PAIN ITS CAUSATION AND DIAGNOSTIC SIG- NIFICANCE IN INTERNAL DISEASES BY DR. RUDOLPH SCHMIDT ASSISTANT IN THE CLINIC OP HOFRAT VON NEUSSER, VIENNA TRANSLATED AND EDITED BY KARL M. VOGEL, M.D. INSTRUCTOR IN PATHOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY; CLINICAL PATHOLOGIST AND ASSISTANT ATTENDING PHYSICIAN, ST. LUKE'S HOSPITAL AND HANS ZINSSER, A.M., M.D. INSTRUCTOR IN BACTERIOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY; ASSISTANT PATHOLOGIST, ST. LUKE'S HOSPITAL PHILADELPHIA & LONDON J. B. LIPPINCOTT COMPANY COPYRIGHT, 1908 BY J. B. LIPPINCOTT COMPANY Manufactured, by J. IS. Lippincoft Company The Washington Square Press, Philadelphia, U. S. A. WB 17* S3S3A HO* Translators' Preface IN undertaking a systematic analysis of pain Dr. Schmidt lias performed a useful service. The great difficulties attending such an analysis hardly need to be emphasized to the general practitioner, who is so often called upon to interpret the sub- jective complaint in terms of the temperament and individuality of the patient. In fulfilling his task the author has throughout tempered his deductions from actual pathological processes with a careful critical consideration of the functional elements which, in the phenomena of pain, so frequently cloud the clinical picture. Wherever possible, how- ever, he has based his conclusions upon the more exact factors of anatomical structure and patholog- ical change. It is self-evident that in the considera- tion of a symptom so purely subjective, composed of such complex psychological and pathological ele- ments, the final interpretation can be made only on the basis of careful clinical observation. The subtle differences, too, which may exist between individual cases of similar conditions preclude the possibility of formulating absolute rules. The author can but point the way to correct analyses and logical deduc- tion. Dr. Schmidt, in the performance of his task, calls upon the experience of many years with a huge clinical material. The thoroughness and concise- 5 6 TRANSLATORS' PREFACE ness with which he has presented his subject have seemed to the translators to justify the preparation of the little volume for the use of American mem- bers of the profession. For the sake of complete- ness they have added a chapter (X) embodying a brief presentation of Head's researches on re- ferred pains and a series of diagrams showing some of the commoner seats of pain or tenderness in visceral disease. Preface THE manifestations of disease that are apparent to the senses of the examiner, and therefore sus- ceptible of objective estimation, are, naturally, espe- cially valuable for diagnostic purposes. Modern medical research accordingly strives to facilitate the solution of diagnostic problems by investigations tending in this direction, such as the study of serum pathology and radiology. It may therefore appear almost like a step backward to lay as much stress on a phenomenon that is so purely objective in nature, and so dependent on the observations of the patient himself, as will be done in the following discussion of the symptom of pain. In this undertaking I have been actuated by the following considerations: In the first place, the objective evidences of disease often do not appear until the malady has reached a certain degree of development, whereas pain is not rarely present at its very inception. Furthermore, under the condi- tions of actual practice a comprehensive investiga- tion of all the objective symptoms is frequently a matter of great difficulty owing to the absence of the necessary facilities, and therefore a careful consider- ation of the patient's own sensations is absolutely essential. Lastly, it is frequently this very symp- tom of pain that impels the patient to seek medical 7 8 PREFACE advice, and it will therefore be the starting point of the diagnostic train of reasoning, while its correct interpretation is the first requisite to the institution of a suitable form of treatment. On the other hand, both during the ten years of my service in the clinic of my honored instructor, Hofrat von Neusser, which brought me in constant contact with the younger members of the staff, and in the course of my long-continued activity as a post- graduate instructor, I have convinced myself that even among those having satisfactory command of the methods of objective examination there is a great deficiency in the ability to make use of the infor- mation conveyed by the manifestations of pain. A realization of this lack was another reason for the preparation of the present volume. The work is intended especially to afford a gen- eral view that will enable rapid orientation in the individual case, and I therefore did not deem it advisable to impair its continuity by the introduction of references to the literature or of polemical dis- cussions. The adoption of a more or less dogmatic method of presentation seemed justified by my long- standing hospital connection, which has also involved much experience in teaching. In discussing the manifestations of pain it has seemed to me that in addition to the organic proc- esses to which they were due and the topographical factors underlying their projection externally, their relationship to function was especially important PREFACE 9 from the standpoint of facilitating diagnosis. The investigation of painful conditions from this point of view leads to- a more* intimate, comprehension of their pathogenesis and therefore to greater success in treatment. May the book fulfil the purpose for which it was written, of serving as a guide in the rapid and correct interpretation and successful treatment of the pain occurring in internal diseases. SCHMIDT. Contents PAGE TRANSLATORS' PREFACE 5 AUTHOR'S PREFACE 7 CHAPTER I. THE SENSATION OF PAIN 15 CHAPTER II. THE FUNCTIONAL MODIFICATION OF PAIN 22 The Influence of Position 22 The Influence of Motion 26 The Influence of Pressure 29 The Influence of Food 33 The Influence of Drugs and Chemicals 38 The Influence of Organic Function 41 CHAPTER III. TOPOGRAPHY IN ITS RELATION TO PAIN 47 The Shoulder 48 Retrosternal Region 50 Scapula and Interscapular Region 51 The Epigastrium 53 ' The Abdomen below the Umbilicus 56 The Lumbar Region (symmetrical) 57 The Lumbar Region (unilateral) and the Flanks 58 Atypical Abdominal Pains 59 CHAPTER IV. QUALITY AND TIME OF OCCURRENCE 65 Colicky Pains 65 Nocturnal Pains 67 CHAPTER V. THE NERVOUS SYSTEM 69 Headache 69 Due to Elevations of Intracranial Pressure 71 Caused by Chemical Poisons 76 Of Reflex Nature 78 Neuralgias Involving the General Nervous System 83 The Face 88 The Occipital Region and Nape of the Neck 90 The Arm 91 Intercostal Spaces, including Upper Abdomen 92 Flanks and Lower Abdominal Region 94 Lower Extremities 95 Neuralgias, Sympathetic System and Vagus 97 11 12 CONTENTS CHAPTER VI. PAGE ORGANS OF MOTION 103 Joint Pains or Arthralgias 103 Muscular Pains or Myalgias 108 Bone Pains or Ostalgias 115 CHAPTER VII. DIGESTIVE SYSTEM 123 Gastralgias 123 Irritable Weakness of Nervous System 126 Direct Causes 126 Pieflex Causes 128 Gastric Ulcers 133 The Colic of Pyloric Stenosis 153 Gastric Cancer 164 Intestinal Ulceration 174 Diseases of the Appendix 182 Lead Colic 192 Malignant New Growths of the Intestines 197 Liver 206 Gall-Bladder Colic 209 Pains without Colic 226 Distention and Inflammation Capsule 228 Pancreas 240 CHAPTER VIII. URINARY SYSTEM AND SPLEEN 249 Kidney 249 True Kidney Pains 249 Muscular Spasm, Urogenital Tract 262 Urinary Bladder 272 Spleen 276 CHAPTER IX. RESPIRATORY AND CIRCULATORY SYSTEMS 282 The Lungs 282 Aorta 292 Peripheral Vessels 314 CHAPTER X. CUTANEOUS TENDERNESS IN VISCERAL DISEASE . 319 List of Illustrations (At End of the Text) FIG. 1. Diagram, anterior view of the human body showing seg- mental distribution of referred pain and tenderness in visceral disease. 2. Diagram, posterior view of the human body showing seg- mental distribution of referred pain and tenderness in visceral disease. 3. Diagram, lateral view of the human body showing seg- mental distribution of referred pain and tenderness in visceral disease. 4. Diagram of head and neck, showing areas of referred pain and tenderness related to visceral disease or to affections of the head and neck. 5. Possible areas of pain or tenderness in diseases of the nervous system, etc. 6. Possible areas of pain or tenderness in diseases of the nervous system, etc. 7. Possible areas of pain or tenderness in diseases of the abdom- inal organs, etc. 8. Possible areas of pain or tenderness in diseases of the abdom- inal organs, etc. 9. Possible areas of pain or tenderness in diseases of the abdom- inal organs, etc. 10. Possible areas of pain or tenderness in diseases of the abdom- inal organs, etc. 11. Possible areas of pain or tenderness in diseases of the abdom- inal organs, etc. 12. Possible areas of pain or tenderness in diseases of the lungs and pleura. 13. Possible areas of pain or tenderness in diseases of the lungs and pleura. 13 14 LIST OF ILLUSTRATIONS FIG. 14. Possible areas of pain or tenderness in diseases of the lungs and pleura. 15. Possible areas of pain or tenderness in diseases of the heart and vessels. 16. Possible areas of pain or tenderness in diseases of the heart and vessels. 17. Possible areas of pain or tenderness in diseases of the heart and vessels. 18. Possible areas of pain or tenderness in diseases of the heart and vessels. PAIN ITS CAUSATION AND DIAGNOSTIC SIGNIFICANCE IN INTERNAL DISEASES CHAPTER I. THE SENSATION OF PAIN. IN order to combat successfully a painful sen- sation manifested by a patient, of whatever sort it may be, it is necessary first to obtain a clear insight into its sources of origin. The more deeply we are able to penetrate into these the more successful and to the point will be our therapeutic measures. A fundamental principle in such an objective study is the analysis of the 'painful sensation into its various elements, its relations to space and to time, its char- acteristic qualitative shading, its area of distribu- tion, associated manifestations, etc. TOPOGRAPHY. The analysis of a pain may most suitably be commenced by determining its topo- graphical characteristics. In order to do this it should be made a rule always to have the patient point out exactly the spot or the region in which the pain is felt, and specify whether it is superficial or deep seated. Vague statements, such as pain in the stomach, in the liver, etc., are of little value and are frequently associated with totally erroneous con- 15 16 PAIN ceptions regarding the situation of the organ in question, so that they serve only to lead astray. Where the pain is a radiating one it is necessary to differentiate between the painful focus and its peripheral radiations. In such cases it will usually be found that the focus often from the diagnostic point of view the most important point coincides with the area in which the pain was localized at the beginning of the attack. Of no less significance than the location of the painful focus, which ordinarily is at least in proximity to the etiological point of origin, are the radiations of the pain, especially in cases in which there is no ground for assuming a neuropathic tendency in the patient. If the opposite should be the case, however, it is advisable not to attach undue importance to the direction of radia- tion from the standpoint of differential diagnosis. Under these conditions one must be prepared to encounter atypical and wholly irregular, bizarre radi- ations. The extent of the area involved by the radiation of the pain in paroxysms such as those of biliary and ureteral colic, etc., frequently appears to be directly proportional to the intensity of the neuropathic tendency. In considering the topography it is also essential to take into account multiplicity or symmetry of the pain, if present. These features in connection with neuralgias, arthralgias, and ostalgias indicate a broader etiological basis, such as a disorder of meta- bolism, and speak against a purely local causation. TIME. A natural sequel of a consideration of ANALYSIS OF THE SENSATION 17 the location of the pain is that of the time of its appearance. Not infrequently the onset of the pain is associated with some definite hour of the day, or exhibits a regular dependence on certain occur- rences, such as the ingestion of food. Or it may appear at some stated time of the day (for example, nocturnal pain), and it is then our task to determine the factors underlying this regularity in recurrence. Now and then a relation to larger units of time, such as the seasons, or distinct phases in bodily develop- ment, may be observed and open up perspectives in the direction of the manner of causation. The duration of the painful sensation must also receive due attention. INTENSITY. The purely quantitative variations, of course, depend on the intensity of the stimulus in question, but not less so on the sensitiveness of the registering apparatus, that is, the patient's psychical characteristics, so that the same etiologi- cal stimulus may appear endurable to one, but may seriously disturb the psychical equilibrium of an- other. This double dependence of the intensity of the painful sensation on stimulus and irritability, and the impossibility of projecting externally the physicochemical events in the sensory nerve sub- stance that take place when pain is experienced, ren- der illusory attempts at the quantitative estimation of the sensation for diagnostic purposes. None the less, we are not entirely without means of control, and can make use of these in cases in which doubt arises regarding the credibility of the patient. 2 18 PAIN SIMULATION. Experience shows that intense and persistent pain in the course of time nearly always leads to more or less serious disturbances in the con- dition of the body as a whole, so that disorders of nutrition are produced and loss of weight results. In some cases, therefore, systematic observations of the patient's weight may serve as a means of control in this regard. When paroxysmal pain is complained of, the determination of the blood pres- sure by means of the tonometer [or, preferably, the sphygmomanometer] is to be recommended in sus- pected cases. This should be done both in the in- terval when the pain has subsided and at the height of the paroxysm. From analogy with the labora- tory experiment of stimulating the sciatic nerve an elevation of the vascular tension during the paroxysm is to be expected, and in fact this phe- nomenon may often actually be observed. In deal- ing with patients suspected of malingering I would suggest that if pain is complained of on pressure, the size of the pupils be observed in order to detect any possible increase in dilatation that may follow the painful stimulus (sympathetic reflex). If this reflex is present there is no doubt of the veracity of the patient in stating that he is experiencing pain. It is advisable, however, to obtain some insight into the patient's susceptibility to reflexes of this sort by the production of an artificial pain, e.g., by pinch- ing. Theoretically, this procedure even offers the possibility of obtaining an insight into the intensity of the original pain by observing the degree of ANALYSIS OF THE SENSATION 19 stimulation necessary to evoke the same reflex, assuming that equal stimuli produce reflexes of equal intensities. Reflex phenomena may be used in other ways as means of control in this direction. Such a one is the unilateral increase in the abdominal reflex which leads to the symptom of muscular rigid- ity (defense musculaire] occurring in abdominal conditions. QUALITY. Patients accustomed to close self- observation often supply information in regard to the quality of their pains. Not infrequently light may be thrown on the pathogenesis or nature of these pains through the description which the patient gives of them as being boring, piercing, colicky, etc. Pain resulting from muscular spasm is often experi- enced as a " cramp" or "griping." In cases of overdistention of hollow muscular organs this phe- nomenon may give its characteristic shading to the pain, and the pain of aneurysmal erosion, for ex- ample, is often described "as if something was boring" or as being "pounding" in nature. Ab- dominal pains must always be considered with re- gard to the presence of a colicky character. The distinctive feature of this lies in its wave-like in- crease and decrease, frequently accompanied by a sensation of griping, "tying up in a knot," or a feeling of overdistention. MODIFYING FACTOKS. The exact analysis of the pain furthermore demands the accurate determina- tion of all of the factors which influence the inten- sity of the sensation, either in the positive or the 20 PAIN negative sense. Such modifying factors are inti- mately connected with the causative condition and are therefore of the greatest importance from the diagnostic point of view. In this connection stimuli of general nature must especially be considered. a. Psychical. Excitement, diversion of atten- tion, suggestion either in the waking condition or under hypnosis, etc. It is evident that painful sen- sations that have what may be termed a psychical origin and from this center are projected to some one zone of the periphery, such as some of the pains of hysteria, are particularly susceptible to psychical modification. The same thing is true of pains which are peripheral and organic in origin but which are brought prominently into the foreground only as the result of abnormal irritability of the central recep- tive organs. In such cases diverting the attention through suitable occupation or pastimes, change of surroundings, etc., has an anodyne action. It is never permissible, however, from such an observa- tion alone to consider a pain as being of purely psychical nature. At the most it is justifiable only to assume the existence of a contributing component of this character. b. Mechanical. Position of the body, motion, solid food, percussion, massage, pressure, concus- sion, etc. c. Thermic. Changes of weather, draughts, etc. d. Electrical. e. Chemical. 1. Dietetic. 2. Eemedial : local or general. ANALYSIS OP THE SENSATION 21 Whenever the pain appears to be dependent on certain organic conditions or organic functions it will nearly always be possible on careful considera- tion to discover the primary causative factor, either in the group of the mechanical or of the chemical cell stimuli. ACCOMPANYING MANIFESTATIONS. Finally, it must not be forgotten that attention should be directed to any possible associated manifestations, whether these are of a purely subjective nature or are also susceptible of objective study. Frequently, of course, these are only remote in nature, such for example as the vomiting or constipation accompany- ing painful abdominal seizures of the most varied types, but sometimes they may also be interpreted as actual local symptoms (peristalsis, diarrhoea, dysuria, icterus, bleeding from the genitals, etc.). By following the preceding scheme it will often be possible to make a rapid diagnosis and to obtain a point of departure for therapeutic measures. At least the diagnostic possibilities will be narrowed and the physical examination or the laboratory investigations may be concentrated in a smaller domain. This is as it should be, for not only accu- racy but also promptness is desirable in diagnosis. CHAPTER II. THE FUNCTIONAL MODIFICATION OF PAIN. THE INFLUENCE OF POSITION. IN discussing the pain associated with the various organs it is often desirable to emphasize its dependence on definite positions of the body, such as the dorsal, the lateral, etc., which fre- quently appear to bear a distinct relationship to the sensation. Observations of this sort lead to the characterization of certain "positions of maximum pain," which term may be applied to those positions which give rise to a pain which previously did not exist or which increase the inten- sity of a pain already present. In so far as the painful position depends on tenderness to pressure of superficial structures, as in joint affections, etc., it has little diagnostic interest, and only those in- stances are to be discussed in which such external causation of the pain is not involved. In gastric ulcer the existence of a painful position has been accorded a somewhat unjustifiable degree of im- portance from the standpoint of differential diag- nosis, and for this reason the interpretation of the symptom is not always clear cut. This subject will be discussed later on in its proper place. As a matter of fact, painful positions may be discovered in connection with the pain complexes of the most varied organs, and this therefore points 22 FUNCTIONAL MODIFICATION 23 to uniformity in the mechanism of their origin. For example, in the discussion of special organs refer- ence will be made to the occurrence of painful posi- tions in diseases of the gall-bladder, of the appendix, in abdominal tumors, aneurysms, pericarditis, etc. I have found that even in intracranial processes, such as cerebellar tumors, there may be painful position in regard to the headache, which occurs on the side opposite to that of the hemisphere in which the tumor is situated and may depend on the pressure of the growth on the vena magna Galeni or the aqueduct of Silvius. In the majority of cases the most general cause of pain is to be sought for in a change of position of the diseased organ, such as occurs in certain positions of the body. All the organs, including new growths, are rather loosely packed in the body cavities, and the firmness of their fixation is very variable, as is shown in enteroptosis for example. Painful traction on diseased organs is likely to result (especially in cases of inflammatory processes in the immediate neighborhood of the structures involved, as in perigastritis, appendicitis, periaor- titis, etc.) in those positions of the body in which the organ is deprived of its firm support. This is ordi- narily the case in the position on the side opposed to the lesion, and the resulting pain will depend on the degree of sensibility caused by the inflammation and on the intensity of the traction, i.e., on the weight and mobility of the displaced mass. Of course other factors also come into play, such as pressure on 24 PAIN neighboring nerve trunks, as in aneurysms, tumors, etc., as well as secondary pressure effects on mus- cular hollow organs like the stomach, intestine, ureter, etc. A special mechanism depending on the local peculiarities of the tissues involved under- lies the position of maximum pain in certain diseases of the aorta or the coronary arteries. It is well known that in some cases of these the horizontal position may give rise to the onset of painful attacks of angina pectoris. In these affections the causa- tive factor is probably to be found in the alterations in the circulation produced by the change in position, such as the slower but more powerful cardiac con- tractions with a possible rise in arterial pressure and greater lateral tension of the chronically in- flamed aorta. What light is thrown on the problem of differ- ential diagnosis by the discovery that there is in a given case a position of maximum pain ? 1. If the problem presenting itself for decision is whether the pain is organic or functional in nature, the existence of a painful position is in favor of an organic lesion. Thus in cases of mediastinal new growth, including carcinoma of the oesophagus, aneurysm of the thoracic and abdominal aorta, gas- tric ulcer, etc., the nature of the attendant pain is not rarely misunderstood and is considered as being a functional manifestation of a neurosis. Under these conditions the demonstration that there is a distinct position of increased pain may be of deci- sive moment. FUNCTIONAL MODIFICATION 25 2. The presence of a painful position always in- dicates the advisability of a search for the organ or new growth causing it, and the location of the sensation attending the painful position will corre- spond to the situation of the organ or new growth in question. The detection of deeply situated tumors involving, for example, the pancreas or oesophagus, is often a matter of difficulty and in these cases the presence of a painful position may be taken as being corroborative of doubtful palpa- tory evidence. The occurrence of a painful position points toward a localized process, especially in deal- ing with the abdomen, even when the pain appears to be diffuse, as in appendicitis, intestinal cancer, cholelithiasis, nephrolithiasis, etc., and so may be of service in differentiating an ordinary intestinal colic from similar painful sensations originating in appendicular disease or localized carcinoma. The lateral posture is a painful position par ex- cellence, for it involves the most favorable condi- tions for abnormal displacement and traction. The dorsal position (e.g., retroperitoneal processes) or the sitting posture may also come into question, however. In the latter case the symptom is usually difficult to interpret. Pain in the small of the back and in the flanks is not infrequently caused after long sitting, especially if the body is inclined for- ward, by swollen abdominal organs like the kidney, spleen, liver, etc. These pains do not, however, appear very promptly, but only after long contin- 26 PAIN uance of the position, and the pain may sometimes also be explained as being the result of fatigue of the dorsal musculature. THE INFLUENCE OF MOTION. Under this heading only those forms of pain will be discussed that are modified in clearly recognizable fashion through bodily motion, either general or local. In these cases the pain may be produced or aggravated as if by carefully planned experi- mentation, and the differential diagnosis is facili- tated by tests in this direction. A more or less superficial connection between pain and bodily mo- tion in the sense that rest has a beneficial effect is very widespread and may, to some extent, be explained through the steadiness of the circulatory conditions (headache), and in the absence of me- chanical insults (gastric ulcer) when the body is at rest. On the other hand, there is a group of painful sensations that appear on motion as the inevitable result of the general pain mechanism. 1. DISORDERS OF THE ORGANS OF MOTION. These are maladies usually involving the extremities, which are accessible to careful and extensive physical ex- amination so that special difficulties are not likely to be encountered. The greatest source of error is to be found in the fortunately comparatively rare diffuse diseases of the osseus system, such as osteo- malacia and disseminated lesions of the bone- marrow. These possibilities must therefore always be kept in mind. FUNCTIONAL MODIFICATION 27 2. DISORDERS OF THE CIRCULATORY APPARATUS. The intimate relationship existing between the vas- cular and muscular systems has as a result, that in disorders both of the central and peripheral portions of the circulatory system, motion may appear as a potent source of pain. The circulatory system is also one of the channels through which the physical and objective act of motion transforms itself into the subjective sensation of pain. Every muscle, whether it is striated or smooth, when in action makes increased demands on the vascular system as a whole, and also on its own peripheral district. In this way it is easy to understand on the one hand the possibility of the causation of local pain on locomotion in local disorders (crural, mesenteric, and coronary vessels), and on the other hand it is clear that muscular action may produce pain indepen- dently of peripheral demands through the indirect effect on the central portions of the circulatory sys- tem, as in aortitis, aneurysm, etc. It is therefore an easily explainable fact that all of the symptoms produced by aneurysms or chronic inflammation of the aortic walls, and especially pain, may be in- creased or brought about by bodily motion. If, for example, retrosternal or epigastric pain is caused as the result of severe muscular exertion, such as climbing stairs, running, or battling against the wind, the possibility of the presence of disease of the circulatory system must always be suspected (atheroma of the thoracic and abdominal aorta, scle- rosis of the coronary arteries, hepatic congestion). 28 PAIN The same is true in regard to pain in the shoulder, or brachial neuralgia (aneurysm). 3. ABDOMINAL DISOEDEKS. In these there is not rarely an exquisite interdependence between pain and motion. This is especially true of acts that are accompanied by simultaneous exercise of the abdom- inal muscles, such as lifting weights, stooping, rais- ing the head, defecation, backward or lateral inclina- tion of the body, coughing, sneezing, etc. Undoubt- edly it is the accompanying elevation of intra- abdominal pressure that gives rise to the painful paroxysms in already congested organs (ureteral and biliary colic, etc.), either directly or through the interference with the venous flow. Before the onset of typical attacks of pain and also after the subsidence of these the appearance of distinctly localized pain as the result of efforts of the sort just mentioned may direct attention to a local disorder in the nature of latent appendicitis or cholecystitis, etc. Pain in the neighborhood of the appendix, for example, is not rarely elicited during defecation, in drawing on the shoes, lifting the head, bending the trunk to the left, on sitting down, etc. Pain in the epigastrium on bending the body backward would suggest the presence of an epigastric hernia. The pain produced through forcible motion at the hip joint in inflammatory and suppurative proc- esses in the neighborhood of the ileopsoas muscle involving the appendix, caecum, kidney, and para- metrium finds its explanation in the local pressure caused. Under these conditions it is important not FUNCTIONAL MODIFICATION 29 to make the examination in the horizontal position, in which the abdominal muscles are relaxed, but to have the patient standing, as then the pressure effects are more pronounced. Of course it is also necessary to think of inflammatory processes involv- ing the joint itself. The pain accompanying certain movements of the thigh in incarcerated hernia (ob- turator hernia) must not be overlooked in this con- nection. The jar communicated to the abdomen along the lower extremity on putting the foot to the ground may give rise to pain ; for example, in the neighborhood of an inflamed appendix, a movable kidney, or in cholecystitis. This pain appears when the foot of the same side strikes the ground, and is more pronounced in walking down hill owing to the greater force of the concussion. THE INFLUENCE OF PRESSURE. The influence of pressure, especially pressure from within, is of great importance in the mech- anism of spontaneous attacks of pain. An elevation of intracranial pressure gives rise to most severe headache. A rise of tension in the arterial system may produce extremely painful paroxysms; in- crease in the internal pressure in the liver, spleen, or kidney may cause acute pain through the tension of the capsule of the organ, and the same thing is true of localized distention in the gastro-intestinal canal. Pressure from without exerted for the purpose of testing a painful condition is usually not effective 30 PAIN from all directions, as in the above instances, but only from a given point. Nevertheless, under some conditions spontaneous pressure effects in all direc- tions may be experimentally imitated and made use of for differential diagnosis ; for example, in dealing with the digestive tract. I remember one case in which the nature of a tumor below the left costal arch was in doubt until the colon was inflated. At once pain, localized strictly to the tumor region, ap- peared, and at the autopsy carcinoma of the splenic flexure of the colon was revealed. In a similar way in cases of carcinoma of the oesophagus with stenosis the administration of effervescent draughts may give rise to localized pain, evidently caused by the tension from within. PRESSURE FROM WITHOUT. When applied for diagnostic purposes this may be used in order to obtain more exact information in regard to the location of already existing pain, or it may be re- sorted to to discover a hitherto unrevealed area of hyper algesia. In doing this it is well to remember that, even under physiological conditions and accord- ing to the degree of individual susceptibility, strong pressure may be more or less painful, and it is advis- able always to compare similar areas on the two sides. It is further desirable always to outline the zones of hyperaesthesia to pressure as accurately as possible. The more deeply the pressure is carried the greater is the loss of the resulting pain in local- izing value, and this is particularly true of the abdominal cavity. FUNCTIONAL MODIFICATION 31 PERCUSSION. By means of this it is possible to obtain an accurate estimate of the effect of pressure and this method of examination should never be omitted, especially in examining the abdomen. Posi- tive results will generally be obtained by this proce- dure in dealing with organs that touch the abdomi- nal wall with even only a portion of their surfaces, as the stomach, intestine, liver, and spleen in the anterior parts and the kidney in the posterior parts. The examination of the linea alba in this way for its whole length, from the xiphoid process to the symphysis, is especially to be recommended. If there is any diastasis of the recti, pressure or per- cussion in this region is not transmitted through the abdominal musculature, as is the case over the recti, but causes distinct manifestations of pain if one of the' organic lesions in question is present. In general it may be said that at every examina- tion of the abdomen for purposes of rapid orientation it is wise to test the sensibility to pressure of the region of the pylorus and gall-bladder, the three .flexures of the colon, the neighborhood of the appen- dix, and the hernial openings. Any local sensitive- ness to pressure in the rectum or vagina should also be noted. The testing of local sensibility to pres- sure also forms a useful method of rapid orientation in cases in which accurate palpation is rendered impossible owing to tension of the abdominal walls as in ascites. Among the pathological processes of a general nature that underlie pressure or percussion pain in 32 PAIN the abdominal region the first place must be given to peritoneal irritation, either circumscribed or diffuse. In addition, increase in the internal pressure also plays an important role; for example, in such con- ditions as hepatic congestion, and circumscribed or diffuse gastro-intestinal distention, especially when accompanied by ulcerative or peritonitic lesions. Thus the hyperaesthesia of the congested liver dimin- ishes in proportion to its decrease in size, and the tenderness of gastric ulcer may decrease from an excessive degree to a very slight amount within a few hours owing to the subsidence of gastric disten- tion. The sensitiveness of an inflamed appendix may in the same way diminish suddenly on the expul- sion of faeces and gas. "While in most cases it is natural to associate any existing abdominal tender- ness with the topographically related organs the rarer possibilities must also be kept in mind. For example, the symptom may have its seat in the ab- dominal musculature itself, as in the epigastric tenderness due to fatigue of the origins of the recti following persistent attacks of coughing. If the seat of the pain is situated behind the muscle the contraction of the latter usually diminishes or abol- ishes the effect of the pressure, and this may be of value in differential diagnosis. The vascular system of the abdominal cavity, particularly the aorta, may also be the seat of tenderness in the epigastrium. Furthermore, the possibility of neuralgic tenderness of the sensory tracts should not be forgotten, as in lead colic, gastric crises, etc. Sometimes in abdom- FUNCTIONAL MODIFICATION 33 inal neuralgias of this sort intense pressure, over the epigastrium for example, may seem to have the effect of relieving pain. This sign may sometimes be made use of in diagnosis, though caution is neces- sary, as the same thing exceptionally occurs in organic diseases. I am inclined to consider the accurate localiza- tion of tenderness of the sympathetic nerve fibres and plexuses running deep down along the spinal column as theoretically highly desirable but prac- tically impossible, and the same thing may be said in regard to the determination of tenderness of the solar plexus. THE INFLUENCE OF FOOD. While the importance of the exact determination of the alimentary causation or modification of pain phenomena is very great, the difficulties attending the demonstration of a relationship of this sort are no less so. This is especially the case when the evidence consists only of the biased or inaccurate observations of the patient himself. Frequently the connection between the two events is denied with the statement that pain is present also when food is not being taken and that the composition of the ingesta has no noticeable effect. It is evident that both of these conclusions are erroneous. In the first in- stance, it is permissible to draw only the inference that the ingestion of food is not the only pain-produc- ing factor, and in the second that the quality of the food is of slight importance. The difficulty of estab- 34 PAIN listing a relationship of cause and effect is also increased through the fact that in most cases the pain, at least as far as it involves the gastro-intes- tinal tract, appears only several hours after the ingestion of food. If the pain begins during the taking of the food itself a deep-seated stenosis of the oesophagus, par- ticularly carcinomatous, should be thought of even in the absence of well-defined dysphagia and though the pain be localized in the epigastrium. The pain- ful sensations caused by the food masses that become impacted above the stenosis are not infrequently referred to the epigastrium, are accompanied by a feeling of pressure, and usually disappear suddenly at the moment that the bolus passes the obstruction. Alimentary modification of the pain is ordinarily to be taken for granted only when the pain follows the ingestion of food with great regularity and after the lapse of a uniform interval of time. In these cases it is always advisable to determine the relationship experimentally by modifications in the amount and composition of the food. The ingestion of food may serve to produce pain in several ways, among which the most important are as follows: 1. The increase in gastro-intestinal peristalsis following the taking of food may serve mechanically to induce pain. In this connection the effect of cold appears to be especially noteworthy, as when cold water is taken. The colicky pain sometimes appear- ing in acute enteritis or appendicitis a short time FUNCTIONAL MODIFICATION 35 after a drink of cold milk, for example, is certainly caused in this way. When inflammatory ulceration exists in the oesophagus, pylorus, intestine, etc., it is natural to assume that the muscular contrac- tions set in motion for the purpose of carrying along the contents of the viscus form the cause of the pain, so that it is easy to understand that the composition of the food itself may not be of any particular importance. 2. Chemical stimuli in the form of ingested acids, spices, etc. The decomposition products resulting from bacterial action on carbohydrates and fats must also be. included under this head. 3. Local irritation due to the mechanical action of substances like hard bits of meat and similar bodies, distention of the gastro-intestinal wall through the formation of gas due to the fermentation of farinaceous foods, fruits, etc. This mode of causation seems to play an especially important role in cases of gastro-intestinal ulceration. The factors mentioned above have a positive action ; that is to say, cause* increase in pain, but there is also the possibility of an influence in the opposite direction. It is a fact that not only in gastric neuroses but also in cases of ulcer and some- times in gastric carcinoma the ingestion of food may alleviate or entirely relieve previously existing pain. Two possibilities must be considered in this connec- tion: 1. The excessive and painful peristalsis is relieved by the* entrance of food into the stomach (the growling of a hungry stomach). In cases in 36 PAIN which the nature of the food seems to be unimpor- tant, so that even a piece of bread, for example, has an anodyne effect, this appears to be the most nat- ural explanation. 2. The food consumed, such as milk, for example, combines with acid after the fash- ion of an alkali. In regard to the time of appearance of alimen- tary pain phenomena the variability of the causes explains the differences observed in the period of their appearance, although in the same individual the time intervals in cases of organic disease are often very uniform. The painful attacks attending lesions of the pylorus, for example benign stenosis, appear with great regularity two or three hours after the midday meal, probably in connection with the expulsive period of digestion. Cases are ob- served often enough, however, in which the interval is as much as five or six hours. I consider that attempts to draw inferences from such observations regarding the position of the lesion, for example, that it is a duodenal ulcer, are entirely unwarranted. On the one hand the appearance of the pain of pyloric ulcer may be much delayed as has been men- tioned, and on the other, in duodenal ulcer and intes- tinal affections including those of the colon (cancer of the sigmoid flexure, appendicitis, etc.), the pain may be felt a very short time after the food has been taken. It is interesting that in some cases of pyloric ulcer the onset of the pain is delayed if the quantity of food taken is very large. This is probably due to the fact that the expulsion of the gastric contents FUNCTIONAL MODIFICATION 37 is retarded. When there is a clearly demonstrable connection between the ingestion of food and the pain, internal gastro-intestinal lesions, especially those of an ulcerative and stenotic character, must be thought of. In addition, the somewhat rarer perigastritic processes should be kept in mind, such as adhesions between stomach and liver in syphilis of the latter organ, adhesions between stomach and colon in carcinoma of the splenic flexure, etc. En- largement of the organs in the neighborhood of the stomach must also be considered, such as echino- coccus of the liver or spleen, pancreatic cysts, etc., but these lesions are more apt to be accompanied by a sensation of uncomfortable pressure rather than by direct pain. Organic lesions are particularly likely to be pres- ent in cases in which there are no fluctuations in the intensity of the symptoms, in which the effect of psychical factors is slight or entirely absent, and the alimentary factor is characterized by great consist- ency. Owing to the close interrelationship between the gastro-intestinal tract and the large abdominal glands, the liver and pancreas, it is natural to expect a priori that on account of the circulatory changes in these organs attending the digestive act pain from these districts also should be subject to alimen- tary modification. Such interdependence is very irregular in its manifestation, however, and fre- quently cannot with certainty be demonstrated at all. Equally irregular is the alimentary relation- ship of the pain often observed after the subsidence 38 PAIN of lead colic or gastric crises. In the former con- dition painful attacks are not rarely the result of a diet that tends to gas formation. Pain resulting from disease of the circulatory system is also susceptible of modification by the in- gestion of food, as will appear later. Attacks of angina pectoris may follow meals excessive in amount or composed of food causing gastric and intestinal distention. The phenomenon may prob- ably be explained in part by the rise in blood pres- sure and increased demand upon the heart. The influence of food ingestion may also be observed in cases of atheroma involving the gastro-intestinal vessels. THE INFLUENCE OF DRUGS AND CHEMICALS. All forms of pain exhibit a widespread suscepti- bility to modification by the administration of drugs, quite independently of the effects of the narcotics. Furthermore, there may be in some cases a specific susceptibility obviously depending on more or less fundamental factors in the mechanism of production of the pain in question, and which may be made use of for the purposes of differential diagnosis. It is well known with what regularity the paroxysms of angina pectoris respond to the administration of the vasodilators. For this purpose I should especially recommend erythrol tetranitrate in the form of pills containing 0.01 g. each. In a case presenting indefi- nite pain in the neighborhood of the heart or in the epigastrium and where there are other reasons for 39 suspecting vascular disease, the resort to an erytlirol tetranitrate test may be of great diagnostic value, especially if the effect is more or less sudden and the same result always follows a repetition of the test. Obscure neuralgic pains in the left upper extremity may also be unmasked in this way and be found to depend on an irregular form of angina. Reflex pain of this sort in the upper extremity is sometimes relieved by the application of cold to the precordium. Local anaesthetics may be used for the purposes of differential diagnosis in order to determine whether the cause of the pain is peripheral or cen- tral. The subcutaneous injection of cocaine has been recommended for this purpose in trigeminal neuralgia and a 5 per cent, ointment of morphine has been used with a similar object. In testing the gastric mucosa the use of ansesthesin in 0.5 g. doses, or of cocaine (about 16 drops of a 1 per cent, solu- tion), may be recommended. The pain of gastric ulcer or of ulcerating carcinoma of the oesophagus usually ceases within about a quarter of an hour after the administration of these amounts of anaes- thesin or cocaine. If this occurs in a case under consideration, duodenal ulcer is improbable, and I therefore suggest this anaesthesin test as a means of differential diagnosis between gastric and duodenal ulceration. A prompt result following the anaes- thesin treatment in cases of epigastralgia usually indicates a lesion of the gastric mucosa such as ulcer or carcinoma and justifies the assumption of a local 40 PAIN causation of the pain. If the pain is accompanied by evidences of stenosis, such as increased gastric peristalsis or dysphagia, a positive result of the test would point to internal stenosis with changes in the mucous membrane. In order to decide the question whether a gastric pain is partly or entirely caused by hyperaesthesia to hydrochloric acid this may be given while fast- ing in doses of 1-5 drops of the dilute acid to a tablespoonful of water. The administration of alkalis such as sodium bicarbonate forms a pendant to this test. It must be borne in mind, however, that sodium bicarbonate may bring relief and ces- sation of pain by causing the stomach to expel any gas that may be present. Epigastric tenderness due to hepatic congestion is usually very amenable to digitalis treatment. If it shows a tendency to in- crease while the other evidences of congestion sub- side the complication of gastric ulcer must be sus- pected (ulcer in a congested stomach). The rapid relief of headache or neuralgic pain by the administration of iodine and mercury of course suggests syphilis. In cases of headache, tri- geminal neuralgia, sciatica, etc., accompanied by con- stipation, it is advisable to resort to purgation in endeavoring to obtain insight into the etiology of the pain. While the intestinal condition is not very frequently the sole cause of the pain, there is no doubt that it sometimes is an important factor, and the diagnostic and therapeutic aims may be united. In gastric ulcer, the colic of pyloric stenosis, lead FUNCTIONAL MODIFICATION 41 colic, etc., an important role in the pain formation is often played by stagnation of the fecal masses. Paroxysms of abdominal pain of the most varied nature (gall passages, ureters, etc.) frequently re- spond very directly to the cautious evacuation of the intestine either through cathartics given by mouth or through the rectum. The hypodermic injection of distilled water may be of diagnostic value in obscure pain, especially in cases in which the patient's suffering is completely or in part the result of autosuggestion. Even if the pain diminishes there is always the possibility that in addition to the functional element there is also an organic causative factor, and in this way it is possible to form an idea of the intensity of the latter. Obscure pain about the thorax (shoulder, interscapu- lar space, etc.) which is increased by the injection of tuberculin probably is related to an underlying tuberculous process. THE INFLUENCE OF ORGANIC FUNCTION. The coincidence of certain pain phenomena with one or another organic function may form the start- ing point of a diagnostic analysis. Sometimes such a conjunction may afford appreciable assistance, but it must be confessed that often there is danger of its leading into error. DEFECATION. The act of defecation, for example, may exhibit the most varied relationships to pain phenomena of widely differing origin. Coprostasis of long .duration causes stagnation and abnormal 42 PAIN decomposition in the entire digestive tract, includ- ing the stomach, and it is not surprising, therefore, that the pain accompanying many gastro-intestinal conditions, such as appendicitis, intestinal stenosis, lead poisoning, ulcer, stenosis of the pylorus, etc., may be favorably affected by the cautious production of an evacuation, a fact which de- serves careful consideration from the standpoint of therapeutics also. In dealing with inflammatory lesions in the abdomen care must be taken, however, that the act of defecation does not involve too great a degree of exertion of the abdominal musculature. Otherwise precisely during the act of defecation strictly localized pain may be caused corresponding to the position of the inflamed appendix or diseased gall-bladder, or in the neighborhood of a carcinoma of the colon or gastric ulcer. Such an occurrence may have diagnostic value in determining the posi- tion of the process in question. This localized pain, accompanying abdominal straining, may be spoken of by the patient and be of assistance in the diag- nosis in cases of quiescent appendicitis, or on the other hand, in the early stages of the disease. Back- ache resulting from gastro-intestinal distention (in- testinal stenosis, etc.) is usually perceptibly relieved after a movement of the bowels. If the movement is regularly preceded by pain immediately before the act, deep-seated ulcerative processes such as carci- noma of the rectum should be suspected. In cases of latent angina pectoris severe abdom- inal straining during defecation may cause the onset FUNCTIONAL MODIFICATION 43 of a paroxysm, or slight retrosternal premonitory sensations may be induced. The favorable effect of defecation is often indubitable and even astonishing in many cases of headache, especially, it appears to me, in those types which are accompanied by an elevation of intracranial pressure. A laxative frequently is much more effective than large doses of antineuralgics, even in cases of severe organic lesions like brain tumors. In these cases the im- provement must depend on alterations in the intra- cranial circulation, for the effect is often very sud- den. Meteorism may lead to stasis in the superior vena cava and in the cerebral veins through the restriction of the respiratory venous aspiration, and the important part played by normal intestinal peri- stalsis in facilitating the venous circulation in the portal district must also be considered. In these cases, too, the act of defecation may give rise to temporary increase in the headache if it is accom- panied by undue straining efforts. The onset of gastric crises in tabes not rarely occurs in conjunction with defecation and the evacu- ation of fluid stools. It is likely, however, that the act of defecation is in these cases only indirectly to be associated with the gastric symptoms (increased gastro-intestinal peristalsis). In enteroptosis, in- testinal atony and neuropathic conditions persistent constipation sometimes appears rather to have the effect of deferring the onset of functional pains, such as gastralgias. 