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t:.A.\^\2.-:^ 



^Harvard Uniwcreity 

Ch€ COeilical School 

■nd 

Ch€ School of 'Public Ttealth 



GhcGlftof 

Dr. Francis W. Palfrey. 



1 ' 



tViE BOSTON 
JOUBSiUiU 



L 



PRESS NOTICES OF DR. SAVILLS 
SYSTEM OF CLINICAL MEDICINE. 



" The method of the hook is strikiogly Dovel. The author approaches the various 
diseases from the point of view of symptoms and physical signs. ... If there is a royal 
road to clinical diagnosis, we find it here. Certainly the path of the medical man who 
refers to this book will be greatly smoothed. . . . We have tested the book on several 
occasions, and never once found it lacking. ... No one who uses this as a work of 
reference wiU be disappointed in it, for the writer has practically included everything 
essential for the diagnosis of disease at the bedside. We know of no other work on 
clinical diagnosis which so fuUy supplies the needs of the general practitioner as this 
one does. " — Medical Timet. 

" The second edition shows in every way an advance upon the first, which itself stood 
as the wonderful aooompUshment of a Uborious task on pioneer lines." — St. Mary'e 
HoepiUU Gazette, 

"We have carefully renewed our acquaintance with this manual, and in our opinion 
it is the best work on the subject of clinical medicine in the English language. It will 
well repay careful atudy."—W*tt London Medical JowmaL 

" The fruit of a wide experience, presented in a manner calculated to be of very prac- 
tical value to the senior student, and no less to the practitioner of medicine. It departs 
from the usual methods of medical textbooks, and deals with the various diseases from the 
I)oint of view of their leading symptoms. Differential diagnosis then becomes the prom« 
Inent feature, and by careful classification, and an extensive system of cross-references, it 
is exceedingly easy to follow out any line of investigation in coming to a diagnosis. But, 
while this is the case, room is also found for etiology, pathology, and treatment, so that 
complete clinical pictures are presented. The writer is concise in his descriptions. The 
book is well illustrated ahd has been brought thoroughly up-to-date. It ought to be 
widely known, and should be in the hands of every medical practitioner."— &to«^to 
Medical Journal. 

"To Dr. Savill occurred the original, and, as he admits, the ambitious, idea of 
writing a textbook of medicine which should be clinical in its method, so as to enable 
the cardinal symptoms presented by the patient to be referred to their true cause— in 
other words, of following the method which must of necessity be adopted in practice, 
working from effects back to cause. ... In our review of the first edition wo referred 
totheadmirablemannerin which Dr. Savill had carried out his idea, . . . and we wished 
the book the success it deserved. . . . The essential feature of Dr. Savill's book is its 
practical character. It aims at teaching a practical method of diagnosis, and the direc- 
tions given in regard to all diagnostic procedures are thorough, and often comprise 
useful hints. We can again confidently recommend Dr. Savill's book as a helpful and 
practical work on clinical diagnosis."— lancet. 



^ 



A SYSTEM 



OF 



CLINICAL MEDICINE 

DEALING WITH THE 

DIAGNOSIS, FROG NO SIS, AND TREATMENT 

OF DISEASE 

FOR 

STUDENTS AND PRACTITIONERS 



BY 

THOMAS DIXON SAVILL, M.D. Lend. 



Third Edition 
thoroughly revised 



NEW YORK 

WILLIAM WOOD & COMPANY 

MDCCCCXII 



HARVARD UNIVERSITY' 
SCHOOL OF medicine; A>,'D F'JZLin HLr^-' 

■f ilULlM2 



PREFACE TO THE THIRD "EDITION 



The kind letters received from practitioners at home and abroad, together 
with the fact that the second edition of " Clinical Medicine " was sold 
out in less than two years, seem to prove that the book is supplying the 
want described by Dr. Savill in the Introductory Chapter. 

