones, 405 
 pain in extremities, lancinat- 
 ing, 352 
 paresthesia in extremities, 
 
 286 
 
 Acromegaloidism, 442 
 Acroparesthesia, pain in ex- 
 tremities, 266 
 Actinomycosis, pain in bones, 
 
 417 
 
 prevertebral, pain in shoul- 
 ders, 128 
 Addison'a disease, articular 
 
 pain, 491 
 headache, 535 
 muscular pain, 369 
 pains in extremities, 261, 346 
 paresthesia in extremities, 
 
 261, 286 
 
 retrosternal pain, 230 
 Adipositas dolorosa, arthralgia 
 
 in, 500 
 
 pain in extremities, 281 
 Adrenals, diseases of, pain in 
 
 sacrum, 92 
 diseases of, retrosternal pain, 
 
 228 
 insufficiency of, cardiac pain, 
 
 4 
 
 insufficiency of, headache, 535 
 Akinesia algera, or dysbasia, 
 
 303 
 
 pain in extremities, 303 
 Albuminuria, orthotic, head- 
 ache, 536 
 orthotic, pain in shoulder, 
 
 535 
 
 Alcaptonuria, sacral pain, 92 
 Alcoholism. See Poisoning. 
 Aleucemia, pain in bones, 426 
 Anasarea, pain in extremities, 
 259
 
 572 
 
 INDEX 
 
 Anemia, hemolytic, percussion 
 sensitiveness in bones, 429 
 
 hemorrhagic, acute pain in 
 heart, 6 
 
 infantum pseudoleucemica, 
 Jaksch, articular pain, 471 
 
 infantum pseudoleucemica, 
 Jaksch, percussion sensi- 
 tiveness in bones, 429 
 
 pain in shoulder, 126 
 
 paresth'esia in extremities, 
 267 
 
 pernicious, pain in bones, 426 
 
 pernicious, paresthesia in ex- 
 tremities, 279 
 
 pernicious, percussion sensi- 
 tiveness in bones, 426 
 Aneurysm of the heart, cardiac 
 
 pain, 5 
 Angina Ludovici, pain in the 
 
 neck, 175 
 
 Angina pectoris and aneurysm 
 of the aorta, 70 
 
 and fever, 71 
 
 and neuritis of the aortic 
 plexus, 68 
 
 and dyspnea, 69 
 
 dead fingers, 296 
 
 dyspeptogenous, 44 
 
 girdle pain, 207 
 
 girdle pains in neck, 186 
 
 headache, 549 
 
 or gastralgia, 27 
 
 or intercostal neuralgia, 62 
 
 or neuritis of the phrenic 
 nerve, 63 
 
 or occipital neuralgia, 69 
 Angina pectoris, or pseudoan- 
 gina pectoris in carcinoma 
 of the pancreas, 57 
 
 in carcinoma of the stomach, 
 58 
 
 or in carclialgia, 67 
 
 in cholelithiasis (hepatic 
 colic), 53 
 
 in dilatation of the esopha- 
 gus, 65 
 
 in esophagalpria, 67 
 
 in embolism of the pulmonary 
 artery, 48 
 
 in esophagospasms, 65 
 
 in fibrous mediastinitis, 50 
 
 in gastric diseases, 58 
 
 Angina pectoris, in gastric vol- 
 
 voulus, 51 
 
 in intestinal diseases, 60 
 in membranaceous colitis, 61 
 in mediastinal tumors, 50 
 in neuritis of the vagus 
 
 nerve, 64 
 in neurosis of the vagus 
 
 nerve, 64 
 
 in pancreatitis (necrosis), 57 
 in peracute congestion of the 
 
 liver, 55 
 
 in perforation of the peri- 
 cardium, 51 
 in perigastritis, 51 
 in pulmonary stenosis, 48 
 in sclerosis of the pulmonary 
 
 artery, 48 
 
 in pylorus stenosis colic, 60 
 in syphilis of the liver, 54 
 in thrombosis of the pulmon- 
 ary artery, 51 
 in ulcus ventriculi, 51, 59 
 in thrombosis of the superior 
 
 vena cava, 51 
 
 in tumors of the heart, 50 
 or thoracico brachial neural- 
 gia, 62 
 
 or trigeminal neuralgia, 69 
 pain in chest, 203 
 pain in extremities, 297 
 pains in region of ensiform 
 
 appendix, 219 
 pains in shoulder ,112, 137, 
 
 140, 142 
 
 pain in throat, 181 
 paresthesia in the extremi- 
 ties, 290 
 paresthesia in extremities, 
 
 271 
 
 retrosternal pain, 221 
 (stenocardia), 26 
 vasomotoria, 41 
 Anginose state, 71 
 or gastric crises, 72 
 or pericarditis, 71 
 Anglophobia, 38 
 Angina tonsillaris. See Ton- 
 sillitis. 
 Anthrax, headache, 556 
 
 pain in sacrum, 80 
 Antrum of Hiehmore, diseases 
 of, headache, 538
 
 INDEX 
 
 573 
 
 Aorta abdominal, aneurysm of. 
 
 sacral pain, 98 
 
 Aorta, insufficiency of, head- 
 ache, 527 
 pectoral, aneurysm of, and 
 
 angina pectoris, 70 
 aneurysm of, cardiac pain, 12 
 aneurysm of, girdle pain, 206 
 aneurysm of, lancinating 
 
 pains in extremities, 352 
 aneurysm of, pain in the 
 
 chest, 199, 203, 221, 244 
 aneurysm of, pain in the ex- 
 tremities, 332 
 aneurysm of, pain in the 
 
 shoulder, 114, 122, 134, 142 
 diseases of, retrosternal pain, 
 
 220 
 embolism or thrombosis of, 
 
 pain in extremities, 312 
 perforation of, pains in chest, 
 
 251 
 perforation of, retrosternal 
 
 pain, 248 
 
 rupture of, cardiac pain, 251 
 rupture of, pains in back, 
 
 114, 163 
 rupture of, pains in chest, 
 
 251 
 rupture of, pain in shoulder, 
 
 138 
 sclerosis of, angina pectoris 
 
 in, 28 
 sclerosis of, anginoid pains, 
 
 14 
 sclerosis of, pains in chest, 
 
 244 
 sclerosis of, pain in shoulder, 
 
 135, 142 
 Stenosis of, angina pectoris 
 
 in, 27 
 syphilis of, angina pectoris 
 
 in, 28 
 syphilis of, anginoid pains, 
 
 14 
 Aorta, thoracic, aneurysm of, 
 
 pains in the back, 163 
 pectoral, sclerosis of, pain in 
 
 back, 163 
 syphilis of, pains in back, 
 
 163 
 
 Aortalgia, cardiac pains, 10 
 pains in region of ensiform 
 
 process, 219 
 pains in shoulder, 112 
 Aortitis, angina pectoris in, 27 
 cardiac pain, 22 
 girdle sense, 206 
 pain in back, 163 
 Apoplexy, meningeal, sacral 
 
 pain, 90 
 Appendicitis, pain in shoulder, 
 
 140, 144 
 
 Arteriosclerosis, cardiac pain, 9 
 dead fingers, 297 
 pain in extremities, 307 
 pain in neck, 180 
 paresthesia in extremities, 
 267, 291 
 
 Arteritis, pain in extremities, 
 311 
 
 paresthesia in extremities, 
 
 291 
 
 Arteritis. See Brain. 
 Artery, anonyma, aneurysm of, 
 cardiac pain, 12 
 
 anonyma, aneurysm of, pain 
 in chest, 221 
 
 anonyma, aneurysm of, pain 
 in shoulder, 142 
 
 celiac, diseases of, pain in 
 back, 168 
 
 cerebral. See Brain. 
 
 constriction of an, headache, 
 528 
 
 constriction of an, pains in 
 extremities, 315 
 
 constriction of an, paresthe- 
 sia in extremity, 292 
 
 coronary of the heart, embo- 
 lism, thrombosis, angina 
 pectoris in, 29 
 
 coronary of the heart, scle- 
 rosis of, angina pectoris in, 
 28, 35 
 
 coronary of the heart, scle- 
 rosis of, anginoid pains, 14 
 
 coronary of the heart, scle- 
 rosis of, pains in shoulder, 
 139 
 
 coronary of heart, syphilis of, 
 anginoid pains, 14
 
 574 
 
 INDEX 
 
 Artery, cutaneous, embolism of, 
 
 pain in extremities, 266 
 cutaneous, thrombosis of, 
 
 pain in extremities, 264 
 embolism or thrombosis of 
 
 an, pains in extremities, 
 
 312 
 intercostal, sclerosis of, pains 
 
 in chest, 244 
 mammary, sclerosis of, pains 
 
 in chest, 202 
 pulmonary, embolism of, 
 
 pseudoangina pectoris in, 
 
 49 
 pulmonary, retrosternal 
 
 pains, 247 
 
 pulmonary, sclerosis of, pseu- 
 doangina pectoris in, 48 
 pulmonary, stenosis of, pseu- 
 doangina pectoris in, 49 
 pulmonary, thrombosis of, 
 
 pseudoangina pectoris in, 
 
 50 
 Arthralgia in abnormal growth, 
 
 499 
 
 in adipositas dolorosa, 500 
 in articular neuralgia, 496 
 in chronic constipation, 497 
 in climacterium, 499 
 in epilepsy, 495 
 in gout, 498 
 in hysteria, 495 
 in infectious diseases, 600 
 in insufficiency of the thy- 
 
 reoid glands, 500 
 in lead poisoning, 498 
 in malaria, 498 
 in multiple sclerosis, 495 
 in neurasthenia, 495 
 in pelvic and abdominal dis- 
 eases, 497 
 
 in rachitis tarda, 498 
 in tabes, 497 
 in uremia, 499 
 syphilitic, articular pain, 451, 
 