44 PAIN VOMITING. If vomiting accompanies abdominal pain the coincidence of the latter with this common symptom is more apt to lead astray than to be of direct diagnostic service, unless it happens that the nature of the vomitus (blood, sarcinae, lactic acid bacilli, hyperchlorhydria, etc.) gives the necessary clue. One may easily be deceived by the vomiting in chronic intestinal stenoses, for example in tu- berculous ulceration of the small intestine, and in the absence of peristaltic movement be led to assume a gastric lesion such as stenosis of the pylorus as the starting point of the pain. Slight alleviation of the pain after vomiting is sometimes observed in painful seizures of the most varied nature, such as angina pectoris, renal infarct, chole- lithiasis, etc. Prompt and often complete relief to the pain is particularly characteristic of attacks of colic due to stenosis of the pylorus. DEGLUTITION. Pain accompanying the act of swallowing may depend on internal or external causes. If the source of the sensation is in the upper part of the oesophagus its detection will ordi- narily not prove difficult. If the patient has fever the possible existence of laryngeal tuberculosis should not be forgotten. If the dysphagia is due to ulcer- ation of some portion of the cesophageal mucosa an increase in the pain is usually caused on taking acids or spiced articles of food. On the other hand, the administration of local anaesthetics like anaesthesin will prove beneficial. This effect of food or drugs is generally absent if there are other causes for the FUNCTIONAL MODIFICATION 45 disturbance in deglutition, unless secondary ulcera- tions have been caused. The deglutition pain of aneurysm frequently radiates into the left shoulder or below the clavicle. MENSTKTJATION. While it is natural to refer to the genital apparatus pains occurring together with menstruation or at least, if they involve regions at a distance such as headache or gastralgia, to asso- ciate them with this function it must always be borne in mind that the menstrual process leads to increased irritability of the system in general. Therefore, whenever there is already present an irritative condition, such as cholelithiasis, appen- dicular disease, ulcer of the stomach, etc., attacks of pain may be brought on in these regions of lessened resistance. This is especially true of the appendix, owing to its topographical relationships and its circulatory connections. In distinction to this many obstinate abdominal pains such as gastralgias seem to be checked during pregnancy. This is particu- larly the case in enteroptosis, probably in part owing to the diminution of the abnormal mobility of the abdominal organs. EESPIKATION. In dealing with shoulder pains in- duced by respiration, it is always advisable to think of the possible presence of apical tuberculosis with secondary perineuritis of the brachial plexus (ten- derness on pressure). Pain in the domain of the thoracic muscles may of course be purely myogenic in nature in spite of its dependence on the respira- tory act. The retrosternal pain sometimes produced 46 PAIN by deep respiration in cases of atheroma of the aorta may be explained by the traction on the vessel. Both local and diffuse peritonitic lesions such as perihepatitis, perigastritis, etc., as well as lesions of movable abdominal viscera in general, are fre- quently the seat of pain on sudden inspiratory dislo- cation, especially that caused by diaphragmatic breathing. CHAPTER III. TOPOGRAPHY IN ITS EELATION TO PAIN. WHILE in external diseases the site of pain nearly always corresponds to tne lesion, this is true of internal affections only with certain reservations and in this connection there is found an unending source of diagnostic errors. Even the general ques- tion of whether the presence of local pain indicates the existence of any disease of an internal organ and is not due to an external lesion, may sometimes be difficult to answer. Before arriving at the conclu- sion that a certain painful sensation is caused by internal disease, it will be found practically useful to exclude the possibility of an affection of the organs of motion joints, muscles, or bones- as well as of disorders of the nervous system (v. Neural- gias). The patient's own sensations and his de- scription of the pain as being deep seated may some- times, but not always, point to the existence of an internal lesion. The following discussion of pain in connection with topography will be devoted only to those mani- festations that are the result of disease of the inter- nal organs. The inclusion of disorders of the organs of motion and of the nervous system would lead too far afield. Even with this restriction, how- ever, completeness of exposition is out of the ques- tion and therefore only certain districts of the body 47 48 PAIN will be considered, which, may be regarded as nodal points for painful sensations emanating from dif- ferent directions. The obvious will be omitted and only more unusual and easily overlooked phenomena will be discussed, particularly from the therapeutic standpoint. For the purposes of practical differen- tial diagnosis it will not do to hold too closely to purely topographical considerations. It is espe- cially desirable to study the factors that influence the pain; that is to say, the examination must in- clude a test of function as well as of the accompany- ing symptoms, as has already been pointed out in detail in the section on the analysis of pain. In the following pages I will be as brief as possible, as a more detailed discussion of the various organic pains may be found in the chapters devoted to each of these. I. THE SHOULDER. The internal organs coming in question under this head are as follows : a. Lung. Affections of the pulmonary apices, especially tuberculosis and new growths, not infre- quently cause spontaneous shoulder pain as well as tenderness of the brachial plexus, probably through the development of perineuritis or direct involve- ment of the branches of the plexus. I have found that tenderness is particularly apt to occur at the junction of the outer and middle thirds of the upper border of the trapezius. TVTien pain in the shoulder is complained of by persons of tuberculous appear- ance this possibility should be kept in mind. TOPOGRAPHY 49 b. Thoracic Aorta. Aneurysm and atheroma of the thoracic aorta not infrequently are accompanied from the very first by persistent shoulder pain. This may be either bilateral or only on one side. In addition to spontaneous pain there is frequently also tenderness over the brachial plexus as well as in the upper intercostal spaces in front. Of great diagnostic importance is the fact that the pain is increased by exertion, such as stair climbing, etc., as well as its coincidence with increased heart action. Quieting cardiac activity by bodily rest and the application of cold compresses generally relieves this aortic shoulder pain. Motion at the shoulder joint may be free and painless, but lifting the upper arm from the side above the horizontal line is likely to evoke pain (traction on the subclavian artery?). It must be remembered that, especially in athero- matous disease of the subclavian artery and in cases of the arthritic diathesis, aneurysm of the aorta and chronic aortitis may coexist with more or less inde- pendent disease of the shoulder joint (rheumatic joint lesions). c. Subdiaphragmatic Organs. Inflammatory processes occurring in the liver, spleen, or stomach, or in their subphrenic surroundings. Shoulder pains transmitted in this way through the phrenic nerve of the same side usually do not attain particu- lar intensity. The causative lesion, such as echino- coccus of the liver, subphrenic suppuration, peri- splenitis in leukaemic spleens, perigastritis in ulcer of the stomach, etc., ordinarily causes much more 4 50 PAIN acute local symptoms, so that if the possibility of this connection is kept in mind the danger of misin- terpreting the shoulder pain is not very great. The shoulder pain may sometimes be latent and appear only on pressure on the brachial plexus or on the above-mentioned pressure point at the upper edge of the trapezius. II. RETROSTERNAL REGION. a. Circulatory Apparatus. The pain accom- panying such affections as aortic aneurysm, chronic aortitis, and sclerosis of the coronary arteries, which are the ones most often concerned under this head- ing, is accompanied by a pronounced sense of con- striction, and has the further peculiarity of being promptly influenced and increased on exertion such as running, climbing stairs, etc. The very intense retrosternal pain that is sometimes seen in cases of pericarditis is not paroxysmal but is persistent. b. Mediastinum. Bifurcation of the trachea and local affections of the mediastinum. The retroster- nal pain often accompanying the cough in acute bronchitis is usually to be explained by the inflam- matory condition at the bifurcation of the trachea. In some cases similar changes in the neighboring lymph glands may contribute to its causation. The more or less severe and persistent retrosternal pain not rarely accompanying severe dyspnoea of long duration may have a similar origin, and I have found this symptom a not infrequent accompaniment in cases of miliary tuberculosis. Mediastinal new TOPOGRAPHY 51 growths, such as lymphosarcoma, etc., also not infre- quently cause retrosternal pain that may be relieved to some extent by leaning forward (transfer of the pressure to the sternum and relief of the more sensi- tive posterior structures). Such pain may be in- creased by rapid walking, etc., probably through the forced inspiration and consequent increase in the motility of the trachea and traction on the surround- ing structures. This observation may lead to the erroneous diagnosis of angina pectoris. c. (Esophagus, Stomach, and Liver. Fairly se- vere retrosternal pain may be due to stretching of the wall of the oesophagus on taking food if the lower portion of the tube is stenosed. Pain of this nature exhibits extreme dependence on alimentary condi- tions. Retrosternal radiation of the pain is not rare in ulcer of the stomach and pyloric stenosis, although in these conditions the pain is rarely found only in this situation. The same thing is true of hepatic affections. In the preceding, retrosternal sensations have been considered only in so far as they reach the point of actual pain. Sensations such as the feel- ing of oppression sometimes occurring in nervous asthma, tuberculosis, dilatation of the right heart, or tabes, are not within the limits of the discussion. III. THE SCAPULA AND INTERSCAPULAR REGION. More than in any other part of the body pain in this district suggests the possibility of disease of the organs of motion (spinal column, dorsal muscles) 52 PAIN as well as neuralgia. Only after these have been excluded or on the demonstration of corresponding organic lesions is it justifiable to consider the latter as being responsible for the pain. In general the possibilities are the same as those relating to shoul- der pains, and here also pulmonary affections like tuberculosis are not unimportant. Sometimes chronic inflammatory changes in the pleura leading to the formation of adhesions or glandular changes, acting like the retroperitoneal glands in causing backache, may manifest themselves subjectively by interscapular pain. Secondary neuralgic conditions of the intercostal nerves must also be thought of; at any rate pains of this sort always indicate an exhaustive examination of the lung. Aortic lesions (aneurysm, chronic aortitis) also not rarely give rise to pain in the interscapular region, especially on the left side. Frequently there is also a feeling of painful pressure and sometimes a dependence on particular positions of the body. A priori, an increase in such pain is to be expected on exertion. The intimate relationship of the liver and gall-bladder, spleen, and stomach to the shoulder blades of the same side is well known, and reference may be made to what has been said above. Of gastric disorders it is particularly stenosis of the pylorus that gives rise to painful attacks with radiation into the left, or more frequently, both shoulder blades. This radiation of the pain seems to some extent to run parallel with the intensity of the distention of the stomach during the paroxysm. TOPOGRAPHY 53 The shoulder pains previously described repre- sent a spatial prolongation of the radiation which ordinarily rarely passes upward beyond the spine of the scapula. It may also be mentioned that the radiation of headache into the interscapular space is generally associated with an increase in intracranial pressure, as in brain tumor, meningitis, etc. IV. THE EPIGASTRIUM. The series of organic lesions manifesting them- selves through pain in the epigastrium is so great that from the standpoint of practical differential diagnosis it seems more suitable in each case to abandon promptly the purely topographical factor and to turn the attention to certain characteristic features of each type of epigastralgia, such as those comprised in the modifying factors, accompanying manifestations, etc. In this way more rapid orien- tation is possible and the diagnostic possibilities may rapidly be narrowed. Here again, as was pointed out at the beginning of the chapter, lesions of the organs of motion, such as the muscular pain follow- ing persistent cough, muscular haematoma, etc., and diseases directly concerning the nervous system, like the neuralgia of spondylitis, the girdle pains of tabes, or gastric crises, will not be discussed at length. The most important differential points to be dis- cussed are as follows : a. Tenderness to Pressure and Percussion. It is true that most of the spontaneous pains in this dis- 54 PAIN trict are accompanied by tenderness to pressure, but the exact localization of this, and particularly the determination of the point of maximum tenderness, may be of importance. This is true, for example, for the tender gall-bladder in cholelithiasis, pain on pressure under the left costal arch in gastric ulcer or carcinoma, or in syphilis of the left lobe of the liver, sharply circumscribed tenderness in ulcer and epigastric hernia, the relation of the sensitive point to the edge of the liver, and so on. The absence of tenderness in spontaneous attacks of pain would suggest, though not without reservation, the diag- nosis of gastric crises, essential gastralgia, or lead colic. Its presence, however, is not sufficient to exclude the latter affection. b. Colic. In addition to the common paroxysms of biliary colic and gastralgia, such conditions as intestinal stenosis, new growths of the small intes- tine, tuberculous intestinal ulceration, etc. as well as particularly appendicular disease, pancreatic colic, and angina pectoris must also be considered. c. Collapse. The evidences of collapse may ap- pear at the acme of any attack of colic, but such severe general symptoms are especially suggestive of perforation, as in gastric or duodenal ulcer, acute intestinal obstruction, gastric crises, pancre- atic necrosis, and angina pectoris. d. Causation through the Ingestion of Food. Under this heading may be included gastro-intes- tinal lesions, processes in the neighborhood of the stomach accompanied by progressive increase in TOPOGRAPHY 55 size, such as echinococcus of the liver, splenic tumor, deep-seated stenoses of the oesophagus, and more rarely, angina pectoris and cases of painful intermit- tent dilatation of the abdominal aorta. e. Causation through Exertion. In this class may be grouped diseases of the circulatory appa- ratus, like sclerosis of the coronary arteries and chronic aortitis. The sensation of painful pressure due to hepatic congestion of course is also consid- erably increased on motion. f . Position. The existence of a position of maxi- mum pain (v. p. 22) generally may be taken as indi- cating an organic origin for the symptom. g. The Influence of Drugs (v. p. 38). This con- cerns particularly the internal administration of local anaesthetics, of hydrochloric acid and alkalies, as well as of erythrol tetranitrate. Of much more importance than localization in the epigastrium is the determination of asymmetrical distribution of the pain. If this is more manifest on the right or the left, either spontaneously or on pressure, an organic condition is a priori more likely. A. Localization on the Right Side. Below the right costal arch : Spontaneous pain and tenderness in disease of the gall-bladder, of the pylorus, the duodenum (ulcer!), the hepatic flexure of the colon, as in carcinoma or flatulence, renal infarct, etc. In appendicular disease the tenderness is usually lower down; in pleurisy and pneumonia of the lower lobe there is usually only tenderness. B. Localization on the Left Side. Below the left 56 PAIN costal arch: Here both in spontaneous pain as well as in tenderness to pressure ulcerative conditions in the stomach should always be thought of first, particularly as occurring in the middle region of the organ, although gastric crises sometimes, even if rarely, are distinctly left-sided. Furthermore, intes- tinal carcinoma, particularly of the descending colon (radiating to the anus) , should be thought of. When there is a tendency to flatulence pain in this region is also not uncommon. Lesions of the pancreas (cysts), affections of the spleen, and left-sided pleu- risy, if the pain is caused simply by pressure, must also be considered. V. THE ABDOMEN BELOW THE UMBILICUS. In order to avoid error, it should always be taken into account that in cases of enteroptosis organs situated in the upper part of the abdomen, such as the kidney, stomach, or gall-bladder with a corset liver, may give rise to pain in the lower abdomen. On the other hand, viscera originally situated in the pelvis may in some conditions develop upwards (urinary bladder, ovarian cysts, extrauterme preg- nancy, etc.). In cases of bilateral tenderness tend- ing toward the pelvis ovarian conditions and para- metritic affections should be thought of in women; also conditions in the colon and about the neighbor- ing hernial openings. Pain on the left side suggests the various affections of the sigmoid flexure, includ- ing carcinoma, dysentery, membranous enteritis, volvulus, foreign bodies introduced through the anus, TOPOGRAPHY 57 etc. If on the right side, attention is directed to lesions in the neighborhood of the caecum and the appendix, including tuberculous glands or ulcera- tions, intestinal perforation in typhoid fever, disten- tion of the caecum in atony of the colon, etc. VI. THE LUMBAR REGION (SYMMETRICAL). Symmetrical lumbar pain is but little adapted to furnish decisive diagnostic information. After ex- cluding lesions of the musculature or fascia, such as lumbago and diseases of the spine, like spondylitis, osteomylacia, etc., there is a wide range of possibili- ties in which nearly all the abdominal organs com- pete, including particularly the female generative system. The demonstration of alimentary modifica- tion of the backache is of importance since it occurs in ulcerative processes of the stomach or large intes- tine. In these as well as in disorders of the colon, for example carcinoma, the pain often appears within even a few minutes after the ingestion of cold fluids or solid food. This phenomenon is prob- ably to be interpreted as the result of a reflex stimu- lation of intestinal peristalsis. Accumulations of gas above stenoses appear to be particularly prone to induce backache. Very deep-seated carcinomas frequently lead to pain in the neighborhood of the sacrum, and the same may be said of haemorrhoidal conditions. Backache occurring during pregnancy and which is particularly severe on walking is of great practical significance, as it is a symptom of osteomalacia. A dependence on motion, particularly 58 PAIN stooping, is also often present in backache not orig- inating in the apparatus of motion itself, as in hepatic, splenic, and renal processes, new growths of the colon, etc. The dorsal position is particularly likely to be painful in cases of retroperitoneal tumor formation through enlarged glands, aneurysm, pancreatic cysts, etc., and it seems reasonable to explain this on the ground of the increase in compression accompanying this position. Prolonged sitting sometimes has the same effect when there is swelling of abdominal organs. A rather rare condition that I have ob- served is backache occurring in chronic lead poison- ing. This is sometimes accompanied by radiation into both thighs and is followed by colicky pain in the neighborhood of the umbilicus. VII. THE LUMBAR REGION (UNILATERAL) AND THE FLANKS. The presence of spontaneous pain or tenderness in the right or left lumbar region or in the flank has much greater diagnostic value and restricts the pos- sibilities much more than backache that is symmetri- cal. Frequently there is no spontaneous pain, but it is necessary to test for tenderness by pressure, or preferably by light blows with the ulnar side of the clenched fist. Under these conditions painful renal affections must always be thought of, particularly if the corresponding flank is also tender. Further- more, on the right side: Appendicitis with retro- csBcal abscess, hepatalgia, and especially choleli- TOPOGRAPHY 59 tliiasis. On the left side : Gastric ulcer, perisplenitis, and pancreatic lesions. ATYPICAL ABDOMINAL PAINS. "While the limits comprised under such a heading as this are necessarily arbitrary, its introduction is justifiable from the practical standpoint. For vari- ous reasons abdominal pains not rarely offer unusual difficulties in diagnosis. Frequently it does not suf- fice simply to observe and to correlate the- observa- tions to form diagnostic conclusions, but it is necessary to go further and consider even the rarer possibilities. The processes that most often lead to diagnostic errors may perhaps be classified in the following way : 1. Atypical Attacks of Colic and Thoracic Proc- esses. The source of the pain is found in a more or less characteristic and anatomically sharply cir- cumscribed organic lesion, but the attacks of pain are rudimentary or there is an absence of localizing symptoms pointing to the organ in question. It is well known, for example, that appendicular disease or lesions of the gall-bladder frequently manifest themselves by pain in the middle of the epigastrium, and that biliary and ureteral colic and the pain of pancreatic disease may appear in paroxysms embrac- ing a wide area. Wrong diagnoses are to be avoided only by the most careful search for a point of maxi- mum tenderness, such as the testicle, gall-bladder, etc., and possible attendant symptoms such as dysuria, glycosuria, urobilinuria, etc. In this con- 60 PAIN nection those cases should also be considered in which the source of the abdominal pain is found out- side of the abdomen, like the epigastric pain of chronic thoracic aortitis or disease of the coronary arteries and the tenderness under the costal arch and in the flank in cases of pleuropneumonic disease of the same side, etc. 2. Cystic New Growths and Foreign Bodies in the Intestine. Under this heading cyst formations, such as those of the" mesentery, pancreas, and ovaries, must be considered. As will be pointed out in de- scribing pancreatic pain the sensations attending these are not susceptible of uniform interpretation. For example, mesenteric cysts may on occasion give rise to pain through the obstruction caused to the passage of gastric and intestinal contents (direct stenosis, volvulus?), or they may give rise to second- ary neuralgia (solar plexus). The latter possibility enters particularly into the question of pancreatic cysts. The obstruction of venous trunks through the torsion of the pedicle may lead to a rapid increase in pressure in the interior of the cysts and therefore give rise to pain through the augmented tension of the cyst wall. Pathological processes in the abdominal lymph glands, both mesenteric and retroperitoneal, must be thought of in cases of obscure spontaneous attacks of pain as well as when tenderness to pressure exists (typhoid, tuberculosis, neoplastic mesenteric glands, etc.). Swollen glands, for example in leukaemia, are particularly likely through compression of neighbor- TOPOGRAPHY 61 ing nerve centers, such as the solar plexus, to cause neuralgias of the severest type and resembling attacks of colic. In this group may be included also the pain accompanying the course* or termination of a tubal pregnancy (v. the differential diagnosis of appendicitis). 3. Visceral Neuralgias and Disorders of Circula- tion. The cause of the pain lies not in the organ itself, but in its nerve supply or in its vascular system. Experience shows that cases of this sort are particularly liable to misinterpretation because through the law of probabilities lesions of the organs themselves are more likely to be thought of. The neuralgiform attacks sometimes occurring in spinal diseases, particularly in tabes, cerebro- spinal syphilis, etc., and manifesting themselves in certain organs, such as the stomach, intestine, blad- der, etc., as well as independent processes in the abdominal sympathetic and its ramifications will be taken up partly in describing the various organic pains and partly in the discussion of the visceral neuralgias. In order to avoid repetition, reference is made to the chapters in question. On the other hand, in the chapter on the vascular system we shall discuss the manner in which anatomical changes in vessels, like dilatation, constriction, occlusion, embol- ism, and thrombosis, may occasion pain in the corre- sponding organs, and reference will be made to the importance of functional disorders like vascular spasm. It is therefore to be recommended always to keep this possibility in mind in investigating 62 PAIN attacks of abdominal pain in which the necessary underlying factor such as mitral stenosis, or athe- roma with cardiac insufficiency is present. It is well to remember, however, that these are more or less rare and that, on the other hand, circulatory disor- ders may give rise to abdominal pain in other, even though indirect, ways. For example, patients with portal obstruction are prone to meteorism and may suffer from extremely severe pain from flatulent colic, or there may be a secondary nephrolithiasis due to sedimentation of urine in the renal pelvis of a congested kidney, or complications like gastric ulcer or cholelithiasis whose development appears at times to be favored through the congestion. 4. Acute Intestinal Stenoses, Hernias, etc. In- testinal affections from the borderland of surgery and internal medicine. Here we should first con- sider the pain often suddenly arising under severe general manifestations, spontaneously or after ab- dominal straining, and accompanying acute interfer- ence with the passage of intestinal contents, whether produced by external or internal incarceration, strangulation, volvulus, or intussusception. Where evidence is obtained pointing in this direction, such as increased peristalsis with severe general symp- toms, the subjective sensation of impeded intestinal activity, acute meteorism, etc., the most careful study of the nature of the pain is to be recommended. While the diffuse colic attending these conditions is not characteristic, the search after definite local pain phenomena may be of decisive value. It is TOPOGRAPHY 63 above all necessary to determine exactly the region in which the pain began, as this may at least permit conjecture in regard to the site of the lesion. Just as in chronic intestinal stenosis the location of the pain sometimes corresponds to the situation of the obstruction, the same thing may be true in acute cases. It is of equal importance to test for local tenderness to pressure, and in this connection the various hernia! openings should of course be most carefully examined. Gall-stones or foreign bodies impacted in the in- testine may also occasion atypical local tenderness which is difficult to interpret. In considering hernial pain the position of the body must be taken into account as well as the local tenderness, since it may determine the intensity of the trauma acting at the moment on the contents of the hernial canal or her- nial opening. For example, the attitude of "Atten- tion" or bending the trunk backward frequently gives rise to pain in cases of the extremely small and therefore easily overlooked hernias of the linea alba, while on leaning forward the epigastric pain, which is frequently interpreted as due to ulcer, is relieved. Forcible bending forward may of course also serve to bring on the pain. Abduction and for- cible rotation inward of the thigh usually increases the pain of incarcerated obturator hernia. This group of easily misinterpreted atypical ab- dominal pains also includes the more or less painful sensations that accompany abnormal fermentative processes in the intestinal canal. The neuropathic 64 PAIN constitution, enteroptosis, and the tobacco habit not rarely furnish the underlying groundwork of this condition. The pain often involves the flexures of the colon, is frequently characterized by great sever- ity and a colicky nature, and may also be accom- panied by local tenderness. The examination of the stools is of great importance and often reveals a strongly acid reaction and an abnormal flora with the presence of leptothrix-like rod forms which give the starch reaction. The pain frequently subsides rapidly immediately after the discharge of flatus or feces. CHAPTER IV. QUALITY AND TIME OF OCCURRENCE. COLICKY PAINS. The classification of pains from the standpoint of their quality, as a rule, has but little practical diagnostic value. One group stands out distinctly, however, and that is the one compris- ing the pain of colic. This is characterized by a gradual onset and subsidence, that is, a wave-like curve of intensity with summits and valleys, and by the sensation of spasmodic contraction. The first peculiarity is also manifested by the pain of neural- gia, and therefore in abdominal cases the recognition of the nature of the symptom may be attended by considerable difficulty. In such instances the pres- ence of the spasmodic element, as well as possible accompanying manifestations such as active peri- stalsis or borborygmi, may give the necessary clue. Pathogenesis of the Pain of Colic. How does the pain of colic originate! It occurs in regions where there are muscular, hollow organs and is linked with this anatomical structure. In regard to the general pathogenesis of colic, from the purely clinical stand- point I agree with those who explain the phenom- enon by supposing that along the course of a muscu- lar tube a band of spasmodic contraction approaches another fixed contracted ring, driving before it the contents of the organ. As a result of this there must 5 66 66 PAIN beoverdistentionof the constantly shortening portion lying between the two rings, and I regard this pain of distention as being the chief factor in the mechan- ism of the condition. It is a fact that the paroxys- mal attacks of pain sometimes occurring in lesions of the renal parenchyma (nephritis, tumor, etc.) as the result of acute congestion, haemorrhage, etc., in their qualitative shading are hardly to be distinguished from the pains of colic. Here the distention of the capsule is probably the only active factor. If the stationary ring of contraction relaxes, the formerly distended portion collapses, the tension of the wall subsides and the contents move on. This may be directly observed in cases of gastro-intestinal ste- nosis. The advance of the contents is rendered evi- dent by loud borborygmi, and with their onset the pain usually subsides. Is the stationary contraction ring itself a source of pain I It is a fact that cases may be observed in which a spastic tumor at the pylorus of an entirely empty stomach suddenly appears under the palpating fingers, while at the same time severe pain is felt by the patient. As the tumor vanishes the pain also ceases. It seems out of the question in such a case to assume the existence of distention of the walls in view of the empty con- dition of the stomach, and observations of this sort appear to me to indicate that local spasm of the nature of the ordinary sural cramp is also capable of evoking the pain. In regard to the separate forms of colic, the differential diagnosis, etc., refer- ence may be made to the discussion of the individual OCCURRENCE 67 organic pains as well as to the section on atypical abdominal pains. For the purposes of rapid orientation in doubtful cases of colic it should be remembered that unilateral tenderness of the testicle to pressure, disorders in the evacuation of urine and in its nature, and pain on pressure in the renal region are found in ureteral colic. Elevation of temperature, ileocsecal pain, and leucocytosis accompany appendicitis. The exami- nation may also require a search for tenderness and enlargement of the liver and gall-bladder, mesenteric or ovarian cysts, extrauterine pregnancy, tenderness about the hernial openings, gastro-intestinal peri- stalsis, sarcinae in the stools and in the gastric con- tents which occur in stenosis of the pylorus, lead line on the gums, abnormalities of the pupillary and patellar reflexes, glycosuria and the absence of indi- can with peritoneal symptoms indicating pancreatic disease, glandular masses in the neighborhood of the solar plexus, menstrual irregularities, and cardiac and aortic lesions pointing to angina pectoris with epigastric localization. The time of occurrence of the pain has differen- tial value only if there is regularity in this, or if there is a relationship to the ingestion of food or to organic function. In this connection reference may be made to what has been said above. NOCTUKNAL PAINS. A special group is formed by attacks of pain characterized by more or less ex- clusively nocturnal onset. An undeniable relation- ship in this regard is manifested by: (1) The pain 68 PAIN of colic in general. As a physiological example labor pains deserve the first place. With the inactiv- ity of striped muscle there seems to be associated an increased activity of the smooth muscle fibres, and it may be said that at night smooth muscle is in the ascendant. Colicky seizures of the most varied sorts show a pronounced tendency to manifest themselves during the midnight hours. (2) Pains due to a dyscrasia. In this category may be included the uraemic headaches, urasmic cramps of the calf muscles, and gouty seizures. It seems to me natural to assume that as a result of the diminution in metabolic function through the absence of muscular work and its attendant respiratory and cutaneous activity, when a dyscrasia exists the toxaBmic curve ascends at night and leads to nocturnal attacks of pain. The connection between syphilis and noctur- nal pain may accordingly be regarded only as a par- ticular example of a connection actually having a much deeper foundation. CHAPTER V. THE NERVOUS SYSTEM. HEADACHE. THIS designation, although it really connotes only a topographical characteristic of the pain, is usually employed when an organic pain is in question, that is, cerebral pain. In order to justify the latter assumption, it is necessary to regard the brain, to- gether with its enveloping membranes, as an entity, a principle that, by the way, will be found per- fectly natural in the description of hepatic, splenic or renal pains, etc. Paradoxical as it may seem at the first blush to draw parallels of any sort between organs that are so different in function and struc- ture, it cannot be denied that the general basis of the phenomena of pain in the organs just mentioned possesses certain characteristics in common. Varia- tions in the volume of the organs with the attending tension of the capsule, and more or less independent inflammatory processes of their enveloping mem- branes, are important factors in the general pathol- ogy of pain involving the organs in question. For example, in proportion as the volume of a congested liver diminishes under the action of digitalis its ten- derness to pressure decreases, to reappear again suddenly at a time when auscultation demonstrates the onset of a perihepatitis. In this case the condi- 69 70 PAIN tions are plainly evident, for the organ is accessible to direct physical examination. It is different in cases of cephalalgia, for although the ophthalmo- scope may give valuable information, for the most part we are confronted by the rigid bony cranium which sets at naught our efforts in the way of physi- cal examination. We are therefore forced to form an opinion concerning the general mechanism of pain from case to case, taking into consideration the modi- fying factors and the accompanying manifestations. Under these conditions it is hardly possible to avoid reasoning by analogy. FUNDAMENTAL CAUSES OF HEADACHE. The follow- ing factors of general pathology may be grouped as belonging to the fundamental causes of headache : I. Mechanical factors, involving a rise in intra- cranial pressure: (a) Chronic (new growths, hydro- cephalus). (b) Acute. Under this heading vaso- motor disturbances must be considered, such as angioneurotic hydrocephalus and also interference with the venous return, as in sinus thrombosis, paroxysms of coughing accompanying congestion in the superior vena cava in consequence of mediastinal new growths, tricuspid insufficiency, etc. II. Chemical factors: Anaemia, toxaemia, inflam- mation. III. Eeflex factors. The meninges, receiving their innervation from the trigeminal nerve, are to be regarded as the com- mon point of attack of all these. THE NERVOUS SYSTEM 71 I. Headache Due to Chronic or Acute Elevations of Intracranial Pressure. By way of preface, it may be pointed out that increased pressure in the arterial system sometimes occurs together with intracranial hypertension, and may under certain conditions serve as a predisposing factor. On the other hand, it is evident that intra- cranial tension may also be increased in cases of low arterial pressure. BRAIN TUMOR AND HYDROCEPHALTJS. The ana- tomical processes to be considered in this connection are in the first place tumors, which may increase cerebral pressure partly per se through the increase in the bulk of the intracranial contents, but which may also do this as a consequence of their relation- ship to important channels such as the veins of Galen or the aqueduct of Sylvius. The latter element par- ticularly serves to explain the fact that of the intra- cranial processes leading to headache tumors of the posterior fossa deserve first place. Cerebral abscesses, of course, behave in the same way. A form of hypertension headache is caused in those cases of acquired hydrocephalus of adults in which the manifestations of increased cerebral pressure arise, sometimes in stormy fashion with the symp- toms of an infectious disease (serous meningitis), in other cases in a more or less insidious manner, or at least without evidences of acute infection. The etiology of these cases of hydrocephalus running a course like that of brain tumor is far from clear, 72 PAIN and the assumption of the existence of chronic menin- gitic processes is usually a mere hypothesis. Intes- tinal processes such as constipation with acetonuria, as well as anaemic blood changes like chlorosis, seem to have some causative influence. The headache arising under these conditions resembles, particu- larly in the acute cases, the headache of acute menin- gitis, and also, it is true, the hypertension headache of brain tumors. The headache of acute meningitis may also be included in this category. POSITION OF THE HEAD. On careful observation of such cases of hypertension headache, as I may briefly call them, it is undeniable that the position and motion of the head is of considerable influence on the pain. The patient often succeeds in reducing his suffering to a minimum by bending the head far backward and burying it in the pillow. No doubt this position produces a certain diminution of ten- sion and may be compared to the midposition as- sumed by inflamed joints. On the contrary, bending the head forward appears to increase the pain, and similarly, rotation of the head is often painful, the sensation usually being experienced in the nape of the neck and sometimes apparently on the side oppo- site to that toward which rotation has taken place. On lying down the patients not rarely fix the head with the hand. Swallowing sometimes serves to bring on pain. The patient therefore usually at- tempts to bring the head into a certain "midposi- tion" and to maintain it passively in this attitude without innervation of the neck muscles. Another THE NERVOUS SYSTEM 73 set of painful stimuli have in common the fact that through increased heart action the blood supply to the brain is increased but the venous return is in- hibited. Of this description are various mechanical factors like stooping, lifting weights, sitting up rapidly or lying down quickly, the horizontal posi- tion, hard straining at stool, etc. Extreme heat may act in a similar way, and is usually not well borne. Furthermore, various chemical stimuli of a dietetic nature may be mentioned, such as the use of alcohol, tobacco, coffee, tea, etc. HEADACHE AND CONSTIPATION. Finally, I should like- to call attention to the frequently very close re- lationship between hypertension headache and con- stipation. Practically this is of the greatest impor- tance, but theoretically it is no less interesting. When hypertension headache appears in conjunction with constipation of long duration, for example, in chlorotic persons, together with other symptoms of intestinal intoxication like urticaria, acetonuria, etc., a causative connection immediately suggests itself, and as a matter of fact calomel is a sovereign remedy in these cases. I can also recall cases of undoubted hypertension headache in cerebral tumor in which the administration of a laxative gave prompt relief and far surpassed the effect of the antineuralgics prescribed. The connection between constipation and headache is undeniable, but the ex- planation of this is pure theory. The widely sup- ported toxin theory seems to me to be not very satis- factory, or at least not of itself all sufficient, in view 74 PAIN of the extreme suddenness with which the pain often ceases on evacuation of the bowels. In this connec- tion the role played by intestinal peristalsis as an accessory to the portal circulation might be thought of as well as the interference with circulation in the domain of the superior vena cava that results through constipation and gas accumulation in the abdomen, owing to the pushing upward of the diaphragm. TOPOGRAPHY AND ACCOMPANYING MANIFESTATIONS. A topographical peculiarity of hypertension head- ache appears to me to lie in its preference for the nape of the neck, as well as in its tendency to radiate along the spinal column, particularly in the region between the shoulder blades. The patients fre- quently complain of feeling "as if the head were being split open," "as if the head would burst open, ' ' sensations that may well be in harmony with the underlying condition. Changes in the fundus of the eye are particularly prominent among the accompanying manifestations. They may be partly of purely mechanical nature, such as dilatation of the veins, or haemorrhages; partly inflammatory in origin. In these cases there may be lymphatic con- gestion with an accumulation of the products of metabolism, and it may readily be assumed that not only in the optic nerve but also in the trigeminal or occipital nerves similar alterations may develop with secondary neuralgia. Pressure points may often be demonstrated over the distribution of the occipital and trigeminal nerves. Hiccough, vomiting, and ab- THE NERVOUS SYSTEM 75 normalities in pulse and respiration may be re- garded as vagus symptoms. Not rarely symptoms due to irritation of the optic and acoustic nerves are observed, such as spots dancing before the eyes or buzzing in the ears, as well as attacks of vertigo. While the explanation on mechanical grounds of the headache accompanying intracranial processes that encroach on the available space is satisfactory, the headaches caused in other ways are difficult to understand. The thought suggests itself that the same mechanical factor of elevation in intracranial pressure that exists permanently and to an extreme degree in the processes described above may also occur intermittently and, so to speak, in rudimentary form. Here consideration from case to case of the mode of onset and accompanying symptoms may serve to give the clue. For example, headache such as occurs in persons with neurasthenic, irritable weakness of the vasomotor system after psychical excitement, mental exertion, straining the eyes through reading, etc., may be explained in this way. These are influences that, according to general physiological conceptions, are associated with in- creased blood supply to the organs in question, and temporary intracranial elevations of pressure might easily be produced, particularly if there is a condi- tion of vasomotor ataxia induced through nicotinism. The elevation of blood pressure which is so often seen in neurasthenics may serve as a favoring factor, and this condition always deserves consideration in 76 PAIN the diagnosis and treatment of headache. In gen- eral the neurasthenic headache is characterized by the readiness with which it is influenced by the re- moval of the exciting cause (mental exertion, sexual habits, etc.). II. Headache Caused by Chemical Poisons. UREMIA. Albuminuric headache or the cephal- algia caused by renal insufficiency may be taken as a paradigm of this type, although here in addition to the toxaemic element no doubt mechanical factors, such as cerebral redema or hydrocephalus, together with arterial hypertension, frequently play a not un- important role in the pain production. The relief to the pain that frequently follows epistaxis or blood letting at the mastoid process may be ex- plained on this basis. As with the headache of hypertension, the seat of the uraemic headache is not rarely the occipital region but in general it may be said that there are no entirely characteristic fea- tures, so that in every case of obstinate cephalalgia the examination of the urine for serum albumin is urgently demanded. The prompt effect frequently following large doses of cerium oxalate (about 0.5 g.) is an interesting fact. It is difficult to deter- mine to what extent the headache occurring in cases of angiosclerosis without albuminuria depends on arterio sclerotic renal insufficiency. Here again the high blood pressure may come into play, as appears to me to be shown by the relief not infrequently afforded by an incidental nose-bleed, so that the THE NERVOUS SYSTEM 77 advisability of producing this artificially may even suggest itself. LEAD POISONING AND GOUT. The basis of the headache in chronic lead and metal poisoning in general is probably not constant, and the same thing is true of the uric acid diathesis and the peculiar type of headache well known to the laity as migraine. It is true nevertheless that Trousseau's classical dictum, "migraine and gout are sisters," deserves full consideration. INFECTIOUS PKOCESSES. The relations between infectious processes such as syphilis, malaria, tuber- culosis, influenza, etc., and their associated head- aches, are no less uncertain. In part, there may be direct toxic action on the pain-conducting trigeminal tract; in part, transitory elevations of intracranial pressure incited through inflammatory hyperasmia of the meninges and the intracerebral blood vessels. This holds also for cases of suppurative or tubercu- lous meningitis. ANEMIA. It is undeniable that patients with blood changes, such as chlorosis or pernicious anaemia, not rarely suffer from headache, and it is equally true that headache is often entirely absent in cases of pernicious anaemia of the most severe sort. It is hardly wise therefore to speak off-hand of an anaemic headache. When headache is espe- cially intense in anaemic patients, the idea of intra- cranial rise in pressure through hydremic hydro- cephalus suggests itself. In such cases elevating the head is frequently of benefit, and the patients 78 PAIN often behave in a manner similar to that discussed under the heading of hypertension headache. Just as hydremia appears to predispose to fluid exudates in general, it seems sometimes to give rise to transu- dation into the ventricles of the brain. This is not intended to deny, however, that anaemic blood changes may not cause headache without an inter- mediate condition of hydrocephalus. These are then susceptible to the same therapeutic measures as the underlying condition and are relieved by a more abundant blood supply, such as is caused by lowering the head. III. Headache of Reflex Nature. Here irritative stimuli are concerned particu- larly in the distribution of the trigeminal nerve which under some circumstances may find an echo, as it were, through radiation in the meningeal dis- tribution of this nerve. Even in cases of restricted localization the differentiation may be difficult be- tween neuralgia and cephalalgia in the sense of cere- bral pain. At any rate, in making the differential diagnosis of headache, it is advisable not to leave out of consideration any existing manifestations in the distribution of the trigeminal nerve. THE EYE, NOSE, AND EAR. This is especially true of the eye; the combination of headache and visual disturbances should always lead to the most careful examination of the eye, including investiga- tion of the tension of the eyeball, the visual field, and examination for excavation of the optic disc. THE NERVOUS SYSTEM 79 Furthermore, there is no doubt that other disturb- ances such as weakness in convergence, hyperme- tropia or presbyopia, astigmatism, etc., may furnish the starting point of headache, especially in cases in which a general predisposition to headache is already supplied by other factors such as the neuropathic constitution, disorders of nutrition, etc. Overzealous treatment by specialists must therefore be deprecated and the general pre- disposing condition should receive full therapeu- tic attention. This is equally true in regard to the relations between headache and inflam- matory and suppurative disease or swellings in the nasal passages and their accessory cavities (frontal headache in iodide coryza, etc.). Particularly con- vincing are those cases in which months of anti- neuralgic treatment of obstinate frontal headache are suddenly permanently terminated by the dis- charge of a quantity of pus through the nose. Proc- esses in the frontal and sphenoid sinuses are of particular significance in this connection. That the ear should require full consideration among the organs of special sense is evident through the pos- sibility of otogenous cerebral abscesses, sinus thrombosis, etc. The examination of the mastoid process for tenderness should never be omitted. STOMACH AND INTESTINE. Any existing gastro- intestinal disorders (parasites, constipation, dys- pepsia, latent cholelithiasis) must also be taken into account. Just as cerebral processes like brain tumors, meningitis, or migraine frequently evoke 80 PAIN vomiting, constipation, or other secondary gastro- intestinal disturbances, a similar influence seems to be possible in the opposite direction also. Stag- nation of fecal masses deserves consideration, as has already been indicated. Even though the head- ache may seldom be caused by constipation alone, this often affords an important contributing cause, the removal of which, as for example in cases of brain tumor, may lead to an immediate and con- siderable improvement in the pain. In women, affections of the genital apparatus also require careful attention. DIFFERENTIAL DIAGNOSIS. In the differential diagnosis of headache it is necessary first to deter- mine the primary causes of the condition and to determine its position in one of the three main groups mentioned above. It is better not to label the case at all than to resort to so inadequate a term as "nervous headache," "habitual headache," etc. TOPOGRAPHY. An exact inquiry into the details of the pain frequently gives important clues in re- gard to its causation. Localization of the pain at the back of the head and the nape of the neck radiat- ing downward along the spinal column between the shoulder blades, would suggest particularly hyper- tension headache or renal headache, if there is no disease of the vertebral column itself or rheumatic affection of the neck muscles (torticollis). Involve- ment of the frontal region, on the other hand, would direct attention to functional disorders of the eye or diseases of the nose and nasal sinuses, particu- THE NERVOUS SYSTEM 81 larly the frontal sinus. The depth at which the pain is said to be situated is always of importance. Su- perficial headache -points to trigeminal neuralgia or rheumatic disease of the galea. A unilateral head- ache indicates idiopathic migraine, if an appropriate history is obtained of hereditary predisposition, onset in youth, and typical accompanying manifesta- tions like vomiting, scintillating scotoma, etc. If hemicrania begins later in life, a secondary form such as that due to tumor, nephritis, syphilis, etc., is suggested. QUALITY AND INTENSITY. The quality and sever- ity of the pain also deserve analysis. In general the greatest intensity is exhibited by hypertension headache, the attacks of migraine, and trigeminal neuralgia. The quality of the pain of the first-men- tioned type, which is often described as * ' splitting, ' ' harmonizes well with the underlying process, which frequently no doubt involves a maximum of intra- cranial pressure. The time of onset, too, may give a clue. Headache appearing only by day is prob- ably not of syphilitic o'rigin, but nocturnal increases in intensity are also observed in non-luetic cerebral processes, such as brain tumor or uraemia. MODIFYING FACTORS. Most suggestive indica- tions are generally afforded by a careful considera- tion of the conditions under which the pain is modi- fied. Headache primarily of psychical origin is the most readily susceptible to psychical influences. The greater the part played in the etiology by mechanical factors, especially intracranial hyper- 6 82 PAIN tension, the more will purely mechanical factors, such as position of the head and body, movement of the head, local bleeding, etc., have the power to in- fluence the pain. In this connection reference may be made to what was said above regarding hyperten- sion headache. Palpation of the skull is always to be recommended in order to discover any possible pressure points corresponding to the emergence of sensory nerves (trigeminal or occipital), syphilitic periostitis, or rheumatic changes in the calvarium or cranial aponeurosis. The effect of refrigeration through draughts, cold, etc., comes in question par- ticularly in neuralgia and rheumatic headaches or those of extracerebral nature. Heat is frequently badly borne in hypertension headache. In this way the analysis of the pain itself will frequently guide the examiner in one direction or another, even though the diagnosis does not at once follow. The careful and detailed general physical examination is not to be avoided in this way, but may be shortened. Certain tests are always to be recom- mended for the purpose of rapid orientation : 1. Estimation of the blood pressure and of any existing vascular changes (nephritis, angiosclerosis, lead poisoning). 2. Pulse rate (bradycardia in tumors, hydro- cephalus, meningitis). 3. Examination of the urine for serum albumin and acetone. In intestinal autointoxication these appear early, but in meningitis later. THE NERVOUS SYSTEM 83 4. Testing the intra-ocular tension in order not to overlook a case of glaucoma. 5. Ophthalmoscopic examination of the fundus of the eye. 6. Testing the patellar reflex, which may be absent in cerebellar tumors or meningitis. 