The arrangement and the scheme of the book have been in no way 
altered. This edition has been carefully revised, and much new matter 
has been added, although the size of the volume remains unaltered. The 
additional matters are described very briefly under the symptoms for which 
the patient seeks advice, so that they may be dififerentiated from the 
other conditions which give rise to the same symptom. Amongst the 
cidditions may be named Acute Pulmonary (Edema, Family Congenital 
Chotemia, Aplastic Anaemia, Hirschsprung's Disease, the Serum Disease, 
Multiple Myeloma and other rare bone diseases, Adrenal itis. Rocky 
Mountain Fever, Japanese River Fever, Rat- bite Fever, Psittacosis, 
Ochronosis, Enterogenous Cyanosis, Amyotonia Congenita, Family 
Periodic Paralysis, Atrophic Spinal Paralysis of Infants, and other rare 
conditions which do not merit mention in the preface. Certain sections 
have been rewritten. 

I have felt very keenly the responsibility of bringing this edition up-to- 
date in a manner that would accord with the ideal of its author. To 
secure that thorough and adequate revision necessary to render the book 
as trustworthy and complete as in previous years I have sought the 
assistance of experts in several departments. I desire to express my 
gratitude to Dr. F. Foord Caiger, who is responsible for the revision of the 
first two groups in the Chapter on Fevers ; to Dr. F. M. Sandwith, for 
revision of Tropical Fevers ; to Dr. Leonard WiQiams, for revision of 
Diseases of the Thyroid ; to Dr. Angus McGillivray, for revision of the 
section on Diseases of the Eyes ; to Dr. Elizabeth Fraser, for revision of 
the sections on Immimity and Bacteriology ; and to Dr. R. H. Cole, for 
revision of the section on Insanity. I have also to thank those who helped 
me with useful suggestions — in Diseases of the Nervous System, Dr. Harry 
Campbell ; in Diseases of Women, Dr. L. Garrett Anderson ; and for 
valuable advice as to additions throughout. Dr. Frederick Langmead. 
To Dr. James Mackenzie I am indebted for two illustrations of polygraph 
tracings in Diseases of the Heart, and for advice as to alterations in the 
section on the Pulse. 

In conclusion, I have gratefully to acknowledge the valuable assistance 
throughout, both in the revision and in proof-reading, of Dr. Gordon R. 
Ward, who is responsible also for the alterations in the chapter on 
Diseases of the Blood. 

AGNES SAVILL. 

Harley Street, 

Jfay, 1912. 

Vll 



PREFACE TO THE SECOND EDITION 



This work differs from current books on medicine chiefly in this respect, 
that it approaches the subject from the point of view of symptoma- 
tology, first describing the symptoms or effects of disease, and then tracing 
these symptoms to their causes — namely, the various diseases which may 
be in operation It was written to aid my professional brethren in general 
practice in their daily work (which consists of tracing symptoms to their 
causal disease) and to help senior students who had reached the stage 
when medicine may be profitably studied in the wards. It was an original, 
and perhaps a too ambitious, project, but the rapid sale of the first edition, 
which has now been out of print neariy two years, and the number of kind 
and suggestive letters received from medical men in general practice in 
many different parts of the world, and from teachers and senior students, 
encourage me to believe that I have in some measure succeeded. 

This edition appears in one volume instead of two, as being more con- 
venient. The amount of material remains approximatoly the same, new 
mattor replacing old. In deference to the wishes of many of my readers, 
the smallest of the three types (nonpareil) in the first edition has been 
replaced by medium-sized type (brevier), so that now only two main types 
instead of three are used. Space has been saved by the lines of type being 
closer, and consequently the bulk of the volume forming the second edition 
is somewhat smaller than the bulk of the two volumes together which 
formed the first. 

The arrangement and scope of the work are unchanged. Clinical 
medicine moves less rapidly than pathology, so it has not been necessary 
to make any very extonsive alterations. The book has, however, been 
brought thoroughly up-to-date. The exigencies of a busy life have pre- 
vented my giving as much time to its revision as could be wished, but I 
have been fortimato in securing the valuable aid of Dr. Frederick S. 
Langmead and Dr. Agnes F. SaviU. The last-named is mainly responsible 
for the chapter on Diseases of the Skin, the first-named for the alterations 
in the chapter on Diseases of the Joints ; both are responsible, with me, 
for general revision throughout. 

I should like to take this opportunity of acknowledging the valuable 
criticisms I have received from many correspondents, and to say that 
further suggestions and criticisms from future readers will be gladlv 
welcomed. 

T. D. S. 

September J 1909. 