 454 
 Arthritis. See also Articular 
 
 Rheumatism and Gout. 
 Arthritis deformans, articular 
 
 pains, 483 
 or arthropathy, 505 
 or neuralgia (neuritis), 483 
 
 Arthritis deformans, or oateo- 
 arthropatie hypertrophi- 
 ante, 504 
 
 or osteomalacia, 443 
 
 or osteomalacia (osteoporo- 
 sis), 505 
 
 or syringomyelia, 494 
 Arthritis, acute, or osteomyeli- 
 tis, 470 
 
 enteric, articular pain, 458 
 
 gonorrhoic and typhoid, 464 
 
 gonorrhoic, articular pain, 
 448 
 
 gonorrhoic or syphilitic, 454 
 
 mon-, or osteomyelitis, 507 
 
 mon-, pneumococcic, articular 
 pain, 475 
 
 mon-, post traumatic, articu- 
 lar pain, 475 
 
 mon-, rheumatic, articular 
 pain, 475 
 
 mon , rheumatic, gonorrhoic, 
 articular pain, 475 
 
 mon-, syphilitic, articular 
 pain, 475 
 
 septic, articular pain, 449 
 
 septic, mitigated, articular 
 pain, 474 
 
 syphilitic, articular pain, 454, 
 478 
 
 syphilitic, glandular swell- 
 ings, 454 
 
 syphilitic or gonorrhoic, 454 
 
 tuberculous, articular pain, 
 
 475 
 
 Arthropathy, articular pain, 
 477, 493 
 
 in prosiasis, articular pain, 
 
 490 
 Arthrogryposis, articular pain, 
 
 472 
 
 Articular rheumatism, acute, 
 and gout, 489 
 
 and typhoid, 464 
 
 gonorrh. and typhoid, 464 
 
 headache, 558 
 
 mitigated, 474 
 
 muscular pains, 376 
 
 pain in bones, 419 
 
 pain in extremities, 340 
 
 pain in sacrum, 77 
 
 or neuritis, 472 
 
 or poliomyelitis, 473
 
 INDEX 
 
 575 
 
 Articular rheumatism, swelling 
 
 of lymphatic glands, 455 
 Articular rheumatism, chronic, 
 
 articular pain, 469, 478 
 and gout, 487 
 in climacterium, 503 
 nodose, 503 
 
 or paralysis agitans, 503 
 or sclerodermia, 504 
 or syringomelia, 494 
 paresthesia in extremities, 
 
 267 
 
 Articular rheumatism, syphili- 
 tic, articular pains, 491 
 tuberculous, articular pains, 
 
 452, 491 
 Articular rheumatism. See also 
 
 Arthritis, Rheumatism. 
 Articulation, sacro-ileac, arthri- 
 tis of, or of the hip joint, 
 508 
 arthritis of, or osteomyelitis, 
 
 508 
 
 diseases of, sacral pain, 85 
 Aseitee, sacral pain, 76 
 Asthma, bronchial, pain in 
 
 back, 168 
 
 bronchial, feeling of constric- 
 tion in the neck, 188 
 bronchial, pain in shoulder, 
 
 132 
 hay-, feeling of constriction 
 
 in throat, 1"88 
 
 Atropin poisoning, pain in ex- 
 tremities, 385 
 Axilla, pain in, 360 
 Autointoxication. See Intes- 
 tines. 
 
 Barlow's disease, pains in bones, 
 
 425 
 Basedow's disease, angina pec- 
 
 toris in, 35 
 articular pain, 472 
 cardiac pain, anginoid, 16 
 muscular pain, 370 
 pains in bones, 429 
 paresthesia in extremities, 
 
 286 
 percussion sensitiveness in 
 
 bones, 429 
 retrosternal pain, 230 
 
 Bedsores, pain in extremities, 
 
 260 
 
 Blood, diseases of, percussion 
 sensitiveness in bones, 429 
 Blood pressure. See Hyperten- 
 sion. 
 Bones, atrophy of, Sudek's, 
 
 pain in bones, 400 
 brittleness of, 432 
 diseases of, after diarrhea, 
 
 pain in bones, 424 
 hyperostitis of, or Paget's 
 
 ostitis, 420 
 hyperostoeis of, headache, 
 
 nocturnal, 514 
 hyperostosis of, pain in 
 
 bones, 403 
 
 Bones, neoplasms of, or arthri- 
 tis deformans, 505 
 or chronic syphilitic articu- 
 lar rheumatism, 506 
 or chronic tuberculous articu- 
 lar rheumatism, 491 
 or myeloma, 412 
 or Paget's ostitis, 420 
 pain in bones, 401, 406, 413 
 Bonee, pains in, lancinating, 
 
 429 
 
 pains in, nocturnal, 398 
 percussion sensitiveness in, 
 
 429 
 
 spontaneous fracture of, ar- 
 ticular pain, 477 
 swellings in, 433 
 Botulism, feeling of constric- 
 tion in throat, 188 
 Bradycardia, angina pectoris 
 
 in, 37 
 Brain, abscess of, headache, 518 
 
 anemia of, headache, 527 
 Brain, arteries of, aneurysm of, 
 
 headache, nocturnal, 514 
 aneurysm of, migraine in, 566 
 Brain, arteries of, sclerosis of, 
 
 and neurasthenia, 523 
 cardiac pain, anginoid, 16 
 headache, 523, 532 
 headache in or migraine, 563 
 muscular pain, 389 
 or neurasthenia, 523 
 paresthesia in extremities, 
 281
 
 576 
 
 INDEX 
 
 Brain, arteries of, syphilis of, 
 
 headache, 525 
 
 sypuilis of, pain in extremi- 
 ties, 283 
 
 thrombosfs of, headache, 524 
 
 thrombosis (embolus) of, 
 
 paresthesia in extremities, 
 
 283 
 
 Brain, diseases of, articular 
 
 pain, 493 
 migraine in, 565 
 muscular spasms, tetanic, 388 
 pain in back, 155 
 pain in shoulders, 138 
 paresthesia in extremities, 
 
 281 
 
 trismus in, 348, 384 
 Brain, fatty embolism of, mus- 
 cular spasms, tetanic, 390 
 hemorrhage of, headache, 524 
 hyperemia (acute, passive), 
 
 headache, 528 
 increased pressure in, and 
 
 headache, 530 
 sinus phlebitis of, headache, 
 
 530 
 
 syphilis of, migraine in, 566 
 tumors of, headache, 518 
 tumors of, migraine in, 549 
 tumors of, muscular spasms, 
 
 tetanic, 390 
 
 tumors of, pain in extremi- 
 ties, lancinating, 353 
 Breast, wall of, diseases of, 
 
 stitches in side, 247 
 Bronchial carcinoma, pain in 
 
 back, 164 
 
 pain in shoulder, 131 
 Bronchiectasy, articular pain, 
 
 472 
 Bronchi, foreign bodies in, pain 
 
 in chest, 246 
 Bronchitis, pain in shoulder, 
 
 132 
 Broncholithiasis, retrosternal 
 
 pain, 226 
 Bronchosarcoma, retrosternal 
 
 pains, 224 
 
 Bmck's disease, pain in bones, 
 425 
 
 Bursitis subdeltoidea, pain in 
 
 shoulder, 111 
 subscapular, pain in shoulder, 
 
 121 
 Buttocks, pains in, 103 
 
 C 
 
 Cachexia, pain in extremities, 
 
 279 
 percussion sensitiveness in 
 
 bones, 431 
 
 Caison disease, pain in extremi- 
 ties, 288 
 
 pains in extremities, lancin- 
 ating, 351 
 
 Calcaneous spur, pain in ex- 
 tremities, 343 
 Calves, cramps in, 355 
 Cardiac pain, anginoid or neu- 
 rasthenic, 15 
 Cardialgia, pseudoangina pec- 
 
 toris in, 67 
 
 Cardioptosis, cardiac pain, 8 
 Cervical muscles, diseases of, 
 
 pains in neck, 169 
 Cellulitis retroperitonealis, pain 
 
 in sacrum, 94 
 Chest, pressure, oppression in, 
 
 255 
 
 Chiragra, pains in joints, 488 
 Chloroma, headache, 514 
 pains in bones, 426 
 pains in nape of neck, 193 
 swelling in bones, 434 
 Chlorosis, dead fingers in, 296 
 pain in shoulders, 126 
 paresthesia in extremities, 267 
 percussion sensitiveness in 
 
 bones, 429 
 
 Cholecystitis, pain in back, 166 
 pain in chest, 255 
 headache, 548 
 
 Cholelithiasis, headache, 547 
 pain in back, 166 
 pain in chest, 255 
 pain in sacrum, 93 
 pseudoangina pectoris in, 53 
 retrosternal pain in, 230 
 Cholera, muscular pain, 377 
 Chorea, paresthesia in extremi- 
 ties, 286 
 
 Climacterium, arthralgia in, 
 499
 
 INDEX 
 
 577 
 
 Climacterium, articular rheu- 
 matism, chronic in, 603 
 headache, 531 
 pain in bones, 427 
 pain in chest, 202 
 pain in sacrum, 99 
 paresthesia in extremities, 
 
 287 
 Coccygodynia. See Pain in 
 
 Nates. 
 
 Cold. See Arthritis. 
 Coitus interruptus, pain in sac- 
 rum, 101 
 
 Colitis membranacea, pseudo- 
 angina pectoris in, 61 
 Colitis, ulcerous, articular 
 
 pains, 458 
 Colon, carcinoma of, pain in 
 
 sacrum, 101 
 Comptodactylia, 503 
 Constipation, headache, 542 
 headache in, or migraine," 560 
 pain in extremities, 332 
 pleurodynia in, 237 
 Cramps, pianoplayers', pares- 
 
 thesia in extremities, 271 
 writers', paresthesia in ex- 
 tremities, 271 
 Cranium progeneum or acro- 
 
 megaly, 440 
 
 myeloma of, headache, 514 
 neoplasms of, headache, noc- 
 turnal, 514 
 
 Cretinism or acromegaly, 441 
 Crises gastriques. See Gastric 
 
 Crises. 
 