7. Testing the pupils (syphilis and meningitis). Among the cranial nerves the facial and hypo- glossal ^deserve most attention, as slight disorders of either of these do not give rise to complaint and are therefore easily overlooked. In taking the history, attention must be paid to such accompanying manifestations as vomiting, which suggests hypertension headache, migraine, or glaucoma, and acute disturbances of vision indicat- ing migraine, glaucoma, or nephritis. The matter of preceding or still existing nasal or aural dis- orders should also be investigated. Lacrimation or secretory disturbances of the nasal mucosa or salivary glands, accompanying the attacks of pain, arouse suspicion of the existence of trigeminal neuralgia. NEURALGIAS INVOLVING THE GENERAL NERVOUS SYSTEM. Inasmuch as every stimulus requires transmis- sion by the nerve trunks in order to be experienced as a sensation, it at first seems rather paradoxical to speak of "nerve pains" as a distinct variety. Clinically, however, this term connotes the concep- tion that the source of the pain is not to be found 84 PAIN in the parenchyma of an organ, from which it is transmitted to the sensorium through the special nerve trunk belonging to the organ, but rather that it acts upon the sensory trunk itself in its peripheral portion. The first task of the diagnostician is to discover, as far as possible, the seat and variety of this cause. If this attempt is not successful the assumption is warranted that there is present a neuralgia in the more restricted sense; that is, a nerve pain concerning whose etiological basis bio- chemical information is not yet available and histo- logical investigations will probably never enlighten us fully. It is therefore necessary to keep in mind that the diagnosis of neuralgia in its restricted sense is a diagnosis by exclusion and that up to a certain point it remains doubtful. Repeated reinvestigation in regard to the etiology is accordingly extremely desirable. The point of attack of the neuralgia-producing factor is probably in most cases to be found in the course of the peripheral neurone. Nevertheless it is desirable to remember that the central conducting tracts, the medulla, pons, optic thalami, and their surroundings, and probably also the cerebral cortex, as well as the posterior portions of the gray matter of the cord, may be the seat of the disease. In these anatomical districts pain may be produced, not only as the result of organic, but also from functional disturbances. The neuralgias arising in hysteria, cerebral tumors, tabes, syringomyelia, myelitis, etc., are probably to some extent to be interpreted as THE NERVOUS SYSTEM 85 having a central origin of this nature. Much more varied are the general and special factors that give rise to neuralgias in the peripheral nervous system. As it seems advisable to pass these in review in every doubtful case, I wish to make at least the attempt to arrange them in classified form. A. DIEECT FACTORS. 1. Mechanical. These are principally pressure effects through new growths, particularly glandular swellings, aneurysms, inflammatory processes with exudation in the neighborhood of nerves, hernias, etc. 2. Thermic. This group includes the complex of stimuli comprised under chilling, draughts, etc., the mode of action of which is difficult to analyze. The underlying cause frequently lies much deeper and the thermic stimuli have only an exciting effect. 3. Chemical Factors with Secondary Disorders of Nutrition. Their point of attack is certainly often indirect, involving the vascular system. Scle- rotic and spastic conditions in the domain of the vasa nervorum must not be forgotten in this connection. (a) Non-infectious exogenous toxins: Proto- plasmic poisons of the most varied nature would be included here, such as arsenic, lead, alcohol, nico- tine, mercury, etc. (b) Toxins infectious in nature: Syphilis, ma- laria, influenza, tuberculosis, gonorrhoea, etc. 86 PAIN (c) Dyscrasic endogenous toxins: Gout, carci- noma, diabetes, nephritis, anaemia, adiposis dolorosa of Dercum. Here may best be included also those local dis- turbances of metabolism that underlie the so-called occupation neuralgias which result from the exces- sive use of certain nerve tracts. Furthermore the attacks of pain involving the distal portions of the extremities and accompanied by vasomotor disturb- ances, such as erythromelalgia, Raynaud's disease, etc. B. EEFLEX FACTORS. The. stagnation of fecal masses, intestinal para- sites, various visceral disorders involving the heart, gall-bladder, genital apparatus, kidney, etc., may be concerned in the causation of neuralgias, and it is natural to assume a reflex element under these con- ditions. On the other hand, neuralgias in certain nerve tracts may incite neuralgias elsewhere as through the sympathetic vibrations of musical strings. How is A NEURALGIA TO BE RECOGNIZED? As re- gards the diagnosis of neuralgias as such, the recog- nition of the fact that a pain corresponds topo- graphically to a peripheral sensory nerve tract, and like this exhibits a linear rather than a diffuse dis- tribution, is frequently sufficient to establish the nature of the case. Naturally it is not enough to determine only the spatial limits of the spontaneous pain, but the presence of painful pressure points should also be sought for. This is the more impor- THE NERVOUS SYSTEM 87 tant since in this way latent neuralgic conditions not manifesting themselves spontaneously may be detected for example, the tenderness to pressure of the brachial plexus on the left or both, sides in angina pectoris. The pressure points usually corre- spond to those portions of the nerves which are sub- ject to trauma through their superficial position, a firm or bony substructure, etc., but as these are not constant there is little wisdom in overloading the memory with ballast of this nature and anatomical knowledge is the best guide. In addition to the me- chanical factor of pressure, traction may be used for evoking the pain experimentally. This is true for the trigeminal nerve (movement of the lower jaw), the occipitalis major (rotation of the head), and the sciatic nerve (flexion at the hip joint with ex- tended knee) . The susceptibility to influence in this way may also, however, lead to confusion with muscle, joint, or bone pains, and caution is necessary in interpreting the results. The anatomical unity of the pain may be entirely upset through the in- volvement of bone, periosteum, muscle, and joint nerves in the neuralgic process, and these possibili- ties must always be reckoned with. Paroxysmal onset (frequently at night) is a common characteris- tic of neuralgic pains. At any rate, the mere fact of nocturnal occurrence does not justify the con- clusion that syphilis is the underlying factor, although in general the absence of nightly exacerba- tions may be used with some probability as being against syphilis. The periodical onset of the pain 88 PAIN and its relief by quinine may find its explanation in the malarial nature of the neuralgia, but this is not necessarily so. SITE OF THE LESION, WHETHER CENTRAL OB PERIPHERAL. After a painful condition has been identified as a neuralgia, it is always necessary to determine the" site of the lesion. The possibility of cerebrospinal localization (brain tumor, tabes, syringomyelia, syphilitic spinal meningitis, etc.) must always be thought of, and the reflexes and possible disorders of motility, like flaccid or spastic paralysis, ataxia, vesical or rectal disturbances, should be considered. After determining the peripheral character of the neuralgia the question of etiology arises, and in regard to this reference may be made to the classification given above. It is of the greatest practical importance not to over- look a beginning new growth, to think of the possi- bility of cardiac or aortic lesions, and to guard against failure to recognize some dyscrasic factor by careful examination of the urine. The possi- bility of reflex origin must also always be given due weight. THE FACE. In order to determine the causative factor in cases of trigeminal neuralgia, the course of the nerve from the Gasserian ganglion onward should always be kept in mind, so that such conditions as tumors of the nerve itself, aneurysms of the internal carotid, destructive processes of the meninges and at the base of the skull, like tuberculosis, syphilis, THE NERVOUS SYSTEM 89 carcinoma, actinomycosis, etc., may not be over- looked. The distribution of the nerve must also be considered and the processes in the. eye, teeth, alveolar cavities, nose, ear, etc., that may come in question. In infectious processes the discovery of pronounced tenderness at the- point of emergence of the supra-orbital nerve suggests influenza, typhoid fever, or malaria. Under these conditions, however, as well as in meningitis, it should not be forgotten that the pain on pressure may be only a part of the general hypersBsthesia. Of the reflex etiological factors, reference may be made particularly to the stagnation of fecal masses and disorders of the female genital system. There is no doubt that at times, as in cases of headache, a laxative is the best antineuralgic remedy. Similar conditions also ob- tain, both in trigeminal neuralgia and in headache, in regard to the general pathological conditions, as is not surprising when one considers that the dura mater is supplied in part by the trigeminal nerve. The underlying conditions that give rise to the symptom complex of angina pectoris must also be counted among the reflex visceral factors. It is true, however, that isolated trigeminal neuralgia is unusual under these circumstances, although unilat- eral radiation in the districts of the third and second branches, with pain in the teeth, is not of excep- tional rarity. It seems to me that there is a possi- bility of the radiation occurring through the vascu- lar channels, perhaps owing to spasmodic conditions due to the sclerosis. 90 PAIN THE OCCIPITAL REGION AND NAPE OF THE NECK. Of the sensory tracts supplying this region there may be mentioned, toward the midline the occipitalis major, more laterally the occipitalis minor, and still further outward supplying the posterior surface of the ear, the auricularis magnus. Diseases of the vertebral column and of the meninges of the cervical portion of the cord have a particular etiological bearing. Since the second cervical nerve whose posterior branches, as the occipitalis major nerve, supply sensory filaments to the skin of the occipital region passes between the atlas and axis, the occur- rence of mechanical injuries in this region may be readily understood through the great mobility of the parts. At the same time, the fact is explained that neuralgia of this region may restrict the move- ments of the head, although the muscles and joints themselves are not involved. Neuralgias in this situation are probably also caused mechanically in cases of elevation of the intracranial pressure, espe- cially when due to processes encroaching on the pos- terior cerebral fossa, as in hydrocephalus following serous meningitis (Quincke) or due to chlorosis or tumors of the posterior fossa. Of the visceral diseases chronic nephritis seems to me to be particularly prone to give rise to occipital neuralgia, perhaps through intracranial elevations of pressure. In addition, glandular proc- esses (lymphosarcoma) and more rarely aneurys- mal dilatations of the vertebral artery may come in question. THE NERVOUS SYSTEM 91 THE ARM. The neuralgias occurring in the brachial plexus and involving especially the ulnar and radial dis- tricts, may be caused either through direct or reflex factors. 1. Direct Causation. In addition to spinal dis- orders like tabes, syringomyelia, etc., one should think of vertebral disease, supraclavicular or axil- lary compression by glands, aneurysmal dilatations of the subclavian or innominate arteries, and the presence of cervical ribs. The brachial plexus may also be directly involved in cases of inflammatory processes or malignant growths of the apical pleura, and in this way spontaneous brachial neuralgia or at least tenderness of the plexus may result. I have formerly directed attention to this symptom of "unilateral plexus tenderness" in incipient phthisis, and have frequently made use of it to good advantage. Abnormal exhaustion of the nerve tracts through local overexertion, as in piano play- ing, must also be kept in mind. 2. Reflex Causation. The neuralgic conditions of the brachial plexus, whether spontaneously pain- ful or existing only as a latent neuralgia manifest- ing itself by tenderness on pressure, may overstep the purely neurological limits since they not rarely are accompanying evidences of visceral lesions. Sometimes, though less often, they present a certain degree of independence, or may be accompanied by mild motor manifestations of a paretic or spasmodic 92 PAIN nature. A neuropathic constitution undoubtedly affords a favorable soil for radiations of this sort. The thoracic viscera, particularly the heart, peri- cardium, and large vessels, as well as the diaphragm and the abdominal organs coming in contact with it, are likely to be concerned in this way. The side of the organic lesion then usually corresponds to the side of the plexus neuralgia. There is no doubt that the phrenic nerve is the reflex tract in many such cases, and therefore tenderness over the third and fourth spinous processes should always be looked for. Particular emphasis may be laid on the fact that sometimes spontaneous pain may be absent while the pressure tenderness is constant, as in angina pectoris or perisplenitis. In discussing the separate organic pains, these reflex arm and shoulder neural- gias will be explained in detail, and in order to avoid repetition reference is made to the sections in question. INTERCOSTAL SPACES, INCLUDING THE UPPER ABDOMEN. The intercostal nerves, whose lower branches send sensory fibres also to the upper portion of the abdominal wall, very frequently cause spontaneous pain, but still more often occasion tenderness to pressure. In addition to localized central processes like spondylitis, tabes, syringomyelia, etc., it is espe- cially internal diseases that are accompanied by either tenderness or spontaneous pain in the regions supplied by the intercostal nerves. THE NERVOUS SYSTEM 93 Diseases of the lung, and particularly of its pleural covering, deserve first place in this connec- tion. In nearly all cases of pneumonia and pleurisy the intercostal spaces are sensitive to pressure, nota- bly in the axillary region, although it must remain an open question whether the tenderness does not depend on direct mechanical trauma to the inflamed pleura and whether there may not also coexist an inflammatory condition of the intercostal muscula- ture transmitted through the lymphatics. It is sug- gestive that the tenderness in cases of pulmonary infarct and tuberculosis frequently corresponds ex- actly to the site of the infarct or infiltration, and shows no relation to the usual pressure points of intercostal neuralgia. Suppurative pleural exu- dates are likely to be accompanied by special tenderness, while pleural processes accompanied by contraction only rarely give rise to severe neuralgias. Diseases of the circulatory apparatus, such as mitral stenosis, are frequent causes of intercostal neuralgia. Usually the pain is located on the left side in the neighborhood of the apex beat. The mode of origin of intercostal neuralgia in dilatation of the aorta and mediastinal new growths demands no explanation; no doubt in addition to direct trauma reflex stimuli also come into question just as for the brachial plexus, especially for the upper intercostal spaces. The aneurysmal neuralgias of direct causation are not rarely characterized by dependence on exercise and position, owing to 94 PAIN stronger pulsation of or dislocation of the sac. Dis- eases of the subdiaphragmatic organs like choleli- thiasis, perihepatitis, pyloric ulcer, and perisple- nitis are also prone to cause tenderness of the axil- lary portions of the lower intercostal spaces on the corresponding side. If the liver or spleen is in- volved the area of tenderness often coincides with the dulness, and this may be of diagnostic impor- tance. Here, no doubt, reflex stimuli are concerned similar to those causing the hypersesthesia of cer- tain spinous processes that is frequently also present. In pyloric ulcer and cholelithiasis this tenderness to pressure and percussion often occurs over the twelfth thoracic vertebra. In cases of sud- den intense intercostal neuralgia the imminent onset of herpes zoster should be thought of. THE FLANKS AND LOWER ABDOMINAL REGION. Leaving aside the neuralgias of spinal origin which have already been spoken of several times, idiopathic conditions of this sort are rare in the present regions. Of the intra-abdominal causes, retroperitoneal processes such as glandular masses, aneurysm of the abdominal aorta, and renal diseases at once suggest themselves. The renal causes in- clude tumors pressing on the nerve trunks passing over the posterior surface of the organ, inflamma- tory and suppurative processes, or perinephritic cicatrization following infarct, etc. Another etiological factor is formed by hernias which may induce neuralgia through pressure along the hernial canal. THE NERVOUS SYSTEM 95 LOWER EXTREMITIES. 1. Anteriorly and Internally (Crural Nerve). Pain of the same linear distribution as that of neu- ralgia may sometimes be caused by phlebitic proc- esses in the internal saphenous vein. It may also be the result of femoral hernia and may stand in relation to diseases of the kidney such as nephro- lithiasis, and of the appendix. Beyond this, refer- ence may be made to the general underlying causes of neuralgic pain (v. classification on page 85). 2. Externally. The neuralgias occurring in the district of the external cutaneous nerve, and there- fore involving the external and posterior surface of the thigh from the iliac crest to the knee, are not usually founded on causative factors specific for the locality. The etiological possibilities coincide with those of neuralgia in general, and therefore include trauma, gout, syphilis, tabes, pernicious anaemia, etc. As the nerve traverses a fibrous canal in the fascia lata of the thigh, it is not astonishing that tension of this structure, such as is caused on standing or walking, easily produces exacerbations of the pain, whereas rest brings relief. 3. Internally. Neuralgias involving the* region of the adductors of the thigh always suggest the presence of a possibly incarcerated obturator hernia, especially if the thigh cannot be approached to the midline. 4. Posteriorly. (The sciatic plexus.) The pain that is principally concerned under this heading is linear in distribution and often extends down the 96 PAIN entire posterior side of the lower extremity. Even the laity usually interpret this correctly as a " nerve pain." If there is in addition tenderness over the course of the nerve and pain on stretching it by forcible flexion at the hip with extended knee, there is little room for doubt. Diseases of the hip joint differ in that flexion of the hip is painful even when the knee is kept flexed. It is the duty of the physician not to rest content with the diagnosis of sciatica, which may already have been made by the patient, but to investigate the particular source of the trouble, and here as in neuralgias in general I think that I may formulate the rule: If nothing is found, search further. The scheme of causes given above may serve to aid in the general task of orien- tation. Examination of the rectum and vagina should never be omitted in order that any possible pelvic lesions, such as new growths of the intestine or pelvic bones, may be detected, and the patient's general condition (emaciation, etc.) should be care- fully considered. The degree of fulness of the rectum should also be taken into account; there is no doubt that a connection exists between fecal stagnation and pain in the sciatic plexus, though it is difficult to ex- press an opinion in regard to the details of the relationship. Usually the condition is merely a pre- disposing and not a causative factor. Before decid- ing to accept the assumption of a purely mechanical direct action of fecal masses on the nerve plexus, it is advisable to think of the association that may THE NERVOUS SYSTEM 97 exist between headache or trigeminal neuralgia and constipation, and of the fact that fecal accumula- tions probably also serve to increase pain through the interference with venous return (vasa ner- vorum). The possible existence of external or inter- nal varicosities (involving the nerve sheath) with phlebitic or thrombotic processes must always be thought of. In this respect conditions are of course much more unfavorable in the lower extremities than in the upper. Bilateral pain always suggests median lesions involving the vertebral column or spinal cord, or diffuse dyscrasic disorders like dia- betes. Pain of maximum intensity that is refrac- tory to all treatment sometimes is encountered in tumors of the cauda equina. A careful examination of the nervous system, with special attention to the tendon reflexes of the lower extremities, bladder dis- turbances, atrophies, etc., should never be omitted. NEURALGIAS INVOLVING THE SYMPATHETIC SYSTEM AND THE VAGUS. A priori the assumption suggests itself that the neuralgic manifestations just described for the cerebrospinal system may also, in the presence of the corresponding etiological factors, occur in the separate portions of the sympathetic system and the viscera supplied by it. This view is fully confirmed by the clinical observations. The task of correctly interpreting visceral neuralgias of this sort is, of course, much more difficult. In this case one is deal- ing not with the anatomically distinct, simply con- 7 98 PAIN stmcted, and directly accessible nerve tracts of the cerebrospinal nervous system, but with plexuses and groups of ganglia for the most part inaccessible to physical examination. The problem is further com- plicated by the fact that the separate networks have as end stations organs like the stomach, intestine, ureter, genitals, etc., in which painful lesions may originate primarily. Theoretically three possibili- ties may be_ considered and in practice these are shown to be well founded. (a) Simple Neuralgia. The pain-producing process is a neuralgic condition in one of the im- portant tracts of the vegetative nervous system, and the corresponding organ is anatomically intact. Gastric crises may be regarded as an example of this sort and a pendant in the province of the cerebrospinal system would be neuralgia of the sec- ond and third branches of the trigeminal nerve without any disease of the teeth. (b) Simple Organic Pain. The pain has exactly the same character in regard to localization, quality, accompanying manifestations, etc., but is the result of an anatomical or functional disorder of the organ itself. As a paradigm reference may be made to the pain of gastric ulcer. Recently an attempt has been made to argue away the existence of stomach pains as such and to regard the cause of every gastric pain as being a sympathetic neuralgia. This is entirely inadmissible and in opposition to the facts of clinical observation. One has only to think of the stomach-ache that is promptly checked by a dose THE NERVOUS SYSTEM 99 of alkali or by the administration of local anaes- thetics such as anaesthesin or cocaine. The same thing is true of pyloric stenosis, and the explanation offered by the advocates of the theory just men- tioned to the effect that the sympathetic nerves are compressed by the distended stomach is extremely improbable. The existence of true gastralgia, re- sulting from purely local anatomical and functional disturbances, is as certain as the occurrence of pain in dental caries. (c) Mixed Forms. I believe that a combined form of visceral pain is not at all rare in which both the sensory-conducting tract and the organ in ques- tion play a distinct role in the causation of the pain ; as an example, trigeminal neuralgia and painful dental caries may be mentioned. Such a combined origin of pain in the sympathetic and vagus districts is probably commoner than is ordinarily supposed, particularly in neuropathic individuals. It is con- ceivable that the anatomically or functionally active organic process might arise only secondarily as the result of atrophic disturbance due to a primary neuralgic condition, but the reverse is also probable, as well as coincident causation. When such mixed forms of visceral neuralgia are in question, it is clear that, to continue the example chosen above, the extraction of the decaying tooth may bring relief commensurate with its component of painful sen- sation, but the pain will continue as long as the neuralgic condition of the trigeminus does not im- prove. In the same way, in other cases of mixed 100 PAIN form, the same attacks of pain may recur after the removal of gallstones or the treatment of a pyloric stenosis by gastro-enterostomy. Through exact analysis of the conditions, as well as the study of the psychical make-up of the patient, it is possible from case to case to interpret these mixed forms correctly and to determine approximately the rela- tive proportions of the two components. The prog- nostic and therapeutic importance of an analysis of this sort is self-evident. ETIOLOGY. As far as the etiological sources of the visceral neuralgias are concerned it may be said that there is a far-going, deep-seated correspondence between the cerebrospinal and sympathetic nervous systems. In this connection reference may be made to the scheme of causes given above as well as to the section on gastralgia. HOW MAY A VlSCEEAL NEUKALGIA BE EECOGNIZED? The diagnosis of a visceral neuralgia is probably one of the most difficult of differential problems and can never be made with absolute certainty, as it is nearly always a diagnosis by exclusion. For ex- ample, what is known concerning the positive symp- toms of a neuralgia of the cosliac plexus is so inade- quate and so vague that a conscientious clinician would never venture to make this diagnosis directly. The cause of pain induced by deep pressure over the abdomen is difficult to determine. Whoever is anxious to discover tenderness to pressure of the sympathetic fibres or of the solar plexus will usually succeed in doing so ! If the psychical equilibrium is THE NERVOUS SYSTEM 101 intact, there is no neuropathic tendency, and etiologi- cal factors of the variety in question are absent, one should be very reluctant to think of a visceral neural- gia. But in this neurasthenic age cases that comply with these requirements are very rare, while on the other hand, even serious nervous disturbances do not exclude the possibility of an organic lesion as the basis of the pain, the more so as they may be second- ary. The important general rule of unity of etiology in disease is open to many exceptions in. this prov- ince, and painful states due to a combination of functional and anatomical components are certainly very numerous. TOPOGRAPHY. The topography of the pain usu- ally has no differential significance. The distri- bution of the pain in a neuralgia of the ureter de- pending on chronic lead poisoning is the same as that caused by the passage of a concretion, and hysteri- cal angina pectoris radiates in the same way as the true organic type. Essential gastralgias, it is true, are rarely asymmetrical in their localization, in con- trast to the pain of ulcer and pyloric stenosis, and this is particularly true of the tenderness to pres- sure. Gastric crises, however, with their tendency to a left-sided localization, at least so far as the spontaneous pain is concerned, form an exception to the rule. MODIFYING FACTORS. A careful study of these is always of great importance. Whenever reflex in- volvement is evident, as, for example, in cases of gastric pain at the time of menstruation, it is per- 102 PAIN missible to think of a simple visceral neuralgia, but it should not be forgotten that the pain of ulcer or biliary and appendicular colic may be induced through the profoundly disturbing process of men- struation. In general, it may be regarded as posi- tive evidence of the existence of a pronounced func- tional component if a sedative regime comprising general hygiene and psychical rest, the diversion of the attention, and administration of quieting drugs like the bromides or valerian, has a notable and per- sistent effect on the intensity and frequency of the pain. On the other hand, it is fair to assume a prominent local component when purely topical treatment like the administration of alkali in gastric pain is promptly effective. Serious consideration must be accorded to mechanical factors and their effect. If a given position of the body always causes prompt increase in the pain, it is natural to think of a localized anatomical lesion of the organ in question (cf. p. 22). The most exhaustive physical and functional examination of the organ that appar- ently is involved and the consideration of its secre- tions or excretions is of course of the greatest importance in reaching a decision. CHAPTER VI. ORGANS OF MOTION. I. JOINT PAINS OR ARTHRALGIAS. TOPOGRAPHY. In view of the clearness of the topographical relations and the ease of accurate functional examination, it is ordinarily not difficult to identify an arthralgia as such. Only when the joints concerned are difficult of access, like those of the vertebral column or of the sacro-iliac synchon- drosis, or are abnormal (manubrium-corpus), are difficulties to be expected. Sometimes, however, the topographical considerations themselves may lead astray, as an illustration of which may be cited the pain in the knee that so often precedes coxitis in young persons. On the other hand, it is always our duty not to remain satisfied with the general diag- nosis of arthralgia but to determine which anatomi- cal component of the articulation is the seat of the pain. Accordingly, the articular extremities of the bones, the fibrous capsule, the neighboring tendons and tendon sheaths, and adjoining muscles must all be tested as regards painfulness. The examination must include all structures standing in anatomical relationship to the joint capsule, such, for example, as burssB, nerve trunks, vessels, or fibromas in the subcutaneous tissues. It is also necessary to distin- guish between deep-seated and superficial pain. Functional arthralgias of the sort that sometimes 103 104 PAIN occur in neuropathic individuals are not rarely ac- companied by marked cutaneous hyperaesthesia with- out deep-seated tenderness, so that in functional coxalgia forcible pressure of the head of the femur against the acetabulum is easily borne, although even gentle touching of the skin gives rise to pain. In general it may be said that arthralgias do not radiate. The necessary conducting tracts are want- ing, a condition in contrast to the joint pains of neuralgic origin, such as the shoulder pain of angina pectoris. An exception to this rule is formed by coxalgia; in this the pain may radiate down the thigh toward the knee. The same thing is true for the ankle joint in flat foot. In other articular conditions radiation is generally to be expected only in cases of neuritic or spinal complications, such as tabes or syringomyelia, or if the pain is purely functional in nature. INTENSITY. Assuming a normal nervous system, the severity of the pain seems to depend on the degree of acuteness in onset as well as the intensity of the inflammatory process, and therefore many cases of acute polyarthritis, gonorrhoeal joint affec- tions, and gout are highly painful. When the ner- vous system is in a state of hypersensitiveness (hysteria) a disproportion may be observed between the objective conditions and the subjective sensa- tions, but this by itself may not be sufficient to ex- clude the organic nature of the affection. Where, however, the pain-conducting tract is damaged, as in tabes and syringomyelia, one must be prepared to en- ORGANS OF MOTION 105 counter very slight degrees of pain or even the total absence of this symptom in spite of anatomical changes of considerable extent, and this discrepancy may direct the attention into the proper channel. KELATIONS IN REGARD TO TIME. The relation of joint pains to time can be made use of only with great caution in differential diagnosis. The occur- rence of nocturnal exacerbations is frequently pointed out in cases depending on syphilis in the secondary or tertiary stages. The absence of noc- turnal increase may in general render syphilis less likely, but its presence is far from rare in non- syphilitic conditions also, and may occur often enough in cases of ordinary acute polyarthritis and especially in gouty arthralgias. Only the functional arthralgias of neuropathic nature seem never to be accompanied by nocturnal increase in pain. The occurrence of arthralgias during pregnancy or in the puerperium always suggests gonorrhoea (lighting up of old foci) or sepsis. MODIFYING FACTORS. Among the most important characteristics of a joint pain is its susceptibility to mechanical influences. These may vary in nature, and the two most important are (1) pressure in the neighborhood of the joint (effect on the bone ends, capsule, etc.) ; (2) active and passive motion. 1. In examining joints, particularly when the larger ones are involved, one should never omit to investigate the possibility of a bone process, such as tuberculosis, syphilis, or osteomyelitis, as the underlying cause of the joint affection, and for this 106 PAIN purpose the articular extremities of the bones should be carefully palpated and be pressed against each other. No less care should be used in examining the fibrous capsule and tendon sheath. 2. The production of pain through active and passive motion is of course one of the chief evidences of an arthralgia. It should be remembered, how- ever, that motion of a joint may also give rise to pain through traction on inflamed muscles, nerve trunks, or vessels (e.g., the shoulder pain in aortalgia) with- out there being any lesion of the articulation itself. If, however, even slow motion of very slight extent causes pain the diagnosis of arthralgia receives greater justification. These are cases in which im- mobilization of the joint is the best analgesic, but in functional arthralgias fixation is very badly borne. This fact may be of differential diagnostic value as well as the noteworthy difference between superficial and deep tenderness. The mechanical factor of trauma may be the inciting agent of both functional and organic arthralgias. THERAPEUTIC INFLUENCES. The mechanical fac- tors are supplemented in their action by chemical agents. This is especially the case from the thera- peutic standpoint, but may also be made use of in differential diagnosis. Only in exceptional cases are gonorrhoeal joint affections and the arthralgias of rheumatoid arthritis and gout favorably influenced by the salicylates. Mercury and iodine again are particularly effective in cases of syphilitic arthralgias. ORGANS OF MOTION 107 ACCOMPANYING MANIFESTATIONS. Not rarely the pain may be practically the only manifestation of the joint affection, and this is not exclusively the case in functional arthralgias, but may occur in organic lesions. The harmful agents attacking the joints may also invade the muscular and nervous systems (neuritis), and such complications must be thought of in testing for tenderness on pressure. Possible involvement of the bones, as in syphilitic periostitis, the growth of osteophytes, erosion of the articular surfaces, etc., must be thought of. Where fever is an accompanying symptom the bacteriologi- cal cause of this should be determined if possible and efforts be made to discover the primary focus of in- fection. This may be sought for in the tonsils, acces- sory nasal cavities, the middle ear, the urethra, pros- tate, parametrium, etc. Particular attention should of course also be given to endo-, peri- and myocardial changes. ETIOLOGY. In the foregoing the recognition of an arthralgia as such has been discussed, and from a consideration of the facts elicited in this way much light will often be thrown on the etiology of the process. A definite conclusion in this regard can of course be arrived at only from a complete investi- gation of the disease process. To begin with, the adoption of the following classification is suggested : 1. Arthralgias of infectious origin: a, acute; b, chronic. 2. Arthralgias due to disorders of metabolism. 3. Arthralgias of neurogenous nature. 108 PAIN 1. The streptococci require special consideration under this head as the inciters of the ordinary acute polyarthritis, or of sepsis. Other organisms of importance are gonococci and the pus-producing cocci in general (staphylococci, diplococci, and men- ingococci), and of less frequent occurrence ex- cepting the tubercle bacillus bacilli such as 'those of typhoid fever, dysentery, leprosy, and influenza. Diseases like scarlatina, variola, parotitis, and syphilis are also to be thought of in this connection. 2. Under this heading are grouped the arthri- tides of the uratic diathesis and its variants, the arthritis of lead poisoning, and the joint processes sometimes accompanying psoriasis, as well as many cases of chronic polyarthritis, although in these the possibility of an infectious etiology must always be kept in mind. The cases of intermittent hydrops of the knee and the joint conditions of haemophilia may also be included in this class. The position of arthritis deformans is not yet clear. 3. The arthralgias of neurogenic nature, such as those of tabes and syringomyelia are ordinarily char- acterized by slight intensity which may diminish to almost nothing. They therefore offer a striking con- trast to the arthralgias sometimes occurring in neuropathic individuals and forming an articular manifestation of hysteria. II. MUSCULAR PAINS OR MYALGIAS. Tenderness on pressure over a muscle and pain whick is increased on passive stretching or active contraction, form the most important indications for ORGANS OF MOTION 109 the diagnosis of a myalgia. In dealing with the extremities and with the musculature of the head and neck the problem does not ordinarily present great difficulties, providing that there are no painful in- flammatory conditions of the overlying skin and subcutaneous tissues. SOUBCES OF ERROK. It is hardly necessary to point out how puzzling it may be to interpret cor- rectly pain in the region of the diaphragm. Diffi- culties may also be encountered in investigating the musculature of the chest, the back, and abdomen, since functional examination may not give satisfac- tory results or may be hard to carry out, and the pain on pressure may be referable to underlying organs. In this regard it is important, particularly in dealing with the abdominal muscles, to ascertain whether, when the muscle is in a state of contraction, it is equally or even more tender. If the sensitive point is situated beneath the muscles a decrease or disappearance of the tenderness may be expected, as the contracted muscle yields but little to the pres- sure. Reference may also be made at this point to the myalgias frequently occurring in laborers through muscular fatigue or the effects of exposure. These are particularly frequent in the thoracic muscles, and as the pain is increased by respiration owing to the functions of the muscles involved, sus- picion of pleural processes is easily aroused. In these cases it is important if possible to raise _the muscle from its underlying structures and test it for tenderness by taking it between two fingers. In gen- 110 PAIN eral the tenderness is increased when the muscle is contracted. I should also like to call attention to the tenderness of the abdominal muscles, particularly in the epigastrium, which is not uncommon after severe protracted coughing, as in phthisis. If there happen to be at the same time abdominal symptoms such as gastric disorders, diarrhoea, etc., confusion may easily arise and the pain of gastric ulcer or peritoneal irritation be thought of. The same thing is true in regard to myalgia coming on acutely after the lifting of heavy loads, which may persist for months. In cases in which the diseased muscle be- longs to the deeper layers, e.g., the deep muscles of the neck, diagnostic difficulties may present them- selves, and there is danger of confounding the con- dition with a bone lesion. GENERAL, PATHOLOGY AND ETIOLOGY. In discuss- ing the general pathology of muscular pain, the fact must be emphasized that the chief site of the sensa- tion is probably to be found less in the parenchyma than in the connective tissue framework. This is most highly developed in the tendons and aponeu- roses, and the pain may extend to these, so that in considering the myalgias these structures must also be taken into account. The pain of cramp, such as that of the calves of the legs, is etiologically among the most easy to understand. In this the purely mechanical factor of pressure is concerned, a form of pain mechanism that is also encountered in organs composed of unstriped muscular fibre, like the intes- tine and uterus. Otherwise inflammatory processes ORGANS OF MOTION 111 are the most fundamental causes of myalgias, both those of endogenous nature due to disorders of metabolism and those of exogenous origin depending on toxins in general, and especially those of bacterial nature. The myalgias that are more or less physio- logical in nature and follow over-exertion through the accumulation of fatigue toxins may also be grouped in the class of endogenous origin. It must always be taken into account that the real cause of the myalgia may be found extramuscularly in a primary painful affection of the peripheral nervous system, such as neuritis, provided that sensory intramuscular fibres are involved; an example of this is the tenderness to pressure of the calves of the legs of drunkards. MODIFYING FACTOES. As has already been pointed out tenderness is an important aid in the diagnosis of myalgia. It must be ascertained whether this symptom is locally limited or is diffuse throughout the muscle and tendon. Local lesions such as traumatic or spontaneous haematomas, abscesses, tubercles, gummas, muscular cicatrices, echinococcus cysts, new growths, etc., frequently are characterized by local tenderness. Where the mus- cular inflammation is diffuse, as the result of infec- tion or through causes of a general type, the tender- ness will also be diffuse in nature. Such a condition might be due to infection with the pus-producing cocci, acute infectious polyarthritis, typhoid fever, influenza or gonorrhoea. Other processes that may be mentioned are intestinal autointoxication, Unver- richt's dermatomyositis, haemorrhagic myositis, and 1 12 PAIN parasitic diseases, especially trichinosis. In contra- distinction to the neuralgias spontaneous exacerba- tions of pain are very rare ; the symptom is caused through pressure, or active and passive motion. Of other modifying influences climatic conditions such as dampness, draughts, etc., may be mentioned, par- ticularly in connection with myalgias localized in the muscles of the shoulder, neck, and lumbar region. If the process is situated in the muscles of respira- tion the movements of deep breathing, coughing, sneezing, defecation, etc., give rise to pain. The same is true of swallowing if the muscles of deglu- tition are involved. Of therapeutic influences men- tion may be made especially of the effect of salicy- lates and preparations of iodine and mercury. ETIOLOGY. Owing to the great variety of the proc- esses giving rise to myalgias, it is difficult to arrange them in a scheme of classification. The distinction of most service in differentiation is be- tween, on the one hand, the type running its course as a local and afebrile condition, and on the other, the type diffuse in nature and presenting the picture of a severe infectious disease. 1. MUSCULAK AFFECTIONS CHIEFLY LOCAL IN NATUKE. Traumatic hasmatomas and hernias of muscle (the adductor group) ; haematomas following pre- ceding vascular damage (typhoid fever, sepsis, phosphorus poisoning, arsenic poisoning, jaundice, etc.) ; rheumatic affections due to cold, for ex- ample, in the shoulder or lumbar aponeurosis ; mus- ORGANS OF MOTION 113 cular cicatrices following fibrous myositis through local venous thrombosis, for example, deep-seated varicosities in the muscles of the calves; atheroma of the muscular arteries (intermittent claudication) ; muscular abscesses and infarcts, gummas, tubercles, echinococcus cysts, new growths. 2. MUSCULAR AFFECTIONS CHIEFLY DIFFUSE IN NATUKE. 1. In general infectious processes through pus organisms, acute articular rheumatism, typhoid fever, influenza, syphilis, etc., Unverricht's der- matomyositis, haemorrhagic polymyositis, acute delirium. 2. In constitutional disorders, such as the rheu- matic diathesis and ossifying myositis. The latter is unlikely after the twentieth year. 3. In parasitic diseases, particularly trichinosis. 4. Periarteritis nodosa. This is most often seen between the twentieth and thirtieth years. DIFFERENTIAL DIAGNOSIS. As has already been pointed out the diagnosis of myalgia in general is founded on the symptoms of tenderness to pressure and of increase in pain on active and passive motion. Alterations in the volume and consistency of the structures concerned have a corroborative value, but are not a conditio sine qua non for the diagnosis. If the symptoms mentioned are noted as well as the absence of spontaneous exacerbations the danger of confusion with neuralgia is ordinarily not very great. It is well to keep in mind the pains that are 114 PAIN often associated with the milder states of weakness ; for example, in the shoulder girdle in cases of aortic disease, processes in the liver and spleen, or in apical tuberculosis. The connection of lesions of the kid- ney, such as calculus and new growths, as well as of the prostate or parametrium (metastasis of carci- noma), with pain in the thigh, also deserves con- sideration. Involvement of the neck muscles may simulate meningeal rigidity or spondylitis, though the contrast between the intensity of the apparent stiffness of the neck and the absence of other menin- geal symptoms, and especially the tenderness of the muscles, will guard against error. Similar consid- erations will serve to exclude tetanus when the muscles of mastication come in question. In differ- entiating between pleural pain and rheumatoid affec- tions of the thoracic muscles the chiefly, and often exclusively, axillary localization of the former seems to me to be of significance. In order to guard against mistakes it is always advisable to pay par- ticular attention to the presence of tenderness of nerve trunks and of joints, and it should be remem- bered that the simultaneous occurrence of disease in these structures is not impossible. ACCOMPANYING MANIFESTATIONS. In addition, the temperature and the general condition should receive careful scrutiny. Serious illness with typhoid-like symptoms suggests the not rarely fatal cases of Unverricht's dermatomyositis whose etiology is still uncertain, haemorrhagic polymyositis, or in the pres- ence of the appropriate initial intestinal symptoms, ORGANS OF MOTION 115 trichinosis. In the latter case', the combination of multiple myalgia with eosinophilia is of particular importance. The presence of cutaneous oedema is also significant. It is brawny and firm, with non- involvement of the joints in Unverricht's dermato- myositis, and involves the eyelids in trichinosis. If the swelling is limited to one lower extremity, local thrombotic conditions come in question, such as those occurring in the cachexia of malignant disease or as post-infectious complications. III. BONE PAINS OR OSTALGIAS. The danger of misinterpreting pain caused by the irritation of sensory fibres in the bone-marrow and periosteum and of ascribing to it a different nature (rheumatic or neuralgic) is shown by experience to be no slight one. This is in part explained by its comparative rarity, and in addition there is no dis- tinct localization in the affected part, particularly in diffuse skeletal disease, such as osteomalacia, new growths of the bone-marrow, etc. Furthermore, as far as the factor of motion is concerned, the symp- toms correspond to those of many commoner and therefore better known painful conditions. For ex- ample, if the bone exhibits periosteal changes at the point of insertion of muscular masses, contractions in these will naturally be painful and there will be danger of confusion with muscle or joint pain. Spontaneous exacerbations, which may be nocturnal in character and occur, for example, in osteomalacia, new growths of the bone-marrow, and post-typhoid 116 PAIN osteomyelitis, may simulate neuralgic or spinal processes, and this the more so if alteration in gait, increased reflexes, etc., are present, as in osteo- malacia. If one further reflects that infectious and dyscrasic factors, as well as malignant processes, play a particularly important role in the etiology of ostalgias, it is to be expected a priori, that compli- cating muscle, joint, and nerve pains may appear both primarily and secondarily. From this it is easy to understand that errors in diagnosis may readily occur. ETIOLOGY. It is advisable to begin by passing in review the various general and specific disease processes associated with bone pain. 1. Infectious processes, such as typhoid fever, in- fluenza, sepsis, etc. The lesions of the bone-marrow in these conditions may be manifold in nature and run through all the stages from simple hypersemia to fibrous exudation, necrosis, and the formation of specific granulation tissue such as a gumma or a tubercle. The scale of subjective pain sensations corresponds to this range of anatomical changes, running the gamut from slight pain evoked only through strong pressure to the most severe spon- taneous paroxysms. Usually the primary lesions run their course in the bone-marrow itself and the periosteal involvement is secondary, although the possibility of an initial affection of the latter cannot be excluded. The infectious process may be principally or entirely localized in the bone-marrow and give rise ORGANS OF MOTION 117 to local, exceedingly intense pain (acute osteomye- litis), or the lesions may be very slight and be dis- covered only when special search is made for them. For example, in the course of typhoid fever and far into the convalescence it is wise not only to watch for spontaneous ostalgia (often manifesting noc- turnal exacerbations), but also to look for tender- ness in the portions of the skeleton frequently in- volved in osteomyelitis of this type. These are par- ticularly the tibia, ribs, femur, and clavicle, and especial attention should be given to the epiphyseal regions. The bone processes due to syphilis and tuberculosis and the ostalgias associated with them fall within the province of the surgeon, and are therefore only mentioned. Tenderness pointing to irritation of the bone-marrow, particularly in the sternum, is not infrequently encountered in infec- tious processes like malaria and pneumonia if it is looked for, and the ostitic symptoms sometimes ob- served in biliary cirrhosis may also be placed in this class. Some of the cases at least, of Marie's hyper- trophic osteoarthropathy, associated with clubbed fingers, may be included in the same group, in so far as they occur in empyema of the pleural cavities. The status of the disease of mother-of-pearl workers is still uncertain. 2. New growths, involving especially the bones of the trunk and of the proximal portions of the extremities. This localization is characteristic for the more or less diffuse lesions of the bony frame- work, such as multiple myeloma,lymphadenia ossium, 118 PAIN ehloroma, etc., which therefore exhibit somewhat the course of an internal disease. The correct interpre- tation of the not uncommon pain in these conditions is an essential for the early recognition of the true state of affairs. This is no less true for the cases of metastatic new growths which are often associated with neoplasms of the breast, prostate, thyroid, and adrenal body. Given a history of the removal of a carcinoma of the breast even some years previously, the occurrence of indefinite pain always suggests the possibility of ostalgia. Paradoxical as it may sound, it is precisely the indeterminate nature of a pain that suggests the possibility of its originating in the bone. 3. Blood diseases. It is very tempting to explain the tenderness in the lower part of the sternum that is so often observed in the grave blood diseases like pernicious anaemia, myelogenous leukaemia, and pseudo-leukaemia as being associated with hyperas- mic and inflammatory changes in the bone-marrow. Sometimes this symptom is one of the earliest sub- jective disturbances. On leaning against the edge of the table in writing, on resting against the win- dow sill, or in bending over the washtub, the patients experience pain in the portion of the sternum pressed upon, and on examination pronounced tenderness is discovered, particularly in the lower half of the bone. An interesting observation is that the sternal pains are controlled by arsenic, and as I have convinced myself in numerous cases, are least troublesome dur- ing the acme of the drug's action. In the myeloge- ORGANS OF MOTION 119 nous forms of leukaemia they may run parallel to the rise and fall in the number of leucocytes. These pains never occur spontaneously, but are always produced only by pressure over the lower half of the sternum. In exceptional cases there is also tender- ness in other portions of the skeleton, like the humerus or ilium. 