• • ■ 

via 



TABLE OF CONTENTS 



INTRODUCrriON 



PAOK 



Evolution of medioine — Origin of the work — Plan of the work — Special features 

— Advantages of the author's method — Responsibilities - - - xx> 

CHAPTER I 

CLINICAL METHODS 

Definitions — CSase-taking ; remarks on the interrogation of. and physioal examina- 
tion of patients ; scheme of case-taking — Examination of children and 
infants — ^Three methods of diagnosis discussed — Principles of prognosis and 
of treatment — General rules in clinical investigation — Classification of 
diseases --.-..--- 1 

CHAPTER II 

THE FACIES, OR EXTER17AL APPEARAKCES OF DISEASE 

The physiognomy in various diseases, acute and chronic ; causes of swelling of 
the face ; causes of alterations in the colour and complexion of the face ; the 
face in detail — The physiognomy in infancy and childhood — Variations in 
the form of the skull — The physiognomy in diseases of the nervous system — 
The decubitus and attitude in disease — ^The general conformation of the 
body — Causes of emaciation — Causes of enlargement of the body ; obesity 
- Dwarfism and its various causes - . • - - 15 

CHAPTER III 

THE HEART AKD PERICARDIUM 

Introduction — Part A. Symptomatology : breathlessness ; Cheyne-Stokes res- 
piration ; dropsy ; palpitation ; pain in the chest ; syncope ; cough ; cyanosis 
— ErythrsBmia ; sulph-hsBmoglobinsemia ; methsemoglobinsemia — Sallow- 
ness ; pyrexia ; sudden death — Lymphatism - - - - - 28 

Part B. Physical examinaiion : landmarks of the chest ; inspection ; palpation ; 
localisation of the apex ; percussion ; resistance to palpation ; auscultation ; 
the pulse ; the polygraph and electro-cardiogram - - - - 40 

Part C. Diseases of ike heart and pericardium, their diagnosis, prognosis, and 
treatment : classification ; routine procedure — Acute diseases : acute peri- 
carditis ; acute endocarditis ; ulcerative or malignant endocarditis ; paroxys- i 
mal tachycardia ; angina pectoris — Chronic diseases : classification ; 
hypertrophy of the heart ; dilatation of the heart ; hydro-pericardium ; 
congenital heart disease ; chronic endocarditis, cardiac valvular disease 
(C.V.D.) ; varieties of cardiac murmurs ; table of differentiation of various 

ix 



TABLE OF CONTENTS 



PAor 



forms of oaidiao valvular disease — Systolic murmurs : mitral regui^tation ; 
aortic stenosis ; aortic aneur3r8m ; tricuspid regurgitation ; pulmonary 
stenosis ; fallacies in the diagnosis of S3rstolio murmurs — Diastolic murmurs : 
aortic reguigitation ; mitral stenosis ; aortic aneurysm ; tricuspid stenosis ; 
pulmonary regurgitations ; fallacies in the diagnosis of diastolic murmurs — 
Double murmurs : audible at the base ; and at the apex ; fallacies in the 
diagnosis of double murmurs — General symptoms of cardiac valvular 
disease ; causes of C.V.D. : auricular fibrillation ; prognosis and treatment 
of C.V.D.— Fatty heart ....... 50 

CHAPTER IV 

ANEITRYSM OP THE AORTA AND OTHER INTRATHORACIC TUMOURS 

Anatomy of the mediastinum — Intrathoracic aneurysm ; symptoms and signs ; 
three clinical and anatomical varieties ; causes ; diagnosis ; prognosis : and 
treatment .-.--.... 90 

Other mediastinal tumours ; signs and symptoms ; causes and anatomical 

varieties ; prognosis and treatment - - - - - - 95 

CHAPTER V 

THE PULSE AND ARTERIES 

The meaning of " the pulse '* — Clinical investigation — Rapid pulse — Slow 
pulse : — Stokes- Adams disease — Irregular pulse — High blood-pressure ; 
its symptoms, causes, prognosis, and treatment — Low blood -pressure ; its 
symptoms, causes, prognosis, and treatment — The pulse in relation to the 
prognosis and treatment of disease - - - - - - 98 

Diseases of the arteries ; symptomatology ; physical signs and clinical varieties — 
Atheroma — Arterial sclerosis — Arterial hjrpermyotrophy — Functional 
diseases of the arteries - - - - - - - 11(> 