 Cyclothymia, migraine in, 567 
 Cysticercus, muscular pain, 374 
 
 Decubitus, pain in sacrum, 88 
 
 Degeneration, adiposo-genital, 
 pain in bones. 425 
 
 Dementia precox, 92 
 headache, 525 
 pain in back, 159 
 pain in extremities, 261 
 paresthesia in extremities, 
 261 
 
 Dengue, articular pain, 460 
 pain in sacrum, 82 
 
 Dercum's disease, pain in ex- 
 tremities, 261 
 
 see Adipositas dolorosa. 
 Dermatomyositis, muscular 
 pain, 371 
 
 or phebitis, 375 
 
 Diabetes mellitus, angina pec- 
 toris in, 33 
 
 headache, 541 
 
 headache, nocturnal, 514 
 
 muscular pains, 369 
 
 pain in extremities, 332 
 
 pain in extremities, lancinat- 
 ing, 351 
 
 paresthesia in extremities, 
 
 267 
 
 Diaphragm, cramps in, girdle 
 feeling in, 206 
 
 diseases of, pain in chest, 247, 
 256 
 
 diseases of, pain in region of 
 ensiform cartilage, 218 
 
 diseases of, pleurodynia in, 
 237, 247 
 
 elevation of, cardiac pains, 9 
 
 elevation of, cardiac pain, an- 
 ginoid, 19 
 
 eventration of, cardiac pains, 
 12 
 
 eventration of, pains in chest, 
 252 
 
 eventration of, pains in shoul- 
 der, 117 
 
 foreign bodies in, pain in 
 shoulder, 117 
 
 hemorrhage below the, pain 
 in chest, 252 
 
 hernia of, cardiac pains, 12 
 
 hernia of, pain in shoulder, 
 117 
 
 hernia of, or pneumothorax, 
 252 
 
 hernia of, pains in chest, 247, 
 252 
 
 hernia of, pleurodynia of, 247 
 
 paresis, acute, of, pain in 
 
 chest, 253 
 Diaphragmatitis, pain in chest, 
 
 208 
 
 Digitus semi-mortuus, 296 
 Diphtheria, articular pains, 450 
 
 muscular spasms, tetanic, 392 
 
 trismus in, 384
 
 578 
 
 INDEX 
 
 Dorsal muscles, diseases of, 
 
 pain in back, 159 
 diseases of, pain in shoulder, 
 
 126 
 
 Drumstick fingers, 436 
 Duodenum, carcinoma of, pains 
 
 in back, 168 
 
 rupture of, pains in back, 168 
 ulcer of, pains in back, 168 
 ulcer of, pain in sacrum, 93 
 ulcer of, retrosternal pain, 
 
 230 
 Dysbasia, angiosclerotic, pains 
 
 in extremities, 298, 344 
 see also Limping. 
 Dysbasia, or achillodynia, 306 
 or akinesia algera, 303 
 or arterio - sclerotic neuritis, 
 
 301 
 
 or flatfoot, 304 
 or ischias, 301 
 or meralgia, 303 
 or myotonia, 306 
 or neurasthenia, 303 
 or occupational neurosis, 290 
 or peripheral neuritis, 301 
 or rupture of muscular fascia, 
 
 306 
 
 or trichinosis, 307 
 spinal, girdle sense, 206 
 spinal, or osteomalacia, 445 
 Dysentery, articular pains, 458 
 
 pains m extremities, 340 
 Dyspepsia, headache, 548 
 
 see also Flatulence 
 Dysphagia lusoria, pain in 
 
 chest, 227 
 Dyspragia and angina pectoris, 
 
 39 
 
 Dyspragia, intermittent or cer- 
 vical rib, 309 
 intermittent, muscular 
 
 cramps, 353 
 
 intermittent, pain in extremi- 
 ties, 307 
 
 intermittent, pains in shoul- 
 der, 111 
 
 intermittent, see also Limp- 
 ing. 
 
 Dysbasia, spinal, paresthesia in 
 extremities, 279, 290 
 
 E 
 
 Ear, diseases of, headache, 538 
 Eclampsia, muscular spasms, 
 
 tetanic, 393 
 Edema, Quincke's, migraine in, 
 
 567 
 
 Quincke's, paresthesia in ex- 
 tremities, 272 
 
 resorption of, headache, 541 
 see also Hydrops. 
 Edematous disease, muscular 
 
 pain, 381 
 Elephantiasis or acromegaly, 
 
 442 
 
 Empyema and pleurodynia, 242 
 Empyema, interlobar, pains in 
 
 shoulders, 144 
 interlobar, pleurodynia in, 
 
 236 
 necessitatis, pain in chest, 
 
 196 
 
 necessitatis or perforation of 
 a pulmonary cavern through 
 the wall of the chest, 196 
 necessitatis or subcutaneous 
 
 abscess, 196 
 pain in chest, 216 
 see also Pyothorax. 
 Encephalitis, articular pains, 
 
 459 
 
 headache, 517 
 
 muscular cramps, tetanic, 389 
 pain in extremities, 332 
 trismus in, 383 
 
 Encephalopathia, saturnine, 
 muscular spasms, tetanic, 
 389 
 
 Endarteritis. See Brain. 
 Endocarditis lenta, articular 
 
 pains, 450 
 Ensiform process, pains in the 
 
 region of, 218 
 Ehteroptosis, cardiac pain, 7 
 
 pain in sacrum, 76 
 Epilepsy, arthralgia in, 495 
 cardiac pain, anginoid, 17 
 headache, 535 
 
 muscular spasms, tetanic, 393 
 or migraine, 567 
 pain in extremities, 268, 346
 
 INDEX 
 
 579 
 
 Epiphyses, affection of, syphili- 
 tic, brittleness of bones, 
 433 
 
 Ergotism. See Poisoning, ergot. 
 Erysipelas, articular pain, 458 
 headache, 509, 552 
 pallidum, pain in extremities, 
 
 264 
 
 pain in throat, 173 
 trismus in, 384 
 Erysipeloid, pain in joints, 466 
 
 pain in extremities, 263 
 Erythema nodosum, pain in 
 
 bones, 428 
 Erythema contagiosum, pain 
 
 in sacrum, 82 
 
 Erythema nodosum, pain in ex- 
 tremities, 258 
 Erythromelalgia, migraine in, 
 
 567 
 
 pain in back, 161 
 pain in extremities, 261 
 Esophagalgia, pseudoangina 
 
 pectoris in, 67 
 
 Esophagitis, pain in neck, 184 
 Esophagospasm, pseudoangina 
 
 pectoris in, 66 
 retrosternal pain, 227 
 Esophagus, carcinoma of, pain 
 
 in shoulder, 123 
 dilatation of, pseudoangina 
 
 pectoris in, 65 
 
 diseases of, pain in back, 183 
 diseases of, pain in ensiform 
 
 process, 219 
 diseases of, pain in shoulder, 
 
 133 
 diseases of, pain in throat, 
 
 184 
 diseases of, retrosternal pain, 
 
 226 
 diverticulum of, pain in 
 
 throat, 184 
 
 intermittent angiosclerotic 
 dyspragia of, pseudoangina 
 in, 68 
 
 perforation of, into the air 
 passages, retrosternal pain, 
 223, 226, 248 
 ulcer of, retrosternal pain, 
 
 227 
 
 Eventration, diaphragmatic. 
 See Diaphragm. 
 
 Extremity, defective circulation 
 in, paresthesia in extremi- 
 ties, 293 
 
 gangrene of, pain in extremi- 
 ties, 310 
 lower, overburdening of, pain 
 
 in extremities, 347 
 lower, overburdening of, pain 
 
 in sacrum, 77 
 Extremities, pain in, 257 
 Eye, diseases of, headache, 536 
 
 P 
 
 Farcy. See Glanders. 
 Fasciitis plantaris, pain in ex- 
 tremities, 343 
 Feet, cold, 295 
 pains in, 359 
 
 Fever and angina pectoris, 71 
 exanthematous, headache, 552 
 exanthema tous, muscular 
 
 pains, 378 
 
 exanthematous, pain in ex- 
 tremities, 338 
 
 recurrent, articular pains, 460 
 recurrent, headache, 552 
 recurrent, muscular pains, 
 
 378 
 
 recurrent, pains in sacrum, 82 
 recurrent, trismus in, 384 
 Fingers, drumstick, 436 
 elongation of, or acromegaly, 
 
 440 
 
 Flatfoot, or dysbasia, 304 
 pain in extremities, 304 
 pain in knee joint, 507 
 pain in small of back, 77 
 Flatulency, feeling of constric- 
 tion in throat, 188 
 headache, 543 
 paresthesia in extremities, 
 
 275 
 Fossa, supraclavicular, pains in 
 
 extremities, 327 
 Furunculosis, pains in extremi- 
 ties, 260 
 pains in nape of neck, 189 
 
 G 
 
 Gall flstulae, pain in bones, 408 
 Gastric crises, tabetic or status 
 anginosus, 72
 
 580 
 
 INDEX 
 
 Gastritis. See Stomach. 
 Gastroenteritis, pain in extrem- 
 ities, 340 
 
 Gastroptosis, pain in chest, 220 
 Gastroxynsis, headache, 548 
 
 or migraine, 562 
 Giantism, or acromegaly, 439 
 Girdle sense, painful, 204 
 Glanders, articular pain, 464 
 
 headache, 556 
 
 muscular pain, 376 
 
 pain in bones, 417 
 
 pain in extremities, 260 
 Glands, fever in, pain in neck. 
 171 
 
 internal secretory, diseases of, 
 pain in extremities, 261 
 
 internal secretory, diseases of, 
 paresthesia in extremities, 
 286 
 
 internal secretory, diseases of, 
 
 retrosternal pains, 230 
 Glaucoma, headache in, or mi- 
 graine, 566 
 
 headache, nocturnal, 514 
 
 see also Eye. 
 Globus hystericus, 185 
 Gonorrhea, muscular pain, 376 
 
 pain in bones, 399 
 
 pains in sacrum, 83 
 Gout and articular rheumatism, 
 489 
 
 and migraine, 567 
 
 angina pectoris in, 35 
 
 arthralgia in, 498 
 
 articular pain, 468, 478, 485 
 
 headache, 386, 543 
 
 lead, articular pains, 498 
 
 laterosternal pain, 233 
 
 muscular pain, 358 
 
 pain in back, 154 
 
 pain in bones, 398, 428 
 
 pains in chest, 211 
 
 pain in extremities, 332, 338 
 
 pain in extremities, lancinat- 
 ing, 350 
 
 pain in sacrum, 77 
 
 pain in shoulder, 105 
 
 tophi, 488 
 Groin, pain in, 360 
 Growth, abnormal, arthralgia 
 in, 499 
 
 abnormal, pains in bones, 426 
 
 Growth, abnormal, pains in ex- 
 tremities, 347 
 Gullet. See Esophagus. 
 