4. Dyscrasias. Bone diseases of dyscrasic and trophic nature. For the sake of completeness ref- erence may be made to the extremely rare condition of ostitis deformans (Paget) and of leontiasis ossea (Virchow). The pains occurring about the head in cases of the latter are probably neuralgic in origin rather than ostalgias, and are due to pressure on the nerves through the proliferation of bone. In acromegaly ostalgia is not ordinarily observed and the condition may be dismissed with simple mention. OSTEOMALACIA. In this disease ostalgia appears in its purest and most concentrated form. It must always be our aim to make the correct diagnosis at a time before palpable changes in the skeleton have developed, but this is rendered possible only by familiarity with the initial pain symptoms. The lumbar region and the lower extremities are usually indicated by the patients as the chief seats of dis- comfort, at least in the puerperal forms. Whenever pains having this localization appear in the course of a pregnancy the possibility of a beginning osteo- malacia should be thought of. In contradistinction to the pain due to neuralgic disorders or spinal affections, like myelitis, the pains of osteomalacia 120 PAIN usually subside completely during rest, and their onset is intimately connected with mechanical fac- tors. Active and passive movement, coughing, laughing, sneezing, yawning, etc., either become im- possible or cause pain, even in far distant parts such as the lower extremities. Active motion, such as walking, stooping, and rising after being seated for some time, usually causes the patients great discom- fort. On getting out of bed they carefully lift out each leg in turn, holding by the thigh. Deep respira- tion often gives rise to pain in the ribs, and descend- ing^ stairs is sometimes still more uncomfortable than the ascent owing to the jarring of the body that it occasions. While moving about is exceedingly arduous, remaining in the same position for any length of time, either sitting or lying, results in an increase of the pain, so that the patients are obliged to change their position constantly, and sleep is therefore very broken. The movement of abduction at the hip joint is particularly prone to cause paroxysms of pain, as well as rapid dorsal flexion at the ankle joint. In the latter case a pain is not rarely caused which runs the entire length of the lower extremity, radiating to the pelvis and some- times accompanied by dorsal clonus. Lateral com- pression of the thorax, or of the pelvis at the level of the trochanters or the iliac crests, promptly causes pain. Wearing a corset and tight lacing sometimes appear to relieve the subjective symptoms, evidently through the support given to the spinal column. ORGANS OF MOTION 121 It is clear that the mechanical factors influencing the pain of osteomalacia are not deficient in charac- teristic qualities. If in spite of this, confusion with other affections, particularly those of rheumatic nature, is not rare, this may partly be explained by the fact that to some extent they respond in the same way to therapeutic measures. My experience leads me to speak of the prompt relief to pain afforded by the diaphoresis caused by hot-air baths, as well as of the improvement often spontaneously occurring during the hot summer months. Complications such as myalgias of the adductors and calves, joint pains of arthritic nature, and neuralgias like sciatica also sometimes occur and may contribute to render the picture of typical osteomalacia indistinct as regards its pain phenomena. As suggested above, accom- panying symptoms like ankle clonus, together with the apparent weakness of the lower extremities, may even give rise to confusion with spinal affections. The intimate relationship between the pain of osteo- malacia and mechanical factors like motion, as opposed to the more spontaneous onset of the paroxysms of spinal pain, should be sufficient for the purposes of differentiation. The absence of bladder disturbances is also an important diagnostic point. The differentiation from spondylitis in the dorso- lumbar region with secondary neuralgia of the pel- vis in which I have found that there may also be tenderness of the pelvic bones owing to involvement of the perio steal nerves is ordinarily not difficult. It is sufficient to think of this possibility in order to 122 PAIN avoid error by a careful examination of the spinal column. Where typical bony changes already exist an extended analysis of the pain phenomena may of course be dispensed with. In its onset, however, the disease belongs to the subjective ostalgias discussed above. FUNCTIONAL OSTALGIAS. It may be assumed a priori in view of the analogous observations in the province of joint and muscle pains that ostalgias may sometimes appear as manifestations of a gen- eral neurosis, like hysteria. In fact, there are obser- vations on record showing the possibility of the simulation of osteomalacia by that great artist in imitation, hysteria. In such cases error is to be avoided by a careful study of all the attendant symp- toms, but it must be borne in mind that the existence of hysteria does not exclude osteomalacia and that the latter disease in a hysterical subject will present confusing symptoms due to this tendency. REFLEX OSTALGIAS. Reflex sensitiveness to pres- sure and percussion over the spinal column may occur in abdominal processes without any anatomical lesion of the bone itself. This is particularly the case in gastric ulcer and cholelithiasis, in which the hyperalgetic spot is often over the twelfth dorsal vertebra at the level of the lower pulmonary border, or in the interscapular space. The local tenderness to pressure and percussion sometimes exhibited by areas of the skull overlying cortical cerebral tumors may be due to slight degrees of periostitic irritation (internal erosion). CHAPTER VII. DIGESTIVE SYSTEM. GASTRALGIAS. IN this section those paroxysms of pain are to be described which are colicky in nature, are localized in the epigastrium, are frequently accompanied by objective gastric symptoms, such as vomiting, eruc- tations, etc., and which in the absence of anatomical disease of the stomach are usually interpreted, and misinterpreted, as "nervous gastralgia." GENEKAL PATHOGENESIS. In view of the negative nature of the condition, it is not astonishing that even the existence of gastralgia as a painful sensa- tion arising in the stomach itself is sometimes denied, and the sensation in question is assumed to arise entirely outside of the organ in the vagus and sym- pathetic nerve tracts. According to this view gas- tralgia would be sharply differentiated from the pains occurring in other muscular hollow viscera, such as the gall-bladder, intestine, ureter, uterus, etc., and would be brought into association with the neuralgias. For the same reason that it would be improper in the case of a tumor of the Gasserian ganglion, accompanied by pain in the teeth, to speak summarily of toothache, the term gastralgia should be avoided and be supplanted by the expression sympathetic or vagus neuralgia, with the addition of the underlying cause. In analogy to the condi- 123 124 PAIN tions existing in neuralgias of the cerebrospinal nervous system the occurrence of tenderness along the nerve tracts in question, the vagus, the sympa- thetic nerves, and the solar plexus might be ex- pected. It is clear, however, that owing to the topo- graphical relations tenderness to pressure in the neck or over the anterior surface of the spinal column, in the abdomen, etc., is far from comparable in diagnostic value to the demonstration of distinct tenderness over the sciatic nerve, for example, and it is especially necessary under these circumstances not to allow the wish to become father to the observation. Of course the occurrence of gastralgia is per- fectly possible as a purely neuralgic disturbance in the course of the sensory tracts without the exist- ence of any causative motor or secretory disorders in the organ itself. This is especially the case when the attacks of pain persist even when the stomach is empty and are not influenced by alkalies, local anaesthetics, or the ingestion of food. The gastric crises of tabes may serve as a paradigm of this group, and the similar conditions appearing in syringomyelia, multiple sclerosis, cerebrospinal syphilis, vagus lesions, etc., may also be pointed out. VAGUS GASTRALGIA. For example, in a case of gastric crises under my observation, the patient was able to cut short mild attacks by inserting the finger deeply into the left external auditory meatus (vagus DIGESTIVE SYSTEM 125 fibres), but the act was accompanied by violent coughing. Starting with this observation of the patient's, to the effect that it was possible to inhibit the painful process evidently situated in the left vagus by a sort of counter-stimulation such as is applicable to the act of sneezing, I prescribed with good effect the application to the left auditory meatus of a pledget of cotton moistened with a mix- ture consisting of three drops of oil of mustard, one gram of menthol and ten grams of liquid petrolatum. It would be interesting to repeat this experiment in other cases of suspected vagus gastralgia. GASTRALGIAS OF GASTRIC ORIGIN. In addition to these gastralgias which are, so to speak, extra- stomachic, there are also undoubted essential gas- tralgias which probably preponderate, and in which the underlying cause is formed by the motor element ; that is, pyloric spasm alone or in combination with coincident dilatation of the gastric wall at the antrum of the pylorus, as well as secretory disturbances such as hyperacidity and acid hyperaesthesia. From the latter point of view especially, the alkali test should be made in every case of gastralgia by giving a pinch of sodium bicarbonate during the attack. This test is of value in differentiating the various gastralgias, but even in case prompt relief is afforded it must be remembered that the effect may be the result of the combined action of various factors. ETIOLOGY. The causes of gastralgia may be classified as follows : 126 PAIN I. IKRITABLE WEAKNESS OF THE NERVOUS SYSTEM. This factor is in most cases the fundamental cause of the essential gastralgias. Without the in- creased susceptibility to pain that it involves, no doubt many of the special factors, for example those of alimentary nature, would be inadequate to cause actual painful phenomena. In these cases the appli- cation of the therapeutic lever is particularly effec- tive, and improvement may often be secured even in the persistence of the specific cause of the pain. The most varied influences and processes may com- bine to produce the condition of irritable weakness of the nervous system, mental overexertion, psychi- cal emotions, sexual aberrations, anaemias, the arthri- tic diathesis, chronic infections such as tuberculosis with possible secondary sympathetic and adrenal lesions, syphilis, chronic intoxications such as nico- tinism, plumbism, alcoholism, arsenic poisoning, etc. These conditions contribute their part in giving rise to essential gastralgias ; they are factors that occur also in the causation of neuralgias in the cerebro- spinal nervous system (cf. classification on p. 85). Frequently they simply prepare the soil for the subsequent action of more specific causes. II. DIRECT CAUSES. A. ACTING CENTRALLY. This heading comprises especially diseases of the central nervous system, such as tabes, syringomyelia, multiple sclerosis, cere- brospinal syphilis, etc. It is difficult to decide to DIGESTIVE SYSTEM 127 what extent disturbances of metabolism such as the arthritic diathesis, diabetes, and the chronic infec- tions and intoxications mentioned in the preceding paragraph, have a central or a peripheral effect. In this class may also be included the gastralgias, often accompanied by vomiting, sometimes occurring in cases of vascular lesions such as atheroma of the abdominal aorta, of the coronary arteries, the cceliac axis, etc., and concerning whose exact mechanism we are still ignorant. B. ACTING PERIPHERALLY. Here the point of at- tack lies in the sensory nervous apparatus of the stomach itself. Organic lesions of the gastric mucosa, such as ulcerative or inflammatory proc- esses, may serve to induce gastralgias, especially if there is. an already existing predisposition. The actual mechanism of pain production frequently de- pends on a pyloric spasm of reflex nature; that is, on a pathological increase in motor activity which of course may reach its maximum when there is a permanent tendency to abnormal peristalsis, as in pyloric stenosis. Among the chemical factors whose existence in a given case is indicated by the prompt temporary effect of the administration of alkalies are to be counted the inorganic and organic acids, contact of which with the gastric mucous mem- brane may induce gastralgias of the most severe type. In view, of what was said above under section L, it may be expected that in hyperaesthesia small amounts of acid will be effective, while the variety of the acid is also not without importance. 128 PAIN ACIDITY. The complaints usually ascribed to hyperacidity and capable of being modified by the administration of alkali might therefore more cor- rectly be spoken of as due simply to acidity, since frequently they result not from an excess of acid but through an increased susceptibility to acids. Here again those gastralgias might be mentioned that sometimes occur with an anatomically intact stomach after the ingestion of strongly acid foods or those forming acid on decomposition (animal fats, milk) or strong spices, coffee, etc. Mechanical factors, such as insufficient mastication, overeating, and foods tending to gas formation, also come in question. HUNGER PAIN. Just as quantitative and qualita- tive abnormalities in the ingestion of food, including poisoning, may lead to gastralgiform attacks, pro- tracted fasting may have a similar effect. This appears rather paradoxical, since apparently noth- ing becomes a cause. In reality it is probably the physiological increase in peristalsis (growling of the empty stomach) that accompanies the sensation of hunger, and sometimes perhaps also the gastric juice secreted under these conditions that causes the pain, and this is particularly likely to occur if the predis- position already spoken of in section I. exists or the stomach has become a locus minoris resis- tentia through ulcerative processes (particularly ulcer, rarely carcinoma). III. REFLEX CAUSES. The gastralgias comprised under this heading in- clude those sometimes occurring in diseases of the DIGESTIVE SYSTEM 129 appendix, disorders of the female genital apparatus, sometimes even in nasal affections, hernias of the omentum in the linea alba, movable kidney, etc. In such cases it is always necessary to determine whether factors from groups I. and II. are not also concerned, and accordingly one-sided special treat- ment must be avoided. I consider it very probable that the epigastric pains often accompanied by gas- tric symptoms such as vomiting, eructations, the feeling of peristaltic unrest, etc., which sometimes occur in cases of more or less latent gall-bladder disease as well as in pancreatic conditions and dis- eases of the aorta and coronary arteries, are, as a matter of fa,ct, to be regarded as reflex gastralgias. DIFFEKENTIAL DIAGNOSIS. Colicky pains in the epigastrium associated with gastric symptoms of course always suggest gastralgia, but a satisfactory diagnosis can be made only through the proper inter- pretation of the causative factors. For this purpose it is necessary to pass in review the possibilities sug- gested under headings L, II., and III., unless defi- nite peculiarities of the pain give the necessary clue. TOPOGKAPHY AND TIME. Attention may be called to the purely left-sided character of the pain that is sometimes observed. Biliary colic is never re- stricted to the left half of the epigastrium leaving out of account the possibility of transposition of the viscera. Primary gastralgias ordinarily do not radiate into the upper extremities, particularly not as opposed to cholelithiasis into the right shoulder and arm. Eadiation into the left upper extremity 9 130 PAIN is also very rare as compared to the epigastric form of angina pectoris. For a consideration of the ten- dency to radiation exhibited in the colic of pyloric stenosis reference may be made to the section in question. It is also advisable to try to ascertain the depth of the pain from the surface in order to avoid erroneously interpreting intercostal neuralgias in the epigastrium as gastralgias. For this reason it is always wise to test the cutaneous sensibility of the epigastrium. The regular daily recurrence of the attacks, particularly if a relationship to the taking of food can be demonstrated, suggests the possibility of the conditions discussed in group II. B, such as ulcer, pyloric stenosis, etc. On the other hand, great irregularity in the appearance of the pain points more to the central diseases spoken of under group II. A, and perhaps the reflex factors of group III. MODIFYING FACTOES. In order to avoid errors in drawing conclusions from the causative factors, it is always necessary to remember that these are occasionally multiple in nature. Not without reason was the group included under the heading of irritable weakness placed first in the list of etiological factors, for gastralgias of the most varied origin may be founded on this basis. This indeed is true of attacks of pain in general, and the occurrence of a gastralgia under the influence of emotional excitement, such as anger or grief, is far from justifying the exclusion of an organic cause. Among the mechanical factors I should attach a not unimportant role to the matter of bodily posi- DIGESTIVE SYSTEM 131 tion. If the gastralgia is merely the result of func- tional or organic disease of the nervous system the effect of position will in most instances be hardly perceptible. The reverse may be the case to a very pronounced degree, however, if organic lesions of the stomach (II. B) or reflex stimuli from abnor- mally movable organs (III.) are concerned. If gastralgic seizures occur in connection with rapid motion, stair-climbing, etc., masked forms of angina pectoris must always be thought of. Pronounced tenderness, particularly on percussion of the epi- gastrium or on pressure, renders the existence of an organic condition likely, especially if asymmetrical, but exceptions in this regard may be encountered both on the organic and on the functional side. Particular attention must of course be given to the effect of diet. The mechanical, chemical, and thermic factors concerned in the ingestion of food tending to gas formation, strongly acid, spiced, or fatty foods, cold fluids, etc., are of importance, espe- cially in dealing with the organic processes spoken of under group II. B. The effect of acids and the opposite test with alkalies is also of importance. In the same way it seems to me that the action of local anaesthetics, such as cocaine, alypin, and anass- thesin is of importance from the diagnostic stand- point. If the administration of such agents causes rapid decrease in the discomfort the presence of local pain-producing factors such as ulcer, carci- noma, haemorrhagic erosion, or hyperaesthesia of the gastric mucosa may be regarded as demonstrated, 132 PAIN and in making the otherwise difficult decision be- tween gastric and duodenal ulcer the prompt produc- tion of relief in this way points in favor of the former lesion. A possible interdependence between the onset of gastric pain and constipation of long duration should not be overlooked. In hydrochloric acid hyper- sesthesia or hyperacidity, as well as in ulcer and pyloric stenosis, there is no doubt in regard to a connection of this sort, and it probably depends on interference with the emptying of the stomach and secondary stagnation and fermentation of its con- tents. The effect of menstruation should also be considered. ACCOMPANYING MANIFESTATIONS. Although in cases of gastralgia the best advice that can be given is to make a complete physical examination involv- ing all the organ systems, in addition to the analyt- ical study of the paroxysms in the manner just indicated and keeping in mind the possibilities sug- gested in the introductory classification, it may be helpful to emphasize several points that aid in rapid orientation, although not of great importance per se. Among these may be mentioned the possible coinci- dence of bladder disturbances or pains in the lower extremities (tabes). The syndrome gastralgia and distended bladder always awakens suspicion of gas- tric crises. High blood pressure, accompanied by arteriosclerotic pallor of the face and dyspnrea, even though slight, suggests an arterial starting point such as angina pectoris. Gastralgia and sarcinae DIGESTIVE SYSTEM 133 in the vomitus or in the feces point to ulcerative stenosis of the pylorus. The same thing is true of visible gastric pefistalsis or marked gastric meteor- ism (not to be confounded with distention of the epigastrium through an enlarged liver in choleli- thiasis). Examination for a palpable or painful gall-bladder, for the presence of a hernia in the linea alba, or for tenderness of the appendix and parametrium, should never be omitted. GASTRIC ULCER. TOPOGRAPHICAL CONSIDERATIONS. It might be assumed a priori that in ulcerative processes of the gastric mucosa the pain, whether spontaneous or produced artificially through pressure or percussion, would have a more or less asymmetrical left-sided localization corresponding to the position of the organ. As a matter of fact, this is true in a large number of cases, at least so far as ulcers in the neighborhood of the cardia or the central part of the stomach are concerned, and may be made use of in differential diagnosis. Exclusively or principally left-sided spontaneous pain or tenderness to pres- sure, either in the epigastrium or in the anterior or posterior lower thoracic region, renders painful processes of the right side of the abdomen and par- ticularly gall-bladder affections improbable, and therefore limits the diagnostic possibilities from the very beginning. The painful area to be outlined by pressure or percussion is not rarely situated on the left side 134 PAIN anteriorly, just below the costal arch, somewhat to the median side of the mammary line. It is also sometimes possible to discover another point of ten- derness on the left side posteriorly, close to the verte- bral column, at about the level of the twelfth dorsal or first lumbar vertebra. Concussion of the left lower portion of the thorax with the fist at about the level of the lower pulmonary border is also often exquisitely painful as compared with the right side. Even when the pain is median in onset it frequently radiates in the direction of the left costal border and to the left scapula. This is particularly likely in cases with perigastritic adhesions to the dia- phragm, the transmission probably taking place through the phrenic nerve into the shoulder. There may then also be a pressure point over the outer and middle third of the upper border of the trapezius muscle. While the left-sided position of the pain is not pathognomonic of gastric ulcer its diagnostic significance is the result of the position of the organ in the abdominal cavity and cannot be neglected. The great frequency with which the smaller median and right-sided prepyloric and pyloric portion of the organ is the seat of ulcerative lesions causes the pain to occupy a similar position in a great propor- tion of the cases. Not only is the spontaneous pain experienced in the middle portions of the epigas- trium, but on testing the sensibility by percussion the maximum point of tenderness is frequently found on a line connecting the xiphoid process with the umbilicus. I must caution, however, against draw- DIGESTIVE SYSTEM 135 ing conclusions in regard to the site of the ulcer from this position of the area that is painful on percus- sion. It is easy to convince oneself, for example, that in cases of hepatic congestion in which the hypersensitiveness of the organ to mechanical insult is no doubt the same throughout, percussion is always most painful in the midline of the epigas- trium, while on the right and left sides it may cause little or no discomfort. This may be explained as follows : On either side of the midline the recti blunt the force of the blow through their contraction, but in the center, where, especially in cases of ulcer, diastasis of the recti may exist together with enter- optosis, this defense musculaire is wanting and the impact is received unaltered by the stomach. This is apt to be overdistended with gas and the in- creased tension may result in pain production quite independently of the actual position of the ulcer. In most cases the lesion appears to be near the pylorus on the lesser curvature. The tenderness to percus- sion frequently begins about four finger breadths below the xiphoid process and extends to the neigh- borhood of the umbilicus. If it begins immediately below the xiphoid and corresponds to an area of dul- ness, the possibility of hyperalgesia of the liver, per- haps through congestion, or following an attack of gall-stones, must be seriously considered. It must also be remembered that hepatic congestion and ulcer may occur coincidently and that the development of an ulcer may be favored by the vascular and cir- culatory disturbances. Therefore in cases of myo- 136 PAIN cardial degeneration, mitral stenosis, etc., with pain- ful congestion of the liver and accompanied by symp- toms suggesting gastric ulcer, the relations of the tender area to the liver edge should be carefully studied. If it is situated below this the possibility of ulcer must always be thought of. Just as spon- taneous pain and tenderness to percussion or pres- sure may occur in the midline anteriorly, symmet- rical backache or hyperalgesia of one or more thoracic or lumbar vertebrae (usually the twelfth dorsal or first lumbar) may sometimes be encoun- tered. Ulceration of the pylorus itself not rarely causes exquisite tenderness on the right side, which may be either just to the right and above the um- bilicus or nearer to the costal border and therefore in unpleasant proximity to the gall-bladder. The radiation of the pain of pyloric ulcer is less inti- mately associated with the ulcer as such than with the pyloric stenosis, and will therefore be discussed with the subject of colic due to this condition. At present only the retrosternal radiation sometimes observed in ulcers of the lesser curvature will be mentioned. Ordinarily only the lower part of the sternum is involved, but sometimes the sensation extends upward toward the neck, and when it is accompanied by the sense of oppression and is de- pendent on motion (traction), confusion with angina pectoris may result. The pain of ulcer is nocturnal in a considerable proportion of cases, the paroxysms frequently occur- ring during the midnight hours (from 11 to 1 o 'clock) DIGESTIVE SYSTEM 137 and lasting into the early morning. The relation between the ingestion of .food and the onset of pain varies greatly from case to case, and I should never venture from this to draw conclusions in regard to the localization of the ulcerative process. Often the pain begins immediately after eating, but sometimes it does not occur until hours after the last meal. In pyloric ulcer, particularly if there is also stenosis, there is more regularity in this regard and the pain customarily begins two or three hours after the midday meal, as will be explained at greater length in discussing the subject of pyloric colic. THE NATURE AND PATHOGENESIS OF THE PAIN. The nature of the pain is very variable. Sometimes the feeling of a "sore spot" is complained of; fre- quently there is simply a diffuse sense of pressure in the epigastrium, a sensation of heaviness "as if there were a stone in the stomach. ' ' Sometimes it is described as being cutting, piercing, burning, or gnawing, or it may be spasmodic or throbbing in character. The intensity of the pain, and especially also the tenderness, may vary in a short time between wide limits so that while at one moment even deep pressure may not be painful, a few hours later even the contact of the shirt may seem unbearable. It is evident that the ulcerative process itself undergoes no change within so short a lapse of time, but gastric distention may develop, and I think that this accounts for the rapid fluctuations so often encoun- tered. The more the ulcerated gastric wall is stretched by gas formation the greater will be the 138 PAIN tenderness to pressure and percussion. Before be- ginning to discuss the actual causation of the pain, it may be well to say a few words in regard to its pathology. It is evident that the conditions are rather more complex than in ulcerations of the buccal cavity, for example, for here we have an organ whose wall may sometimes be abnormally distended through the accumulation of gas, and which, on the other hand, is subject to spasmodic contraction. Furthermore, one must take into ac- count its peritoneal covering, which may become inflamed over the ulcerated area (perigastritis), and also the production of acid gastric juice which may serve as a source of irritation. Every one of these factors, and of course to a much greater degree their combination, may occasion pain. At this point I should like to touch briefly upon the question as to why the deep ulcerations of the gastric mucous membrane caused by carcinoma rarely give rise to painful seizures similar to those of the benign simple ulcer. The acidity of the car- cinomatous stomach is also often high owing to the formation of organic acids, such as lactic, acetic, and butyric. In the explanation of this apparent para- dox two factors play a large part. (1) The carcino- matous stomach is much less prone to spastic con- traction than is the stomach with simple ulcer. The latter in spite of the frequently existing moderate degree of motor insufficiency is still undoubtedly in a state of motor hyperexcitability (irritable weak- ness), and every spasmodic contraction of the ulcer- DIGESTIVE SYSTEM 139 ated gastric wall may serve to cause pain. (2) In ulcer the stomach is more liable to meteorism, espe- cially if there coexists pyloric stenosis, either func- tional through spasm, or organic through cica- tricial contraction. The resulting tension of the wall of the organ is a very active source of pain. At any raie the two- mechanical factors of contraction and overdistention play an exceedingly important part in the pathogenesis of the pain of ulcer. Not rarely psychical factors, such as excitement or anger, are adduced by the patients as initiating the attacks of pain. If one takes into consideration the interdependence between the emotional state and the motor and secretory functions of the stomach, and on the other hand, the fact that the intensity of stimulus necessary to evoke pain in an emotionally excited person is reduced, the demonstration of such a relationship will probably never be regarded as by itself sufficient reason for assuming the existence of a functional disorder. It is especially necessary to be on one's guard since gastric ulcer is not rarely associated with the neuropathic constitution and a tendency to enteroptosis. The mechanical factors in the process of pain production are of the greatest differential value in dealing with the pain of ulcer as opposed to that of other gastralgias, such as those occurring in organic or functional nervous disorders like tabes or neuras- thenia, or those due to secretory anomalies or to intoxications (lead, nicotine). It is clear from what has been said above that the way in which mechanical 140 PAIN factors act will not be uniform and that the position of the ulcer and any existing adhesions will be of importance. A peculiarity frequently observed in cases of ulcer is that during the paroxysms, and sometimes also at other periods, the position of the patient while in the horizontal posture, whether on the face, back, or side has an undoubted effect on the intensity of the pain. It may at once be pointed out that similar observations may be made in painful affections of other organs, such as the liver, kidney, appendix, etc. I do not therefore agree with the generally accepted explanation that in certain posi- tions the eroded surface is exposed to the impact, so to speak, of the gastric contents, while in others this is not the case. Assuming that the material in the stomach is pultaceous and therefore not easily mov- able, as must often be the case, this explanation seems somewhat forced. At the most, it could be claimed only that the weight of the overlying layer, which, however, cannot vary very greatly, may have a pain-increasing effect, though this seems to me rather improbable. I should regard it as much more natural that, just as in the case of other painful abdominal organs, displacement, trac- tion, or kinking at the pylorus takes place and in- creases the pain. When the stomach is full it is par- ticularly liable to displacement of this sort as a whole and in part, and this can hardly be without effect in the presence of the inflammatory adhesions usually existing. Such displacement in different positions of the body is the more likely to occur in DIGESTIVE SYSTEM 141 ulcer since not rarely the condition is associated with enteroptosis and lax abdominal walls. This imperfect fixation of the abdominal organs as a whole is further contributed to by the considerable reduction in intra-abdominal padding due to the absorption of fat commonly seen in cases of ulcer. Therefore I should consider the effect of the painful position as due less to a displacement of the gastric contents than to that of the stomach itself (cf. page 22). The patients themselves often complain, for example, that when lying on the left side ' ' a weight seems to pass to the left. ' ' The pain accompanying the lateral position is sometimes experienced on the same side, but may also be contralateral, so that when lying on the right side it is felt to the left of the epigastrium, and often conveys the impression of traction to the right. The painful position may be noted only during the spontaneous paroxysms and frequently appears to depend on overfilling of the organ, which, of course, would predispose to dis- placement. It does not seem to me justifiable to draw conclusions, as is often done, in regard to the localization of the ulcer from the relations between the position of the body and increase or decrease in pain, since the connection evidently does not depend on simple displacement of the gastric contents due to gravity alone. A fairly constant though not invari- able rule is that painful lesions of the pylorus, par- ticularly if accompanied by stenosis, make the right lateral position uncomfortable during the spontane- ous attacks of pain, but more will be said on this subject in discussing the pain of pyloric stenosis. 142 PAIN So far only the horizontal position has been con- sidered. In walking, the body is frequently held in- clined forward, at least at the time of the paroxysm. Belief is sometimes afforded in the sitting or crouch- ing position, but in other cases these attitudes in- crease the patient 's discomfort. Movement of vari- ous sorts is also effective as a mechanical factor. Many patients complain of an increase in symptoms on walking, and it may be assumed that the traction and vibration to which the stomach is subjected, particularly if the abdominal walls are relaxed, is responsible for the pain production. A misstep may give rise to severe momentary pain in the epigas- trium. Exertion while stooping, calling into play the abdominal muscles, as in lifting heavy loads, is a frequent cause of pain, and may bring on a haemor- rhage. I recall an instance in which a patient after lifting a heavy load experienced for the first time a burning sensation below the left breast, which was followed by the development of typical ulcer symp- toms. Violent straining at stool may act in the same way. The respiratory movements may also cause pain, usually on the left side of the epigastrium just below the costal border, particularly if perigastritic com- plications are present. In these cases the sensation may radiate from the epigastrium to the left along the axillary portions of the thorax into the shoulder. It is hardly necessary to indicate that efforts such as those of coughing and sneezing may also be pain- fuL Under these conditions the sensation may be DIGESTIVE SYSTEM 143 located in the thorax. Straining at stool sometimes causes pain in the pyloric region, and in one case of mine about the sternal end of the third rib. The dependence of the pain of ulcer on mechanical stimuli, such as pressure and percussion, is among its most useful diagnostic peculiarities, but the im- pression appears to obtain that, as in the case of an ulcer in the mouth, the sensitive area corresponds to the anatomical lesion and depends on this alone. Pain on pressure and on percussion are, however, undoubtedly dependent on the degree of tension of the stomach wall. If the organ is greatly dilated, as may occur without true cicatricial pyloric stenosis through pyloric spasm and secondary stagnation, pressure and percussion will be particularly painful. This will be the case over a considerable area, and even when the trauma does not correspond to the situation of the diseased spot. This view is further borne out by the enormous fluctuations in sensitive- ness often occurring within a few hours and running parallel to the degree of distention of the organ. The possibility of determining the position and size of the ulcer by outlining the painful area by percus- sion seems to me to exist only when the stomach is not distended. The percussion must be very gentle, as if forcible it acts as a strong vibration, such as that caused by coughing, for example. Tenderness to percussion over the epigastrium should be looked for in the following situations: (1) From the xiphoid process to the umbilicus. (2) In the apex of the angle on each side between the outer border of the 144 PAIN rectus and the costal arch. (3) At a point about 2 cm. to the right of and above the umbilicus. (4) The lower part of the sternum. In the back hyper- algetic areas are. not rarely found in the neighbor- hood of the spinal column, particularly between the shoulder blades in the neighborhood of the twelfth dorsal vertebra. The left flank may also be sensitive to percussion with the clenched fist, less rarely the right, in contradistinction to cholelithiasis. In rare cases the epigastrium, and still more rarely the dor- sal regions just indicated are so hyperalgetic that simple contact and slight pressure (the weight of the bed-clothes, for example) are sufficient to cause pain. Overdistention of the stomach through diagnostic inflation (caution is necessary) may give rise to acute spontaneous pain and tenderness to pressure. So far we have discussed factors concerning whose purely mechanical nature there can be no doubt. The effect of diet presents a much more difficult problem. Here one is dealing with a com- plex of mechanical, chemical, and thermic factors, and this may explain the great variability in the effects of dietary regulation, although certain under- lying principles always stand out clearly from the chaos of inconsistencies. The mere fact that the pain is subject to alimentary modification at all seems to me of greater diagnostic importance than the exact manner and nature of the effect produced. The pain-inducing factor may be regarded as purely mechanical when it is the result of the use of foods causing gas formation. Here, as has already been DIGESTIVE SYSTEM 145 pointed out several times, it is the gastric meteorism which is predisposed to by the atony of the ulcer- ated stomach and its tendency to pyloric spasm that produces the paroxysms of pain through tension of the walls of the organ. This explains the prompt relief that often follows the evacuation of gas and the beneficial effect of the local application of an ice bag. The act of vomiting sometimes checks the pain abruptly. Some foods (e.g., pork) may have a purely mechanically irritating effect through their indigestibility and act as foreign bodies. Acid foods and strong spices, including salt and pepper, are nearly always badly borne. Of beverages, hot tea with milk, and milk to which an alkali like lime water or vichy water has been added, seem to agree the best. Coffee, beer, wine, and cold water often in- duce paroxysms of pain. In exceptional cases the ingestion of coffee or whiskey may bring relief to the pain, possibly through hastening the emptying of the stomach or through an antifermentative. action. Meat sometimes also has a favorable effect which is ordinarily explained as due to the neutralization of the excess of hydrochloric acid. For my part, as the result of numerous observations, I consider that hydrochloric hyperacidity is very far from frequent in ulcer and have furthermore been able to convince myself that in undoubted cases of the lesion even large doses of dilute hydrochloric acid have not in- creased the pain and have sometimes even seemed to have a favorable effect, possibly through an anti- fermentative action. I should always advise testing 10 146 PAIN the effect of acid and alkalies experimentally in cases of gastric ulcer. If the administration of alka- lies relieves the pain the proof of hyperchlorhydria has not been furnished, for there may exist what I think is rather frequent, namely, a hypersesthesia to hydrochloric acid accompanied by even subnormal HC1 values. In addition, the discharge of gas and consequent reduction of gastric meteorism sometimes produced must be taken into consideration. That the ingestion of meat and milk frequently does not act exclusively through the neutralization of hydro- chloric acid is shown by the fact that not rarely a piece of bread will have the same- effect. Increased peristalsis is likely to attend the sen- sation of hunger caused by prolonged abstinence from food. This is evidenced under physiological conditions by the " growling of the* stomach," and the ingestion of food of any sort appears to have a quieting effect on the spasmodically increased motor activity. The effect of tobacco in causing pain, which is not only common in essential gastralgias but also in cases of ulcer, may be due in a similar way to the increased peristalsis. It is not possible to formulate distinct rules in regard to the effect of thermic stimuli on. the pain of ulcer. In most cases moderate warmth, both in- ternally through beverages such as warm milk or tea, as also externally by means of fomentations or hot water bottles, appears to act favorably on the pain, but cold (a swallow of cold water, or an ice bag to the epigastrium) not infrequently relieves in DIGESTIVE SYSTEM 147 cases in which heat increases the discomfort of the patient. Among the interrelationships between the pain of ulcer and the condition of other organs or their func- tions, constipation, which is so frequently seen in this disease, appears to me to be of importance particu- larly from the therapeutic standpoint. Constipation is undoubtedly a pain-producing factor, for when it has persisted for any length of time the intensity and frequency of the attacks nearly always increase, only to subside again after evacuation of the intes- tine. Occasional enemas of oil or glycerine and pos- sibly the regular administration of mild laxatives, such as cascara sagrada, are therefore urgently indi- cated. It appears most likely that the blocking of the fecal masses reacts upon the stomach and causes stagnation in this organ, thus increasing the ten- dency to meteorism. The effect of the latter upon the pain of ulcer has already been discussed at length. It is hardly necessary to point out that a condition of "irritable weakness" of the nervous system is unfavorable, particularly if accompanied by anaemia, and therapeutic measures must be directed along these lines. No less undesirable is the effect of enteroptosis, which is not infrequently encountered in neuropathic individuals. If gas- troptosis exists, the resulting kinking at the pylorus leads to stagnation and abnormal fermentation of the gastric content, while at the same time pain- ful traction on the organ is also likely to be caused. When pregnancy has a beneficial effect on ulcer 148 PAIN and its pain, as was the ease in some instances that I recall, it is possible that among other factors the relief to the condition of enteroptosis produced by the elevation of the abdominal viscera through the enlarging uterus is of importance. ACCOMPANYING SYMPTOMS. Among the symp- toms associated with exacerbations of pain the most characteristic are those standing in close relation- ship to the mechanism of pain production. For ex- ample, the distention of the stomach is often evident from the presence of a rounded swelling, or at least an air-cushion-like resistance, in the left (as con- trasted with cholelithiasis) side of the abdomen. Pressure over this sometimes occasions pyrosis through regurgitation upward, sometimes there is distinct, easily produced succussion.* Frequently there is audible and palpable gurgling owing to the increased peristalsis, or there may be acid eructation or belching of gas smelling like putrid eggs (SH 2 ) and vomiting followed by the immediate cessation of the pain (as opposed to cholelithiasis). Chills occur only rarely and then in neuropathic persons with abnormal vasomotor excitability; the superfi- cial abdominal reflex is sometimes increased on the left side, headache and attacks of vertigo are often seen, as well as the feeling of great heat and sweat- ing, especially during a haemorrhage. Microscopi- cally the examination of the vomitus or of the feces *In cases of gastric ulcer it is desirable, in order to avoid local injury in testing for splashing in the stomach, to shake the whole abdomen by grasping the two sides of the pelvis with both hands. DIGESTIVE SYSTEM 149 may reveal the presence of sarcinae, which is a find- ing of importance. As noted above, I do not regard hyperchlorhydria as a frequent concomitant of ulcer. DIFFEBENTIAL DIAGNOSIS. If the existing pain phenomena are analyzed in detail in this way, pay- ing special attention to the causative factors, mis- takes in diagnosis will be unlikely. In distinguish- ing the paroxysms of gastric ulcer from those of the gastralgias of "nervous" nature, such as may be caused by organic lesions of the nervous system, tabes, multiple sclerosis, syphilis, etc., and which are often dependent on a neuropathic basis, as in hys- teria, exophthalmic goiter or nicotinism, the inter- mittent character of the pain in the latter may be emphasized. In these conditions, in addition to the sporadic nature of the attacks and the lack of sus- ceptibility to influence by mechanical factors, such as position, motion, or pressure, there is also the absence of permanent or consistent modification through diet. In difficult cases it is advisable to make careful dietetic observations in order to deter- mine the degree of tolerance for articles of food badly borne in ulcer. The lack of response to dietary changes will also prevent confusion in cases of epigastric intercostal neuralgia. As opposed to the more occasional attacks of gall-bladder colic, the pain of ulcer is characterized by greater persistence and the action of local anaesthetics is of importance (cf. pyloric stenosis colic). The existence of a hernia of the linea alba, which may exhibit the same epigastric tenderness as ulcer, is easily recognized 150 PAIN by palpation while the patient coughs. Still, even after the discovery of a hernia the possibility of the simultaneous occurrence of both conditions must be kept in mind. The epigastric tenderness some- times seen in chronic bronchitis as a muscular phe- nomenon involving the insertions of the recti and comparable to the pain in the calves after fatiguing marches, is likely to lead to error only if the exam- ination is superficial and gastric symptoms happen to coexist, as in tuberculosis. Hepatic congestion with tenderness seems to offer a possibility of mistakes in diagnosis. In cases of ulcer, associated with cardiac insufficiency and hepatic congestion in which the gastric lesion may be predisposed to by the circulatory disorders the epigastric pain is likely to be ascribed summarily to the hepatic condition, and the stomach symptoms are explained in the same way. It may be that not until perforative peritonitis intervenes, as in a case I have seen, is the true state of affairs recognized. It is important to demonstrate that there is also a spot painful to percussion below the edge of the liver and that the pain does not subside under digitalis as is the case in the hepatic condition. Of course, care- ful study of the attendant circumstances is also necessary. Angina pectoris, especially in its graver forms induced through lesions of the aorta and coro- nary arteries, may simulate the symptoms of ulcer if the pain is localized in the epigastrium and evi- dence of gastric disturbance like vomiting is present. This is the more likely to be the case if the epigas- DIGESTIVE SYSTEM 151 trium is tender to pressure, as the result of inflam- matory atheroma of the abdominal aorta. In deal- ing with persons over forty, of stocky build and pale complexion, with a tendency to dyspnoea, thick arter- ies, and high blood pressure, one should always be slow to make the diagnosis of ulcer, particularly if it is found that rapid motion, stair climbing, etc., give rise to the epigastric pain. The characteristic anguished facies of the patients during the attack also gives a hint as to the true state of affairs. If the dietary has no particular effect on the pain, as is usually the case, the distinction is not difficult to draw. The conditions are more- difficult when the ingestion of food also induces attacks in coronary or aortic angina. In such cases the nature of the food is frequently without significance ; for example, in one case the attacks occurred no matter whether the patient took milk or pork and sauerkraut; it was the ingestion of food as such irrespective of its qual- ity that caused the pain. Those cases should also be borne in mind in which gastric ulcer affords the reflex starting point of hysterical angina pectoris, particularly if aortic lesions are present, such as aortic insufficiency. Neuroses are most apt to occur in anatomically damaged organs. In all cases of suspected ulcer the region of the appendix should be examined for tenderness. Just as appendicular colic not rarely begins in the epigas- trium, chronic appendicitis may be associated with epigastric symptoms simulating ulcer. The possible combination of both conditions must als.o be consid- 152 PAIN ered. In cases of achylia gastrica, such as occur in- dependently or as part of the picture of a pernicious ansemia, ulcer-like symptoms, sometimes even asso- ciated with the apparent symptoms of hyperacidity, may occur. The demonstration of the absence of hydrochloric acid will give the necessary clue. The same thing is true of gastric carcinoma, which some- times begins with typical ulcer symptoms. In chronic gastritis tenderness over the pylorus may be present, though this is usually slight. There may also be similar dietary symptoms, though seizures of severe pain are almost never observed. The possi- bility of ulceration in other portions of the gastro- intestinal canal must also be taken into account. These exhibit similar and therefore confusing die- tary symptoms. I believe that it is impossible to distinguish with any degree of certainty between the pain of gastric and of duodenal ulcer. The appli- cation of the ansesthesin test has already been de- scribed (cf. page 39). If the pain of intestinal ulceration, for example, of tuberculous nature, is accompanied by symptoms such as vomiting, gastric splashing, etc., and is localized in the epigastrium, it is very difficult to make the distinction, particularly in view of the similar behavior of the two affections in regard to the ingestion of food. The case- is ren- dered still more complex if, as in an instance ob- served by me, intestinal symptoms such as diarrhoea and increased peristalsis are absent. Under these conditions the appearance of pain in the lower abdo- men, as well as of tenderness in the ileocaecal region, DIGESTIVE SYSTEM 153 seems to me of great importance; At any rate, great caution is necessary in making the diagnosis in patients having pulmonary tuberculosis. THE COLIC OF PYLORIC STENOSIS. Just as stenosis of the intestine may give rise to attacks of colic more or less independently of the nature of the obstruction, paroxysms of similar eti- ology are occasioned when the pylorus is narrowed. As is the case in the intestinal canal, internal ste- noses induced by lesions of the mucosa produce the most intense attacks of pain. Fresh pyloric ulcera- tions are not necessary for this ; it is rather chronic cicatricial inflammatory changes or malignant new growths that are at fault. In short, the causes of the obstruction may vary, but the pain phenomena in- duced are the same. It therefore seems to me justi- fiable to classify separately the paroxysms of this type and to give them the new designation of pyloric colic. In the pathogenesis of this it appears to me that as in the stenotic colics in general the factor of overdistention is of greater importance than that of muscular spasm. The quality of the pain itself and particularly the accompanying symptoms in ad- vanced cases, such as visible peristalsis, leave no doubt in regard to the underlying causes. At the acme of the paroxysm the patients nearly always complain of pain that is exquisitely colicky and grip- ing in character and is associated with the sensation "as if there were something alive in the stomach region," "as if the stomach were contracting vio- 154 PAIN lently and there were an obstruction to the exit of its contents." The spasmodic attempts of the gas- tric muscles to force the contents of the organ through the stenosed pylorus manifest themselves in this way and sometimes even the direction of peri- stalsis from left to right is manifest to the sufferer. The distention that is ordinarily also present gives rise to an extremely disagreeable or even painful feeling of fulness. OBJECTIVE SYMPTOMS. Although the subjective sensations of the patient depending on the underly- ing conditions of spasm and overdistention give a sufficiently clear picture of the actual condition, the other objective symptoms banish all doubt, at least in well-marked cases. The cardinal phenomenon is the fact that the contours of the stomach are ren- dered visible and palpable. At the same time gur- gling and rumbling sounds may be heard. This so- called rigidity of the stomach is often observed by the patient himself as a " hardening" of the epigas- trium, which is likely to be most marked on the left side. It corresponds in time fairly closely with the paroxysm of pain. The distended stomach does as a matter of fact become harder to the touch and is palpable as a mass resembling an inflated air-cushion in consistency. This is a symptom that deserves consideration in all cases of gastric pain in which pyloric stenosis is suspected. If the abdominal muscles are well developed and the stomach is not greatly dilated the abnormal increase in peristalsis may not be visible, but can be detected on palpation DIGESTIVE SYSTEM 155 as a rapid change in the degree of tension of the organ. In testing for this it is advisable to palpate with the outspread fingers pressing vertically against the abdominal wall, especially over the left half of the epigastrium and below the left costal border. In some cases, particularly if there is no gastric dis- tention, an increase in the pyloric resistance may be felt at the onset of the pain. The sausage-like trans- verse mass so formed disappears again as the pain subsides. If the stomach is more dilated and ap- proaches the vertical in position peristalsis is often most marked in the neighborhood of the umbilicus and little eminences appear at either side of this. More rarely the protuberance is in the neighborhood of the gall-bladder. A similar observation is some- times made by patients with gall-stones and is due to a specie of erection of the gall-bladder. The auscultatory manifestations have the same origin as the visible and palpable phenomena and correspond to the loud borborygmi accompanying intestinal stenosis. They are caused by the gurgling of gas through the narrowed pylorus and are ordinarily followed by decrease of the tension of the gastric wall and subsidence of the paroxysm of pain. The evacuation of gas upward through the cardia has the same effect. The violent peristalsis battling against the pyloric obstruction also often produces eructa- tions of sour material accompanied by retrosternal pyrosis which may extend up into the throat. Finally, there may be vomiting of an abundance of material that is not bile stained, the act being usually 156 PAIN followed by cessation or considerable diminution in the pain, as opposed to the vomiting of biliary colic. Although in the typical cases with marked dilatation the large quantity of the vomitus, which comes up in great gulps, and the facts that the material brought up is almost never bile stained, frequently contains old food particles and sarcinae, and is often hyper- acid, usually make the recognition of the underlying conditions easy, there are other instances in which, in spite of years of stenosis, there is never vomiting, no sarcinae are to be found in the gastric contents, and there may also be no food residue in the fasting stomach. In these cases there is probably a compen- satory change without extreme stenosis, and instead of dilatation there is rather a concentric hypertrophy of the muscular layers. The absence of vomiting may also be caused by perigastric adhesions, and in such cases the careful study of the attacks of colic may be of great diagnostic importance. Of other symptoms frequently observed there may be men- tioned the belching of gas having the odor of putrid eggs (SH 2 ) ; the microscopical pendant to this is the discovery of sarcinae. Another typical manifesta- tion is the presence of gastric splashing, which may be elicited at any time, and is often noticed by the patient in walking. It is only rarely (in neuropathic patients with an excitable vasomotor system) that a short chill accompanies the attack of colic. Eleva- tions of temperature do not go with the seizures of pyloric stenosis, as opposed to biliary colic. Con- stipation is a regular concomitant in almost every DIGESTIVE SYSTEM 157 case of well-marked pyloric stenosis and is aggra- vated at the time of the attack. The urine is often reduced in quantity owing to the loss of fluid through vomiting and is darker in consequence of its concentration. TIME OF ONSET. The time at which attacks of pyloric colic occur is fairly regular. In most cases the pain begins two to three hours after the midday meal; more rarely after the lapse of one to four hours. At this time the expulsion of the gastric con- tents through the narrowed pylorus, or an attempt at this, takes place. Gastric rigidity sets in and gurgling sounds are audible, while' gas is belched up and there are eructations of sour fluid. In short, in typical cases there appear the various manifes- tations of increased but ineffectual peristalsis. The attacks often last from two to three hours and are ordinarily terminated by the onset of copious vomit- ing. These afternoon attacks depending on the in- gestion of the midday meal are in many cases fol- lowed by nocturnal seizures that are regular in recurrence but do not exhibit a distinct connection with the evening meal and have a greater resem- blance to the more isolated and sporadic paroxysms of biliary colic. In some cases this nocturnal type even predominates. As in colic of other sorts the attacks are most likely to occur at about midnight, lasting several hours until copious vomiting relieves the tortured patient from his pain. TOPOGRAPHY. In regard to the situation of the pain I should like to consider especially the ten- 158 PAIN dency to radiation, which is also prominent, as is well known, in gall-bladder colic. This appears to depend in part on the degree of tension of the stomach wall. On the evacuation of gas by belching, there- is often abrupt cessation of the radiating pain ; for example, that passing into the back. Several types may be recognized from the topographical standpoint, but they all have a stenosis of the pylorus (cicatricial) as underlying cause. 1. Type of Pseudo- gall-stone Colic. The pain of the attack begins in the epigastrium or in the pyloric and gall-bladder region, and radiates into the right lumbar region and right shoulder. It accordingly simulates that of biliary colic, and error is to be avoided only by a careful analysis of the attendant circumstances, time of onset, etc. The difficulties may be still further increased in those fortunately rare cases in which pyloric ulceration through in- fection, secondary duodenal catarrh, or adhesions leads to lesions in the gall-bladder or gall passages, and therefore causes jaundice. 2. Type of Gall-stone Colic tvith Left-sided Pain. The pain begins on the left side of the epigastrium and radiates into the left lumbar region, left shoul- der, and possibly left breast. Owing to the left- sided position of the distended organ this type appears to be commoner than the preceding. 3. Type of Pseudo-girdle Pains. The pain be- gins exactly in the middle line of the epigastrium and extends in girdle form with equal intensity to each side to the back. It may also radiate retro- sternally and into both shoulder blades. DIGESTIVE SYSTEM 159 4. Type of Diagonal Radiation. The pain be- gins, for example, in the right half of the epigastrium in the immediate neighborhood of the gall-bladder, but radiates backward, especially into the left shoul- der. Such left-sided radiation is of value in differ- entiating the condition from the ordinarily right- sided biliary colic. MODIFYING FACTORS. In this connection mechani- cal factors are of great importance, particularly in regard to the position of maximum pain (cf. page 22). Lying on the right side is very likely to bring on the pain or to increase it if already present. Dur- ing the intervals between attacks this position is often well borne, however. I have already indicated my doubts in regard to the assumption that the ex- planation is to be found in a simple settling or dis- placement of the stomach contents on to the surface of the ulcer or the cicatricial tissues. This view is also opposed by the observation that in some cases of ulcerative cicatricial pyloric stenosis the right lateral position is well borne, but the left is accom- panied by nausea, belching, etc., so that the patients turn on the right side during the attack. Sometimes in the course of the disease a change in the position of maximum pain is observed so that for a time it may be the right and later the left side. It has been pointed out above that it is therefore much more rational to consider that the effect of position de- pends on kinking, traction, inflammatory adhesions, etc. The part played by the overdistention of the stomach in bringing on the attack is demonstrated 160 PAIN by the fact that the belching of gas and vomiting relieve or cut short the paroxysm. Many patients instinctively massage the distended epigastrium or they furnish a support to the anterior stomach wall by pressure with the fist, and in this way favor the evacuation of gas. It is often possible to demonstrate the presence of pyloric tenderness by percussion and deep palpa- tion. Frequently it is more or less limited to a point in the linea alba between the navel and the xiphoid process. Sometimes there is tenderness of the spinal column to percussion between the shoulder blades. The influence of diet manifests itself in the same way as spoken of under the heading of ulcer. It is hardly necessary to emphasize the fact that owing to the narrowing of the pylorus the ingestion of foods tending to produce distention or fermenta- tion is very likely to cause gastric meteorism, and that these are particularly to be avoided. The fol- owing articles are nearly always very badly borne: Potatoes, turnips, uncooked fruit, cabbage, smoked meat, and fatty foods in general, as well as pastries prepared with yeast, and alcoholic beverages, espe- cially sour wines. Foods that agree well are thick rice soup, spinach, potato puree, tea with milk, milk dishes, chopped ham, etc. The drinking of large quantities of fluid is always of untoward effect. In speaking of thermic stimuli I wish only to point out that in those cases of pyloric colic accom- panied by considerable distention of the stomach, DIGESTIVE SYSTEM 161 the application of cold, possibly through its tonic effect in encouraging contraction, seems to be more beneficial than the various warm applications ordi- narily used in attacks of colic. In some such cases I have seen heat not only unproductive of relief but the patients have even complained of increase in their sufferings. Internally, lukewarm drinks are to be recommended. What was said concerning the effect of the func- tions of other organs on the pain of ulcer is also ap- plicable here. The indication for careful regulation of the intestinal functions is the more important since the tendency to gastric meteorisin is evidently more pronounced than in cases of ulcer not accom- panied by stenosis. There is no doubt in regard to the effect of constipation in increasing pain. Psy- chical factors, such as overwork or excitement, fre- quently cause the attacks to recur at shorter intervals. Disregard of this fact might make con- fusion with functional conditions likely. DIFFERENTIAL DIAGNOSIS. The possibility of mis- taking pyloric colic for biliary colic is particularly great in those cases in which the characteristic evi- dences of pyloric stenosis, such as gastric rigidity, very copious vomiting, etc., are absent, or in which jaundice appears as a result of secondary duodenal catarrh. Sometimes, though fortunately rarely, the two conditions occur in combination. Some of the more important differential signs may be summar- ized in the following table: 11 162 PAIN PYLOBIC COLIC. Active borborygmi in the epi- gastrium. Distention, most marked below the left costal border. Acid eructations with heart burn; copious vomiting of strongly acid material that is not bile stained but con- tains sarcinae and possibly particles of old food. Eructations smelling of SH 2 . Copious vomiting or eructations of gas are followed by a marked diminution in pain. Usually no chill. The fasting stomach contains old food. Attacks are very numerous, often occurring daily for weeks and months. The pain tends to radiate to the left. The attacks regularly begin two to three hours after the midday (or largest) meal. Foods causing gas formation tend to increase the pain. Attacks of colic are sometimes brought on by lying on the right side. Local anaesthetics relieve the pain. BILTABY COLIC. Swelling in the gall-bladder region. Vomiting of bitter material that is bile stained and is not very great in amount. Vomiting has no noteworthy effect on the pain or it may even increase it. Often a chill followed by eleva- tion of temperature. Attacks are sporadic, frequently with intervals of several months. Tends to radiate to the right. Irregularity in time of onset, or a longer interval after eat- ing (about 5 hours). The nature of the food is of comparatively slight effect. The left lateral position is often badly borne and is accom- panied by a feeling of pain- ful traction on the right. Urine contains bilirubin or uro- bilinogen. Numerous as the differential signs are, it may in some cases be exceedingly difficult to distinguish be- tween these widely separated pathological condi- tions. On the one hand, there are cases of very slight DIGESTIVE SYSTEM 1C3 pyloric stenosis in which there is good compensation and the objective cardinal symptoms are absent or few, but in which, possibly in consequence of gen- eral irritability of the nervous system, the attacks of pain may be extremely severe ; while on the other hand cholelithiasis may be accompanied by symp- toms such as gastralgia, or pain due to-' adhesions between gall-bladder and duodenum, which arouse the suspicion of a pyloric stenosis due to ulceration. Finally, of course, the two conditions may coexist. Tuberculous Intestinal Ulceration. Ulcerative processes in the small intestine causing stenosis may give rise to error, particularly if the intestinal symptoms are not well marked. So in one case observed by the author which came to operation, the stools were normal, gastric symptoms, comprising dilatation with persistent splashing, vomiting, etc., were prominent, the effect of diet was as in pyloric stenosis, but the condition was one of very slight chronic intestinal stenosis due to tuberculous ulcera- tion. In this connection attention should be directed to pain in the lower abdomen, which generally does not occur in pyloric colic. On the other hand, I attach little diagnostic value to visible intestinal peristalsis of slight degree, particularly if the ab- dominal wall is relaxed and thin. I have frequently seen this at the acme of gastric peristalsis in un- doubted cases of pyloric stenosis, and regard it as being due to a sort of sympathetic activity. Further differential points may be found in the chapter on gastric ulcer. 164 PAIN GASTRIC CANCER. In view of the various anatomical lesions accom- panying the development of gastric carcinoma, such as pyloric stenosis, ulceration, perigastritis, meta- stases in the liver, retroperitoneal glands, etc., as well as direct extension to neighboring structures, it might well be expected that the course of the dis- ease would be accompanied by pain. As a matter of fact this is true in a certain number of cases, and the character of the pain as well as its modifying factors often indicate the manner of its causation. PAIN AS AN EARLY SYMPTOM. While pain not rarely begins very early, often at a time at which anorexia has not yet set in and the general condition is good, this is to be explained by the fact that in most such instances the growth has commenced very near the pylorus and is causing obstruction at that point. This stricture of the pyloric region, which at first is probably purely spasmodic, manifests itself in a series of subjective sensations which, according to the degree of stenosis and other circumstances, such as the motility and total acidity, closely re- semble those described in the section on pyloric colic. At any rate, these subjective sensations precede the objective evidences of pyloric stenosis, such as gas- tric rigidity, by a considerable period of time, and this very fact gives them a distinct importance. This spontaneous pain due to the early onset of pyloric stenosis may be contrasted with other arti- ficially evoked pains that indicate ulceration and are the result of the anatomical process (new growth DIGESTIVE SYSTEM 165 formation and ulceration) per se. We must there- fore- discuss : I. Pain due to the local process, which usually leads to pyloric stricture. II. Pain caused by the local invasion of other organs, or distant metastases. III. Pain resulting from inflammatory complica- tions, such as perigastritis and local or diffuse carcinomatous peritonitis. I. A priori it might be expected that the phe- nomena comprised under this heading would be iden- tical with those described in the section on pyloric stenosis which was devoted to the benign cicatricial stenosis. One would suppose that the malignancy of the ulcerative process would not alter the char- acter of the pain. In fact, there are cases of gastric carcinoma which during their entire course are ac- companied by just such painful phenomena, pecu- liarities of radiation, etc., as were described in the chapter referred to. In general, however, the inten- sity of the spontaneous attacks is less and the progress of the stenosis and increased activity of peristalsis are often accompanied by a marked de- crease in the pain, so that it may be said that be- nign pyloric stenosis is much more painful than the malignant form. The rather paradoxical-appearing fact that the malignant stenosis is exceeded in pain by the benign process is readily explained on more careful consideration. The mere decrease in appe- tite accompanying carcinoma causes dietary errors which are so often responsible for attacks of colic 166 PAIN in benign stenosis to be much rarer. In addition the musculature of the carcinomatous stomach early becomes atonic, whereas in ulcer it is more likely to be hypertonic, or at least in a condition of irritable weakness, which renders it easily excitable and prone to spasm. At the very beginning of the affection the pain in carcinoma may present great similarity to that of ulcer. While the appetite is still good, the dietary is not appropriately restricted, and therefore the early stages of a carcinoma are sometimes accom- panied by very intense pain. One of the most fre- quent initial symptoms of cancer of the stomach is a sensation of pressure in the epigastrium, usually occurring about half an hour after eating. Some- times this is simply a disagreeable, uncomfortable feeling, but in others it already has the quality of pain. The patients often speak of "a heaviness in the stomach." This sensation of fulness, tension, or pressure in the epigastrium, sometimes accompanied by " burning," appears to correspond to the first degree of commencing narrowing of the pylorus, and may be the result of a functional spasmodic stenosis, for at this time other objective symptoms of perma- nent organic stricture are usually absent. Some- times it is possible at the moment of appearance of this sensation, which frequentty lasts for only a short time, to detect a momentary air-cushion resist- ance in the epigastrium due to a wave of contraction of the organ. If the stenosis increases, stronger contractions striving to overcome the obstruction appear, and these are manifested to the patient as DIGESTIVE SYSTEM 167 pains of a knife-like boring and twisting character. Sometimes the sensation is described "as if a ball were rolling around." These are true colic pains and the spasmodic contraction in the epigastrium may become exceedingly violent; in such cases it is usually followed by vomiting. ACCOMPANYING SYMPTOMS. These variously graduated sensations, ranging from a simple feeling of pressure to colicky pain, may be accompanied by other manifestations also differing in intensity. The slight initial grades of stagnation and the sub- jective sensation of simple pressure, which often is not really painful, may be accompanied by eruc- tation of small quantities of acid fluid, frequently accompanied by heartburn, or there may be belch- ing of odorless gas; while in benign stenoses the gas has the odor of putrid eggs (SH 2 ). Copious vomiting, or indeed vomiting at all, does not usually occur during this initial stage of epigastric pressure after eating. It has already been pointed out that not infrequently advanced malignant stenoses ex- hibit a contrast between the intensity of the stenosis and the slightness of the pain, and an explanation for this has been offered. If a benign stenosis be- comes malignant an apparent improvement may re- sult, as the attacks of pain sometimes become less or cease entirely. It may also be mentioned that in malignant stenosis bile-stained, yellow-colored vomi- tus is more frequent than in cases of benign stricture, owing to the absence of marked pyloric spasm in the former condition. 168 PAIN The vomiting of a coffee-ground character, which occasionally accompanies the benign stenoses, has been mentioned above. In the stage of simple epi- gastric pressure, anorexia is not usually present. On the other hand, there is a certain amount of intol- erance for meat and solid food, especially cooked food, and, even earlier, intolerance for vegetables and for beer. Sluggishness of the bowels deserves to be mentioned as a symptom which is occasionally very early in its occurrence and is rarely absent in the later stages. Chemical and microscopical examinations of the stomach contents are rarely decisive during this initial stage of subjective symptoms. It is always well to note the presence of slight bulging of the epigastrium, especially in its left half, which repre- sents a rudimentary peristalsis and is present espe- cially after the taking of food. This symptom, of course, as well as the rigidity of the epigastrium which comes a little later, depends more or less upon the development and natural stiffness of the abdom- inal muscles. Occasionally the colicky pains occur two or three hours after meals. In other cases they show a de- cidedly nocturnal type (eleven o'clock at night, last- ing until about two A.M.). Frequently, however, they follow directly upon the taking of food. The feeling of heaviness, especially, occurs either imme- diately upon, or within a half hour after, the taking of food. Only in very rare cases are these pains postponed for a longer interval than six to seven hours after a large meal. DIGESTIVE SYSTEM 169 In regard to the abdominal regions involved, a great similarity with the previous conditions may be observed. In many cases, for instance, there is a definite relation between the posture of the patient and the pain. When the patient lies on the right side, there is commonly an increase of pain, abdom- inal bulging, and nausea. Here, as in the case of the pain accompanying pyloric stenosis, the suffering is immediately ameliorated by the belching of gas and by vomiting. In every respect where the mechanical agencies are involved the analogy of this condition with pyloric stenosis is so close that the subject can be dismissed by referring to the chapter on pyloric stenosis. There is a marked similarity also in regard to the influence of diet upon the pain. The sensations of pressure and of hunger which so frequently occur in neuroses of the stomach, in which the pain is alleviated by the taking of food, occur but rarely in this condition. It is an almost invariable rule that food increases or begins the pain, and in this respect the quality of the food plays a very important role, the most troublesome articles of food being boiled beef, heavy vegetables, rye bread, and fluids of all kinds, especially beer and acid wines. We have still to consider th'e localization of the pain, and in this connection we must differentiate between (a) Subjective pains, and (b) Objective pains produced by pressure and percussion. 170 PAIN (a) Subjective Pains. The pain is usually pro- jected forward into the epigastrium. More rarely it is situated retrosternally under the lower half of the sternum. In the epigastrium there may be vari- ations in the position of the pain just as in gastric ulcer. In some cases the left side of the epigastrium becomes the most painful area; in other cases the mid-line is the seat of greatest pain; and, again, in other cases, the suffering is chiefly localized over the pyloric region. The subjective pain may remain localized here, or, just as in benign stenoses, it may radiate especially into the loins and back, toward the hypochondriac regions, and occasionally even into the shoulder blades. The pain which occa- sionally is noticed as radiating up behind the ster- num into the throat is usually accompanied by re- gurgitations of the acid stomach contents, and may easily be controlled by small doses of alkalies. Those pains in the back which are produced by a pyloric stenosis and secondary dilatation of the stomach as such, and not by metastases, are in direct proportion to the epigastric pains, are in- creased and decreased with these, and are simply backward radiations of these pains. Their appear- ance seems to be favored by constipation and they disappear with thorough emptying of the bowels. Such pains may occasionally be produced when the stomach is artificially inflated, a fact which may be regarded as important in clearing up the mechanism of such sensations. DIGESTIVE SYSTEM 171 (b) Objective Pains. Not infrequently it is pos- sible to map out by palpation, and occasionally even by percussion, a definite hyperaesthetic zone in the epigastrium, which frequently corresponds to the position of the tumor. In those cases where a tumor is impalpable on account of its small size or of great muscular development of the epigastrium, the local- ization of such a hyperaesthetic area may, if cau- tiously interpreted, give much diagnostic aid. If such a zone be placed asymmetrically on the left or right side below the costal border, it will be more worthy of notice than if placed mesially. As in gastric ulcer, the vertebral column in its interscapular and dorsolumbar regions, as well as in the left lumbar region, is frequently painful to percussion. II. Following the classification proposed above, we are now about to deal with those painful sensa- tions which depend upon local extension of the proc- ess as well as upon metastases into other regions. These are, of course, of much less importance, since we are no longer dealing with early symptoms ; on the other hand, they will find further mention when we reach the discussion of organic pains of other regions (hepatalgia, etc.). These pains, in contradistinction to those dealt with above, are differentiated in general by their per- sistence and by their independence from digestive influences, so that even when localized in the epigas- trium (metastases into the liver, pancreas, and glands), they are easily separated from the pains previously described. 172 PAIN III. Tnfla.TnTna.tory complications are often the basis for the pains occurring with gastric carcinoma ; these may be more or less local, as in fibrinous or purulent perigastritis, or diffuse, as in carcino- matous peritonitis. The new growth itself does not seem to be par- ticularly sensitive to pressure. In cases where a more severe sensitiveness to pressure exists, we are usually dealing with a superimposed inflammatory process in the ulcerated tumor mass. A localized peritonitis may occasionally be evidenced by a noticeable leather-like creaking brought out by pal- pation. The motion of the tumor mass in such cases produces pain by rubbing against the inflamed por- tions of the peritoneum. This may be brought about by coughing, bending forward, pressure during defe- cation, deep breathing, etc. Eapid changes of position also (from the dorsal position to the right or left) may in the same way, by producing sudden motion of the tumor, give rise to local pain. Whenever the perigastric process extends, giving rise to subphrenic abscesses or to pleurisy, which seems to occur usually on the left side, pain will occur, on this side in the lower inter- costal spaces, in addition to the epigastric pain. But in cases where the peritoneum, as a whole, is involved in the carcinomatous process inflamma- tory changes usually take place and give rise subjec- tively to general abdominal tenderness, and to a painful sensation of general distention. DIGESTIVE SYSTEM 173 The pain which depends upon peritoneal involve- ment may frequently be influenced by local treatment (sapo kalinus, tincture of iodine, alcoholic com- presses, etc.) ; on the other hand, lavage, which fre- quently relieves pains due to stagnation in the stomach and overdistention of its walls, increases the pain when we are dealing with a perigastric con- dition, in that it is contrary to the first principle of treatment in inflammatory processes, i.e., immo- bilization. It is only after a careful consideration of all the elements involved, and a careful physical examina- tion, that we can reach the conclusion that certain pains are due to the development of a gastric carci- noma. Of the most practical importance are the epigastric sensations which have been described un- der I., and which appear at a time when other symp- toms, such as anorexia, progressive emaciation, achlorhydria, etc., are still absent, and the patient is as yet unaware of any severe illness. In this connection all those conditions which have been mentioned under gastric ulcer and pyloric stenosis must again be considered in making the differential diagnosis. The greatest difficulty will be encountered in the exclusion of gastric ulcer, both in its development and in its recurrence. Suspicions of carcinoma will be strengthened when the general symptoms of gastric ulcer and anorexia persist, in spite of rest in bed and regulation of the diet. Diffi- culty may occasionally be experienced in separating carcinoma of the stomach from the dyspepsia which 174 PAIN accompanies cases of chronic tuberculosis. This may occur with but slight involvement of the lungs and may give rise to such extreme anorexia and progressive emaciation that the suspicion of early carcinoma is aroused. These cases, however, are rarely accompanied by the attacks of spontaneous epigastric pains which characterize gastric carci- noma. Even in tuberculosis it is not rare to find epigastric tenderness, and this is easily explained by oversensitiveness at the points of insertion of the rectus muscle, produced by severe paroxysms of coughing. INTESTINAL ULCERATION. Ulcerations of the gut give rise to more or less characteristic phenomena of pain, though they do this less regularly than do ulcerations of the stomach. Tuberculous ulcerations are the most fre- quent, and they may be taken as an example of intense intestinal ulcerative and obstructive condi- tions throughout. Tuberculous ulcerations, how- ever, give rise to attacks of pain more characteristic than those arising from other intestinal ulcers (for instance, those of typhoid and dysentery). The ex- planation for this may be easily found in the fact that they have a greater tendency to produce ste- nosis, and that during their existence the pain is less definitely under dietetic control than is gener- ally the case in typhoid and dysentery. Similarly to gastric ulcers, the tuberculous ulcera- tions of the gut may remain entirely latent. This, DIGESTIVE SYSTEM 175 however, is not frequently the case. The production of stenosis is here, as in conditions of the stomach, one of the chief causes of pain; added to this, of course, are the conditions of enteritis, abnormal fer- mentation, and the peritoneal lesions produced by perienteritis. The pain accompanying stenoses is closely analo- gous to the colic resulting from pyloric stenosis. Even the localization of the pain is occasionally very similar, so that the patient when consulting the physician describes it as epigastric. Spontaneous pains frequently begin in the epigastrium. Badia- tion, in these cases, towards the ileocaecal region is of considerable importance, since such radiation is very uncommon in gastric conditions. This may be due to the anatomical position of the lesion, since the ileocaecal region is involved with special frequency. Pain is noticed in the umbilical region rather more frequently than in the epigastric ; here it may occur to the right or left of the mid-line, and may extend to both sides, encircling the body. The most common seat of the pain, however, is the hypogastric region, and here it occurs especially in the right side. The pain is usually projected forward ; it rarely is localized in the back ; but when it is, the posterior pain is always accompanied by the anterior pain, and is directly dependent upon the taking of food. The objective pains produced by pressure or per- cussion generally correspond, in localization, with the subjective ones; therefore the ileocaecal region 176 PAIN is almost always sensitive. This is likewise true of the hypogastrium, especially when there is dis- tention. There is frequently a well-localized pain- ful zone in the neighborhood of the umbilicus which, especially if situated above the umbilicus, gives rise to a suspicion of gastric ulcer. In such cases it is important to determine whether or not this area of pain is situated above or below the major curvature of the stomach. The time of occurrence of the pain is, in many cases, in direct relation to the taking of food. This is especially noticeable in connection with the large meal in the middle of the day, which is followed, with more or less regularity, within one half to one hour, by attacks of pain which may last for several hours. While the length of this interval between the meal and the onset of pain varies greatly in dif- ferent individuals, there is great constancy in the duration of the interval in the same individual, in that attacks occur in one case with great regularity in from three to four hours, in other cases in from six to seven hours after meals. Whenever a very short time elapses between the meals and the appearance of the pain, we are undoubtedly dealing with a stimula- tion of intestinal peristalsis produced by the food still remaining in the stomach; and it is this peri- stalsis which produces the pains in the ulcerated area. It is important to note that patients with this form of intestinal ulceration may experience entire freedom from pain during intervals often lasting for months. As the disease progresses, these free in- DIGESTIVE SYSTEM 177 tervals become shorter and shorter, until the attacks are of daily occurrence ; this is due, of course, to the constantly increasing stenosis. Mechanical Considerations. Since the condition is most frequently localized in the ileocascal region, the pain is usually most severe in this region. Thus the patients, when lying on the left side, complain of feeling as though something were being drawn from the ileocsecal region into the left side, while when lying on the right side the pain is directly localized in this region. In general, the position on the left side is less painful than that on the right. This is undoubtedly due to the traction brought about by the weight of the diseased gut and of the involved glands, a traction which is the more painful because peritoneal inflammations and adhesions are com- paratively frequent. The condition may be confused with cases of acute and chronic appendicitis where the same pecu- liarities as to the relation of pain and position are present. This error is more easily made because in both of these conditions the patient will be re- lieved by flexion of the right leg at the hip through relaxation of the abdominal muscles during the attacks. The pain which is elicited in circumscribed areas, especially the hypogastric and umbilical regions, by jarring of the body, as in coughing, walking down- stairs, rapid turning and deep inspiration, is easily explained by the correspondingly localized inflam- matory processes in the peritoneum, 12 178 PAIN A number of other minor symptoms unquestion- ably depend upon the fact that the intestinal pain is frequently accompanied by local or general dis- tention. Thus the patients, during their attacks, rub the hypogastrium, place their hands upon their hips and turn the trunk upon the pelvis in an in- stinctive attempt to cause a general distribution of the local distention. The same fact explains the relief produced by enemata, by vomiting, or by the discharge of gas per os or per anum, all of which bring about a relief of the distended intestinal wall. The influence of the diet upon the pain is depen- dent upon this very question of distention; and the same conditions which we considered in speaking of gastric ulcer and of pyloric stenosis must be taken into account here. In the first place, those articles of diet which give rise to fermentation will cause pain. Chief among these are cabbage, turnips, len- tils, potatoes, pastries prepared with yeast, rye bread, beer, not infrequently milk, and furthermore all those articles of diet which are apt to constipate. Great pain can be produced by those articles of diet which produce active peristalsis when present in the stomach; this probably explains the attacks of pain which regularly occur a few minutes after the ingestion of ccld beverages (water, milk), strong coffee, and certain drugs, as thiocol; on the other hand, these very articles which stimulate peristalsis may aid in relieving local distention and thus have the opposite effect. Direct chemical irritation of the ulcerated areas probably occurs very rarely; DIGESTIVE SYSTEM 179 but if it does occur this may explain the production of pain by very acid food such as salad. More fre- quently mechanical injury may be caused by the ingestion of solid food, especially raw fruit ; so that in general a fluid or semi-solid diet is to be preferred. It is self-evident that the quantity of food intro- duced may, by its filling of the intestine, become a serious consideration in the production of pain. Just as the introduction of cold substances may produce pain by their active stimulation of peri- stalsis, so also thermic influences brought to bear from without may play a similar role. Chilling of the feet seems to have special in- fluence in initiating attacks of pain. Thus attacks may be brought on by walking upon a cold floor with bare feet. This is, in general, a peculiarity of pains due to intestinal peristalsis and may have a certain amount of differential value. Applications of cold compresses to the abdomen, in that they relieve dis- tention, usually have a favorable influence; while the application of heat often increases the pain. The secondary symptoms are especially impor- tant because they so frequently give rise to errors in diagnosis. The importance of this fact is well illustrated by those cases of tuberculous ulceration which are accompanied by gastric symptoms, vomiting and belching. The vomiting is often in large quantities, and in the vomitus there are frequently particles of food which have been ingested several days be- fore. In these cases we are unquestionably dealing 180 PAIN with stagnation in the stomach, secondary to the ob- struction in the gut. The very facts that the vomit- ing is copious, that the microscopical examination points to stagnation, and that the clinical signs obtained on palpation indicate moderate dilatation, may give rise to the erroneous diagnosis of pyloric stenosis. This error may be more easily made since the pain in these cases is often localized in the epi- gastrium, and occasionally there may be an entire absence of symptoms referable to the intestines, such as diarrhoea, or even irregularity of the bowels. We have already pointed out the great similarity which may exist between the two conditions in re- gard to the influence exerted upon the pains by the diet. In doubtful cases it is particularly important to remember that, in contrast with pyloric stenosis, the vomitus frequently contains bile, and the pains are radiated either into the hypogastrium, or, more frequently, into the ileocsecal region. The discovery of sarcinae in the vomitus is pretty positive indica- tion of the gastric nature of the condition. Diarrhoea, especially the very foul variety which occasionally accompanies tuberculous ulcerations, is almost unknown in cases of pyloric stenosis. These are almost invariably accompanied by constipation.. For this reason, too, the succussion noticed occasion- ally in cases of tuberculous ulceration is extremely rare in pyloric stenosis. Withal it must not be for- gotten that both conditions may occasionally be pres- ent at the same time. DIGESTIVE SYSTEM 181 It is sometimes extremely difficult to distinguish the condition under consideration from acute or chronic appendicular inflammations. This is true particularly because the point of maximum tender- ness may often be located in the right ileocaecal re- gion, and parsBsthetic sensations may occur on the inner surface of the right thigh. Flexion of the right leg at the hip during the attacks and slight distention of the right ileocaecal region aid in confus- ing the picture. Occasionally bladder symptoms are present, due to pressure of the full bladder upon the inflamed parts. Great help can be derived in such a confusion of evidence from a positive diazo reaction ; in contrast to appendicitis, too, ulcerations of the gut even dur- ing the colicky attacks may be entirely free from temperature. Added to this we may have a previous history of long-continued symptoms of slight intes- tinal obstruction and the general evidences which point to tuberculous trouble, night-sweats, pul- monary symptoms, etc. In those cases in which the stenosis is slight, vis- ible peristalsis is often limited, and is noticeable par- ticularly in the ileocsecal region and in the immediate neighborhood of the umbilicus. The peristalsis is often accompanied by crackling sounds produced by the passage of gas through the stenosis, which is fol- lowed by relief from pain as the pressure upon the overdistended gut is diminished. While occasion- ally slight chilly feelings, or in severe cases even col- lapse, may occur in this condition, a true shaking chill is extremely rare. 182 PAIN It would be impossible to review all the condi- tions which make a differential diagnosis in this con- dition difficult. It is, however, advisable to be sus- picious of tuberculous ulceration of the gut in all those cases of abdominal pains of colicky nature in which there are any other factors in the history or in the physical examination which point to a tubercu- lous tendency in the patient. DISEASES OF THE APPENDIX. It is not wise to speak in a vague way of ' ' appen- dicular colic." The acute or chronic inflammatory conditions of the appendix originate from a variety of causes, and it is necessary to understand clearly the pathological basis of the pains which occur in each of these conditions in order to draw diagnostic conclusions from them. It is generally assumed that the colicky pains in appendicular conditions are primarily due to the intra-appendicular pressure of inflammatory exudates, which cause contractions of the musculature, and a condition not unlike neural- gia. This is an assumption which has much in its favor and cannot be dismissed lightly. This explan- ation of the pains, however, is entirely insufficient for the more chronic conditions where the appendix is well imbedded in the surrounding inflammatory thickenings. Here, of course, distention of its lumen and contraction of its muscular walls are quite out of the question. I should like to suggest that it is quite possible that many of these so-called cases of appendicular colic are nothing more than a DIGESTIVE SYSTEM 183 simple intestinal colic reflexly initiated in the appen- dix. In these cases intestinal inflammations seem frequently to have preceded, the attack of appendi- citis occurring during an acute exacerbation of these. This assumption would be supported by the frequency with which the parasitic flora of the feces is changed from the normal in cases of appen- dicitis, and would explain the previous diarrhoeas which often are present during the early develop- ment of appendicitis. Comparison of the pains in appendicitis with those in tuberculous ulceration of the intestine shows many points of similarity. Distinction be- tween the conditions would be almost impossible, as far as the pains themselves are concerned, were it not that in contrast to the intestinal pains of other diseases, in appendicitis we have added the pains due to peritoneal inflammation, and from this a number of important differential symptoms can be deduced. The early pains of appendicitis rarely corre- spond in localization to the position of the appendix. Usually the pains begin diffusely in the umbilical and hypogastric regions, occasionally in the epigas- trium, and differ in nothing from the pains of ordi- nary intestinal colic following errors of diet, or acute gastro-enteritis. The suspicion of appendi- citis at this stage is not aroused by the character of the pains but depends upon the secondary symptoms, such as temperature, etc., and the absolute absence of the usual causative agents of intestinal colic. It 184 PAIN is only the rare cases which begin with a localized pain over the appendix, or even with a distinctly right-sided pain. Occasionally, there may appear radiations of the pain into the right inguinal or lumbar regions, and this seems to depend upon a retrocaecal position of the appendix. It is extremely important in these cases to determine whether or not there is radiation into the right thigh. This is not often found, but when present may be regarded as characteristic of true appendicular colic, since it never occurs in the ordinary pains of intes- tinal peristalsis. The more irregularly localized pains which occur in this condition are probably never entirely of appendicular origin. In contrast to them, however, we have pains which are due to the localized peritonitis or peri-appendicitis, and these are situated more exactly over the position of the appendix. Extension of such processes and the formation of abscesses will lead to pressure pains in the right inguinal region, as well as to extreme tenderness upon rectal examination (abscess in the pouch of Douglas). These local peritonitic pains are very sharply denned, and are of extreme im- portance in differential diagnosis. There are three principal elements which under- lie the causation of pain in such conditions, which will have to be discussed in greater detail. 1. PRESSURE. There is, almost invariably, pain upon pressure in the ileocsecal region corresponding to the location of the disease. This pain is subject to wide variations in intensity. It is usually great- DIGESTIVE SYSTEM 185 est during the stage of abscess formation, when the abscess wall is subject to great distention. In such cases the slightest pressure, even the weight of the bed-clothes, will be marked by extreme agony. Pain upon pressure may occasionally exist in the right flank as well, especially in cases where abscess formation occurs retrocsecally. When the tender- ness is situated high up under the right costal bor- der, it is probable that the pain is chiefly of peri- toneal origin. It has frequently come to my notice, however, that when the bowels have been freely moved by an enema (for instance, five grams of glyc- erin) the sensitiveness diminishes immediately upon reduction of the distention. This indicates unques- tionably that the pressure of the distended intes- tinal walls upon their inflamed serous coverings may play an important role in the mechanism of these pains; this may also explain those less fre- quent cases in which the sensitiveness to pressure is greater over the left half of the abdomen above Poupart's ligament, than on the right, intestinal distention being more intense on that side. When the appendix itself is pressed upon, radiation of the pain often occurs towards the epigastrium and into the left hypogastrium. We have already considered the more or less traumatic pains produced by examination. Spon- taneous movements of the patient produce pain in the same way, especially contraction of the abdom- inal and pelvic muscles. Thus the first pains fre- quently occur in the ileocaecal region when the 186 PAIN patient stoops, sits down, sits up in bed, lifts a weight, or bends the body back upon the hips. Sometimes even the lifting of the head when in the prone position will give rise to pain. More particu- larly, however, pain is caused by contracture of the right ileopsoas (produced by the bending of the right leg upon the hip). This motion gives rise to pain in the ileocascal region, especially severe when the abdominal muscles are contracted. The pains, therefore, would be greater when, the patient is standing, walking, or climbing stairs than when he is lying down, for in these positions the diseased tissues are compressed between the contracting ileo- psoas and the contracting abdominal wall. It is important to remember this when testing pain on flexion of the right leg, for even during the exist- ence of an appendicitis such motion of the right leg when the patient is lying down may be entirely with- out pain, while the same motion may be very painful when the patient is standing or walking. Thus this symptom of hip flexion is entirely dependent upon the position of the body. In some cases it can be elicited only when the patient is lying on his left side. The first indication of appendicular pain has often occurred during the drawing on of shoes, and here again it is unquestionably a pressure pain, since the patient in carrying out this motion lifts the right leg and produces a contraction of the corresponding pelvic muscles. While this symptom is apparently trivial, it is so frequently the first indication of early appendicular trouble that it may become extremely important in differential diagnosis. DIGESTIVE SYSTEM 187 In some cases of early appendicitis the pain is markedly increased when the patient is lying on the right side, and this again is due to pressure upon the inflamed parts. Because of the pain caused by these muscular contractions, the patient involuntarily re- laxes these muscles and thus many patients with appendicitis bend forward when walking or bend toward the right side, or, when lying down, draw up the right thigh and arouse by their very position the suspicion of appendicitis. 2. JARRING. For diagnostic purposes the most practical way of producing jarring of the abdomen in the ileocaecal region is by percussion. With its help a very exact demarcation of the area of pain can be made, and it is much to be preferred for this purpose to simple palpation. The pathological basis of pain produced by jarring is probably the same as that of the pressure pains. Percussion in the mid-line is often more painful than on either side of the line be- cause of the absence in this location of muscular defenses. Other forces which actively cause jarring of the abdomen are coughing, stepping on the right leg in going downstairs, jumping, etc. In all these cases pains are produced in the appendicular region which are of a sharp, boring nature. This method of pain production is frequently possible before other symptoms have occurred. 