 Habitus asthenicus, pains in 
 
 sacrum, 77 
 
 Habitus scrofulosus, or acro- 
 megaly, 442 
 Hands, cold, 295 
 Hands, pains in, 359 
 Hay asthma. See Asthma. 
 Hay fever, headache, 552 
 Headache, 509 
 
 and increased cerebral pres- 
 sure, 530 
 
 due to bad housing and poor 
 living, 551 
 
 due to strong light overhead, 
 551 
 
 during period of pubescence, 
 533, 550 
 
 hereditary, 559 
 
 in cranial sutures, 551 
 
 induration, 513 
 
 localization of, diagnostic 
 value of, 568 
 
 nocturnal, 514 
 
 posttraumatic, 515 
 
 school, 550 
 
 vasomotoric, 531 
 Head's zones, 195 
 Heart, aneurysm of, cardiac 
 pain, 5 
 
 debility of, pain in shoulders, 
 126 
 
 dilatation of, pain in shoul- 
 der, 140 
 
 diseases of, angina pectoris 
 in, 27, 37 
 
 diseases of, cardiac pain, an- 
 ginoid, 17 
 
 diseases of, retrosternal pain, 
 221 
 
 displacement of, abnormal, 
 cardiac pain. 
 
 dissociation of. headache, 549 
 
 extrasystolic condition of, 
 cardiac pain, 6 
 
 fatigue of (over -stretching), 
 cardiac pain, 3
 
 INDEX 
 
 581 
 
 Heart, hyperexcitation of, car- 
 diac pain, 4 
 
 insufficiency of, feeling of con- 
 striction in throat, 187 
 insufficiency of, headache, 550 
 insufficiency of, pain in ex- 
 tremities, 320 
 
 rupture of, cardiac pain, 23 
 spatial constriction, cardiac 
 
 pain, 11 
 
 thrombus in, pain in extrem- 
 ities, 312 
 tumors of, pseudoangina pec- 
 
 toris in, 49 
 Heat-stroke, headache, 551 
 
 muscular spasms, tetanic, 393 
 Hemarthros in hemophilia, 476 
 Hemarthros in spontaneous 
 
 fracture of bones, 477 
 in scurvy, 477 
 Hematoma, subphrenic. See 
 
 diaphragm, 
 subcutaneous, pains in chest, 
 
 199 
 
 subcutaneous, pains in ex- 
 tremities, 260 
 
 Hematomyelia, pains in sac- 
 rum, 90 
 
 Hematomyelia, pains in ex- 
 tremities, 332 
 Hemicranic state, 565 
 Hemoglobinuria, paroxysmal, 
 
 articular pains, 460 
 paroxysmal, muscular pains, 
 
 380 
 
 paroxysmal, pains in extrem- 
 ities, 325 
 due to marching, pain in 
 
 muscles, 380 
 Hemophilia, articular pain, 467, 
 
 476 
 Hemorrhages, cessation of, pain 
 
 in the head after, 529 
 Hemorrhoids, pains in sacrum, 
 
 101 
 
 Hernia, diaphragmatic. See dia- 
 phragm. 
 
 obturatoria, pain in extremi- 
 ties, 325 
 
 Herpes zoster, pains in chest, 
 203 
 
 Humerus, inflammation of, 
 chronic, pain in shoulder, 106 
 neoplasm of, pain in shoulder, 
 106 
 
 Hydrophobia, pain in throat, 
 
 see also Rabies. 
 Hydrops, chronic articular, ar- 
 ticular pain, 479, 500 
 resorption of, articular pain, 
 
 460 
 Hygroma, pain in foot (hand), 
 
 360 
 Hypertension, arterial, cardiac 
 
 pain, anginoid, 18 
 arterial, essential, pareathe- 
 
 sia in extremities, 283 
 arterial, headache, 534 
 arterial, migraine in, 568 
 Hyperthyreoidism, articular 
 
 pain, 490 
 cardiac pain, 16 
 headache, 535 
 muscular pain, 370 
 Hypophysis, diseases of, head- 
 ache, 518 
 tumors of, muscular pain, 
 
 370 
 
 tumors of, pain in extremi- 
 ties, lancinating, 352 
 Hypotension, arterial, head- 
 ache, 534 
 
 Hysteria, arthralgia in, 496 
 cardiac pain, 35 
 feeling of constriction in 
 
 throat, 185 
 headache, 510, 521 
 headache, nocturnal, 514 
 laterosternal pain, 233 
 muscular spasms, tetanic, 388 
 or migraine, 568 
 or osteomalacia, 445 
 pain in chest, 201, 246 
 pain in extremities, 346 
 pain in sacrum, 91 
 pain in shoulder, 112 
 paresthesia in extremities, 
 
 294 
 trismus in, 383 
 
 Icterus, headache, 548 
 
 Icterus gravis, trismus in, 385
 
 582 
 
 INDEX 
 
 Infectious diseases, articular 
 
 pain, 457 
 
 arthralgia in, 500 
 headache, 521, 552 
 muscular pain, 376 
 muscular pain after, 381 
 muscular spasms, tetanic, 392 
 pain in bones, 428 
 pain in extremities, 333 
 pleurodynia after, 381 
 percussion sensitiveness in 
 
 bones, 430 
 triamus in, 383 
 Influenza, headache, 552 
 muscular pain, 377 
 pain in bones, 428 
 pain in chest, 215 
 pain in extremities, 338 
 pain in sacrum, 80 
 pain in throat, 170 
 trismus in, 384 
 
 Intestinal autointoxication, 
 paresthesia in extremities, 
 276 
 Intestinal diseases, pseudoan- 
 
 gina pectoris, 60 
 Intestinal parasites, headache, 
 
 548 
 
 headache, or migraine, 362 
 Intestine, axial tortion of, pain 
 
 in sacrum, 98 
 
 Intestines. Sec Rectum, Flatu- 
 lence. 
 
 Intrapelvic disease, pain in ex- 
 tremities, 299 
 Intraperitoneal disease, pain in 
 
 extremities, 323 
 Ischias, 362 
 
 or dysbasia, 301 
 or ponitis, 473 
 or lumbago, 338 
 or rheumatism of gluteal 
 muscles, 508 
 
 Joints, diseases of, pain in knee 
 
 joint, 507 
 hip, arthritis of, or ischias, 
 
 507 
 arthritis of, or osteomyelitis, 
 
 607 
 
 Joints, hip, arthritis of, or of 
 
 sacroileac joint, 607 
 pain in flatfoot, 507 
 knee, pain in. in disease of 
 
 hip joint, 307 
 neuralgia of, arthralgia in, 
 
 sacroileac. See Articulation, 
 eternoclavicular, diseases of, 
 pain in chest, 220 
 
 K 
 
 Kidneys, diseases of, headache, 
 
 540 
 diseases of, pain in sacrum, 
 
 93 
 Ktimmel's disease, pains in 
 
 back, 159 
 
 Leprosy, swelling in bones, 435 
 Leptomeningitis. See Meningi- 
 tis. 
 
 L e u c e m i a, enlargement of 
 glands, pain in joints, 467 
 
 headache, 557 
 
 or myeloma, 412 
 
 pain in bones, 412, 426 
 
 pain in joints, 466 
 
 pain in sacrum, 82 
 
 percussion sensitiveness in 
 
 bones, 426 
 
 Limping, intermittent, pain in 
 back, 161 
 
 intermittent, pain in extrem- 
 ities, 299 
 Lipoma, pain in extremities, 
 
 202 
 
 Liver, abscess of, pain in shoul- 
 der, 114 
 
 abscess of, perforation of, 
 into pleura, pains in chest, 
 251 
 
 diseases of, laterosternal pain, 
 233 
 
 diseases of, pain in back, 168 
 
 diseases of, pain in nape of 
 neck, 194 
 
 diseases of, pain in shoulder, 
 145
 
 INDEX 
 
 583 
 
 Liver, diseases of, retrosternal 
 
 pain, 229 
 echinococcus of, pain in 
 
 shoulder, 114 
 
 peracute congestion of blood 
 in, pseudoangina pectoris 
 in, 55 
 sarcoma of, pain in shoulder, 
 
 115 
 spirillosis of, cardiac pain, 
 
 56 
 
 syphilis of, pseudoangina pec- 
 toris in, 54 
 Lues. See Syphilis. 
 Lumbago, or ischias, 338 
 or myeloma of bones, 368 
 pain in sacrum, 74 
 Lumbar puncture, headache, 
 
 521 
 Lung, actinomycosis of, pain in 
 
 chest, 199 
 carcinoma of, retrosternal 
 
 pain, 224 
 
 cavern of, perforation of, 
 through pectoral wall or 
 empyema necessitatis, 198 
 cavern of, perfororation of, 
 through pectoral wall or 
 pulmonary hernia, 198 
 cavern of, perforation of, 
 through pectoral wall or 
 subcutaneous abscess, 198 
 cavern of, perforation of, 
 through the pectoral wall, 
 pain in chest, 198 
 diseases of, muscular pain, 
 
 383 
 
 diseases of, pain in extremi- 
 ties, 327 
 diseases of, pain in nape of 
 
 neck, 193 
 diseases of, pleurodynia in, 
 
 243 
 diseases of, pain in shoulders, 
 
 112, 120 
 
 echinococcus of, perforation 
 of, into the pleura, pain in 
 chest, 251 
 echinococcus of, pleurodynia 
 
 in, 243 
 
 emphyseiTv of, articular 
 pains, 472 
 
 Lung, emphysema of, pain in 
 
 bones, 429 
 
 emphysema of, pain in ex- 
 tremities, 346 
 
 emphysema of, percussion 
 sensitiveness of bones, 429 
 infarct of, pain in back, 164 
 infarct of, pleurodynia in, 
 
 244 
 
 neoplasms of, pain in shoul- 
 der, 143 
 
 tuberculosis of, headache, 558 
 tuberculosis of, pains in 
 
 shoulders, 127, 143 
 tuberculosis of, paresthesia 
 
 in extremities, 267 
 tuberculosis of, pleurodynia 
 
 in, 243 
 Lymphadenia of bones, Nothna- 
 
 gel, pain in bones, 425 
 Lymphadenitis, pain in extrem- 
 ities, 320 
 
 Lymphangitis, pain in extremi- 
 ties, 320 
 
 Lymphatic glands, diseases of 
 
 bronhial, pain in neck, 171 
 
 bronchial diseases of, pain in 
 
 shoulder, 120 
 
 bronchial, perforation of, car- 
 diac pain, 23 
 
 bronchial perforation of, re- 
 trosternal pains, 222 
 dorsal, diseases of, pain in 
 
 back, 161 
 mediastinal, inflammation of, 
 
 pain in chest, 246 
 mediastinal, inflammation of, 
 
 pain in shoulder, 129 
 mediastinal, neoplasm of, 
 
 pains in shoulder, 131 
 mediastinal, perforation into 
 the air passages, retroster- 
 nal pain, 249 
 
 mediastinal, perforation of, 
 into the aorta or pericar- 
 dium, retrosternal pain, 249 
 mesenteric, diseases of, pain 
 
 in the sacrum, 95 
 of neck, inflammation of, 
 
 pain in neck, 170, 183 
 retrosternal, diseases of re- 
 trosternal pain, 222
 
 584 
 
 INDEX 
 
 Lymphatic glands, nuchal, dis- 
 eases of, pains in nape of 
 neck, 192 
 
 retro peritoneal, diseases of, 
 pain in sacrum, 95 
 
 swelling of, in acute leucemia, 
 455 
 
 swelling of, in articular rheu- 
 matism, 455 
 
 swelling of, in Still-Chauf- 
 fard's disease, 455 
 
 swelling of, in syphilitic ar- 
 thritis, 455 
 
 Lyssa. See also Rabies, 
 pain in throat, 185 
 
 M 
 
 Malaria, arthralgia in, 498 
 headache, 552, 557 
 muscular pain, 378 
 muscular spasms, tetanic, 392 
 paresthesia in extremities, 
 