3. DISPLACEMENT. Under this heading we will consider chiefly those tearing pains which are pro- duced in certain positions of the body by the weight of the diseased organs. It is not surprising that the 188 PAIN slightest displacement of this kind should cause pain when we consider that we are dealing with fresh in- flammatory adhesions. This must be our interpre- tation of the pains complained of by patients who are unable to lie upon the left side, and who inform us that, in this position, they feel a painful drawing as though something were falling from the right to the left side. When the peritoneal process has ex- tended into the left side the same variety of pain may be caused by the right-sided position. It is clear that such pains must be primarily influenced by two factors : (1) The closeness with which the abdominal organs are held together. For instance, when the abdominal muscles are flabby and weak, and the viscera are in consequence very loosely packed to- gether, even the slightest change of position will give rise to displacement. (2) The formation of a tumor in the ileocaecal region, either in the form of exudate or of enlarged glands. When the patient is lying on the left side the weight of the tumor mass will exert considerable traction, a traction which may, however, be exerted by the weight of the intestinal contents themselves. The pains described in the foregoing paragraphs are all referable to the localized peritoneal inflam- mation. The general intestinal pains which are added to those of more purely appendicular origin are difficult of interpretation. It is not easy to say whether the basis of these lies in the appendix itself, DIGESTIVE SYSTEM 189 or whether they are to be regarded as an accompany- ing intestinal colic. The localization of these colicky pains aids us but little in determining this. At any rate, it seems wise to restrict the term " appendicular colic ' ' to those cases only in which, with other symp- toms of appendicitis, sudden colicky pains occur spontaneously without previous reference to pre- vious dietetic errors or other causes. More frequently, however, the beginning of the colicky attacks is directly dependent upon intestinal disorders, especially those following errors in diet, and it would be hard to understand how such influ- ences could affect the appendix itself. The fact that diarrhoea frequently occurs in these cases points to the likelihood that we are often dealing with an acute or an exacerbated chronic enteritis in the course of which changes in the appendix and its peritoneal sur- roundings may occur. The diarrhoea is of great differential importance since it occurs frequently in early appendicitis, whereas constipation is the rule in cases of lead colic, gall-bladder colic, and the pains of pyloric disease and diseases of the ureters. This is likewise true of most of the gastric pains (ulcer and hyper- chlorhydria) which may in other respects have a superficial similarity to appendicitis. In differen- tiating the condition from the ordinary acute inflam- mations of the small and large intestines, our most important aid lies in the localized peritoneal pains which have been spoken of above; of special impor- tance is the hip-flexion symptom. Help may be de- 190 PAIN rived from the bladder symptoms, which aid us in determining the existence of a local peritonitis. These often consist of pains during micturition; strong pressure is required to expel the urine, and occasionally retention of urine occurs. In differentiating the intestinal pains produced by the ingestion of irritating substances or by flatus, we are aided particularly by the temperature. Occasionally errors are made in cases where for- eign bodies, introduced per os or per anum, give rise to a suspicion of appendicitis, the similarity being more marked because of the increased temperature. It is often extremely difficult to differentiate appen- dicular pains from those produced in inflammatory diseases of the female genitals (parametrium, tubes, and ovaries) ; this is especially true because often disease of the adnexa and appendicitis occur to- gether. In such cases only a very exact analysis of the pains will lead to a correct interpretation. The pains of peritoneal origin in both of these conditions show great similarity. In a general way, however, the symmetrically bilateral location of the pain, and the deeper, pelvic position of the tender- ness will point more directly to parametritis than to appendicitis. The influence of menstruation upon the pains must be carefully considered, without for- getting that it is not rare for adhesions to have formed between the appendix and chronically in- flamed ovaries, and that the existence of a parame- tritis by no means excludes the existence of an appendicitis. DIGESTIVE SYSTEM 191 Furthermore, in differentiating between these two conditions we can be guided by the fact that enteric pains are almost never present in diseases of the genitalia, and that the diet is entirely without influence upon the pain. Appendicular colic may occasionally be simulated by right-sided ectopic pregnancy. During rupture, pain occurs which radiates into the right thigh and is accompanied by collapse and sensitiveness of the abdomen. The absence of temperature, however, the presence of acute anasmia, and occasionally bleed- ing from the genitals, with a previous history of pregnancy, and the discovery of a periuterine tumor, lead us in the right direction. Occasionally we will have to consider in the dif- ferential diagnosis torsion of a right-sided ovarian cyst, hydrosalpinx, etc. In women, too, in the ab- sence of fever and leucocytosis, it is necessary to search carefully for signs of hysteria, especially in the abdominal regions (viz., analgesia of the umbili- cal region). It is absolutely necessary, however, to analyze carefully the various factors which influence the pain in these cases, for, unquestionably, a true appendicitis may occur in an hysterical individual. When we consider that the appendicular pains are distinctly due to two components, on the one hand a local peritonitis, on the other hand a colic, it is plain that other inflammatory processes occurring in the ileocaecal region may give rise to the same symptom complex, chief among these being tuber- culous, actinomycetic, and malignant processes. 192 PAIN Similarly localized tenderness may occasionally occur in diseases of the kidney and gall-bladder, in psoas abscesses, in right-sided pleurisy, and in pneumonia. LEAD COLIC. When sudden attacks of colic occur in an anaemic individual who gives a history of dyspepsia, ano- rexia and constipation, and when these attacks are localized in the epigastrium and are accompanied by retraction and rigidity of the abdominal walls, our first thought must be of chronic lead poisoning. On the other hand, it would be hasty to conclude from the coincidence of colicky pains and the signs of chronic plumbism that we are necessarily dealing with a neuralgia of the mesenteric plexus due to lead. Occasionally, other toxic conditions must be consid- ered, to which patients with lead poisoning are par- ticularly predisposed. Chief among these is nico- tine poisoning. It is not rare, also, to find tubercu- losis in individuals with lead poisoning, and in such cases we may well be dealing with tuberculous ulcer- ations. Again, ulcerative processes in the stomach and duodenum are not infrequent during the course of lead poisoning, and may be especially favored by the condition of the vessels and by a tendency to spastic contraction in the stomach and intestinal canal. Furthermore, I should like to call attention to the fact that in cases of chronic lead poisoning there is sensitiveness to pressure in the region of the appendix, and for this reason also the question of appendicitis must be considered. It goes without DIGESTIVE SYSTEM 193 saying, furthermore, that chronic lead poisoning does not protect against the colics of gall-stones and renal calculi. It becomes necessary, therefore, in each case, to consider carefully the individual symp- toms and to analyze the pains as they occur. In regard to the factors modifying the pains we can assume that, because of the nervous origin of the disease, dietetic influences do not come under consideration; and, as a matter of fact, this con- clusion is justified by actual fact. The pains in this condition are independent of dietetic influences. This is in contrast to the state of affairs found in the case of most intestinal pains (tuberculous ulcera- tions and stenosis of the gut) and therefore is of the greatest differential importance. It would, how- ever, be silly to expect that the hyperaesthetic gut of chronic lead poisoning may not react forcibly to errors of diet, and all those articles of food which cause much flatus may in these cases give rise to true colic. This, of course, would not represent a true case of lead colic, but would simply consist of a colica flatulenta favored by the existing lead poison- ing. It is probable that in a great many cases of so-called lead colic the pains are caused by the pres- ence of stagnated fecal material and abnormal quan- tities of gas, and thus are explained the frequent prompt results gained therapeutically by high ene- mata, and the observation frequently made by patients that the passage of gas immediately relieves the colic; in some cases, too, relief may be experi- enced from vomiting. 13 194 PAIN Excessive use of tobacco is unquestionably an important factor in the initiation and increase of the colicky pains, a consideration which is worthy of notice therapeutically. Alcohol in concentrated forms, such as brandy, in many cases causes diminu- tion of the pains. Mechanical agencies, because of the neuropathological basis of the pains, have little influence. Changes of position do not influence the pain in these cases as they do in ulcerative processes or in the localized peritoneal inflammations. It is fre- quently claimed that pressure upon the abdomen is not painful in cases of lead colic, but on the contrary often relieves pain. This is true in a great many instances, but cannot be regarded as a rule. Pain on pressure may frequently be due to the fact that there exists a severe neurasthenia which is accom- panied by general hyperaesthesia. In those cases where gas collects, locally or diffusely, in the intes- tinal tract during the attacks, it is perfectly natural that there should be a certain amount of tenderness to pressure over the distended intestinal coils. The sensitiveness of the abdomen to pressure, therefore, can give us little help in differentiating this condi- tion from the peritoneal processes. Flexion of the thighs upon the abdomen frequently gives relief; but it is important to notice whether both thighs are flexed or whether the right thigh simply, as would be the case in appendicitis or in the tuberculous ulcerations of the intestine. The application of heat usually influences the colic favorably. The application of cold often ini- DIGESTIVE SYSTEM 195 tiates an attack. Emotional excitement may fre- quently give rise to a severe attack of pain. The pains, which are chiefly of a sharp, boring or cutting character, and which are almost invariably paroxysmal, are located principally about the um- bilicus. Occasionally, however, they occur in the epigastrium. When the attack is at its height it is hard to refer the pains to any particular region, and they may cover the abdomen diffusely. The pain is as a rule limited to the abdominal region and only in the rarest cases radiates into the sternum, the chest and the shoulders. On the other hand, pain frequently occurs in the lumbar region, and may radiate into the genitals or bilaterally into the thighs (lead colic of the ureters). There is no radiation into the ileocaecal region, as is so frequently the case in tuberculous ulcerations. This region, however, and occasionally the region of the sigmoid flexure are often quite sensitive to pressure. This can be easily explained by the fact that in these two regions especially there is apt to be stagnation of the feces which, with slight inflammatory changes, leads nat- urally to tenderness. As far as the time of occurrence of these pains is concerned we are able to gather no facts of differ- ential importance. The very irregularity of the at- tacks, which often show prolonged intervals between separate seizures, should give us some clew. Attacks occur more frequently during the night than during the day ; but this peculiarity is common to all varie- ties of abdominal colic. 196 PAIN The most important of the secondary symptoms which accompany the colicky attacks are the follow- ing: Nausea and vomiting, often an absolute intol- erance for solid or fluid food, constipation preceding the attack, sometimes with tenesmus, usually with retraction of the abdominal wall. Visible peristalsis and succussion are rarely present, and are found only in those cases where the constipation is of a very chronic order and where the abdominal walls are extremely flabby. There are practically no alarming general symptoms. The diagnosis, of course, will be much strengthened by the discovery of other symptoms of chronic lead poisoning, such as a lead line, weakness of the muscles supplied by the radical nerve, and high blood pressure. The high blood pressure itself is by no means constant in these cases, since it may even be diminished in cases where the anaemia is severe or where tubercu- losis exists as a complication. There are other conditions which, resting on a purely neuropathological basis, may also produce gastro-intestinal colic, and from these we must occa- sionally differentiate lead colic. Chief among these, of course, would be the intestinal crises of tabes, and hi such cases the nervous system must be care- fully examined in order to make the differentiation. Ulcerations of the gut with stenosis may give rise to difficulty in diagnosis. Lead colic is ex- cluded in such cases by the close relation of the pains to the taking of food, their constancy, and their definite variation upon changes of position. The DIGESTIVE SYSTEM 197 discovery of sarcinae in the vomitus or in the feces during an attack would point quite distinctly to the existence of pyloric stenosis. In distinguishing lead colic from appendicitis and peritonitis, our chief strongholds are the afebrile course and the absence of a leucocytosis. These two conditions carry with them also voluntary immo- bilization of the abdomen and the patient usually assumes a supine position, whereas in lead colic the constant restlessness is characteristic, and the patient may walk about or remain in a sitting posi- tion, pressing his hands upon his abdomen. The indifference of the patient to mechanical disturb- ances of the abdomen is quite characteristic and helps very much in differentiating lead colic from other conditions. This aid is lost, however, in those cases mentioned above of neurasthenic patients, who occasionally show abdominal sensitiveness. In closing, it is necessary to call attention again to the fact that, even when chronic lead poisoning can be definitely diagnosed, the possibility of a com- plicating gastric ulcer or renal calculus must not be overlooked. MALIGNANT NEW GROWTHS OF THE INTESTINE. There is nothing absolutely characteristic about the pains occurring in the conditions we are about to discuss. They may be caused by organic changes and mechanical stenosis of the gut, and the disten- tion and increased peristalsis dependent upon these. Or, again, their pathological basis may rest chiefly 198 PAIN upon peritoneal involvement. The pains are impor- tant, nevertheless, from a diagnostic point of view, in that they frequently occur during the very early stage of the condition when other physical signs are entirely lacking. These pains are frequently regarded as harmless manifestations of intestinal indigestion such as fol- low errors in diet or exposure to cold, and yet if the phenomena of the pains are carefully analyzed we may often find distinct reasons for believing that there is a well-localized cause for the attacks. Whenever this can be accomplished an important diagnostic advance has been made. Corresponding with the localized process from which they arise, there is a tendency in such cases towards a localization of the pains. This is par- ticularly true of the neoplasms of the large intestine where frequently, at the very beginning of the at- tacks, the pain is felt in the seat of the lesion, and, in consequence, usually occurs in the cascum or in the three flexures of the large gut. At the height of such an attack the pain is generally diffuse, but centers chiefly in the region of the umbilicus, and is fre- quently accompanied by pain in the lumbar regions. Whenever the obstructing process lies in the neigh- borhood of the splenic flexure there may be distinct radiation into the lower half of the thorax and occa- sionally, though rarely, into the left leg (one case of hysteria). When the neoplasm occurs in the hepatic flexure the condition may strikingly simulate gall-bladder colic. The pains begin in the neighbor- DIGESTIVE SYSTEM 199 hood of the gall-bladder, radiate backwards into the small of the back, and frequently reach even to the right shoulder blade. Radiation towards the anus is a phenomenon of extreme importance, for it indicates most frequently a deep-seated carcinoma of the sig- moid flexure. Occasionally it may accompany new growths which are situated higher up in the colon, but whenever it is present it appears to the writer to be a most important sign of stenotic processes in the large intestine. In carcinoma of the sigmoid flexure and rectum a more distinct localization can often be made. When the process is situated in these regions there are frequently dull pains in the left inguinal region which radiate into the left tes- ticle. Again pains may arise in the left half of the epigastrium and radiate towards the anus ; radiation into the left inguinal region and along the outer aspect of the left thigh occurs and seems to be a particular accompaniment of left-sided tumors. Pains in the back are rarely present, or when occur- ring are simply added to the sum of the other pains. The same may be said of pains in the region of the left sciatic nerve. Not less important than the topographical consid- erations are those symptoms which give us a clew to the factors influencing the pains, and these aid us particularly in differentiating the localized carcino- matous processes from those occurring in acute or chronic enteritis. It appears to me of special importance, when- ever intestinal colic occurs in older people, to deter- 200 PAIN mine whether there is a "position of the greatest pain, ' ' such as that which we have considered in the discussion of the pains accompanying ulcers. When we are dealing, for instance, with a carcinomatous process in the region of the hepatic flexure, the patients will frequently tell us that they cannot lie comfortably upon the left side because in this posi- tion they have pains in the right side which give them the impression of a mass dropping from right to left. This is unquestionably in many cases due to traction upon peritoneal adhesions and therefore points strongly towards the extension of a local process. The occurrence of such an extremely im- portant diagnostic position of pain is not infre- quently noticeable at an earlier stage than the occur- rence of any local sensitiveness to palpation. It is always important to examine the abdomen carefully for sensitiveness to local pressure, since in many cases pains may be produced in this way, which then give an important clew. Absence of abdominal ten- derness does not, of course, exclude absolutely the condition under consideration, for sensitiveness to pressure may be absent in those neoplasms which are situated in the pelvis, in the neighborhood of the rectum and in the lower half of the sigmoid flexure. Local sensitiveness corresponding to the seat of the tumor is occasionally felt during strong contraction of the abdominal muscles, such as that produced by lifting a weight or in defecation. Deep diaphrag- matic inspiration may give rise to such pain, espe- cially in cases where peritoneal inflammations are DIGESTIVE SYSTEM 201 present. The same kind of pain may be elicited by careful inflation of the rectum. Whenever pains are present in the lumbar region these are increased by stooping. The peculiarities of the pain in cases of malig- nant tumors which we have so far enumerated, have a diagnostic significance chiefly because they lead us to suspect a localized cause for the attacks of colic, and therefore considerably limit the diagnostic field. For, by reaching such a conclusion, we are able to exclude a great many of the more generalized causes for intestinal colic, such as the conditions caused by flatulence and the ordinary intestinal in- digestion. The differentially significant phenomena in the case of neoplasms are based upon the early occurrence of a local peritonitis, giving rise to the occurrence of a position of the greatest pain, and to local sensitiveness. No specific or characteristic factors, of course, can be ascribed to those phenom- ena which depend upon flatulence and consequent distention of the gut, or upon the increased peristal- tic contractions of the intestinal muscles. If the symptoms depending upon these conditions are par- ticularly prominent they lead easily to confusion with other conditions. However, these general pains will aid very much in differentiating the conditions we are speaking of from colicky attacks occurring with diseases of other organs. This would be par- ticularly important in cases such as carcinoma of the hepatic flexure where the confusion with gall- bladder colic is very easy, and where such general 202 PAIN intestinal symptoms protect us from mistaking one condition for the other. This becomes especially significant when we consider how frequently even the secondary symptoms of these' two conditions (fever and slight jaundice) are common to- both. When, in intestinal new growths, the attacks of pain are dependent chiefly upon the general intes- tinal condition, their onset may frequently be directly related to some thermic stimulation, such as the application of cold, walking with bare feet upon a cold floor, sudden throwing off of the bed-clothes or drinking cold fluids. The reason for this is a stimu- lation of peristalsis. Again, the attacks of pain may be incited by articles of diet which increase the pro- duction of gas in the intestine, such as certain vege- tables, bread, etc., and frequently in the history of intestinal carcinoma the first attack of pain is directly referable to such errors of diet. It is well to remember these things in order to protect our- selves against mistaking the early symptoms of a carcinoma for simple intestinal colic, and it is espe- cially desirable when dealing with older individuals to search carefully for the existence of a new growth even when the colicky pains seem to have been directly connected with an error in diet. It frequently happens that the positive physical signs are delayed for a long period after these first subjective symptoms have been noticed. In those cases where the above-mentioned subjective symp- toms are absent, but where we have some other reason to suspect the existence of a neoplasm, it is DIGESTIVE SYSTEM 203 well to attempt by palpation and by changes of posi- tion to produce artificially the conditions most favor- able to the production of the pains ; and in this way we may be led to a clearer comprehension of the case. An important symptom which is frequently pres- ent in these cases is prolonged constipation. The passage of feces or gas from the intestine is usually followed by an immediate diminution of the pains. The patients themselves frequently, during the at- tacks of colic, massage the abdomen in the region corresponding to the position of the tumor in order to diminish their pains. Thus the distribution of the distention which is probably the cause of the pain actually leads to great relief. Occasionally, even, the definite localization of the spontaneous massage carried on by the patient will be of diag- nostic aid. While there is generally no distinct relation be- tween the attacks of pain and the taking of food, occasionally there does exist some regularity in their occurrence in relation to the large meal. In some cases attacks occur within two to three hours after the meal, and are probably directly dependent upon the occurrence of powerful peristalsis during this time. This same interpretation may be given to the frequency of nocturnal attacks. During early car- cinoma there are usually intervals of several months between the attacks of pain. As the disease pro- gresses the intervals become shorter and shorter, a fact which may have much diagnostic significance, 204 PAIN since these intervals depend upon the nature of the process. Frequently the pains occur a short time before defecation. This is chiefly the case in those carcinomata which are situated well down under the sigmoid flexure. The symptoms which occasionally accompany the pains due to intestinal neoplasms are often of such a nature that their erroneous interpretation might well lead to false localization of the disease in the stomach, the gall-bladder, the kidneys, etc. Thus vomiting is frequently present at the height of the attack, and, with it, appear epigastric pains. The suspicion of gastric disease aroused by these symp- toms can be allayed by remembering that whenever vomiting occurs in intestinal neoplasms we may pre- suppose a considerable degree of stenosis and may, therefore, expect such vomiting to be accompanied by visible or palpable intestinal peristalsis. When the vomitus is bile-stained, is foul, or contains B. coli, we will, of course, be led to recognize the intes- tinal character of the condition. In carcinoma of the splenic flexure pains fre- quently occur immediately after the taking of food, and are caused either by inflammatory adhesions to the stomach, or by direct invasion of that organ. In such cases careful distention of the rectum will usually give rise to immediate pains in the region of the splenic flexure. The pains of carcinomata of the hepatic flexure are frequently confused with gall-bladder colic, especially when the pain is local- ized over the gall-bladder, because of adhesions or DIGESTIVE SYSTEM 205 direct metastatic growth. Icterus is often present in these cases, and a sensation of resistance in the neighborhood of the gall-bladder may be felt. In such cases, as we have mentioned before, especial attention must be paid to- the influence which the application of cold exerts upon the production of peristalsis and to the presence of visible peristalsis or succussion in the ascending colon. The tendency to diarrhoea, the occasional foul stools containing mucus, and the presence of blood or of an abnormal flora in the feces, are additional evidences pointing to carcinoma. The local bulging which might occur in the neighborhood of the gall-bladder when the intestine in this vicinity is abnormally distended could very easily be misinterpreted as a large gall- bladder. Chills occur in this form of intestinal carcinoma also, just as they occur in gall-bladder colic. In some cases, especially in carcinomata of the sigmoid flexure or the caecum, difficulty in urina- tion, pain in the bladder, frequent micturition, and even radiation into the testicle may be present, and these may easily lead to false conclusions. In this connection it is simply necessary to remember the danger of error and to avoid it whenever the tumor is impalpable and visible peristalsis is absent by careful examination of the stools and the peculiari- ties of defecation, such as tenesmus and distention of the descending colon. In differentiating carcinomatous disease of the intestine from the other more distinctly enteric causes of colic (flatulence, intestinal indigestion, etc.) 206 PAIN we have already called attention to the fact that a careful analysis of the pain alone may give us much basis for a sharp localization of the pathological condition. A distinct recognition of this, if we con- sider the relatively limited number of such localized processes in the intestinal tract, will make the fur- ther differential diagnosis quite simple, for there are few ulcerative or stenotic conditions with well- localized symptoms which are of practical impor- tance. Thus, in the ileocascal region we have, outside of carcinoma, to deal almost exclusively with tuberculosis; in the sigmoid flexure, almost exclu- sively with dysentery or occasionally membranous enteritis. LIVER. There are three chief factors which give rise to pain in the region of the liver. These may be dis- cussed in three groups, as follows : I. CONDITIONS OF SPASM OK DISTENTION IN THE BILE-PASSAGES AND GALL-BLADDER. The pains occurring in this region are closely analogous to those occurring in the gastro-intestinal tract a fact which is not surprising when we con- sider the great similarity between the two systems functionally and anatomically. As in the intestinal tract, a simple narrowing in the system of bile ducts is followed by spasm and overdistention in front of the stenosis, which consequently give rise to colicky pains. Thus here, too, colicky pains may be caused without absolute anatomical occlusion of the lumen. DIGESTIVE SYSTEM 207 While such attacks of gall-bladder colic are usually associated with, the presence of gall-stones, this is not by any means necessary, and it is illogical to speak invariably of such attacks as gall-stone colic. Further analogy to the conditions in the alimen- tary canal is found in the fact that inflammatory processes without any existing organic stenosis may be accompanied by the same attacks of pain, the con- ditions for such attacks being especially favorable in the appendix to the gall-duct system the gall- bladder. Here a colicky attack may be initiated by an inflammatory exudation with a rapidly increasing intravesical pressure and overdistention of the walls. In discussing the conditions in the biliary system which can give rise to spasms and overdistention, with their consequent attacks of colic, we shall have to consider : (a) Stenosis due to carcinoma at the papilla of Vater or in the head of the pancreas, ascarides in the ductus choledochus, aneurysms of the hepatic artery, intrahepatic carcinoma, cysts and gummata, kinking of the cystic duct in enteroptosis by adhe- sions, etc. (b) Inflammation, as in cholangeitis with or without biliary cirrhosis, acute yellow atrophy, cholecystitis with or without the formation of stones, carcinoma, etc. It is hardly necessary to mention that occasion- ally attacks of colic may be initiated by a combina- tion of (a) and (b). It is a universal rule that wherever secretions accumulate because of the for- mation of a stenosis the opportunity for infection 208 PAIN and for the development of a "stagnation-flora" is particularly favorable. It would probably be very advisable to drop the expression gall-stone colic entirely, and to substitute for it the words, gall-bladder colic or gall-duct colic, terms which imply no premature anatomical diag- nosis. This may seem pedantic, because in the ma- jority of these cases stones are actually present, but this slow method of diagnosis seems to the writer extremely desirable, since by its use we may often avoid overlooking other and rarer causes for these attacks. II. DiSTENTION OF THE LlVEB CAPSULE. Whenever a free flow of blood out of the hepatic veins is prevented, a swelling of the liver results which leads to painful distention of the peritoneal coverings. A similar condition is caused by obstruc- tion to the flow of bile. The presence of cysts in the liver tissue, and the growth of neoplasms, may give rise to a similar result. Distention of the capsule of the liver may also be produced by active hyper- semia. Thus in malaria, pernicious anaemia, par- oxysmal haemoglobinuria, leukaemia, diabetes, this occasionally occurs. In the last-named condition, however, the sensitiveness to pressure is usually of very moderate degree. III. INFLAMMATORY PROCESSES IN THE CAPSULE OF THE LIVER (LOCAL AND DIFFUSE PERIHEPATITIS). The general diagnosis of a hepatalgia is based chiefly upon the discovery of sensitiveness to pres- DIGESTIVE SYSTEM 209 sure or percussion, upon the size of the organ as determined by the liver dullness and upon a close analysis of the subjective pains. It now becomes our task to analyze more closely the details of the mechanism of these pains. In doing this we shall find that the groups which we have just discussed will often act in combination. I. Gall-bladder Colic. It is plain, from the very pathological conditions underlying the pains occurring in diseases of this organ, that the general phenomena must frequently be of an extremely complicated nature. Thus, ad- hesions between the gall-bladder on the one hand, and the duodenum or colon on the other, may give rise to entirely independent attacks of pain ; the develop- ment of peritonitis, the occurrence of septic throm- bosis in the lower extremities, with the pains that occur in them simulating radiation from the original seat of trouble, offer extreme difficulties to inter- pretation. It must also be remembered that, at the height of the attacks, neurasthenic patients may experience most unusual radiations of pain into the left arm or into the right leg, so that in judging of the condition it is especially important to pay attention to the pains which have occurred at the very beginning of the attack. The usual locations of the earliest pains are in the epigastrium, in its middle portion or just below the right costal margin. Whenever the attack of colic is localized chiefly on the left half of the epi- 14 210 PAIN gastrium we will be much more apt to think of a simple gastralgia (excepting, of course, in cases of transposition of the organs). The natural explana- tion of this right-sided position of the pain is found in the topography of the gall-bladder and the liver. The pain most usually radiates from the epigas- trium upwards, in rare cases up to the right half of the neck and to. the right acromion process. More often, however, it radiates, in front, up to the right nipple and backwards into the shoulder blade and into the right lumbar region. The radiations which occasionally occur into the right arm and leg, or even into the left arm, are present only at the height of very intense attacks of colic, and only in patients who are of unusually neurotic constitution. The paraesthesias which occur occasionally in the arms are probably of a vasomotor nature. "Whenever the radiations into the left arm are prominent we must consider the possibility that the attack of gall- bladder colic by increasing the blood pressure has brought on secondarily an attack of true functional or organic angina pectoris. Radiations into the genitals with retention of urine and severe pains above the symphysis occur but rarely, but when they do occur usually depend upon the development of the peritonitis which occa- sionally accompanies the gall-bladder inflammation ; pains in the lower extremities, especially those which occur in the nerves of the legs, are frequently due to septic thrombi. Such complications must be very carefully considered in order that we may avoid any DIGESTIVE SYSTEM 211 confusion with renal calculi. It is only at the very height of the attacks that the pains are diffuse or lack definite localization. While the localization of these subjective pains is extremely important, just as much help can be obtained by a careful determination of those areas which are tender to palpation and percussion. 1. THE GALL-BLADDER ITSELF. This organ is often enlarged and is usually markedly tender to palpation and percussion. There are certain pecu- liarities connected with this tenderness, the pres- ence of which confirms the diagnosis of gall-bladder tumor and aids in distinguishing it from the lower pole of the kidney. Pressure upon the gall-bladder frequently produces radiation of the pain along the phrenic nerve towards the acromion. Radiations backward towards the left half of the epigastrium and towards the ensiform process are quite frequent. This artificially produced radiation is an important adjunct to the spontaneous radiations. 2. THE MID-LINE OF THE EPIGASTRIUM FROM THE ENSIFORM TO THE EDGE OF THE LIVER. In this region, corresponding to the area of liver dullness, limited below by the edge of the liver, there is in almost all cases of early gall-bladder colic marked tenderness to percussion. In those cases which are accompa- nied by icterus, this tenderness may remain for a long while after the end of the attack of colic and may, by its diminution, indicate an improvement in the accompanying pathological changes. This symptom of tenderness to palpation in the mid-line which 212 PAIN occurs in cases- of gall-duct colic is directly referable to increase of intrahepatic pressure, and will receive further attention in the section on hepatic conges- tion. 3. THE BIGHT LUMBAR REGION (LIMITED ABOVE BY THE BASE OF THE LUNG). Here we are dealing with a symptom which frequently remains for some time after the attack proper has ended, and has probably the same etiological causes as the symptom just described under 2. In order to determine the pres- ence of this symptom it is best to tap lightly with the ulnar surface of the fist upon both lumbar re- gions in order to compare the tenderness of the two sides. In addition to these well-localized areas of pain there are other varieties of pain which undoubtedly are of reflex origin (phrenic nerve, etc.). (a) Tenderness in the area of the shoulder girdle. There is great tenderness to pressure in the right brachial plexus ; this symptom is rare. More frequently there is a point of sensitiveness situated along the upper portion of the trapezius muscle, about three fingers' breadth distant from the acro- mion. Pressure at this point causes pain which radiates towards the gall-bladder. Pressure upon the gall-bladder, on the other hand, may cause pain radiating towards this point. There exists thus a mutual radiation from one point to the other. The pains we have just discussed are not fre- quent in their occurrence, but when they are present they may be of considerable importance in differen- DIGESTIVE SYSTEM 213 tiating these conditions from other similar attacks of colic, such as those of pyloric stenosis, etc. They are also found, however, in cases of liver abscess, and in general in all cases of subdiaphragmatic inflammations. (b) Tenderness to palpation along the vertebral column. There is no localized tenderness over any one particular spinous process. The hyperassthetic zone extends usually over several spinous processes and is commonly subject to great variations, but, in general, it occurs between the fourth and the twelfth thoracic vertebrae. Occasionally there may be ten- derness to pressure in the ileocsecal region. This, when present, is not easy to interpret. Probably in most cases it is a direct transmission of the pressure upwards, and thus in reality a true gall-bladder pain. On the other hand, we must remember that in patients with gall-stone disease, and liver disease in general, there are usually intestinal disturbances, chiefly chronic constipation, and it is necessary for us therefore to think of chronic inflammatory con- ditions of the appendix. In order clearly to differentiate between gall- bladder colic and attacks of paroxysmal pain from other causes, it is necessary to pay very close atten- tion to the gradual increase and decrease of the attacks and to the cramp-like, sharp character of the pain. In those cases in which stone formation is present this characteristic of a rapid rise to a climax and gradual decrease, is especially marked, and the intensitv of the attack seems to reach its 214 PAIN maximum at the time when the stone is expelled. There are cases which have a more chronic and latent character and which in the course of years may have no sharp attacks, but in which there is a constant sensation of soreness in the epigastrium. Such cases of gall-stones without actual colic usually occur together with enteroptosis, and these run their course with constant parassthetic sensations in the region of the epigastrium. The weakness of the abdominal muscles, as well as possible relaxation of the musculature of the gall-ducts may be responsible for this. The attacks of colic may occasionally be preceded and followed by pains of another nature. These are usually sharp, cutting sensations which are directly dependent upon deep breathing and coughing, and which are due to inflammatory changes about the gall-bladder. In these cases auscultation may re- veal a leather-like creaking over the gall-bladder, and the patient may have a distinct sensation of the gall-bladder being pressed against the abdominal wall, or of an inflated stomach. As regards the influence of the taking of food upon the attacks of gall-bladder colic, we may say that a marked contrast exists between this condition and cases of pyloric stenosis. There is no injury done to the affected parts by the food, as is the case in gastric ulcer, and peristalsis of the gall-ducts, if at all excited by the taking of food, is certainly not so deeply influenced as is intestinal or gastric peri- stalsis. We may thus say that, in these cases, the DIGESTIVE SYSTEM 215 relation of the taking of food to the beginning of an attack is entirely unimportant, and, as a matter of fact, this is true in all those cases where chole- lithiasis occurs in patients of otherwise normal gastro-intestinal tracts. The taking of food is im- portant in relation to the attacks only in those cases where we are dealing with delicate, anaemic individ- uals, often with some degree of enteroptosis, espe- cially those with gastroptosis and general atony of the stomach. These cases are chiefly limited to the female sex, and in them a differential diagnosis be- tween a gastric condition and gall-bladder colic is extremely difficult. It is not at all out of the question that in some of these cases following an error in diet, a gastralgia with cramp-like contractions of the stomach is started which may secondarily give rise to an attack of colic in the gall-ducts, the muscular activity of the two systems being functionally so closely allied. The influence of diet upon gall-duct colic is similar in many ways to its influence upon the pains of pyloric stenosis, and it is not at all unlikely that, accompanying some cases of gall-stone, there actually does occur slight obstruction at the pylorus or in the duodenum itself. On the one hand, gas- troptosis, which is so often present, may readily lead to kinking of the duodenum and subsequent stenosis; on the other, it is not infrequent to find adhesions between the pylorus and the gall-bladder which may cause similar obstruction. The articles of diet which are especially apt to be responsible for the attacks are all those which lead 216 PAIN to distention, vegetables, carbohydrates, bread, etc.; also fat, meat, cheese, acid food, beer, etc. Attacks are occasionally inhibited by strong alcohol in the form of brandy. The quality of the food is often less important than the quantity, in that the attack is initiated simply by the mechanical overfilling of the stomach. Just as in the case of the pain accompanying ulceration of the pylorus, in these cases the position of the patient has an important influence upon the course of the attacks. The pain is especially severe when the patient is lying on his left side. In this position he may complain of a drawing sensation which gives the impression of something being tugged from the right hypochondriac region toward the left. This pain, in the left-sided position, is especially severe whenever there is great flabbiness of the abdominal walls, and therefore corresponding mobility of the abdominal organs. Mechanically the explanation is extremely simple since, in this posi- tion, the swollen organs are freely suspended from their inflamed peritoneal attachments. It is true that in some cases there is pain also in the right- sided position, and this is easily explained by the fact that greater pressure is exerted upon the liver and gall-bladder ; but when this does occur the pain is not accompanied by nausea and belching, as is almost invariably the case when the right-sided pains occur with ulceration and stenosis of the pylorus. Inflammatory changes in the neighborhood of the gall-bladder and in the serous coverings of the liver DIGESTIVE SYSTEM 217 give rise to other secondary symptoms. Thus the jarring accompanying speech, rapid walking, run- ning down hill, coughing and sneezing, gives much discomfort during the attack and for a long time afterwards. Likewise those motions are very pain- ful which are accompanied by pressure upon the abdominal organs in general, such as stooping, put- ting on the shoes, lifting a weight. Bending for- ward occasionally causes pain in the back, and owing to this the patients often instinctively relax their abdominal muscles by walking in a stooping position or shoving a pillow under their backs. Like the stomach and intestine, the gall-bladder has an important functional dependence upon the central nervous system, and it is thus not surprising that observations have been made which would indi- cate that attacks of gall-stone colic have been initi- ated by psychic or emotional impulses. It is at least worth considering whether such attacks cannot be reflexly initiated from other organs, the kidney, the genitals, the stomach, or the intestine, either in th'e presence of gall-stones or with any other lesion of the bile passages. Abnor- mal irritability of the nervous system may certainly be regarded as a factor favoring the attacks. There is a very definite connection between gall- stone colic and conditions of obstruction in the alimentary canal. Thus, prolonged constipation may occasionally start an attack, probably by pre- venting the free expulsion of bile, and occasionally an attack of colic may be interrupted by a free evacu- 218 PAIN ation of the bowels by enema or otherwise. Such close interrelation is logically to be expected when we consider the close functional relationship of the gut and the bile passages. As regards the time of attack, there is unques- tionably a greater frequency during the night or evening, but this is not striking and attacks may occur at any time during the day. In differentiating gall-stone colic from pyloric stenosis, we may be helped by remembering, first, the long, free intervals occurring between attacks of the former condition, in contrast to the almost uninterrupted suffering of the latter. When attacks occur daily for weeks we may usually conclude that we are dealing with stones which are immovably lodged in the cystic duct or with one of those cases of enter opto sis mentioned above. Stones which are situated further down, in the less narrow common duct, usually give rise to very little peristaltic unrest in the gall-duct system. The most important of the secondary symptoms which are to be considered is vomiting. This symp- tom especially may lead to confusion in pointing towards a gastric condition, such as ulceration at the pylorus; but the character of the vomiting is quite different in the two conditions. In the case of pyloric ulceration or stenosis the vomiting is usually very copious, does not consist of bile, has a sour taste, and is usually followed by immediate relief from pain ; in gall-stone colic it is usually full of bile, is bitter in its taste, and in most cases increases the DIGESTIVE SYSTEM 219 pain because the jarring of the act, as well as the pressure of the abdominal muscles, causes consider- able pain in the sensitive liver and gall-bladder. If the physician is present during the attack, examination of the urine will quickly determine whether obstruction of bile exists or not. Such a decision is much more difficult when we have to make, up our minds simply by means of the state- ments of the patient. We must not lay too much weight upon the patient's statement that his urine was dark during the attack, for in the attacks of the colic of gastric ulcer we often notice the excretion of a dark concentrated urine. If the patient is able to tell us that the urine has left yellow marks upon the linen or that there has been pruritus, the likeli- hood of the existence of true icterus becomes very strong. Jaundice is occasionally absent in diseases of the liver and, on the other hand, is often present in other diseases, chiefly in gastric and appendicular disease, in duodenal ulcer and in carcinoma of the hepatic flexure ; nevertheless, when icterus has never been present in patients whose disease has existed for a considerable period, extreme caution must be used before a diagnosis of hepatic disease is made. Shaking chills and rises of temperature are fre- quently present during the attacks themselves, but are of much less importance than increased tempera- ture which is present for some length of time after the attacks. The chills and rise of temperature dur- ing the attack may be present in many other condi- tions in persons who have irritable vasomotor sys- 220 PAIN terns. The temperature which occurs after attacks, however, is usually an expression of an infection, such as that which is frequently present in gall- bladder colic, and is therefore of much more impor- tance in clearing up the diagnosis. Herpes is rarely present. The symptoms which appear on physical exam- ination are chiefly tumor of the gall-bladder and liver, creaking friction sounds over the gall-bladder, crepitant rales over the base of the right lung, and occasionally also over the base of the left lung (splenic enlargement). There are a number of conditions which may simulate gall-bladder colic. Chief among these are : 1. Cicatricial and ulcerative processes of the pylorus (see page 162). 2. Duodenal Ulcer. The localization of the at- tacks may be very similar in the two conditions. In a general way the same distinguishing characteris- tics may be drawn between these two conditions as are useful in differentiating gall-bladder colic from pyloric stenosis. In duodenal ulcer there is almost immediate relief after vomiting because of the evacuation of the distended stomach. 3. Appendicitis. The danger of false, diagnosis is especially due to the fact that many cases of cholelithiasis show tenderness to pressure in the ileocsecal region ; this is usually caused by an abnor- mal position of the gall-bladder on account of a sinking and rotation of the liver. In a great many cases also there may be a chronic inflammatory process of the appendix directly re- DIGESTIVE SYSTEM 221 lated to the chronic constipation accompanying gall- stone disease. A superficial examiner might there- fore easily misinterpret attacks of colic with sensi- tiveness in the ileocaecal region as appendicular colic. On the other hand, cases of true appendicitis may simulate gall-stone colic when the appendicular pain is situated high up, because of an abnormal position of the appendix. Careful analysis of the pains, to- gether with most painstaking examination of the liver for enlargement, tenderness, etc., can alone give us clearness. 4. Carcinoma of the Colon. Another condition which it is difficult to differentiate from the pain under consideration is carcinoma of the hepatic flexure of the colon, with adhesions to the gall-blad- der and liver. In these cases there are colicky at- tacks with localization and radiation similar to those of true gall-stone colic. Added to these, slight jaundice is present, due to adhesions to or metas- tatic infiltration of the bile passages. The difficulty may be further increased by the presence of a rounded sensitive tumor which cannot be separated from the liver. While the examination of the feces and other subjective signs will clearly differentiate these con- ditions, the writer would like to call attention, for the purpose of rapid diagnosis, to the great differ- ence which exists in the reaction of the pains of these two conditions to thermic influences. When- ever the attacks of pain are easily brought on by the application of cold (cold drinks, exposure of the 222 PAIN abdomen, etc.), gall-duct colic is extremely unlikely, this characteristic being peculiar chiefly to the paroxysmal pains occurring in the intestines. Eises of temperature occur in ulcerating carci- noma of the colon and therefore give us no differ- ential help. However, chills at the time of the attack would point more particularly to gall-stone colic. In addition, it is important to consider the con- stancy of the pain, its dependence upon dietetic influences, its relief by the expulsion of flatus, etc. As far as objective symptoms are concerned the most important are those which point to obstruction of the gut. These, of course, may be absent for a long time. Most important among them are bor- borygmi in the region of the tumor and succussion sounds along the ascending colon; it must not be forgotten, however, that even disease of the gall- bladder may secondarily lead to slight obstruction in the region of the hepatic flexure. Diarrhoea when present would point towards an intestinal origin of the pains, for gall-duct colic, especially when due to stone, is almost always accom- panied by constipation. 5. Movable Kidney. Errors are very easily made, because it is not infrequent that, together with an irregular cholelithiasis, there exists a movable kidney which is assumed to be the cause of the entire trouble. This combination is quite usual, and there- fore errors often occur. A mistake is most easily made when we are dealing with cases of chole- lithiasis which run their course with constant pain DIGESTIVE SYSTEM 223 in the epigastrium, without the real colicky attacks and without icterus. The pain in these cases is influenced by jarring and motion, and it is not at all unlikely that when the kidney is movable and at the same time gall-stones are present, the tugging of the loose kidney may reflexly lead to peristaltic unrest in the bile-duct system. If the colicky pains occur while the body is in complete rest, for instance, during sleep, of course the assumption of movable kidney is quite out of the question. 6. Hysteria. This error can be made only when the existing cholelithiasis is of an atypical kind. Here also one must not forget that the conditions may frequently coincide. Whenever, of course, purely mechanical methods, such as the position of the patient, exert an influence upon the pain, we can hardly assume that the condition is entirely of a functional nature. So, too, it is important to know whether there is a lack of harmony between the gen- eral nervous condition and the severity of the local pain, for with an improvement in the general ner- vous condition, the local pains in the epigastrium are rather more likely to increase than to decrease when gall-stones are present. General rules can- not be made for cases of this kind, and it is of the greatest importance to consider carefully the in- dividuality of the patient in order to make a correct diagnosis. When, together with the existence of gall-stones, severe hysteria is present, even opera- 224 PAIN tive interference will not always guarantee complete cessation of the pains. It seems that in these cases we must consider that we are dealing in part with a visceral neuralgia (solar plexus? cf. page 97), in which the gall-bladder pain has the same relation to the neuralgia that a carious tooth would have to the ordinary trigeminal neuralgia. The extraction of the tooth might bring about a temporary improve- ment, but the neuralgic foundation would remain. It is an open question whether or not pure neural- gia of the liver may exist by itself without organic foundation. According to some observers such cases may occur with all the attributes of a true gall- stone colic, except fever and inflammatory changes. 7. Syphilis of the Liver. Attacks of pain may occur in the train of rapidly developing liver gum- mata, the causes of the pain being sudden tension of the liver capsule and local peritonitis. The con- fusion of this condition with gall-stone colic seems to be all the more likely because these cases are fol- lowed by jaundice and increase of temperature, and palpation of the liver reveals enlargement and ten- derness. However, more careful examination will frequently show unevenness of the liver surface, and, on the other hand, syphilitic processes occur frequently in the left lobe of the liver; thus there may be a peculiar left-sided localization of the pains, a localization which hardly ever occurs in gall- stone colic. In every difficult case the prompt im- provement under iodides may be decisive. Similar DIGESTIVE SYSTEM 225 symptoms may occur with primary or secondary car- cinoma of the liver. In our introduction we have already called atten- tion to the fact that while gall-bladder colic is usually caused ,by the existence of gall-stones, there may nevertheless exist cases of true gall-bladder colic without the presence of gall-stones. These cases, as it was pointed out, are chiefly dependent upon inflammatory stenoses along the bile ducts. The occasional combination of a gall-stone colic with haematemesis and melaena would lead us to think of aneurysm of the hepatic artery. Likewise we would have to consider ulcerative-stenotic condi- tions at the papilla of Vater. In patients who are suffering from marked en- teroptosis mild attacks of such colicky pains would suggest kinking along the cystic duct. When other symptoms point to biliary cirrhosis the possibility of an inflammatory colic of the gall-ducts must be thought of. It is a point of practical importance that in pa- tients who have their first attack of gall-stone colic at an advanced age, or in those in whom such attacks are repeated only after prolonged intervals, we may be dealing not with gall-stones but with a developing carcinoma of the gall-bladder, or possibly with both conditions together. An early operation for carci- noma of the gall-bladder is made possible only on the basis of the subjective phenomena, and even then only upon a diagnosis of probability. 