 288 
 percussion sensitvieness in 
 
 bones, 430 
 pleurodynia in, 236 
 Malleus. See Glanders. 
 Malta fever, articular pains, 
 
 461 
 
 headache, 556 
 pains in bones, 418 
 pains in sacrum, 52 
 see also Fevers. 
 Mamma, abnormally large, car- 
 diac pain, 1 
 arteries of, sclerosis of, pain 
 
 in chest, 202 
 carcinoma of, pain in chest, 
 
 200 
 
 diseases of, pain in chest, 200 
 hypertrophy of, pain in chest, 
 
 200 
 involution of, pain in chest, 
 
 200 
 
 Mania, acute or rabies, 185 
 Mastodynia, pain in chest, 201 
 Mediastinitis, pain in back, 162 
 pain in neck, 176 
 pain in shoulder, 115, 131 
 pseudoangina pectoris in, 50 
 retroaternal pain, 222 
 retroeternal pressure feeling, 
 232 
 
 Mediastinum, diseases of, girdle 
 eense, 206 
 
 diseases of, laterosternal pain, 
 233 
 
 diseases of, pain in shoulders, 
 123, 127 
 
 tumors of, pain in chest, 244 
 
 tumors of, pain in shoulders, 
 142 
 
 tumors of, pseudoangina pec- 
 toris in, 50 
 
 tumors of, retrosternal pain, 
 
 223, 248 
 
 Meningeal hemorrhage, muscu- 
 lar spasms, tetanic, 390 
 Meningismus, headache, 558 
 Meningitis, chronic, pain in 
 sacrum, 88 
 
 epidemic, articular pain, 459 
 
 epidemic, headache, 554 
 
 epidemic, pain in sacrum, 79 
 
 epidemic, paresthesia in ex- 
 tremities, 280 
 
 headache, 517 
 
 muscular spasms, tetanic, 389 
 
 pain in extremities, 332 
 
 pain in nape of neck, 190 
 
 pain in neck, 181 
 
 serous, headache, 518, 558 
 
 spinal, pain in back, 155 
 
 trismus in, 383 
 
 tuberculous, pain in sacrum, 
 
 78, 88 
 
 Meningo-myelitis, pain in sac- 
 rum, 89 
 
 Menstruation, articular pain, 
 474 
 
 headache, 521, 531 
 
 pain in chest, 202 
 
 pain in sacrum, 99 
 
 paresthesia in extremities, 
 
 288 
 Meralgia, or dysbasia, 304 
 
 pain in extremities, 304 
 
 paresthesia in extremities, 
 
 275 
 
 Mesentery, diseases of, pain in 
 backj 168 
 
 tearing on, pain in sacrum, 
 97 
 
 tumors of, pain in sacrum, 
 97
 
 INDEX 
 
 585 
 
 Metabolic diseases, pains in ex- 
 tremities, 332 
 
 Metatarsalgia, pain in extremi- 
 ties, 344 
 Migraine, deuteropathic, 566 
 
 headache, nocturnal, 514 
 
 or epilepsy, 567 
 
 or gastroxynsis, 562 
 
 or gout, 567 
 
 or headache due to uremic, 
 urotoxic causes, 559 
 
 or headache in constipation, 
 562 
 
 or headache in glaucoma, 564 
 
 or headache in intestinal 
 parasites, 562 
 
 or headache in nicotine pois- 
 oning, 562 
 
 or headache in sclerosis of 
 cerebral arteries, 563 
 
 or hysteria, 568 
 
 or myalgia of the head, 565 
 
 or occipital neuralgia, 563 
 
 or pain in frontal sinus, nasal 
 or dental region, 563 
 
 or trigeminal neuralgia, 563 
 
 pain in nape of neck, 193 
 
 paresthesia in extremities, 
 
 267 
 Miliary tuberculosis, headache, 
 
 553 
 
 Mitral stenosis of oatium, an- 
 gina pectoris in, 27 
 
 stenosis of oetium, pain in 
 
 extremities, 312 
 Mongolism, articular pains, 495 
 Morton's disease. See Metatar- 
 salgia. 
 
 Muscles, neoplasms of, muscu- 
 lar pain, 357 
 
 rupture of, or dysbasia, 306 
 
 rupture of, pain in extremi- 
 ties, 306 
 
 rupture of, pain in sacrum, 
 
 75 
 
 Muscular rheumatism and mye- 
 loma of the bones, 357 
 
 muscular cramps, 353 
 
 muscular pain, 357, 373 
 
 or trichinosis, 373 
 
 pains in extremities, 340 
 Muscular spasms, tetanic, 385 
 
 Myalgia of head, headache, 512 
 headache in or migraine, 565 
 Myalgia or neuralgia, 379 
 
 pain in muscles, 365, 376 
 Myasthenia, paresthesia in ex- 
 tremities, 286 
 Myelitis, pain in nape of neck, 
 
 191 
 paresthesia in extremities, 
 
 279 
 
 pain in extremities, 331 
 pain in sacrum, 90 
 Myeloma, headache, nocturnal, 
 
 514 
 
 muscular pain, 357 
 or carcinoma of bones, 412 
 or leucemia, 412 
 or lumbago, 357 
 or muscular rheumatism, 358 
 or osteomalacia, 412 
 pain in bones, 412 
 Myocardia, dead finger in, 297 
 Myocarditis, acute, cardiac pain, 
 
 3 
 epistenocardiac, cardiac pain, 
 
 6 
 paresthesia in extremities, 
 
 267 
 
 Myomalacia, pain in heart, 6 
 Myositis, articular pain, 491 
 muscular pain, 362, 366, 373, 
 
 375 
 Myositis, pain in nape of neck, 
 
 190 
 
 Myotony or dysbasia, 306 
 pain in extremities, 306 
 Myotyphoid, pain in muscles, 
 
 ' 376 
 
 Myxedema, articular pain, 491 
 headache, 535 
 muscular pain, 370 
 or acromegaly, 441 
 pain in back, 155 
 pain in extremities, 261, 346 
 pain in nape of neck, 189 
 paresthesia in extremities, 
 261, 286 
 
 N 
 
 Nates, pain in, 103 
 Neck, actinomycosis of, pains 
 in neck, 175
 
 586 
 
 INDEX 
 
 Neck, feeling of constriction in 
 throat, 185 
 
 phlegmon of, pains in neck, 
 
 174 
 
 Nephritis. See Nephrosclerosis. 
 Nephrolithiasis, pain in shoul- 
 ders, 118 
 
 Nephrosclerosis, dead finger, 
 297 
 
 paresthesia in extremities, 
 
 267 
 
 Nephrosis, headache, 540 
 Nerve, cutaneous, disease of, 
 pain in extremities, 265 
 
 intercostal, disease of, pain 
 in back, 161 
 
 oculomotor. See Oculomoto- 
 rius. 
 
 phrenic, neuritis of (neural- 
 gia), angina pectoris in, 63 
 
 phrenic, neuritis of (neural- 
 gia), cardiac pain, 13 
 
 phrenic, neuritis of, intercos- 
 tal pain, 233 
 
 phrenic, neuritis of (neural- 
 gia), pain in neck, 182 
 
 phrenic, neuralgia of, pain in 
 shoulder, 118 
 
 phrenic, disease of, pain in 
 
 shoulder, 144 
 
 Nerve roots, posterior, diseases 
 of, or of nerve trunks, 329 
 
 diseases of, pain in extremi- 
 ties, 329 
 
 pain in back, 155 
 
 diseases of, pain in nape of 
 neck, 190 
 
 diseases of, pain in chest, 203 
 
 diseases of, pleurodynia in, 
 
 245 
 
 Nerve, sympathetic, disease of, 
 headache, 533 
 
 trigeminal, compression of, 
 headache, 513 
 
 trigeminal, neuralgia of, or 
 angina pectoris, 69 
 
 trigeminal, neuralgia of, 
 headache, 513 
 
 vagus, irritation of, feeling 
 of constriction in neck, 187 
 
 vagus, neurosis of, pseudo- 
 angina pectoris, 64 
 
 Nerve-trunk, lesion of, or of 
 nerve-roots, 329 
 
 lesion of, pain in extremities, 
 
 322 
 Nerves, diseases of, 321 
 
 mechanical injury of, pares- 
 thesia in extremities, 272 
 Nervous system. See Plexus. 
 Neuralgia, intercostal, or an- 
 gina pectoris, 62 
 
 intercostal, pain in chest, 202 
 
 intercostal, pain in shoulder, 
 121 
 
 lumbo-abdominal, pain in sac- 
 rum, 78 
 
 occipital, headache, 310 
 
 occipital, headache in or mi- 
 graine, 565 
 
 occipital, or angina pectoris, 
 69 
 
 of trigeminal nerve, or angina 
 pectoris, 69 
 
 or arthritis deformans, 483 
 
 of trigeminal nerve, headache, 
 513 
 
 thoraco-brachial, or angina 
 pectoris, 62 
 
 see Myalgia 
 
 Neurasthenia and cerebral ar- 
 teriosclerosis, 521 
 
 arthralgia in, 495 
 
 girdle sense in, 205 
 
 muscular pains, 369 
 
 or dysbasia, 303 
 
 or acromegaly, 443 
 
 or cerebral arteriosclerosis, 
 521 
 
 pain in back, 156 
 
 pain in cheat, 215 
 
 pain in extremities, 303, 331 
 
 pain in sacrum, 90 
 
 pain in shoulder, 112, 121 
 
 parestheaia in extremities, 
 295 
 
 retrosternal pain, 231 
 Neuritis, articular pain, 472 
 
 muscular pain, 362 
 
 muscular spasms, 353 
 
 or acute articular rheuma- 
 tism, 472 
 
 or arthritis defonnans, 483 
 
 or dysbasia, 301 
 
 or phlebitis, 357
 
 INDEX 
 
 587 
 
 Neuritis, pain in extremities, 
 
 301, 321, 332 
 
 pain in extremities, lancinat- 
 ing, 350 
 paresthesia in extremities, 
 
 273 
 brachial, pain in shoulder, 
 
 107 
 
 Neurofibromatosis, pain in ex- 
 tremities, 262 
 Neuromyositis, muscular pain, 
 
 371 
 
 Neurosis, cardiac pain, 15 
 climacteric, anginoid cardiac 
 
 pain, 15 
 occupational, muscular 
 
 cramps, 353 
 
 occupational, or dysbasia, 291 
 occupational, paresthesia in 
 
 extremities, 353 
 pain in back, 156 
 pain in shoulder, 112, 118 
 pain in sacrum, 90 
 pseudoangina pectoris in, 35 
 vasomotoric paresthesia in 
 
 extremities, 295 
 Nodes, Heberden's, 501 
 
 Heberden's or gouty, 501 
 Nose, diseases of, headache, 537 
 diseases of, headache in, or 
 
 migraine, 562 
 
 Nuchal muscles, diseases of, 
 pain in shoulder, 139 
 
 O 
 
 Obstipation, arthralgia in, 498 
 
 Ochronosus, articular rheuma- 
 tism in, articular pain, 484 
 
 Oculomotorius, paralysis of, 
 periodic, headache in or 
 migraine, 567 
 
 Omagra, pains in joints, 468 
 pain in shoulder, 105 
 
 Omalgia, pain in shoulder, 107 
 
 Omarthritis, pain in shoulder, 
 105 
 
 Oral cavity, diseases of, head- 
 ache, 539 
 
 Osteoarthritis deformana. Sec 
 Arthritis. 
 
 Osteoarthropathy or arthritis 
 deformans, 604 
 
 Osteoarthropathie hypertrophi- 
 
 ante, articular pain, 504 
 Marie's, 436 
 pain in bones, 422 
 Osteoarthropathy or acrome- 
 
 paly, 422 
 Osteocopic pains. See Pains in 
 
 Bones. 
 Osteogenesis imperfecta tarda, 
 
 pain in bones, 425 
 Osteomalacia, girdle sense, 205 
 or hysterical pseudoosteoma- 
 
 lacia, 445 
 or arthritis deformans, 444, 
 
 505 
 
 or Paget's ostitis, 421 
 or spastic spinal paralysis, 
 
 445 
 
 or spinal arteriosclerosis, 444 
 or spondylarthritis, 444 
 or syphilis of bones, 444 
 pain in bones, 407 
 pain in sacrum, 87 
 paresthesia in extremities, 
 
 267, 288 
 Osteomyelitis, arthralgia in, 
 
 498 
 
 mitigated, 475 
 or acute arthritis, 470 
 or arthritis of sacroileac 
 
 joint, 508 
 or ischias, 508 
 
 or muscular rheumatism, 508 
 or omartnritis, 507 
 pain in bones. 415 
 pain in shoulder, 106 
 percussion sensitiveness in 
 
 bones, 429 
 Osteopathy, hunger, headache, 
 
 514 
 
 hunger, pain in bones, 407 
 Osteoperiostitis, actinomycotic, 
 
 pain in bones, 418 
 malleosa, pain in bones, 417 
 pain in bones, 396 
 syphilitic, pain in bones, 414 
 Osteoporosis or arthritis de- 
 formans, 505 
 pain in bones, 283 
 paresthesia in extremities, 266 
 Osteopsathyrosis, articular 
 
 pain, 491 
 brittleness of bones, 432
 
 588 
 
 INDEX 
 
 Osteotabes, Ziegler, pain in 
 
 bones, 425 
 Ostitis deformans, headache, 
 
 nocturnal, 514 
 or acroraegaly or hyperosto- 
 
 sis, 420 
 
 or neoplasm of bones, 421 
 or ostitis gummosa, 420 
 or senile osteomalacia, 421 
 Paget, articular pain, 491 
 Paget, pain in bones, 402, 419 
 Ostitis fibrosa, headache, 403, 
 
 422 
 
 Ostitis, pain in bones, 395 
 Ostitis melitensis, pain in 
 
 bones, 419 
 Ostitis, syphilitic, or acute 
 
 arthritis, 471 
 syphilitic, or Paget's ostitis, 
 
 421 
 tuberculous, pain in bones, 
 
 415 
 Ostitis typhosa, pain in bones, 
 
 418 
 
 Overexertion, pain in extremi- 
 ties, 347 
 Overfatigue, muscular pains, 
 
 380 
 
 pain in chest, 211 
 paresthesia in extremities, 
 
 266 
 
 Overwork, headache, 532 
 Oxalemia, articular pain, 490 
 Oxaluria, articular pain, 490 
 
 Pachydermia. See Acromegaly. 
 Pachymeningitis, headache, 517 
 or leptomeningitis, 517 
 pain in extremities, 332 
 Pain, anginoid, 14 
 rheumatoid, 431 
 Pancreas, diseases of, pain in 
 
 sacrum, 92 
 necrosis of, pseudoangina pec- 
 
 toris in, 57 
 diseases of, retrosternal pain, 
 
 228 
 
 diseases of, pain in back, 168 
 diseases of, pain in shoulder, 
 144 
 
 Pancreas, sarcoma of, pain in 
 
 sacrum, 96 
 sarcoma of, pseudoangina pec- 
 
 toris in, 57 
 Pancreatitis, pseudoangina pec- 
 
 toris in, 57 
 
 Pappataci fever, headache, 553 
 muscular pain, 379 
 pains in nape of neck, 190 
 Paralysis agitans, or chronic 
 articular rheumatism, 503 
 paresthesia of extremities, 
 
 286 
 Paralysis, progressive, headache, 
 
 525 
 
 progressive, migraine in, 566 
 progressive, pains in extremi- 
 ties, 331 
 Paratyphoid, articular pains, 
 
 451, 463 
 headache, 553 
 muscular pain, 376 
 Parotitis, headache, 552 
 
 epidemic, pains in neck, 177 
 Pectoral muscles, diseases of, 
 
 pain in chest, 218 
 rheumatism of, pains in 
 
 chest, 211 
 Pedalgia, pains in extremities, 
 
 345 
 Peliosis, rheumatic, articular 
 
 pains, 467 
 
 Pellagra, pains in back, 155 
 pains in extremities, 333 
 pains in extremities, 559 
 pains in sacrum, 102 
 paresthesia of extremities, 
 
 290 
 
 trismus in, 385 
 Pelvis, anomalies of, sacral 
 
 pain, 85 
 small, diseases in, arthralgia 
 
 in, 497 
 
 small, disease of, pains in ex- 
 tremities, 323 
 tumors in, lancinating pains 
 
 in extremiites, 352 
 Periarteritis nodosa, articular 
 
 pains, 466 
 muscular pains, 380 
 pains in extremities, 315, 339 
 Pericarditis, angina pectoris in, 
 27
 
 INDEX 
 
 589 
 
 Pericarditis, acute, cardiac 
 
 pain, 5, 21 
 
 adhesive, ( concretio p e r i- 
 cardii cum corde), angina 
 pectoris in, 7 
 epistenocardiac, or status an- 
 
 ginosus, 71 
 epistenocardiac, pain in heart, 
 
 5 
 
 pain in the heart, 8 
 pain in shoulders, 114, 117 
 pleuro-, pain in throat, 21 
 retrosternal pain, 223 
 Pericardium, perforation into, 
 
 angina pectoris in, 51 
 Perigastritis, pain in heart, 25 
 pseudoangina pectoris in, 51 
 pain in shoulders, 116 
 pleurodynia in, 237 
 Periostitis, acute rheumatic, 
 
 pain in bones, 419 
 albuminous, pains in bones, 
 
 417 
 
 Peripleuritis. See Abscess, 
 pain in shoulder, 117 
 subdiaphragmatic, lateroster- 
 
 nal pain, 234 
 subdiaphragmatic, pain in 
 
 nape of neck, 194 
 subdiaphragmatic, pain in 
 
 shoulders, 144 
 
 Pertussis, retrosternal pain, 225 
 Pea planus. See Flatfoot. 
 Pharynx, diseases of, "headache, 
 
 539 
 
 Phlebitis, muscular pain, 362 
 or dermatomyositis, 375 
 or hysteria, 358 
 or neuritis, 358 
 see also Veins. 
 
 Phlebosclerosis, pain in extrem- 
 ities, 319 
 Phlegmon of the skin, pain in 
 
 extremities, 264 
 subpectoral, pain in shoul- 
 ders, 111 
 Pilocarpin, injection of, angi- 
 
 noid pain in heart, 18 
 Plague, headache, 81 
 muscular pain, 378 
 pain in extremities, 321 
 pain in nape of neck, 193 
 pain in sacrum, 81 
 
 Pleura, actinomycosis of, pain 
 
 in chest, 199 
 diseases of, pain in nape of 
 
 neck, 194 
 diseases of, pain in shoulder, 
 
 120 
 echinococcus of, perforation 
 
 of into the lungs, pectoral 
 
 pain, 251 
 neoplasms of, pain in chest, 
 
 238 
 
 syphilis of, pain in chest, 242 
 Pleurisy. See Pleuritis. 
 Pleuritis, diaphragmatic, pains 
 
 in back, 164 
 diaphragmatic, pain in chest, 
 
 250 
 diaphragmatic, pains in nape 
 
 of neck, 194 
 
 diaphragmatic, pains in sac- 
 rum, 77 
 diaphragmatic, pains in 
 
 shoulder, 116, 144 
 diaphragmatic, pleurodynia 
 
 in, 238 
 fibrous adhesive, pains in 
 
 back, 164 
 fibrous adhesive, pain in 
 
 chest, 238, 244 
 fibrous adhesive, pain in 
 
 heart, 8 
 
 fibrous adhesive, pain in sac- 
 rum, 77 
 interlobar, pain in shoulders, 
 
 132, 144 
 
 mediastinal, cardiac pains, 21 
 mediastinal, pains in back, 
 
 161 
 mediastinal, pain in chest, 
 
 238 
 mediastinal, pain in shoulder, 
 
 129, 132 
 
 pain in back, 161 
 pain in chest, 215, 250 
 pain in shoulder, 114, 117 
 perforation of into lung, pain 
 
 in chest, 250 
 Pleuritis sicca (dry pleurisy), 
 
 angina pectoris in, 31 
 cardiac pain, anjinoid, 20 
 muscular pain, 383 
 pain in chest, 212 
 and pleurodynia, 234
 