15 226 PAIN Gall-bladder Pains without Attacks of Colic. In all the preceding conditions we have spoken of attacks of colicky pain which are probably caused by the more or less sudden increase of intravesical pressure or by tonic contractions along the muscu- lature of the bile ducts. There are still those cases to be considered in which the same etiological factors may give rise- to more gradual pathological changes, and therefore express themselves in more constant local pains over the gall-bladder rather than in paroxysmal attacks. Here, too, we must consider stenotic processes which lead to an overdistention of the gall-bladder. The chief conditions which must be thought of in this connection are diseases of the pancreas of an inflam- matory or malignant nature, and inflammatory proc- esses of the gall-bladder itself, either of a local nature (gall-stones, typhoid) or of an ascending nature (duodenal catarrh, cholangeitis, biliary cir- rhosis). Added to these conditions there frequently occur inflammatory changes in the peritoneal cover- ings of the organ, a pericholecystitis ; and this gives us a third factor which, together with the distention and the muscular contractions, adds to the general picture of gall-bladder pains. Such lesions are for many reasons extremely unsatisfactory for physical examination, and the subjective pains, therefore, assume especial diagnostic importance. Generally the pains are localized in the gall- bladder region itself; in cases of enteroptosis or corset liver the pains may be close to the ileocaecal region. DIGESTIVE SYSTEM 227 The peculiarities of the pains which can be pro- duced by physical examination have already been spoken of in the section on gall-bladder colic. Sharply localized, stabbing pains in the gall-bladder region may be caused by percussion in the right loin, by coughing, by sneezing, and by the pressure ex- erted in strong contraction of the abdominal muscles such as vomiting, straining at stool, and rising from a horizontal position. Deep respiration causes pain over the gall-bladder, especially in those cases where pericholecystic complications exist. Spontaneous pain is very slight in many cases ; and often the fact that there is localized pain in the gall-bladder region is brought out only by one of the methods just described. Similar sensations might occasionally be caused by an abnormally movable right kidney. Findings of such a nature, of course, cannot be decisive, since gall-bladder disease is frequently coexistent with movable kidney. It would be much more im- portant to find an enlarged gall-bladder. Increase of the temperature (cholecystitis) and persistence of the pain during the prone position would point towards the gall-bladder as the origin of the pains. Pains due to flatulence, which so frequently occur with atony of the gut, as in chronic nicotine poison- ing and neurasthenia, are occasionally localized over the gall-bladder region (hepatic flexure), but can be easily distinguished from gall-bladder disease by the fact that they vary in their localization. 228 PAIN II. and III. Distention and Inflammation of the Capsule of the Liver. Up to the present time we have spoken only of liver pains which have their seat in the biliary sys- tem, and its appendix, the gall-bladder. Here we had in addition to the factor of distention the cramp- like peristalsis of the muscular elements. In the following paragraphs we will deal with conditions localized in the peritoneal coverings of the liver. In these, pains are caused both by distention, when the liver is enlarged, and by inflammatory processes about the liver (perihepatitis). It is more practical and useful not to separate these two varieties of pain, since, although they are distinct etiologically, they very frequently occur together. (a) Hcematogenous Congestion of the Liver. Such cases are usually caused by cardiac lesions, especially by insufficiency of the right heart. Never- theless occasionally extracardial causes must be con- sidered, such as narrowing of the inferior vena cava by aneurysms, thrombi, fibrous changes of the peri- cardium, fluid exudate in the right pleura, right pneumothorax, and narrowing of the hepatic veins through perihepatitis. Next to the regularly present enlargement of the organ the most constant symptom of these anomalies of the circulation, at least in their acute and sub- acute stages, is the characteristic pain. There can hardly be any reason for doubting that the mechan- ism of the pains in these cases depends upon the DIGESTIVE SYSTEM 229 stretching of the liver capsule. The quality of these pains is almost always that of a feeling of pressure in the epigastrium which varies in degree from, sim- ple discomfort to actual pain, so that the patients speak often of ' ' stomach-ache. ' ' Radiations do not occur in this kind of pain. The patient frequently feels as though there were a constant and heavy- weight upon the stomach. The most characteristic quality by which this species of pain can be recognized is the increase in its severity which occurs whenever more work is laid upon the heart. This, of course, is natural in that it increases the actual cause of the pain. The patient who is suffering from a congested liver com- plains of an increase of the pain when he walks up- stairs, whereas it is very much less marked when he is walking downstairs. Struggling against the wind, running, in short, every physical exertion increase the suffering. Percussion of the liver is painful, and it is not surprising that in the face of the diffuse and even stretching of the liver-capsule the pain, on percus- sion, should have an analogously diffuse and even distribution. As a matter of fact, however, the maximum pain is felt in percussion along the linea alba and extends in this line from the tip of the ensiform down to the liver margin. This close cor- respondence of the zone of greatest pain with the liver dullness in the line of the linea alba is particu- larly important in differentiating this condition from other epigastric pains. For this reason examina- 230 PAIN tion by percussion is more important in this condi- tion than examination by palpation. The explanation of the fact that in spite of the diffuse nature of the process the maximum pain, on percussion, extends along the linea alba probably lies in the circumstance that here the muscular de- fense is least effectual, especially in cases where there is some separation of the recti. Probably the same explanation holds good for a similar localiza- tion of the greatest tenderness along the linea alba in gastric ulcer. Whenever, therefore, one wishes to examine for pain in cases suspicious of hepatic congestion, it is advisable to percuss along the linea alba. If cases dependent upon uncompensated cardiac lesions are examined in this way while they are under treatment with digitalis, it is often possible to notice that the pain will diminish from day to day if approximately the same force- of percussion is used. In this way we have a very simple means of controlling the processes of compensation of the right heart. At the same time the influence exerted by the therapy upon the tenderness throws definite light upon the etiology of the condition. The position of the body has a definite influence upon the intensity of the suffering. The upright position naturally leads to a greater stagnation of blood in the liver, while the horizontal position allows of a better outflow of blood. Dietetic conditions also may have a definite effect upon the hyperaemia of the liver and therefore upon the pains (spices, large quantities of meat, etc.). DIGESTIVE SYSTEM 231 Occasionally mechanical and dietetic conditions may be combined (bodily exertion immediately after meals). The physical signs accompanying increase of the pain are chiefly enlargement and firmer consistency of the organ. The latter condition is frequently noticed by the patient himself, who may observe a diffuse firmness in the epigastrium after exertion. In many cases, of course, the congestion of the liver is merely a secondary factor in the general clinical picture, and it may be easy to explain the enlargement of the organ without paying much at- tention to the character and quality of the pains. The enlargement of the liver falls in naturally with the cyanosis and the redema. On the other hand, there are cases in which the hepatic congestion and the suffering resulting from it may be predominant. The cases chiefly to be considered in this con- nection are especially those of acute pericarditis, which are frequently characterized by epigastric rather than by cardiac symptoms ; and these epigas- tric symptoms, on closer analysis, can be recognized as being due to. hepatic congestion. The same is true of the- symptoms accompanying many cases of adherent pericardium, and in these often the diag- nosis of hepatic congestion can be made before the condition of the heart is recognized. Again there are cases in which, even when the signs of an insufficiency of the right ventricle are perfectly clear, there- may be. much doubt as to whether the existing enlargement of the liver is to 232 PAIN be explained by simple congestion, or whether other pathological processes, for instance cirrhosis, may have a part in it. In just these cases the examina- tion of the organ for its sensitiveness and the zones of distribution of these pains, as determined by physical examination, may lend invaluable aid. The pathological basis of the pain of congestion lies in the acute or subacute distention of the organ and its peritoneal coverings. This, however, pre- supposes the possibility of distending the organ itself. In cases where there has been much forma- tion of fibrous tissue, as in cirrhosis, distention is not possible, and even an acute cardiac insufficiency is unable to produce any marked degree of pain. Therefore, whenever acute general congestion ex- ists without any marked degree of pain in the liver, we must always be suspicious of a preexisting cir- rhosis. It is well, however, to be cautious in those cases where the cardiac lesion has developed in very chronic stages and has carried in its train a consid- erable degree of connective tissue formation (car- diac cirrhosis). Occasionally inflammatory factors, such as acute perihepatitis, may contribute to the production of the pain. Such complications are characterized by a sudden increase in the subjective pain without a corresponding exacerbation of the cardiac condi- tion. In contradistinction to the dull, aching pres- sure produced by stretching of the capsule, this pain is acute and stabbing, and because of its peritoneal and inflammatory nature it is increased upon deep DIGESTIVE SYSTEM 233 respiration (rubbing of peritoneal surfaces). This pain is independent of digitalis treatment, but on the other hand is rapidly and effectually controlled by local treatment. "When perihepatitis is present it is almost impossible to lie upon the painful side. Friction sounds accompany the pains only when there is a fibrinous exudation of considerable quan- tity and the fibrinous masses are of favorable con- sistency. Further details of the pains accompanying peri- hepatitis will be discussed when speaking of syphilis of the liver. (b) Biliary Congestion. In the same way that an overfilling of the blood vessels may lead, by a secondary stretching of the capsule, to liver pains, so the condition of congestion in the bile ducts may give rise to a very similar state of affairs. The suffering produced by biliary congestion, however, rarely equals in intensity that produced by conges- tion in the blood vessels, largely because of the differences of pressure in the two conditions. Nevertheless pain over the liver upon percussion along the linea alba is not uncommon in those dis- eases which are accompanied by congestion of bile (catarrhal jaundice, Hanot's cirrhosis, carcinoma of the head of the pancreas, etc.). These conditions are also accompanied by the gall-bladder pains which we have mentioned above, which occur without true colicky attacks. These may exist in varying degrees, from the simple sensa- tion of pressure to conditions approaching gall- 234 PAIN bladder colic. It is therefore always important to percuss along the linea alba as well as over the gall- bladder itself. Since stagnation of the bile is often directly the result of inflammation of the mucous membrane of the passages, and since, on the other hand, biliary congestion favors inflammation of these passages, it is not surprising that these conditions are fre- quently accompanied by perihepatitis and the pains characteristic of this condition. Therefore the pa- tient who is suffering from Hanot's cirrhosis often complains of a sharp pain along the right costal margin or in the region of the right hypochondrium. This pain is often dependent upon movements which cause peritoneal friction, such as running, coughing, sneezing, or deep respiration. Sometimes, though rarely, it radiates towards the right shoulder. Such variation is entirely consistent with its sub- diaphragmatic position. The pains which occur in the back and are increased by stooping must be explained by the distention of the liver capsule. We have already mentioned that gall-bladder colic may, though rarely, be part of the clinical picture of a Hanot's cirrhosis. Tenderness on percussion over the liver, along the linea alba and over the gall-bladder as well, is occasionally found in cases of catarrhal jaundice, and is directly proportionate to the degree of biliary congestion. In cases where the inflammatory processes are not limited to the larger passages alone but extend DIGESTIVE SYSTEM 235 into the bile capillaries, extension takes place into the peritoneal coverings, and thus a new reason for tenderness is added. Therefore, whenever the pain is extremely acute without great enlargement of the organ, it is logical to think of an inflamma- tory perihepatitis. In such cases also the gall- bladder becomes involved and there is local tender- ness to palpation and percussion, and local pain in the gall-bladder region upon jarring of the body. "When this occurs it is important to think of the pos- sibility of preexisting lesions in the gall-bladder, such as gall-stones, since ordinarily the gall-bladder pains are not an accompaniment of catarrhal icterus. In considering conditions which lead to abnormal stretching of the liver capsule, special attention is due to the cystic new growths of the liver, and par- ticularly to the development of echinococcus cysts. The pains which occur in this condition remind us in many of their peculiarities of the phenomena con- sidered under the heading of gall-bladder colic. In rare instances the passage of small cysts through the bile ducts may give rise to attacks of pain. More frequently, however, pains in this con- dition are due to pressure and consequent stenosis of the gall-ducts. Likewise, sudden changes in vol- ume of the echinococcus cysts frequently occur, and these give rise to inflammatory swelling of the liver tissue surrounding the growth. The attacks of pain, which often occur suddenly, are usually localized in the right hypochondrium under the right costal border, and radiate towards the right shoulder blade 236 PAIN and the sternum. The pain may also begin in the back and radiate forward on both sides; more or less constant pain in both scapulae and in the back may be present. The similarity to gall-stone colic may be accen- tuated by the occurrence of nocturnal attacks. The attacks may be colicky, often severe enough to cause syncope ; again they may be of a more constant dull character. Mechanical factors materially influence the pains. Thus the pain is often at its maximum when the patient lies on the left side, and in this position has a sensation of a heavy mass being dragged from right to left. Jarring of the body increases the pain. Thus sneezing, coughing, per- cussion upon the right loin, or any exertion causes pain. Motions which are dependent upon contrac- tion of the abdominal musculature, bending, lifting, etc., lead to stabbing sensations over the liver. The echinococcus cyst itself is sensitive in but few of the cases. Accompanying the attacks of pain, syncope may occur ; sensations of suffocation and rise of tem- perature are not rare. Singultus may occur and give a clue to the subdiaphragmatic nature of the condition. Great attention must be paid to those symptoms which emanate from the stomach and often lead to an erroneous diagnosis of gastric disease. These are due in most cases to the crowd- ing of the stomach by the cystic sac, which produces the symptoms of slight obstruction and gastric peri- stalsis. This error can be well guarded against if, on principle, in all cases of apparent gastric dis- DIGESTIVE SYSTEM 237 ease, we examine the liver and the spleen as well as the stomach. The statements made in regard to the pain accompanying distention of the liver capsule are hard to reconcile with those cases of carcinomatous infiltration of the liver which are unaccompanied by pain, even when the liver is enormously enlarged. The same is true of most cases of fatty or hyalin infiltration of the liver. The strange behavior of these diseases is probably explained by the more gradual enlargement which the liver undergoes. In carcinoma., especially, the liver is not enlarged in toto but in different places at different times, so that the peritoneal coverings have an opportunity to adjust themselves to the changed conditions. If car- cinoma of the liver is accompanied by pains at all, they are usually traceable directly to stenosis along the bile-ducts (carcinoma of the pancreas or the bile- ducts) or to' the perihepatitis. Occasionally, too, carcinoma of the liver may be complicated by gall- stones, which then would account for the pain. The sharp pains which indicate perihepatitis seem to be associated chiefly with secondary carcinoma of the liver, especially when the primary growth is an ulcer- ating neoplasm of the gastro-intestinal tract. It stands to reason that in such cases the conditions are favorable for secondary inflammatory processes. In cases of this kind occasionally sharp and prolonged attacks of pain occur, and these are dependent upon all those motions which give rise to peritoneal fric- tion, thus pointing to the peritoneal cause of the 238 PAIN suffering. Pain is caused especially by those carci- nomatous nodules which lie subperitoneally and secondarily involve the peritoneum. There are many cases in which it is important to determine whether, with the existence of a gastric carcinoma, the liver has already been involved or not. In these we are forced to pay particular atten- tion to the existence of pain in the right hypochon- drium, since it is hardly ever possible to discover by physical examination carcinomatous nodules sit- uated under the dome of the diaphragm; the same applies to circumscribed tenderness over the palpa- ble liver surface. Acute and paroxysmal attacks of pain of a moderate colicky nature are characteristic chiefly of neoplasms which have caused stenosis of the bile passages. Chief among these are the neo- plasms situated in the pancreas. Carcinoma of the gall-ducts occasionally runs its course without either subjective or objective pain. Local pain involving the gall-bladder and in part the right lobe of the liver accompanies all those cases, however, in which inflammatory changes have taken place within or about the gall-bladder. In these cases, too, mild attacks of gall-bladder colic may occur even without the existence of a gall-stone. The fact that the left-sided position is particu- larly painful in many cases of carcinomatous en- largement of the liver is explained upon purely me- chanical grounds. In this position the heavy organ drops towards the left side and the patient feels a drawing pain which extends from right to left. If DIGESTIVE SYSTEM 239 the capsule of the liver is inflamed this change of position of the liver gives rise to extreme pain, and, in such cases, the patient voluntarily prefers to lie flat upon his back; thus immobilizing the organ. Very frequently stooping gives rise to great pain in the back. Attacks of pain of intestinal origin are not rare in carcinoma of the liver. These are due, on the one hand, to direct infiltration of the colon from the gall-bladder and consequent moderate obstruction. On the other hand, there frequently exists a tendency to meteorism which leads, by a local collection of flatus, to attacks of a colicky nature. These attacks are easily controlled by emptying the bowels. Much more marked than in carcinoma of the liver are the pains which accompany liver gummata, and these are so regular that in all cases where pains occur in the liver region it is necessary to think of this possibility. A local perihepatitis is almost regularly present because of the inflammatory nature of the new growth, and in this secondary phenomenon lies the causes of the pain. This is made particularly evi- dent by the factors which influence the pain. Pain is initiated or increased by deep respiration, by rapid walking, by jarring of the body, by walking downstairs, by slipping of the right foot, and by laughing or coughing. Just as direct pressure upon the painful area increases the pain, so motions which indirectly give rise to greater pressure increase it as well. Occa- 240 PAIN sionally, too, the taking of food will cause increased suffering (perihepatic adhesions). A great deal of differential knowledge may be gained by the therapy. The pains are almost imme- diately relieved by iodides and (in one of the author's cases) by arsenic. If the pains are situ- ated on the right side under the costal margin, there is radiation into the right shoulder blade and into the back. If the pain, in addition to this radiation, assumes the nature of a colicky attack and is accom- panied by vomiting, slight fever, and icterus, the danger of confusing it with gall-bladder colic is plain. Here only an exact physical examination can make the differentiation, by revealing a circum- scribed tumor upon the liver surface. Very fre- quently, however, the pains are situated along the left costal margin, because of the frequent involve- ment of the left lobe of the liver. They are then more constant in their nature, without colicky at- tacks. They may be sharp or dull without giving rise to radiation, and tenderness over the gall- bladder region may be entirely absent. In contradistinction to echinococcus, in the syphi- litic condition the tumor itself is markedly sensitive. PANCREAS. In this organ, in which we have neither the mechanism of muscular contraction nor the intimate relation to the peritoneum found in the liver, there would seem to be very little basis for the develop- ment of characteristic pains. On the other hand, DIGESTIVE SYSTEM 241 experience tells us that certain lesions of the pan- creas are accompanied regularly by attacks of pecu- liarly intense pain. The most important among such lesions are pancreatic cysts. In accounting for this it is of primary impor- tance to consider the intimate relations which the pancreas holds to the nervous system in general and to the solar plexus in particular ; and it is quite likely that, occasionally, we are confronted with purely neuralgic conditions. This, however, does not exclude the possibility that occasionally pains may be produced in the pancreas by exactly the same mechanism by which they are produced in the liver ; that is, by cramp-like contractions and increased pressure in the excretory ducts. Because of the disproportionate structure of the muscular appa- ratus of these ducts, however, it is hardly possible to explain in this way any of the very intense paroxysmal attacks. Again, it is quite easy to understand that many of the pains occurring with pancreatic lesions may emanate from neighboring organs, rather than from the pancreas itself. In this connection the very intimate topographi- cal relation of the terminal end of the ductus chole- dochus to the head of the pancreas is important; the close apposition of these two structures makes it self-evident that any pathological changes in the head of the pancreas would lead to compression of the common bile duct; and this, of course, would lead to stenosis with consequent colicky attacks in the gall-ducts. 16 242 PAIN We must remember, however, that frequently diseases of the gall-passages and of the pancreas may be present at the same time. In cysts of the pancreas, the pancreatic nature of the disease may be particularly obscured by pressure upon portions of the gut, giving rise to paresis, peritonitis, and their consequent train of symptoms. Because of the very intimate relationship of vascular disease to the general pathology of the pancreas, we must occa- sionally think of pains arising in the vessels. From these considerations it naturally becomes clear that any attempt to separate purely local pan- creatic pains from those depending upon the neigh- boring organs must be extremely difficult. The law which states, in a general way, that organ pains correspond in localization to the organ from which they emanate, is borne out by pancreatic conditions. So, because of the chiefly left-sided posi- tion of the pancreas, the pains which arise in it are situated in the left half of the epigastrium, to the left of the umbilicus, or even in the left loin. Occa- sionally with these, radiations may be observed which are symmetrical with 'Lliose occurring in gall- bladder colic. It has been mentioned above that occasionally the colic accomparying pyloric stenosis may behave in the same way. This left-sided character of the pain in pancreatic lesions, therefore, might under certain conditions be of gastric origin, in that the pathological changes in the pancreas have second- arily produced a pyloric stenosis by compression DIGESTIVE SYSTEM 243 and spasm. At all events it is necessary to pay very close attention to the presence of gastric distention, peristalsis, or sarcinae in the vomitus or feces. It is easy to understand that, corresponding with the retroperitoneal position of the organ, pains in the back should frequently occur. These pains sometimes radiate forward and around the waist. Sensitiveness to pain will change in its localization according to the position of the lesion in the pan- creas. Since it is necessary, in palpating, to exert deep pressure towards the vertebral column, the localization of the tenderness is of little diagnostic value. It is important also to look for sensitiveness to pressure and percussion along the upper lumbar vertebrae, a symptom which I have had occasion to notice in several cases of diabetes. This is proba- bly to be regarded as a reflex manifestation corre- sponding to the phenomena occurring with gastric ulcer and gall-bladder inflammations. Whenever the sensitiveness is in the epigastrium, it is necessary, owing to the close relation of vascu- lar disease to disease of the pancreas, to think of the possibility of purely vascular pain (haemor- rhages or atheroma of the aorta). When sensitive- ness occurs along the right costal border, even when sure of the presence of pancreatic disease, we must not neglect to search carefully for tumefaction of the gall-bladder. This may easily follow constric- tion of the common bile-duct in the head of the pancreas. A regular relation of the pains in diseases of the pancreas to the taking of food could logically be 244 PAIN assumed since the food, passing out of the stomach two or three hours after a meal, may readily cause pain by reflexly inciting pancreatic secretion, and therefore producing hyperaemia of the organ ; but, of course, whenever such a direct relation between the meal and the attack of pain occurs it would be more reasonable to think of secondary pyloric stenosis or gastralgia. It has frequently been noticed that the pain in the back emanating from the pancreas occurs with especial frequency at night; and this is explained by the fact that the dorsal position is most apt to cause discomfort. The quality of the pain is of great diagnostic importance, in that it frequently occurs with great suddenness and severity and is accompanied by signs of collapse. The factors influencing the pain are naturally dependent upon the mechanism underlying each in- dividual attack. In cases in which we are dealing with true neuralgia without the presence of other factors, it is quite impossible to influence the* pains in any way except by occasionally effectual narcotics. In cases where the pain is due to pressure of tumors (cyst or neoplasms), or is caused by peri- toneal adhesions to the surrounding organs (as in pancreatic abscesses), the conditions are quite dif- ferent. In such cases purely mechanical causes, jarring and tugging upon compressed nerves in rapid change of position, stooping, coughing, or deep breathing, may exert a very marked influence upon DIGESTIVE SYSTEM 245 the pains. Thus in the case of cysts and neoplasms the dorsal position is very painful, and turning upon the side brings almost immediate relief. When- ever we are sure of the presence of a pancreatic lesion and we can obtain immediate relief from the pains by the belching following the administration of alkaloids, we may conclude that there is present a secondary stenosis of the duodenum with conse- quent distention of the stomach. "When the pains have a purely vascular origin we may expect them occasionally to be initiated by the hyperaemia accompanying digestion. Since, in a general way, the diagnostic aid given us by the pain in these cases is extremely small, it is very important to consider closely all other pos- sible clues. We must remember that a large propor- tion of the cases of pancreatic disease occurs in very stout alcoholic individuals ; and that these are espe- cially prone to arteriosclerosis and therefore to hsemorrhage and necrosis. It is well also to think of the possibility of a pancreatic lesion in all cases of apparent peritonitis, or intestinal obstruction. The same holds true of all cases of colicky abdominal pains which follow a trauma, blows in the epigastrium, etc. If in these cases no indican is found in the urine, but glycosuria appears spasmodically or constantly after the attack of pain, the suspicion of a pancreatic lesion becomes strong. This opinion is much strengthened if, in addition to these signs, the stools show an insuf- ficient digestion of albumins and fats, and physical 246 PAIN examination justifies the consideration of pancreatic disease. In spite of all these things it will often be impos- sible to distinguish diseases of the pancreas from peritonitis, acute intestinal stenosis, cholelithiasis, gastralgia, etc. Some of the lesions of the pancreas are accom- panied by pains of definite quality which, while not entirely characteristic, may still give much diag- nostic aid. (a) Carcinoma of the Head of the Pancreas. Pain in the back with occasionally definite relation to the position of the body may occur. This is by no means a rule. The first pains seem frequently to occur in the neighborhood of the gall-bladder be- cause of the overdistention or stenosis of the com- mon bile-duct. The pains seem to be dependent chiefly upon mechanical conditions, such as the posi- tion of the body, and are similar in this respect to those occurring in the gall-bladder. Again the first pains may be dependent entirely upon the local perihepatitis which accompanies the subperitoneal metastases. In this way, in some cases, the entire attention of the physician may be concentrated upon the liver and gall-passages, and the pancreatic lesion may escape detection. In the same way the attention may be directed chiefly toward the pylorus or duode- num when subjective or objective symptoms of ste- nosis occur in these places. When this occurs, how- ever, the pains are much less severe than in the DIGESTIVE SYSTEM 247 primary ulcerative or stenotic processes of these organs. (b) Pancreatic Cyst. In this condition very sud- den attacks of pain occur, sometimes under the left, sometimes under the right costal border, accompa- nied by syncope, collapse, vomiting and diarrhoea. These attacks may in part be due to sudden increase of tension whenever the cyst contents rapidly in- crease in volume. Again, they may be neuralgic in their nature, or may consist in the colic following secondary stenosis of the gut. (c) Suppurative Pancreatitis. Not rarely the acute attack of pain which occurs in these- cases is followed by icterus. This would naturally lead to the danger of confusing the condition with choleli- thiasis. The error can be guarded against only by very careful palpation and localization of the sensi- tive point. (d) Hemorrhages. When we are dealing with drunkards, very fat people, or individuals with marked arterial changes, all sudden attacks of epi- gastric pain accompanied by collapse and dangerous symptoms must be considered as possibly due to a haemorrhage into the pancreas. It is almost never possible to make this diagnosis with certainty. (e) Pancreatic Calculi. Attacks of pain which are due to stones in the pancreatic duct usually be- gin in the left half of the epigastrium and radiate over the left shoulder. This left-sided localization occasionally permits their differentiation from the very similar attacks of gall-stone colic, a differen- 248 PAIN tiation which is rendered very difficult by the fact that occasionally pancreatic concretions are accom- panied by icterus. The- absence, too, of sensitiveness to pressure over the gall-bladder would be of great aid. Differentiation from ulcerations similarly localized, for instance those occurring in the py- lorus, can be made by considering the independence of the pancreatic pains from the quality and quan- tity of the food. The greatest weight in making these difficult diagnoses must, of course, be laid upon the secondary symptoms. Diarrhoea must be very carefully inquired for, since it is rather a rare symptom in the other varieties of colic. In addition to this careful exam- ination must be made for the detection of glycosuria and of excess of fat in the stools. The stools, too, should be searched for bile-free concretions consist- ing of carbonates and phosphates of calcium. CHAPTER VIII. URINAKY SYSTEM AND SPLEEN. KIDNEY. IN discussing the factors which produce pain in the urogenital system, we may avoid much repetition by calling attention to the close analogy existing between this system and that of the liver and gall- ducts. The pelvis of the kidney, the ureter and the bladder find close analogies in the gall-bladder, the gall-passages and the duodenum, and in a general way the conditions producing colicky pains along these hollow muscular organs are the same. It may be assumed that conditions which produce an in- crease of pressure upon the capsule of the liver, such as congestion of blood or bile, or tumor forma- tion, may find close analogies in the kidney itself. The same holds good of perihepatitis and peri- nephritis. For this reason we can follow approxi- mately the same classification. I. True Kidney Pains. Here the pain is caused by acute or chronic tension upon the kidney capsule or inflammatory changes in the surrounding tissue. In some cases also there may be direct injury by destructive proc- esses of the renal plexus. At any rate it is never correct to speak of renal colic; for in the kidney itself the conditions for the production of such 249 250 PAIN colicky pains are absent, such pains occurring only in hollow organs. While it is impossible to differentiate by their pains alone the various conditions which produce such stretching of the capsule of the kidney, it is for practical reasons better to consider the conditions separately. (a) Embolism of the Renal Arteries. It is ex- tremely rare for this lesion to be accompanied by pain. In the year 1901 I was able to find in the literature only seven reported cases, and therefore it may seem wrong to begin our considerations with this condition. But in kidney infarcts the pain occurs in such a characteristically sudden way that it furnishes a most clear-cut subject for study. The pain in this condition is distinguished from all other true kidney pains only by the great sudden- ness of its onset (apoplectiform). In other respects every one of the details which are observed in kidney pains occurs, and for this very reason a close de- scription of the condition will serve most excellently to illustrate the others. Subjective pains, as well as the objective ones produced by pressure, palpation and percussion, cor- respond in a general way to the position of the organ in front and behind. The kidney extends vertically from the middle of the eleventh thoracic vertebra to the lower limit of the body of the second lumbar vertebra. In an upward direction, therefore, it extends to above the twelfth thoracic vertebra. Its posterior surface for a short distance is apposed URINARY SYSTEM AND SPLEEN 251 to that part of the diaphragm at which the lumbar and costal portions of this organ join. The greater part of it lies against the quadratus lumborum. Since the kidney varies much in its localization we must occasionally be prepared to find abnormal local- ization of the pain. Thus a low position of the kid- ney may give rise to pains in the ileocsecal region. It must be remembered also that in some cases the kidney may have projections towards the median line (horse-shoe kidney), or occasionally in the pel- vis, or the sacrum, along the position of the sacro- iliac junction. These abnormal positions would naturally bring with them abnormal positions of the pain. The kidney pain is especially easy to recognize when we are dealing with the right kidney and the pains are projected forwards. This occasionally happens in- renal infarcts. If we consider the sec- ondary symptoms, such as vomiting, pain in the liver due to congestion, tenderness along the gall-bladder and appendix, and fever, the danger of confusion with gall-bladder or appendicular pain is extremely probable. It seems to the author especially important to note that the pain in disease of the kidney is located particularly in the flank; while along the mammary line in front, or in the lumbar region behind, the tenderness to pressure or percussion is much less marked. Another source of frequent error lies in the fact that pressure of the abdomen often gives rise to a 252 PAIN very diffuse pain (especially when the infarction is bilateral). This is explained by the fact that the pressure reaches the diseased organ indirectly through the interposed organs. For the more exact localization of the pain in these cases percussion is more useful than palpation. The patient in cases of true kidney pain almost always localizes the pain deeply, away from the abdominal wall, a fact which often helps greatly in differentiating it from neuralgia or myalgia. Very occasionally there is sensitiveness in the lower intercostal spaces as far up as the scapular angle posteriorly, and about four centimeters above the costal border anteriorly. This must be regarded as merely a reflex pain, since it occasionally occurs in pyelonephritis without the existence of a second- ary pleural inflammation. Sensitiveness to pressure is found chiefly in: (1) the flank, in the axillary line; (2) the angle between the lateral border of the erector spina* and the twelfth rib; (3) anteriorly in the region below the gall-bladder corresponding to the position of the kidney. A characteristic radiation does not accompany these true kidney pains and therefore is not present with renal infarcts. This is due to the absence of a path of transmission (ureter) ; yet in rare cases there may be sensations in the thigh. When these do occur, they can be regarded as due to pressure upon the twelfth dorsal nerve and branches of the lumbar plexus, by thickening of the capsule. URINARY SYSTEM AND SPLEEN 253 The factors influencing the pains of renal inf arct are chiefly mechanical. Normally the kidney is sup- posed to be entirely immovable. This is quite theo- retical, however, and practically we may find all degrees of mobility. It is not surprising, therefore, that in cases of inflammatory changes within the kidney or about the capsule (partial necrosis of the renal tissue, tuberculosis, etc.), forcible manipula- tion of the organ is accompanied by more or less pain; thus, too, a definite position of greatest pain is developed quite acutely in cases where enterop- tosis and weakness of the abdominal walls are pres- ent. The patients are unable to lie on either side without suffering, and it is peculiar that pain is most severe when lying upon the healthy side. In this position they have the sensation of a painful tugging extending from the diseased side towards the healthy. The actual descent of the kidney downwards toward the side upon which he lies is felt acutely and distinctly by the patient. In the same way definite painful positions are present in tuberculosis, in renal tumors and in pyelo- nephrosis; only occasionally does the position of greatest pain correspond with the diseased side. If change of position and slight tugging by reason of the weight of the organ itself are able to cause pain, it is all the more reasonable to believe that forcible jarring would cause localized pain in the neighbor- hood of the kidney; and this actually occurs with coughing, vomiting, riding in a carriage, jumping, or making a false step. All motions which call for 254 PAIN contraction of the ileopsoas muscle, such as rising, and stretching of the flexed thigh, will of course give pain because of the close apposition of the kidney to the muscle. It is hardly necessary to mention that pressure in the kidney region, or percussion with the clenched fist would cause pain. Strong percussion is espe- cially helpful in localizing the exact extent of the pain and in demonstrating its diminution during con- valescence. It is worth mentioning, too, that in cases of renal infarct the objective pain is present for some time after the subjective has disappeared. The pain accompanying renal infarct resembles, in the suddenness of its onset, colic of the ureter, but is sharply differentiated from the latter condi- tion by the fact that the pain itself, after the onset, is not colicky but stabbing, aching and constant. In attributing any pain to renal infarction, we must consider the condition of the heart (existence of a mitral stenosis). "We must note particularly the sudden onset of the pain and the subsequent absence of any paroxysmal quality. Most abdom- inal pains are of a colicky nature, and the absence of the paroxysmal element is of great differential importance. It is, furthermore, very important to determine whether or not there is difficulty of micturition. Urination becomes difficult (renal dysuria) and can be accomplished only in the standing position and with great exertion; occasionally there are symp- toms of moderate incontinence. The quantity may URINARY SYSTEM AND SPLEEN 255 be at first diminished or there may even be complete anuria. The frequent desire to urinate seems to be absent in these cases, a feature which is of great differential value since pains arising in the excretory passages are usually accompanied by this symptom. The characteristic features of the urine analysis, I have found to be the following : There is often a sudden and copious albuminuria, as high as 2 per cent., which very rapidly diminishes. There is occasionally a very slight hsematuria, often discovered only by microscopical examination. Oc- casionally, also, epithelial casts may be found in the sediment. The consideration of these secondary symptoms which point to the urogenital system will guard us against confusion with the colics of the gall-bladder and appendix, an error which is the more easily made when the embolus is situated on the right side. The vomiting and hiccoughing which occur with the onset, can lead easily to the false diagnosis of acute peritonitis. This is especially so when the infarct is bilateral and in consequence the abdom- inal tenderness is very diffuse. The pain accompanying renal infarct is sharply differentiated from the pains which occur along the ureter (nephrolithiasis) by the complete absence of paroxysms,, the continuous character of the pains, and the slight tendency to radiation. In ureteral colic the pain is of a remarkably intermittent type and radiations are very frequent. In renal infarc- tion the kidney is especially sensitive to pressure, 256 PAIN whereas in the other condition tenderness may occur only along the course of the ureter. It is quite impossible to differentiate the pain of renal infarct from that accompanying other intra- renal conditions. All other diseases which occur in this location may give rise to similar pains, and for that reason the description just given may serve as a type for all true "nephralgia." I will there- fore spend little time in discussing the other patho- logical conditions which occur in the kidney and are accompanied by pain. (b) Acute and Chronic Nephritis, Pyelitis, and Paranephritis. Acute paroxysmal pains may occa- sionally, though rarely, accompany the non-suppura- tive inflammations of the kidney. These are then due to pericapsular inflammation, and damming back of the urine, with acute congestion and increase in the capsular tension. Thus acute hyperaemia, as it occurs in cases of nephritis, may give rise to intense pains which are similar to those just described in renal infarct, and these pains may be one-sided in spite of symmetry in the pathological process. It is therefore advisable to be very cautious in the diagnosis of calculus when sudden- colicky pain occurs in the neighborhood of the kidney in acute nephritis, even when, as in one of my own cases, radiation occurs into the thigh. Such an occurrence, while it must be thought of, is nevertheless extremely rare in all cases of non-suppurative nephritis. I have seen onlv one such case. URINARY SYSTEM AND SPLEEN 257 Of much greater frequency are those uncertain dull back-aches, the relation of which to the kidney is subject to great doubt and must be judged individ- ually in each case. It is very rare that we have any definite factor which points to the kidney as the source of the pain. I have seen cases, however, in which the patient has stated that excessive drinking has increased the pain, while, on the other .hand, discharge of the urine has decreased it considerably. In contrast to lumbago, the pain in nephritis and pyelonephritis is not at all influenced by stooping; while, on the other hand, walking about, severe exer- tion, and pressure increase the pains, just as in the case of lumbago. In these conditions, too, the pain is occasionally one-sided. As a matter of practical importance it is well to examine the urine for al- bumin in all cases where a pain suggestive of lum- bago exists, and this, especially, when no other clearly rheumatic pains are present. It is also important, whenever albuminuria has been discovered, to examine the kidney for tender- ness. Occasionally, hypersemia of the kidney and consequently increased intracapsular pressure will give rise to sensitiveness on palpation. Percussion in the loin is best made with the clenched fist. By palpation in front it is often possible to press directly upon the lower pole of the kidney. When- ever slight pressure in the loin or slight jarring in this neighborhood causes pain and we can determine the presence of hyperaesthesia along the ileohypo- gastric and genitocrural nerves, we must think of 17 258 PAIN the possibility of paranephritic suppuration. In such cases the patient often lies with the thigh flexed and adducted, has chills, and suffers great pain upon change of position. (c) Renal Congestion. Just as the liver is the seat of pain when it is congested in consequence of cardiac insufficiency, so the kidney may be the seat of pain under similar conditions. This, however, occurs much more rarely. The pains in the back are then very promptly relieved by digitalis. (d) New Growths of the Kidney. Pain in the lumbar region and the flank, when unilateral, must occasionally arouse suspicion of an early neoplasm of the kidney and should lead to a careful palpation of the organ. Increase in the intracapsular tension in conse- quence of the enlargement of the new growth, con- gestion or haemorrhage into the tumor, may give rise to pain, even in the early stages. In these cases, too, the pains havethe characteristics of true kidney pains in the special sense of the word, and correspond to the pains described for renal infarct. In conse- quence of the increased weight of the organ the tug- ging pains accompanying change of position will be more noticeable than in infarction, so that the patient cannot bear to lie on the side opposite to that of the diseased kidney. The pain is often provoked by bending, lifting, or the carrying of a heavy weight. This may be due either to temporary passive hyper- semia or to direct pressure by the contracting abdom- inal muscles. In these cases, too, there may occa- URINARY SYSTEM AND SPLEEN 259 sionally be sensitiveness to pressure in the corre- sponding thigh. When the new growth penetrates into the pelvis of the kidney and secondary haemorrhage occurs, a new source of pain arises ; but then we are dealing with the colicky pain belonging to the urinary pas- sages which will be spoken of in a later section. (e) Tuberculosis of the Kidney. In many cases tuberculosis of the kidney occurs without local pain. Nevertheless cases occur in which pain is one of the earliest symptoms. Whenever considerable capsu- lar or pericapsular inflammation occurs, nephralgia will be present, and such pains, in the presence of a tuberculous tendency or of tuberculosis in other parts of the body, must always arouse suspicion. The pain seems to be in many cases extremely acute, and is described as boring like that of a boil. Just as in new growth, so in tuberculosis of the kidney sudden paroxysmal attacks may occur. These occur whenever by ulceration and erosion of a blood vessel a haemorrhage takes place into the pelvis from one of the papillae. The localization of the subjective and objective pains in this condition corresponds more or less closely to that described for renal infarct. The painful sensations which occasionally occur in the bladder and urethra, without any disease in these organs, must be explained by radiation, and consist chiefly in a painful desire to urinate, and burning pain before and after micturition; so that these pains may simulate a cystitis. 260 PAIN (f) Paroxysmal Hcemoglobinuria. In this con- dition there is occasionally an acute hyperjemia of the kidney with consequent intracapsular pressure; the pain in the back which occurs is probably to be interpreted upon this basis. The subjective pain which occurs in one or both kidneys is often accompanied by sensitiveness. The pain is then dependent upon motion, such as ris- ing from a stooping position, bending forward and turning towards the painful side. (g) Movable Kidney. It must be remembered, in considering movable kidney, that many patients in whom an enormous amount of freedom of motion of the kidney exists are almost entirely free from pain. This fact ought to be considered very seri- ously, because it is a quite common error that when a movable kidney is present in a patient, this is taken as the cause for any existing pain. In most cases it is not the wandering kidney which causes the pains. The individuals in whom they are present are usually of an extremely neurasthenic type, and suffer from a general enteroptosis. These are the conditions which should be treated rather than that of the movable organ itself. It stands to reason that in this condition there is a constant tugging on the renal plexus and indirectly therefore upon the solar plexus. This leads naturally to hyperasthesia in the abdominal sympathetic system and consequent irritability of the stomach, gall-bladder and genitals. In this sense, a movable kidney and enteroptosis may be very disagreeable complications of gastric URINARY SYSTEM AND SPLEEN 261 ulcer or cholelithiasis. Whenever an abnormally movable kidney is also tender and sensitive to pres- sure, it is well to think of diseases of this kidney, such as calculi, pyelitis, or tuberculosis. In referring any existing pain to the mobility of the kidney, it is important to determine whether motions which directly result in tugging or jarring of the organ, such as walking downstairs, rapid change of position, etc., are the ones which cause the pain; and it is never just to attribute pains which are present during absolute quiet to this cause. It must be remembered, however, that other diseases which are often accompanied by enteroptosis, such as ulcer, chronic appendicitis, and gall-bladder dis- ease, may also be dependent upon such jarring movements. The exact diagnosis in these cases is often ex- tremely difficult, and it is better, therefore, to let the therapeutic interference precede the diagnosis rather than vice versa. Whenever the pain is re- lieved when the kidney is immobilized by bandages, the diagnosis, of course, is cleared up. It is surely very rare that torsion of the pedicle of a movable kidney occurs; and it is well to think of this only after the exclusion of other causes for the attack. Whenever this does occur the pain that accompanies it can be explained in two ways: 1. Acute venous stasis. 