 590 
 
 INDEX 
 
 Pleuro-pericarditis. See Peri- 
 carditis. 
 Pleurodynia, 234 
 
 pains in chest, 211 
 Plexus, nervous brachial, neu- 
 ritis of, pain in shoulder, 
 107 
 
 nervous celiac, neuralgia of, 
 pain in sacrum, 98 
 
 nervous cervico-brachial, dis- 
 eases of, pain in shoulder, 
 141 
 
 nervous cervico-brachial, neu- 
 ritis of, pain in shoulder, 
 108, 141 
 
 nervous cervico - occipitalis, 
 neuralgia of, pain in nape 
 of neck, 192 
 
 nervous aortic, neuritis of, 
 and angina pectoris, 68 
 
 venous pelvic, ectasy of, pain 
 in sacrum, 98 
 
 venous pelvic, thrombosis of 
 ( thrombophlebitis ) , pain 
 in sacrum, 98 
 Pneumonia, headache, 558 
 
 muscular pain, 377 
 
 pain in nape of neck, 194 
 
 pain in shoulder, 132, 143 
 
 pleurodynia in, 235 
 Pneumothorax and pleurodynia, 
 242 
 
 or diaphragmatic hernia, 250 
 
 pain in chest, 250 
 
 pains in shoulder, 114 
 Poisoning, alcohol, headache, 
 521, 531, 544 
 
 alcohol, muscular pain, 369 
 
 and muscular spasms, 355 
 
 and muscular spasms, tetanic, 
 390 
 
 arsenic, headache, 544 
 
 arsenic, pain in bones, 428 
 
 arsenic, paresthesia in ex- 
 tremities, 289 
 
 atropin, feeling of constric- 
 tion in throat, 188 
 
 atropin, trismus in, 384 
 
 blood poisoning, trismus in, 
 385 
 
 carbon oxid, angina pectoris 
 in, 33 
 
 carbon oxid, headache, 544 
 
 Poisoning, chloroform, head- 
 ache, 531, 544 
 chromic acid, pain in bones, 
 
 428 
 
 coffee, angina pectoris in, 33 
 coffee, headache, 544 
 ergot, muscular cramps, te- 
 tanic, 391 
 
 ergot, paresthesia in extrem- 
 ities, 288 
 
 lead, angina pectoris in, 33 
 lead, arthralgia in, 498 
 lead, headache, 544 
 lead, muscular pains, 370 
 lead, muscular spasms, te- 
 tanic, 389 
 
 lead, pain in sacrum, 99 
 lead, paresthesia in extremi- 
 ties, 289 
 
 mercury, headache, 544 
 mercury, muscular pains, 371 
 mercury, pains in bones, 428 
 nicotine, cardiac pain, 14 
 nicotine, headache, 531, 544 
 nicotine, headache in, or mi- 
 graine, 562 
 nicotine, lancinating pains in 
 
 extremities, 351 
 nicotine, paresthesia in ex- 
 tremities. 289 
 nicotine, trismus in, 385 
 nitrite, headache, 531, 544 
 nitrobenzol, headache, 544 
 opium (morphin), muscular 
 
 spasms, tetanic, 391 
 opium (morphin), trismus in, 
 
 385 
 
 pains in extremities, 332 
 perchloride of mercury, car- 
 diac pains, 14 
 phosphorus, pain in bones, 
 
 428 
 
 retrosternal pains in, 226 
 strychnin, muscular spasms, 
 
 tetanic, 386 
 
 sublimat, muscular pains, 371 
 sulphurous carbon, headache, 
 
 544 
 
 sulphurous carbon, paresthe- 
 sia in extremities, 274 
 tea, angina pectoris in, 32 
 tea, headache, 531, 544
 
 INDEX 
 
 591 
 
 Poisoning, tea, paresthesia in 
 
 extremities, 296 
 tea, trismus in, 385 
 vanilla, headache, 544 
 Poliomyelitis, muscular pain, 
 
 379 
 
 or acute articular rheuma- 
 tism, 473 
 
 pain in extremities, 332 
 pain in nape of neck, 191 
 pain in sacrum, 79, 88 
 Polyarthritis. See Arthritis. 
 Polycythemia, migraine in, 568 
 
 rubra, headache, 528 
 Polymyositis, muscular pain, 
 
 371 
 
 pain in chest, 211 
 Polyneuritis. See Neuritis. 
 Posture of body, forward lean- 
 ing, retrosternal feeling of 
 pressure in, 232 
 Pregnancy, headache, 541 
 pains in chest, 202 
 pains in sacrum, 76 
 paresthesia in extremities, 
 
 270 
 toxic condition in, headache, 
 
 541 
 Pseudoacromegaly in pregnancy 
 
 or acromegaly, 440 
 Pseudoangina pectoris. See An- 
 gina Pectoris. 
 Pseudoosteomalacia, hysterical 
 
 or osteomalacia, 445 
 Pseudoperiostitis, angioneuro- 
 
 tic, 399 
 Pseudorheumatism, infectious, 
 
 articular pains, 457, 480 
 Pseudotabes, peripheral, pains 
 in extremities, lancinating, 
 352 
 
 Pseudotetanus, 392 
 Pseudotetany, hysterical, mus- 
 cular cramps, 353 
 Pseudotrismus, 382 
 Psoriasis, articular pains, 490 
 cardiac pain, anginoid, 17 
 headache, 527 
 pain in shoulder, 112 
 Puberty, headache, 533, 550 
 Purpura, heniorrhagica, articu- 
 lar pain, 467 
 
 Pyelitis and pleurodynia, 237 
 
 pain in sacrum, 83 
 Pyemia, muscular pain, 376 
 Pylorus stenosis, colic, pseudo- 
 angina pectoris in, 60 
 Pyopneumothorax, pain in 
 
 chest, 242, 251 
 Pyothorax. See Empyema. 
 
 pain in chest, 258 
 Pyrgocephalus, headache, 514 
 
 migraine in, 567 
 Pyrosis, retrosternal pain, 228 
 
 Q 
 
 Quicksilver. See Mercury pois- 
 oning. 
 
 R 
 
 Rabies, constriction, girdle 
 
 sense in throat, 185 
 muscular spasms, tetanic, 387 
 or acute mania, 185 
 or hydrophobia, 185 
 pain in sacrum, 90 
 paresthesia in extremities, 
 
 280 
 Rachitis tarda, arthralgia in, 
 
 498 
 
 pain in bones, 403, 408 
 Raynaud's disease, paresthesia 
 
 in extremities, 271 
 Recklinghau$en's disease, pain 
 
 in bones, 422 
 
 Rectum, diseases of, pain in sac- 
 rum, 101 
 Renal colic, pains in sternum, 
 
 234 
 Respiratory organs, diseases of, 
 
 headache, 548 
 Retroperitoneal diseases, livr 
 
 complaint in, 168 
 pain in back, 165 
 pain in extremities, 323 
 pain in sacrum, 92 S. 
 see also Cellulitis and Lym- 
 phatic Glands. 
 Rheumatism. See Articular and 
 
 Muscular Rheumatism. 
 Rheumatismus articulorum no- 
 dosus, articular pains, 446
 
 592 
 
 INDEX 
 
 Rhizomyelia. See Spondylar- 
 
 thritis. 
 Ribs, disease of, or dyspragia, 
 
 308 
 
 diseases of, pain in back, 154 
 diseases of, pain in chest, 215 
 diseases of, pain in neck, 308, 
 
 328 
 diseases of, pain in sacrum, 
 
 86 
 diseases of, pain in shoulder, 
 
 125 
 
 cervical, paresthesia of ex- 
 tremities, 309 
 
 Rigor produced by heat, muscu- 
 lar spasms, tetanic, 394 
 
 S 
 
 Sacral muscles, diseases of, 
 
 pain in sacrum, 73 
 Sacrum, diseases of, pain in 
 
 sacrum, 88 
 Scapula, diseases of, pain in 
 
 shoulder, 119 
 
 diseases of, pain in back, 159 
 Scapular crackling sound, 119 
 Scarlatina, paresthesia of ex- 
 tremities, 288 
 pressure sensitiveness in 
 
 bones, 430 
 
 Scarlet fever. See Scarlatina. 
 Sclerodermia, articular pains, 
 
 491 
 
 nuchal pains, 189 
 or chronic articular rheuma- 
 tism, 504 
 
 pain in extremities, 265 
 Sclerosis insularis multiplex, 
 
 arthrology in, 495 
 articular pains, 472 
 headache, 518 
 migraine in, 566 
 multiple pains in chest, 205 
 pain in extremities, 472 
 pain in shoulders, 106 
 paresthesia in extremities, 
 
 267, 278 
 
 Scurvy, articular pain, 467 
 hemarthros in, 477 
 muscular pain, 380 
 pain in bones, 425 
 
 Scurvy, pains in chest, 215 
 
 pain in extremities, 341 
 Sepsis, headache, 556 
 meningococcal, articular pain, 
 
 451 
 
 muscular pains, 377 
 pains in back, 160 
 pain in chest, 216 
 pains in extremities, 340 
 pains in nape of neck, 190 
 percussion painfulness i n 
 
 bones, 430 
 pneumococcal, articular pains, 
 
 451 
 
 sacral pains, 82 
 Serum sickness, articular pains, 
 
 460 
 Sexual organs, female, diseases 
 
 of, pains in sacrum, 99 
 male, diseases of, pain in sac- 
 rum, 101 
 Shoulder, muscles of, diseases 
 
 of, pain in shoulder, 107 
 pain in, 67 
 
 Shoulder blade. See Scapula. 
 Sphenoid bone, diseases of, 
 
 headache, 537 
 Sinus, frontal, diseases of, 
 
 headache, 537 
 frontal, diseases of, headache 
 
 in, or migraine, 563 
 Skin dorsal, affection of, pain 
 
 in back, 161 
 pectoral, disease of, pain in 
 
 chest, 195 
 
 Skull, diseases of, headache, 513 
 Smallpox. See Variola. 
 Spinal column, arthropathy of, 
 
 pain in back, 151 
 articular diseases of, pains in 
 
 nape of neck, 191 
 diseases of, pains in back, 
 
 147 
 
 diseases of, pain in chest, 216 
 diseases of, pains in nape of 
 
 neck, 191 
 diseases of, pain in shoulders, 
 
 122 
 diseases of, pain in sacrum, 
 
 86 
 
 injury of, pain in sacrum, 88 
 insufficiencv of, pain in chest, 
 217
 
 INDEX 
 
 593 
 
 Spinal Column, neoplasms of, 
 or spondylarthritis anky- 
 lopoietica (arthritis defor- 
 mans), 152 
 
 neoplasms of, pains in back, 
 152 
 
 neoplasms of, pains in ex- 
 tremities, 333 
 
 osteomalacia of, pain in sac- 
 rum, 87 
 
 scoliosis of, pains in back, 
 147 
 
 scoliosis of, pains in chest, 
 
 209 
 
 Spinal cord, arteries, occlusion 
 of, girdle feeling, 205 
 
 arteries, sclerosis of, or osteo- 
 malacia, 444 
 
 diseases of, articular pains, 
 492 
 
 girdle sense, 205 
 
 pain in back, 154 
 
 pains in extremities, 265, 334 
 
 pains in extremities, lancinat- 
 ing, 350 
 
 pain in sacrum, 89 
 
 paresthesia in extremities, 
 
 265, 276 
 
 Spinal cord, syphilis of, pain 
 in extremities, 331 
 
 syphilis of, paresthesia in ex- 
 tremities, 277 
 
 tumors of, pain in extremi- 
 ties, 332 
 
 tumors of, pain in extremi- 
 ties, lancinating, 352 
 
 tumors of, pain in sacrum, 89 
 
 tumors of, paresthesia of ex- 
 tremities, 278 
 Spinal paralysis, spastic, or 
 
 osteomalacia, 445 
 Spleen, abscess of, perforation 
 of, in pleura, pain in chest, 
 252 
 
 diseases of, laterosternal, 233 
 
 diseases of, pain in shoulders, 
 117 
 
 extirpation of, pain in bones, 
 426 
 
 tumors of, pain in sacrum, 92 
 Spondylarthritis, ankylopoietic, 
 pains in extremities, 332 
 
 girdle sense, 205 
 
 Spondylarthritis, or neoplasm 
 
 of spinal column, 154 
 or osteomalacia, 444 
 pains in sacrum, 84 
 pains in nape of neck, 192 
 Spondylitis, acute, pains in 
 
 back, 149 
 
 chronic, pains in back, 144 
 Spondylopathia, traumatic, 
 
 pain in back, 159 
 Sporotrichosis, articular pain, 
 
 466 
 
 swelling in bones, 434 
 Stenocardia. See Angina Pec- 
 
 toris. 
 Sternum, diseases of, pains in 
 
 chest, 218 
 
 pains behind the, 220 
 pains laterally to the, 234 
 feeling of pressure behind the, 
 
 232 
 
 Still-Chauffard's disease, arti- 
 cular pains, 456 
 swelling of lymphatic glands, 
 
 456 
 
 Stomach, anacidity of, head- 
 ache, 534 
 Stomach, carcinoma of, pain in 
 
 back, 164 
 pain in sacrum, 96 
 perforation of into pleura, 
 
 pain in chest, 252 
 pseudoangina pectoris in, 58 
 Stomach, catarrh of, headache, 
 
 548 
 dilatation of, acute, headache, 
 
 548 
 dilatation of, acute, pain in 
 
 chest, 58 
 
 diseases of, pseudoangina pec- 
 toris in, 58 
 diseases of, retrosternal pain, 
 
 228 
 pneumatosis of, cardiac pain, 
 
 anginoid, 19 
 pneumatosis of, pain in 
 
 shoulders, 134 
 
 rupture of, pain in back, 168 
 Stomach, ulcer of, cardiac pain. 
 
 25 
 
 headache, 53~3 
 pain in back, 164 
 pain in chest, 209
 
 594 
 
 INDEX 
 
 Stomach, perforation of, into 
 pericardium, cardiac pain, 
 25 
 perforation of, into pleura, 
 
 pain in chest, 252 
 pseudoangina pectoria in, 51, 
 
 58 
 
 volvolus of, pain in heart, 25 
 Struma, colloid, pains in bones, 
 
 402 
 hemorrhages in, pains in neck, 
 
 180 
 
 malignant, pains in extremi- 
 ties, 328 
 
 Strumitis, pains in neck, 178 
 Subdiaphragmatic d i s e a s e, 
 
 muscular pain, 381 
 retrosternal pain, 231 
 Submaxillary glands, inflam- 
 mation of, pains in neck, 
 177 
 
 Sun stroke, headache, 551 
 Syphilis, articular pains, 454 
 headache, 513, 557 
 headache, nocturnal, 513 
 muscular pain, 380 
 of bones, or osteomalacia, 443 
 pains in bones, 430 
 Syringomyelia, arthropathy in, 
 
 494 
 
 or acromegaly, 440 
 or chronic articular rheuma- 
 tism, 494 
 
 pains in extremities, 332 
 pains in sacrum, 90 
 paresthesia in extremities, 
 
 332 
 see also Spinal Cord. 
 
 Tabes, angina pectoris in, 34 
 
 arthralgia in, 497 
 
 arthropathy in, 493 
 
 feeling of constriction in 
 neck, 188 
 
 girdle sense, 204 
 
 headache, 512 
 
 pain in chest, 204 
 
 pains in extremities, 266, 333 
 
 pains in extremities, lancin- 
 ating, 349 
 
 pain in sacrum, 87 
 
 Tabes, paresthesia in extremi- 
 ties, 266 
 (dorsalis et cervicalis). See 
 
 also Spinal Cord. 
 Taboparalysis, migraine in, 566 
 Tachycardia, paroxysmal, an- 
 
 ginoid cardiac pain, 17 
 cardiac pain, 3, 20 
 feeling of constriction in 
 
 neck, 187 
 
 in angina pectoris, 42 
 pain in shoulder, 140 
 paresthesia in extremities, 
 
 270 
 Tarsalgia, pain in extremities, 
 
 342 
 Teeth, diseases of, headache, 
 
 539 
 headache in, or migraine, 
 
 563 
 
 headache, nocturnal, 514 
 Tendovaginitis, pain in foot, 
 
 pain in hand, 360 
 Tetanus, articular pain, 471 
 feeling of constriction in 
 
 neck, 185 
 
 muscular pain, 366 
 muscular convulsions, local- 
 ized, 354 
 
 pains in chest, 215 
 pain in nape of neck, 189 
 pain in region of ensiform 
 process, 220 
 pain in sacrum, 80 
 pain in shoulder, 126 
 paresthesia in extremities, 
 
 280 
 
 trismus in, 383 
 Tetany, cardiac pain, 13 
 muscular cramps, 353 
 muscular spasms, tetanic, 393 
 paresthesia in extremities, 
 
 269 
 
 trismus in, 384 
 Thyreoid eland, insufficiency of, 
 
 arthralgia in, 500 
 neoplasm of, pain in neck, 
 
 178 
 
 Thyreoid. See also Hyperthy- 
 reoidism, Hypothyreoidism, 
 Strumitis. 
 Thyreoid it is, pain in neck, 178
 
 INDEX 
 
 595 
 
 Tonsilitis, pain in nape 01 neck, 
 
 193 
 
 pain in throat, 173 
 trismus in, 384 
 Tophi, in gout, 488 
 Towershaped skull. See Pyr- 
 
 gocephalus. 
 
 Trachea, foreign bodies in re- 
 trosternal pain, 225 
 stenosis of, retrosternal pain, 
 
 225 
 Tracheiiis, retrosternal pain, 
 
 224 
 
 pain in shoulder, 132 
 Trichinosis, muscular pain, 373 
 or dysbasia, 307 
 or muscular rheumatism, 373 
 pain in chest, 211 
 pain in extremities, 307, 340 
 pain in nape of neck, 189 
 pain in sacrum, 82 
 Trismus, 382 
 Tuberculin injection, angina 
 
 pectoris in, 33 
 Tuberculosis, muscular pain, 
 
 381 
 
 renal, pain in sacrum, 83 
 Turbinate bone, cavity of, dis- 
 eases of, headacne, 537 
 Typhoid and acute articular 
 
 rheumatism, 464 
 and gonorrhoic articular 
 
 rheumatism, 464 
 anti - vaccination, articular 
 
 pain, 463 
 anti - vaccination, headache, 
 
 555 
 
 articular pains, 462 
 bacillus septicemia, articular 
 
 pains, 463 
 headache, 552 
 muscular pain, 81 
 pain in bones, 418, 428 
 pain in extremities, 339 
 percussion sensitiveness in 
 
 bones, 430 
 serum inoculation, headache, 
 
 555 
 trismus in, 384 
 
 U 
 
 Uremia, arthralgia in, 499 
 dead finger, 296 
 
 Uremia, feeling of constriction 
 
 in neck, 188 
 headache, 540 
 
 headache in, or migraine, 561 
 headache, nocturnal, 514 
 muscular spasms, tetanic, 392 
 pain in extremities, 332 
 paresthesia in extremities, 
 
 276 
 
 Urinary congestion, pain in 
 sacrum, 93 
 
 Vagotony, cardiac pain, angi- 
 
 noid, 19 
 
 Variola, articular pains, 458 
 headache, 552 
 pains in extremities, 338 
 pain in sacrum, 81 
 Veins, diseases of, paresthesia 
 
 in extremities, 293 
 phlebitis of, pain in extremi- 
 ties, 320 
 thrombophlebitis of, pains in 
 
 extremities, 315 
 thrombosis of, pains in ex- 
 tremities, 315 
 thrombosis of, parestnesia in 
 
 extremities, 293 
 varicose, pains in extremities, 
 
 318 
 
 varicose, paresthesia in ex- 
 tremities, 291 
 
 see also Phlebosclerosis, Phle- 
 bitis, Plexus. 
 
 Vena cava superior, thrombo- 
 sis of, pseudoangina pec- 
 toris in, 51 
 thrombosis of, retrosternal 
 
 pain, 221 
 Venae iliacse, phlebitis of, pain 
 
 in sacrum, 98 
 
 Vena jugularis interna, phle- 
 bitis of, pain in neck, 181 
 thrombosis of, pain in neck, 
 
 181 
 
 Venae pelvince, thrombosis of 
 (thrombophlebitis), pain 
 in sacrum, 98 
 
 ectasy of, pain in sacrum, 98 
 Vertebral column. See Spinal 
 Column.
 
 596 
 
 INDEX 
 
 Vomiting, feeling of constric- 
 tion in throat, 188 
 
 W 
 
 Weil's disease, muscular pain, 
 379 
 
 pain in chest, 211 
 
 pain in nape of neck, 189 
 
 pain in sacrum, 80 
 
 trismus in, 384 
 Windpipe. See Trachea. 
 Wolhynian fever, headache, 552 
 
 muscular pains, 378 
 
 Wolhynian fever, pain in nape 
 
 of neck, 190 
 pains in bones, 427 
 pains in extremities, 339 
 
 Xiphoid process. See Ensiform 
 Process, 219 
 
 Yellow fever, headache, 552 
 muscular pain, 379 
 pains in sacrum, 80
 
 Date Due 
 
 PR.NTCO.N U...A. CAT. NO. 24 161
 
 A 000453 
 
 909 
 
 WB176 
 77$ 
 1922 
 Ortner, Norbert. 
 
 Clinical symptomatology of internal 
 diseases 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664