2. Acute development of ureteral obstruction with secondary hydronephrosis. In both cases local sensitiveness would be easily ex- plained. In the second case, however, an attack of 262 PAIN polyuria would theoretically be expected towards the end of the attack. On the other hand, it is well to remember that in neurasthenic individuals, among whom the large majority of movable kidneys occur, polyuria is not a rare symptom. II. Pains Caused by Distention and Muscular Spasm along the Urogenital Tract (Renal Pelvis and Ureter). The pains which are considered in this connec- tion are in their genesis closely related to those occurring in the gall-bladder system, and may easily be classified in the same way. The pelvis of the kid- ney may be regarded as analogous to the gall- bladder and the urinary bladder to the duodenum. The characteristics which distinguish the pains in these passages from the true kidney pain (ne- phralgia) are the marked tendency to colicky attacks and the tendency to radiation ; for we have here in contradistinction to the kidney itself a channel for radiation along the ureter and bladder. The chief causes which may give rise to colicky attacks in the genito-urinary ducts are analogous to those which give rise to similar pains in the gall-duct system. 1. Stenotic Processes. The most important causes for stenosis are : (a) Calculi, blood clots, par- ticles of new growth, and aortic aneurysm (on the left side), (b) Kinking and torsion, (c) Carci- noma of the bladder at the points of entrance of the ureters. (This would be analogous in the bile pas- sages to a carcinoma at the papilla of Vater or in the head of the pancreas.) URINARY SYSTEM AND SPLEEN 263 2. Inflammatory Processes, Ascending and De- scending. Pyelitis with or without the formation of calculi ; this may or may not extend into the small tubules of the kidney (pyelonephritis). Ureteritis is entirely analogous to cholecystitis and cholan- geitis, while the pyelonephritis can be compared with Hanot's biliary cirrhosis. All these conditions, and especially the formation of calculi in the kidney pelvis, give rise to colicky, paroxysmal pains. On the other hand, they may also give rise to more constant pains, not colicky in their nature, the understanding of which is of ex- treme importance. These more constant pains are probably due to a moderate degree of distention along the ureters or pelvis. It must be remembered, too, that any pathological process in the renal pelvis easily involves the kidney itself, even when it is only a temporary damming back of urine or an active hypersemia; and this, in its turn, can give rise to the true kidney pain which we have spoken of before. As a practical matter it is almost impossible to separate the purely stenotic and the inflammatory processes which occur along the renal pelves and the ureters. They often occur at the same time, for stagnation, as is well known, carries with it the predisposition to infection. For this reason we may disregard this purely artificial distinction in the consideration of the pain. (a) THE FORMATION OF CALCULI IN THE PELVIS OF THE KIDNEY. Just as in describing the true kidney pain, the pain caused by infarct of the kidney was 264 PAIN used as a type, so the pains occurring in the pelves and ureters are well typified in a general way by the pains caused by a calculus in the renal pelvis. For practical reasons it is well to divide such pains into (1) spontaneous attacks of paroxysmal pain or colic, (2) more constant pains not colicky in their character and often elicited by physical examination. (1) The localization of the colicky pains is rather apt to be confusing to the diagnostician. Sometimes these pains occur first in the region of the gall- bladder along the right costal border. Occasionally they have their seat more deeply in the ileocascal region or, if left-sided, just above the left Poupart's ligament. In comparatively rare cases the lumbar region may be the starting point of the pains. This is not at all surprising when we consider that the lesion upon which the pain is based has its seat, not in the kidney itself, but in the ureter. More important than the actual location of the pain is the radiation, which unfortunately is not always present. This occurs into the thigh of the same side, chiefly radiating down the anterior or external surface, and rarely extending further down than the knee. We must be on the watch, too, for radiations into the bladder and the genitals, with occasional cramp- like sensations in these organs. It is very important to remember that painful sensations in the testicles, ovaries and thighs may for a long time precede the first attack. These pains occur especially at night URINARY SYSTEM AND SPLEEN 265 and their diagnostic importance must not be under- estimated. The pain not infrequently radiates into the lum- bar regions; upward it rarely reaches higher than the angle of the scapula. Whenever the attacks occur spontaneously they seem to be dependent upon mechanical agencies rather than upon digestive causes. Motions which give rise to a sudden stiffening of the abdominal walls, lifting, or throwing, seem frequently to have a causal relation to the begin- ning of an attack. On the other hand, I have seen cases in which attacks have been initiated by the drinking of sour wine, the taking of sour food, such as vinegar, and occasionally the drinking of beer. Such digestive influences upon the attacks occur nat- urally in cases in which, in addition to calculus for- mation, there is an inflammatory change of the mucous membrane of the pelvis and ureter which is irritated by the reaction of the urine passing through it. Whenever a paroxysm ceases with great sudden- ness we are led to believe that a calculus has been discharged into the bladder. The secondary symptoms chiefly to be consid- ered are those which arise from the urogenital sys- tem and therefore point directly to the origin of the colicky attack. Chief among these are the desire for frequent micturition and retention of urine. In tuberculosis of the kidney, kidney infarct, and other conditions of nephralgia or true kidney pain, the 266 PAIN desire to urinate may occasionally entirely disap- pear. Sometimes there is definite sensitiveness of the testicle on the affected side with occasional swelling. Swelling and sensitiveness in the urethra may be the premonition of an attack. Very definite clews, of course, are given by haematuria, albuminuria, ura- turia, phosphoturia, oxaluria, and cystinuria. Eeflex symptoms, aroused in other organs by the renal condition, may considerably cloud the diag- nostic picture. Meteorism with constipation, diffuse distribution of the pains, with collapse, may simu- late acute intestinal obstruction and, in just such cases, the extreme sensitiveness of the testicles is of distinct diagnostic importance. The distended ab- domen itself is often sensitive to pressure, and in such cases distention and sensitiveness are usually localized more on one side than on the other. Occa- sionally there may be no pain in the kidney region itself. Gastric symptoms, such as nausea and vomit- ing, occasionally occur, but are much less frequent than in connection with the colics of the biliary sys- tem, and, during the attacks of renal pain, the diges- tive system is often entirely normal, not even the appetite being changed. In many cases there are subjective sensations, such as a sensation of cold, etc., in the thigh of the same side. There may also be motor symptoms, such as spasm in the muscles of the calf or the thigh of the same side. Sensitiveness to pressure along the ureter on external examination per rectum or pervaginam is of URINARY SYSTEM AND SPLEEN 267 the greatest importance, and from this examination alone the diagnosis of an obstructing calculus can often be made. (2) More constant pains (without paroxysmal quality). Under this heading we include chiefly pain which is not subjectively present but is discov- ered on palpation. We have already called atten- tion to the sensitiveness of the testicle. In addition to this there is usually sensitiveness of the ureter, leading on the right side to pain in the neighborhood of the appendix; on the left side in the neighbor- hood of the sigmoid flexure. The sensitiveness to pressure in the flank and to percussion in the lumbar region is of great impor- tance. The maximum point of sensitiveness is often located just above Poupart's ligament. Occasion- ally when the condition exists on the right side the gall-bladder is very sensitive and errors may arise from this fact. When this is the case, however, very often sensitiveness in the gall-bladder radiates towards the urinary bladder and this, of course, is of great importance. These more constant pains may often be started by the patient's lying on one side. When the process is bilateral lying on either side is painful. In some cases no fixed position can be held for any length of time without great pain. We spoke of such positions of greatest pain when dealing with cholecystitis, and here again symptoms of this kind are due probably to changes in the pelvis of the kidney; they may also be caused by secondary in- 268 PAIN volvement of the kidney in the form either of an acute damming back of the urine, or an acute conges- tion of the kidney itself. Coughing, deep breathing, and jarring of any kind may give pain in nephro- lithiasis. The unilateral neuralgia of the testicle which occurs chiefly at night, and the so-called rheumatic pains in the thigh, may often precede the true colicky attacks by many years. The sensations of weakness, nausea, etc., which usually accompany the colicky attacks may be present by themselves frequently, and are then, almost invariably, wrongly interpreted. Under this heading, too, we must consider that pain in the lumbar region which frequently accom- panies the condition. This is present especially in the lying and sitting postures, and is less marked when walking. Alone, of course, the recurrence of such a pain can give us no diagnostic clue ; but, in connection with other symptoms, such as testicular pain and parsesthesia of the thigh, it may give much additional support to our diagnosis. (b) PYELITIS. Of chief importance are the ascending catarrhs of the urinary passages, usually preceded by a history of an old gonorrhoea, so that in many cases the ureter and the bladder itself may be regarded as diseased together. This variety of pyelitis is the most frequent. The pain occurring in this condition is almost identical with that occur- ring in cases of calculi. This fact is of particular pathological interest, since it lends support to the opinion that pains of this description are, in these URINARY SYSTEM AND SPLEEN 269 cases as well as in gall-bladder condition, caused by the inflammatory lesions rather than by the mere mechanical presence of calculi. Changes of the kidney in all their transitions from a simple inflammatory hypersemia to a fully developed pyelonephritis may accompany this con- dition. A part, therefore, of the clinical picture is made up of the true kidney pain itself. The local- ization of the pain is much the same as that men- tioned above. Occasionally, however, cases occur in which the pain and sensitiveness take place in the region of the gall-bladder and appendix and thus lead to error in diagnosis. The radiation is identical with that which occurs in calculi of the renal pelvis. Radiation may occur at the same time as the colicky attacks or may be entirely independent of them. It may be localized chiefly on the outer side or occasionally on the inner side of the thigh of the same side. Prolonged sit- ting occasionally initiates these radiating pains. In isolated cases it is not so much the sensation of pain as the sensation of weakness and fatigue in the lower extremity of the same side as the disease which gives rise to a suspicion of a lesion in the renal pelvis. Sometimes sensitiveness occurs along the dorso- lumbar portion of the spinal column. Pain occur- ring while the patient is lying on his side is located usually in the side opposite to that of the lesion. Frequently the pain which occurs in this posture is present only during the acute attack and disappears when the attack is over. 270 PAIN There is often a tendency towards relaxation of the abdominal muscles on the diseased side. The patients lean toward that side while walking or sit in a cramped position. Sudden stretching of the abdominal muscles often brings about an attack of intense pain and syncope, in cases which have been before that almost free from pain. In doubtful cases it is often advisable to test cautiously the influence of lifting or carrying weights on the back. Violent jarring, such as is produced by stamping the foot, jumping, etc., will frequently give rise to pain. In contradistinction to lumbago, the pain is not increased by stooping, even when there has pre- viously been severe pain in the lumbar region. Catching cold and exposure to wet often give rise to attacks of pain. This is probably due to the fact that these conditions may provoke an acute exacer- bation of a chronically inflamed condition of the mucous membrane. It need hardly be emphasized that careful micro- scopical examination of the urine and careful atten- tion to the temperature are desirable. Pyemic tem- perature frequently occurs and the individual par- oxysmal attacks may be accompanied by a chill and subsequent sweating. Fever may precede the at- tacks for some time, for the infectious agent, which not infrequently is B. coli or staphylococcus, plays an important role in these cases. The most important secondary symptoms are fre- quent desire to micturate and ardor urinae. URINARY SYSTEM AND SPLEEN 271 (c) HEMORRHAGE FROM THE KlDNEYS. Bleeding from the kidney can unquestionably give rise to paroxysmal attacks of pain, so that the expression Nephralgie hcematurique is fully justified. It is very important to remember that cases of prolonged and constant haematuria exist, so-called 1 'essential haematuria," without a lesion in the kid- ney and without any accompanying pain. Haema- turia, therefore, gives rise to pain only when other underlying factors are present. The most impor- tant of these is the presence of blood coagula (malignant tumors, ulcerative erosions of renal capillaries, as in tuberculosis of the papilla, etc.). The clots in these cases produce the same patholog- ical condition in the ureters as calculi, and occa- sionally cause obstruction. In addition to this, sud- den profuse bleeding may cause severe distention and in this way give rise to paroxysmal pains. It is a general fact that under suitable conditions bleeding into hollow muscular organs may by acute distention give rise to paroxysmal pains. The writer has seen one case at autopsy in which bleed- ing had taken place into the stomach from an cesophageal vein. In this case severe paroxysmal pains in the epigastrium had occurred. A true kidney pain, that is, nephralgia in the true sense of the word, is occasionally caused by bleeding from -vascular tumors of the kidney, by " essential haematuria," or by acute exacerbations of chronic nephritis ; such pains may be due either to distention by the haemorrhage or to acute congestion. 272 PAIN URINARY BLADDER. The chief characteristic of pain in the bladder is the direct relation which it has to the function of the organ, that is, urination. The problem of diagnosis is simpler by far in this organ than in any of the other hollow muscular organs, since pathological changes in micturition can be closely observed by both patient and physician. The mechanism of the pain, therefore, can be more ex- actly studied, and the conditions prevalent here can serve to throw light upon similar pains occurring in the gall-bladder and stomach. The conditions which give rise to bladder pains are the following: 1. CATARKHAL AND ULCERATIVE CHANGES IN THE Mucous MEMBRANES OF THE BLADDER AND THE URE- THRA. These are chiefly caused by acute and chronic forms of cystitis following urethral infections, in- flammatory conditions due to calculi, foreign bod- ies, tuberculosis, neoplasms, etc. Urethral stric- tures and enlargement of the prostate, benign or malignant, are important in that they predispose to cystitis. 2. PERIVESICAL INFLAMMATIONS. These are chiefly diseases of the female genitals and diseases of neighboring parts of the intestine (rectum and appendix). The pain is often directly related to the contrac- tion of the bladder muscle and reaches its maximum at the height of contraction, that is, during the end of micturition and immediately after it. URINARY SYSTEM AND SPLEEN 273 Distention o-f the bladder wall whenever sudden may also cause great pain. This is closely analo- gous to conditions existing in the gastro-intestinal tracts and the bile-ducts. The localization of the pain, both subjective and objective, corresponds to the location of the organ, occurring behind the symphysis. In prostatic dis- ease it is occasionally located in the pierineum. Ra- diation occurs along the urethra and into the glands, into the .testicles, and into the inguinal regions. Sometimes the pain radiates into the anus and the perineum. When this happens it may be explained by the common innervation of these regions by the sacral plexus. Reflexly radiation may occur upwards into the hypochondriac regions, downward into both thighs, and into the regions innervated by the sciatic and the anterior crural nerves. This, for instance, is the case in prostatic tumors. It must not be forgotten that in rare instances prostatic tumors may occur without pain. The gen- eral condition of the nervous system seems to have great bearing upon this feature. As we have said, bladder contraction is the most important factor in producing the pain. The more forcibly, therefore, this contraction occurs (as in stricture, enlargement of the prostate, and calculi), and the more severe the inflammation of the mucous membrane, the more violent will be the attacks. In cases where the mucous membrane of the bladder itself is intact, and the pain is due only to tugging 18 274 PAIN on the perivesical adhesions, the attacks are never very severe. Jarring and sudden changes of position, when they have any relation to the pain at all, point toward the existence of calculi. It is always neces- sary to examine by palpation above the symphysis and per rectum or vaginam. Cold drafts, wetting the feet, etc., may reflexly give rise to bladder peristalsis. The physical and chemical properties of the urine may also exert marked influence upon the pain. Concentration of the urine, as in fever with serous exudation (as in tuberculous peritonitis) or in con- sequence of severe perspiration, may give rise to pain in an irritable bladder. Spicy food and certain drugs, such as urotropin, in large doses, give rise to similar sensations. The most important secondary symptoms to be considered are pyuria and bacteriuria. Whenever these two conditions are absent, we should suspect calculi or perivascular inflammations ; haematuria, too, for obvious reasons, is not rare. Whenever this occurs, together with pains in the bladder, a vascu- lar origin of the pain is most likely. Frequent mic- turition is, next to pyuria, the most usual of the secondary symptoms. The fact that the pains are usually in direct rela- tion to the bladder function, makes an error in diag- nosis rather rare ; yet it is well to remember that the symptoms of disease of the bladder itself are so similar to those of disease of the prostate and pos- URINARY SYSTEM AND SPLEEN 275 terior urethra, that a separation from these is almost impossible without the aid of objective symptoms. Examination of the prostate is, therefore, essential. Differentiation of these conditions from a'ttacks of pain which, like gastric crises, have their origin in the central nervous system, may be neglected because of the extreme rarity of such attacks. On purely theoretical grounds, we may say that conditions dependent upon the nervous system would be independent of micturition. Sensitiveness of the bladder upon examination per vaginam or per rec- tum would point to organic disease. The pains occa- sionally radiate into the rectum and are in direct relation to defecation. This occurs chiefly in dis- eases of the prostate and in vesical calculi, and may lead to an erroneous diagnosis of intestinal disease. Radiations into the genitals and thighs may occa- sionally be misconstrued as ureteral colic. Only careful physical examination can guard us against these errors. In the section on true kidney pains, we called attention to the fact that neoplasms of the bladder may, by obstruction to the ureters, give rise to ureteral colic and sensitiveness of the kidneys them- selves on one or both sides. Conversely, tubercu- lous disease of the kidney may frequently be accom- panied by the subjective symptoms of cystitis, and, even when the bladder and urethra are entirely nor- mal, pains may be produced in them by pressure upon the diseased kidney. 276 PAIN SPLEEN. Pathological processes in the spleen often give rise to pain at extremely early stages of their de- velopment, and, in correspondence with the position of th^ organ, such pain is localized in the left hypo- chondrium. Since we are dealing with a ductless gland the pains produced here cannot possess the manifold variety of those occurring in organs with muscular ducts. Here there are but two factors to be considered: 1. Distention of the spleen capsule with enlarge- ment of the organ. 2. Inflammation of its. peritoneal coverings (perisplenitis). The conditions which a-re accompanied by pain in the spleen are chiefly: (a) Myelogenous Leukcemia. In this condition the pain in the spleen is frequently one of the first symptoms. Sudden and intense pain is caused by inflammation of the capsule with or without the formation of infarcts. Pseudoleukaemia and polycy- themia also give rise to pain in the spleen ; chlorosis and pernicious anaemia more rarely. (b) Cirrhosis of the Liver. Splenic involve- ment is most frequently found in cases of syphilitic cirrhosis, and in such cases the perisplenitis goes hand in hand with the existing perihepatitis. Many of the so-called Banti's cirrhoses (hereditary lues) come under this heading. Splenic pains occasionally accompany Hanot's cirrhosis, but are hardly ever present in the atrophic variety of Laennec. URINARY SYSTEM AND SPLEEN 277 (c) Paroxysmal Hamoglobinuria. During at- tacks of paroxysmal hsemoglobinuria splenic pains may occasionally be noticed. (d) Infectious Processes. The infectious proc- esses which are most commonly accompanied by splenic pain are typhoid fever and malaria. Occurring in the left axillary line, the splenic pains in these diseases are often erroneously re- garded as evidences of a pleurisy or a, lower lobar pneumonia. This error is more easily made since in cases with splenic swelling fine crepitant rales often occur along the line of separation between the lung and the spleen, due to atelectasis of the margin of the lung. Whenever we are attempting to obtain a history of a previous attack of malaria, it is well to inquire whether at the time of the chill there* were pains in the splenic region. Sharp pains along the right costal border often occur together with these and are due to hepatic swelling. Pain on palpation along the left costal border in a patient who is running a temperature and in whom we can exclude pleurisy and subphrenic ab- scess, usually points to marked swelling of the spleen. (e) Heart Disease. In patients with heart le- sions (mitral stenosis, etc.) acute pains occurring in the region of the spleen or sensitiveness in the inter- costal spaces corresponding with the position of the spleen, should always arouse the suspicion of splenic infarction. This suspicion is strengthened by symp- toms of emboli in other regions (renal arteries, etc.). 278 PAIN Progressive increase of the pain in a case of recent endocarditis points to the possibility of sec- ondary abscess formation. Since the position and size of the spleen are subject to great variation in the different patho- logical conditions, it is natural that the exact topog- raphy of the pains should show corresponding varia- tion. In all cases, however, the pain is felt in the left side along the lower thoracic and upper abdomi- nal regions. Whenever pain occurs in this situation examinations should be made for sensitiveness under the left costal border and in the lower intercostal spaces from the eighth downward. Splenic tumors may occasionally give rise to dorsal pain, especially after prolonged lying on the back. When the spleen is so large that it sinks for any considerable distance below the costal border, as in leukaemia, for instance, it is important to deter- mine whether the sensitiveness is of diffuse or cir- cumscribed nature. Circumscribed pains of this de- scription are occasionally due to splenic infarct or local perisplenitis. Every now and then pain occurs along the angle of the left scapula or between the shoulder blades. In some cases there is marked pain in the left shoul- der, often so severe that motion of the left arm becomes difficult. Such radiations may occur spontaneously or may be caused by sudden stooping, trauma, or lying on the left side. In such cases localized points of sensi- tiveness can be determined. The most common situa- URINARY SYSTEM AND SPLEEN 279 tions of these are over the acromion process and at the junction of the external and middle third of the upper edge of the trapezius muscle. The conditions prevalent here are exact counterparts of those exist- ing in the right shoulder with perihepatitis. The quality of the pain is usually described by the patient as stabbing or tearing. Mechanical motions often initiate attacks of pain. The mechani- cal factors to be considered are : 1. Compression of the organ produced by stoop- ing, quick turning to- the left of the trunk upon the hips, lifting of the left arm, etc. In contrast to this, relaxation of the abdominal muscles relieves the pain, and in consequence patients often walk in a stooping position. Palpation and percussion in- fluence the pain in a similar way. 2. Change of Position of the Organ. Lying on the left or right side usually produces pain and a sensation of tension in the left side. This is espe- cially the case when the stomach is empty, the full stomach acting as a sort of cushion. For obvious reasons deep breathing will cause pain when peri- splenitis is present. 3. Sudden Jarring. All varieties of jarring will give rise to pain, prolonged walking, running, riding in a carriage, hiccoughing, sneezing, etc. Occasionally, besides the mechanical means of starting the pain, digestive conditions will influence it. Abnormally large quantities of food will give rise to pain by causing secondary hyperaemia of the organ. This is especially the case when inflamma- 280 PAIN tory adhesions exist between the stomach, and the spleen. The influence of drugs on the diagnosis is not negligible since the pain caused by increased tension of the capsule is diminished by all those drugs which produce a diminution in the size of the spleen. Such are arsenic and quinine. The most frequent secondary symptoms occur- ring with splenic pain are increased size of the spleen as detected by percussion and palpation, fric- tion sounds produced by perisplenitis, and a systolic murmur heard over the splenic vessels. The most important condition to be* considered in differential diagnosis is pleurisy. Differentiation is especially difficult in the case of acute disease, such as malaria and typhoid fever. The pains in these cases are felt in the axillary and intercostal regions. They are dependent upon deep breathing. Lying on the left side is usually painful and occa- sionally produces a cough. There are fine crepitant rales over the area of pain, due to atelectasis caused by the large size of the spleen. By these signs one is led to suspect pleurisy or early pneumonia and to forget the fact that the pain may be due to an increased tension upon the splenic capsule. In the same way infarcts of the lung and spleen may often be mistaken for one another in patients with heart disease. In such cases examination of the spleen reveals its sensitiveness. Much informa- tion, too, can be gathered by careful examination of the intercostal spaces in the axillary line in order to URINARY SYSTEM AND SPLEEN 281 determine whether or not they are sensitive. When the condition is one of splenic pain the sensitiveness in the intercostal spaces is limited pretty well to the area of dulness of the organ. Splenic pains are occasionally misinterpreted as arising in the stomach, since, as has already been mentioned, the taking of food often increases the pain or initiates an attack. In a general way this can be avoided by remembering that in splenic con- ditions the quantity of the food, entirely independent of its quality, gives rise to the attack. In cases where radiation of the pain into the left shoulder takes place, a diagnosis of articular rheumatism is occasionally made. The absence, however, of change in the joint itself, the entire freedom of motion, and the determination of the above-men- tioned points of tenderness (at the acromion and along the border of the trapezius) will aid in the differentiation. CHAPTER IX. RESPIRATORY AND CIRCULATORY SYSTEMS. THE LUNGS. PAIN may unquestionably occur in the trachea and the two main bronchi. At any rate, it is cus- tomary to interpret the retrosternal pain occurring almost regularly with acute bronchitis during the stage of dryness and congestion, as emanating from these organs. On the other hand, distinctive proc- esses which involve the air vesicles of the lung, such as lymphosarcoma and pulmonary abscess, may run their entire course without any pain. It is, there- fore, perfectly safe to claim that lesions occurring in the parenchyma of the lung itself do not give rise to pain. The production of pain in disease of the lung is, therefore, dependent entirely upon involvement of the pleura. This, of course, is most frequently of an inflammatory nature. These simple facts give the key to the compre- hension of all pains which occur in connection with pulmonary disease and permit us to understand their nature and radiations. It must not be forgotten that the visceral and parietal pleura are in very intimate relation with many nerves (brachial plexus, intercostal and phrenic nerves), and that they likewise have close anatomical relation to the intercostal muscles and 282 RESPIRATION AND CIRCULATION 283 diaphragm. For these reasons the occurrence of secondary neuralgias and myalgias is more than likely. Since, therefore, the pains accompanying all the various lesions of the lung are dependent upon the inflammatory pleurisy, it is simplest to describe them all together in a general way, pointing out, as we proceed, the various features of differentiation. As regards localization, these pains correspond almost exactly with the situation of the pleural in- flammation, and the greatest intensity of the pain, both subjectively and objectively, coincides with the most marked auscultatory sounds. Disease of the pleura over the upper lobes (tu- berculosis and neoplasms) evidences itself chiefly by pain in the region of the shoulder, in the supra- and intraclavicular fossae and in the supraspinous regions. These pains should be looked for espe- cially in cases in which we suspect early tuberculosis. The pains in the shoulders, which so often occur in tuberculous patients at the very beginning of the disease, are probably caused in most cases by the adhesions at the apex of the lung found so fre- quently at autopsy. The inflammatory process oc- curring along the summit of the pleura may involve secondarily the brachial plexus and the upper inter- costal nerves. For this reason tenderness along the brachial plexus and along the upper intercostal spaces is frequently present in cases of tuberculosis and is in many cases one of the first symptoms. The point of tenderness which was mentioned as a reflex 284 PAIN symptom of hepatic and splenic enlargements (at the junction of the outer and middle thirds of the upper border of the trapezius muscle) can occasionally be demonstrated in these cases as well. It need hardly be mentioned that carcinoma de- veloping in the apex of the lung might give rise to secondary injury of the brachial plexus and conse- quent neuralgia in the arm. When the pleura are diffusely diseased, as in pleurisy and pyopneumothorax, the subjective pain and tenderness often fail to show a correspondingly diffuse character. On the contrary, they are usually located in the axilla or in front, rarely posteriorly, and, when this does occur, only in the last intercostal spaces. This is due to a number of causes. Chief among these, probably, is the fact that the respiratory excursions of the lung reach their greatest develop- ment at the bases and thus the greatest motion of the pleural leaves upon each other takes place in the costophrenic sinuses. Whatever the reason may be, the facts remain that pains which arise in the pleura are frequently found only in the axillary line, and that sensitive- ness to pressure is limited to the area below the fifth intercostal space. The latter fact may in part be due to the absence of a muscular covering over these spaces. Occasionally, cases of diffuse pleurisy and pleuropneumonia of the lower lobe occur, in which the tenderness is limited to the abdomen, just below RESPIRATION AND CIRCULATION 285 the costal border. This may lead to errors in diag- nosis. In such cases upward pressure in the flank, hypogastrium, and (in right-sided cases) even the ileocaecal region, will give rise to pain. This peculiar distribution of the pain is probably due to involvement of the diaphragmatic pleura. The diaphragm forms a sort of bridge across which the thoracic pain enters the abdominal regions. Even the subjective pain in pleurisy may in a good many cases be localized along the costal border. One of the favorite seats of pain in left-sided pleurisy is the region of the heart apex. This may be due to the fact that during systole the apex of the heart, by friction, increases the inflammation and, therefore, in spite of the diffuse nature of the pleurisy, may give rise to circumscribed pain. Retrosternal position of the pain is rare. It does occur, however, and is usually associated with in- flammation of the mediastinal pleura and with le- sions of the mediastinal lymph nodes. In such cases, however, it would also be necessary to think of pericarditis. The pains occurring in the interscapular space in pulmonary tuberculosis may also occur in diffuse pleurisy. The quality of the pain is rarely characteristic, and it is very difficult to differentiate it from that of intercostal neuralgia or myalgia. As a general rule we may say that the pain is of a sharp and stabbing character. 286 PAIN Special characteristics of the pain are present only in rapidly developing pneumothorax, where the pain, just like the pain accompanying perforation of the gut into the peritoneum, is extremely acute and diffuse, and involves the entire half of the thorax. Added to this there is a peculiar sensation of internal soreness or tearing. Similar pain, how- ever, may be observed in subpleural cavities without perforation, and the confusion may be increased by the occurrence of collapse. Similar acute attacks of pain occasionally accompany the perforation of an empyema. The factors most markedly influencing the pleural pain are: 1. Pressure. There are cases of pleurisy in which even a light touching of the skin of the thorax with a needle, with the bare hand, or with the bed-cover, may give rise to the most intense pain (empyema). On the other hand, there may be all transitions from this extreme condition of sensitiveness to an absolute lack of pain. The factor determining this, of course, is the degree of acuteness and severity of the inflam- matory process. The condition is unquestionably analogous to a similar condition in the peritoneum. The area of sensitiveness to pressure is usually much more diffuse than the area of subjective pain. In every individual case it is important to observe the zone of sensitiveness and to observe its increase or decrease during the course of the disease. In pleuropulmonary disease the pain which occurs in the abdomen is hardly ever spontaneous and is dis- RESPIRATION AND CIRCULATION 287 covered only by examination. While the dia- phragm, as mentioned above, is usually the means of transmission of such pain to the abdomen, in right-sided lesions it is always necessary to consider the possibility of secondary liver pain due to peri- hepatitis or hepatic congestion. Sensitiveness to pressure is limited chiefly to the axillary and anterior aspects of the thorax, and favors the lower intercostal spaces. This is true at any rate of cases of acute pleurisy. In apical tuberculosis when pleural adhesions are developing, the sensitiveness to pressure is usually localized in the subclavicular or subspinous fossae, and in the upper anterior intercostal spaces. The same is true of cavity formation in apical tuberculosis. These objective pains are of especial importance for early diagnosis, since they may appear when subjective pains are still absent. The pain may be definitely ascribed to a pleural lesion whenever sensitiveness to pressure and crepi- tant rales are found in one and the same spot. It is occasionally difficult to exclude intercostal neural- gia. (For a discussion of this refer to the chapter on the subject.) "Whenever pressure upon the rib itself is painful, it is obvious that (having excluded periostitis) we must assume the existence of a secondary intercostal neuralgia. In pericarditis the pain seems to be chiefly sub- jective, modified little, if at all, by pressure; it is 288 PAIN located more anteriorly and retrosternally, rather than in the axilla. 2. Position and Motion. Lying upon the dis- eased side causes pain by direct pressure. For a consideration of this position, therefore, the remarks made in the preceding paragraphs may be consulted. When the patient lies on the healthy side, how- ever, different conditions prevail. In this position the patient frequently suffers great distress, which gives him the impression that the pain is drawing over into the healthy side. Such sensations are chiefly present in cases of pleural exudate, more rarely with cavities, and must be ascribed to a shifting of the organs in the media- stinum. When the patient lies upon the healthy side, also, the work of the diseased side is increased and the pain occurring with respiration is neces- sarily greater. In some rare cases lying upon the abdomen relieves the pain. (This was the case in a patient with pleural pain in the neighborhood of the heart apex.) The pain is increased when the patient is upright and his head is bent forward. This is due to the increased costal respiration. Stooping occasionally gives rise to pain. 3. Inspiration and Expiration. Coughing and sneezing come under this heading, since all these forcible movements in the pleura presuppose an analogous action of the muscles of inspiration. In cases of pyopneumothorax, however, there is no increase of the pain with deep inspiration. This 289 is, in part, due to immobilization of the correspond- ing half of the thorax, and in part to a lack of con- tact between the leaves of the pleura. Whenever a chill or any febrile movement is fol- lowed by sharp pain in the axillary regions, the diag- nosis of pleural pain is obvious, and the first sus- picions are, of course, of pneumonia or pleurisy. Yet it is important to remember that occasionally a malarial chill is accompanied by pain in the lower intercostal regions and in the axillary portions of the left chest. These pains we have already referred to as emanating from the spleen and due to tension in the splenic capsule. The presence of herpes and the fine crepitant rales of atelectasis at the base of the left lung (pushing upward of the diaphragm by the enlarged spleen) increase the possibility of error. Whenever pains occur along the lower portions of the thorax it is wise to think of the subdiaphrag- matic organs and their appendages. The sensitiveness which accompanies acute right- sided pneumonia and pleurisy is occasionally local- ized in the ileocsecal region. This is especially fre- quent in children and may lead to a false diagnosis of appendicitis. The interpretation of thoracic pains is far more difficult in chronic conditions which run their course without fever. In such cases it is always difficult to decide whether the pains have a pleural origin (such as the chronic pleural adhesions so often found in tuberculous individuals) or whether we are 19 290 PAIN dealing with an absolutely independent neuralgia or myalgia. When there have been very severe coughing spells it is always well to think of myalgia due to fatigue (analogous to the pains in the calves of the legs following long walking tours). It is perfectly obvious that the pain due to a muscular or nervous cause may be initiated by the same factors that give rise to pleural pain (respiration, etc.). On the one hand, there may be absolutely no physical signs in the chronic adhesive pleurisies; on the other, the pain in intercostal neuralgia, by limiting respiratory excursion, may lead to secondary atelectasis with crepitant rales. It is very important, therefore, to determine whether the lower border of the lung moves properly with respirations. Examination of the domes of the diaphragm with X-ray is also advisable. Careful differential diagnosis in all these cases is almost impossible, but there are a number of points which may be of great help. 1. One-sided objective or subjective pain, local- ized in the axilla, points with great probability to a pleural origin. 2. The same is true of one-sided pain limited to the apex of the lung, especially when this is accom- panied by ana?mia, emaciation and neurasthenia, even when the physical examination of the lung is negative. 3. Careful investigation of the previous history must be made as regards overexertion of the muscles RESPIRATION AND CIRCULATION 291 of the arm or chest, and exposure to draughts. In- quiry must be made as to rheumatic or neuralgic tendencies, and symptoms of these diseases in other parts of the body must be looked for. These, when present, point toward neuralgic or myalgic origin of the pain. 4. Whenever lying on the diseased side causes coughing, it is obvious that the pain emanates from the pleura. In the preceding section we have differentiated pleural pains from those not localized in the pleura, but we have paid no attention to the differentiation of the specific pleural lesions which may produce such pains. In cases in which there is unquestionably a lesion of the lungs and the pleura, the exact nature of the lesion can be determined only by careful analysis of the pain. The very absence of pain in such cases is of great diagnostic significance. Thus, whenever large areas of dullness occur entirely without sub- jective or objective pains, although it is not possible absolutely to exclude inflammatory pleurisy, never- theless it is advisable to think of neoplasms, echino- coccus, dermoid cysts, and pulmonary abscesses, processes which are not necessarily accompanied by severe inflammations along the pleura and may therefore develop with little or no pain. Dullness along the base of the lung without sensitiveness over the lower intercostal spaces points to the existence of a subphrenic abscess. 292 PAIN Symptoms of pneumonia with infraclavicular pains should lead us to think immediately of a begin- ning apical pneumonia. Analysis of the pain often aids in differentiating a cavity from a pneumothorax, a differential diag- nosis which is sometimes extremely difficult. This is true, too, of cases in which we are trying to decide whether a sudden profuse expectoration is due to the evacuation of a cavity or to the rupture of a sac- culated empyema. In the latter case the act of rupture is accompanied by intense pains and the sensitiveness along the intercostal spaces corre- sponding to the sacculation is immediately dimin- ished, just as after the incision of an abscess. Cavities, on the other hand, since they are more centrally situated, hardly ever lead to much sensi- tiveness of the corresponding costal spaces, and give rise to no attacks of pain during the act of evacua- tion. AORTA. The phenomena which have occupied our atten- tion in the preceding chapters, pains occurring in the alimentary tract, liver and kidney, have had three fundamental factors in common: 1. Local spasm in a hollow muscular organ. 2. Local distention of its capsule or walls. 3. Inflammatory processes in their serous cover- ings. The second and third of these factors, as we have seen, may combine in many of these conditions. RESPIRATION AND CIRCULATION 293 It is beyond doubt that diseases of the thoracic or abdominal aorta (such as aortitis or aneurysm) may give rise to pain. The question naturally arises, therefore, whether the mechanism of this pain is entirely a new one, or whether it is caused by factors similar to those occurring in the other conditions. Anatomically, the severe inflammations of the aorta may involve the vessel wall in toto or in part. Such inflammatory conditions are comparable with the third factor given above. It is a matter of fact, too, that added to the in- flammatory processes constant or paroxysmal over- stretching of the inflamed aortic wall may occur (by aneurysm or increased tension). The condition of tension may be chronic (arteriosclerosis), or there may be a sudden increase of pressure with increased action of the heart and increased resistance in the capillaries (vasomotor disturbances, such as cramps or paresis). These conditions are comparable to those mentioned under the second group (see above) which dealt with overdistention. Since, therefore, we have the two elementary factors, two and three actually present and fre- quently acting in unison, the question arises whether the sympathetic nerve endings embedded in the vas- cular wall are capable of conveying painful sensa- tions. This question can be answered decidedly in the affirmative. Definite affirmative evidence is offered by the pressure pain which is found in in- flammatory processes of the peripheral arteries 294 PAIN (carotid, etc.). Similar support for this opinion is found in the tenderness which unquestionably occurs in the suprasternal fossa over the aortic arch or. over the abdominal aorta, in conditions of chronic aortic inflammation. The etiological factors in aortic pain are, there- fore : 1. Inflammatory and degenerative processes in the aortic wall. 2. A condition of hyperaesthesia of the sympathetic network embedded in the aortic wall. 3. Chronic or temporary, local or general, in- crease of internal pressure in the aorta. These factors need not necessarily occur in com- bination, but when present in combination, of course, produce the most favorable conditions for the occur- rence of pain. Thus, a priori, we may assume that two and three together would be sufficient to produce attacks of pain in individuals of a neuropathic tem- perament. The fact that occasionally aortic processes may run their course without pain does not contradict these statements. One might just as well say that articular inflammation is not the cause of the pains of arthritis because occasionally a case of arthritis runs its course without pain. The conditions of primary importance in this con- nection are usually spoken of as "angina pectoris." The name is purely symptomatic and has no relation to the etiology. The mechanism which gives rise to the pain in these cases may be subject to considerable variation. The anatomical basis underlying the pains of angina RESPIRATION AND CIRCULATION 295 pectoris (excluding, of course, all those cases which are essentially neuralgic) seems to consist of two main features. These are disease of the wall of the aorta itself (the ascending aorta and arch espe- cially) and disease of the coronary arteries. There can be little doubt about the production of pain by disease of the aortic wall. Such pain may be of many kinds, and angina pectoris is, in a way, only a special form of aortic pain. Chronic dilata- tion of the ascending aorta or of the aortic arch fre- quently gives rise to constant pain which, in its localization and radiation, is entirely similar to that which characterizes attacks of angina pectoris. We have already called attention to the fact that the general etiology of the aortic pains stands in close analogy to the pains produced in other organs. Quite frequently severe attacks of angina pectoris can be explained at autopsy by gross pathological lesions either of the coronary arteries themselves or of their mouths (usually narrowing of the entrances to the arteries by atheroma or vegetations). Etio- logical relationship unquestionably exists between these lesions and the attacks. Nevertheless, in many cases there is, at the same time, gross pathological change of the aorta itself, and it is hard to decide which of the symptoms are due to the aortic lesions and which are more directly referable to the disease of the coronary arteries. Generally speaking, it is quite likely that the coronary arteries are more directly responsible for the attacks, for it is proba- ble that, during these, ischemia of the heart muscle 296 PAIN occurs, resulting in a condition more or less analo- gous to intermittent claudication. It seems to me, for this reason, that whenever attacks of angina pec- toris are accompanied by signs of cardiac insuffi- ciency, irregular pulse and general collapse, it is logical to think primarily of disease of the coronary arteries. The problem is much more difficult when with severe attacks of pain there is no cardiac insuffi- ciency. In such cases the heart is usually regular, the pulse is full and of good force, and it is likely that, when this occurs, the pain is of purely aortic origin, without coronary involvement. GENERAL SYMPTOMS. The pains which accom- pany aortic lesions are, in a general way, alike, in spite of the variety of pathological conditions upon which they depend. They are situated usually over the diseased organ, and, therefore, are felt in most of the cases retrosternally. Sometimes there is only a feeling of slight discomfort; in other cases there may be an extremely painful sensation of oppression. The conditions for diagnosis are very much more difficult here, of course, than in other organs, because direct examination by palpation is impossible. This should, however, be attempted as well as practicable by pressure into the suprasternal fossa and upon the abdomen. Acquaintance with the most common directions of radiation is important, since radiating pains may occasionally occur without other symptoms. Eadia- RESPIRATION AND CIRCULATION 297 tion is usually along arterial channels, especially when the aortic process is continued, as in arteritis, into other vessels (carotid and subclavian). In such cases the vessels involved are sensitive to pressure. Tugging on the vessels by turning the head or lifting the arm is painful, and subjective pain pos- sibly due to vascular spasms may be felt to extend even as far as the branches of the larger trunks. When the carotid artery is the channel of radiation, symptoms may occur in the parts supplied by this vessel. There are occasionally unilateral or bilat- eral pains in the teeth of the upper and lower jaws. Eadiation may occur into the temporal artery and, in addition to pain, may give rise to buzzing in the ears. When the subclavian is involved similar symptoms may occur in the upper extremities. It is quite reasonable, therefore, to assume that the radiations accompanying aortic pain occur along vascular channels. This, however, does not exclude the possibility that radiations may occur along the brachial plexus and the intercostal nerves as well. Frequently the left brachial plexus is exquisitely tender, both during and between attacks. This may in pa.rt be a reflex pain, but in part certainly it is due to direct mechanical injury of these plexuses (large aneurysms). Pains in the brachial and cervical plexus, of course, can hardly be explained by direct mechanical injury. Again, pains in aortic ^ this reason, and for the sake of greater clearness, on the following figures /only the so-called m? *ima are indicated. It must be remembered, however, that for the present at least, the evidence sdt-ord&l by the demonstration of areas of cutaneouat tenderness or pain is valuable chiefly in the positive sense and that their absence does not preclude tlr- existence of visceral disease. Further- more, in /Any given cases these areas do not neces- sarily preserve their integrity indefinitely, but as the nenp^HS system becomes impaired as the result of prolonged illness, first, the corresponding dis- trict ( 'he opposite side of the body may become ' m , ul later on still more marked generaliza- tion i y occur until the pain and tenderness invade iiat bear no relation to the affected organ, pc nt of practical importance is that counter- j r :ritntion over the cutaneous area may have thera- Hpeutic value, not only in the immediate relief of Bpain, but also in influencing the underlying condition. 322 PAIN SEGMENTAL DISTRIBUTION OF REFERRED PAIN AND TENDERNESS IN VISCERAL DISEASE. (Compiled from Head.) See diagrams figures 1, 2, and 3. .Third cervical and first, second, and third dorsal seg- .._Third and fourth cervical and first to ninth [sometimes -al seenient*, especiallv the third, fourth, and fifth. Breatr "-urth and fifth dorsal segments. (Esophagr* fth, sixth, and eighth dorsal segments. Stomach. Th,. ' ,, . JL, -d fourth cervical and sixth, seventh, eighth, and ninth dorsal segn, . , . , .-. Cardiac end from the sixth and seventh, and the pyloric end froi; r ninth. Intestines. Down to the , T . ,, .-. -*er part of the rectum: Ninth, tenth, eleventh, and twelfth dorsal st,. , ,,. -, * ' _ ments. The nearer the lesion lies to the kia ,, x^ pain and tenderness associated with the tenth i. rm,- lal segment. Ine lower the lesion in the ureter the more does the fi*'.^ i segment tend to appear. Bladder. Mucous membrane and neck of the bla