CHAPTER VI 

THE LUNGS AND PLEURA 

Introduction — Part A. Symptomatology: cough; broathlessness ; pain in the 

chest ; hemoptysis ; pulmonary embolism - - - - - 1 1 8 

Part B. Physical Examination : inspection and mensuration ; radiography ; 
palpation ; percussion : auscultation : ausoulto-percussion : fallacies ; exami- 
nation of the sputum - . . 1 2H 

Part C. Diseases of the lungs and pleura, their diagnosis, prognosis, and treat- 
ment : classification ; routine procedure — Diagnostic table of acute diseases 
— Acute diseases without dulness on percussion : acute bronchitis ; acute 
suffocative catarrh ; dry pleurisy ; acute pulmonary tuberculosis ; whooping 
cough ; acute pulmonary oedemei — Acute diseases with dulness on per- 
cussion : acute pleurisy with effusion ; empyema ; acute lobar pneumonia ; 
pneumonic form of acute tuberculosis ; aberrant acute pneumonias ; acute 
lobular pneumonia — ^Acute disease with hyper-resonance on percussion : 
pneumothorax — Paroxysmal disease : asthma — Chronic diseases : classifica- 
tion and routine method of procedure — Chronic diseases without dulness : 
chronic bronchitis ; plastic bronchitis — Chronic diseases with dulness : 
pulmonary tuberculosis ; fibroid phthisis ; hydrothorax ; oedema of the lung 
—Rarer diseases : chronic interstitial pneumonia ; thickened pleura ; 
malignant disease of the lung ; hydatid cyst ; atelectasis ; syphilis of the lung 
— Chronic diseases with hyper-resonance : emphysema, and others — 
Diseases with characteristic sputum : bronchiectasis ; gangrene of the lung ; 
abscess of the lung : actinomycosis ; aspergillosis ; blastomycosis - - 133 



TABLE OF CONTENTS xi 

CHAPTER VII 

THE 1TPPSB BBSPIBATOBY PASSAQBS AND THE THTBOID GLAND 

PAOK 

Introduction — ^The Throat : Part A. Symptomatology : sore throat ; hoarse- 
ness ------..- 178 

Part B. Clinical investigation ....... 179 

Pkkrt C. Diseases of the throat : classification of diseases ; acnte catarrhal phaiyn- 
gitis ; hospital sore throat ; chronic catarrhal pharyngitis ; granular (follic- 
ular) phar3mgiti8 ; granular (adenoid) pharyngitis ; acute parenchymatous 
ton^llitis ; acute follicular tonsillitis ; Vincent's Angina ; chronic tonsillitis ; 
Bcaiiet fever ; diphtheria ; syphilitic sore throat ; retropharyngeal abscess ; 
phlegmonous sore throat ; carcinoma ; tubercle ; acute specific fevers - 180 

The larynx : symptoms and cb'nical investigation — Classification of diseases — 
Laryngitis ; acute laryngitis ; oedema glottidis ; the swallowing of a foreign 
body ; chronic laryngitis ; perichondritis ; chronic infantile stridor ; chronic 
tuberculous laryngitis ; chronic syphilitic larjmgitis ; new growths, benign 
and malignant ; paralysis of the vocal cords ; laryngismus stridulus - - 188 

TAe nasal cavities : symptoms and physical examination — Classification of 
diseases — Acute nasal discharge (rhinorrhosa) : acute rhinitis ; snuffles ; 
diphtheria ; acute coryza ; hay fever ; glanders ; myiasis — Chronic inoffen- 
sive discharge : chronic rhinitis, simple and hypertrophic ; cerebro-spinal 
rhinorrhosa ; ulcerations, polypi, and sinus disease ; post-nasal catarrh — 
Chronic offensive discharge (ozena), its causes, prognosis, and treatment — 
Nasal obstruction, snoring, and mouth breathing ; its causes, prognosis, and 
treatment — Epistaxis - - - - - - - 199 

The thyroid gland — Introduction — Symptomatology — Physical examination and 

classification of diseases — Graves' disease ; bronchocele ; cretinism - - 209 

CHAPTER VIII 

THE MOUTH, TONaUE, AND QXTLLBT 

The mouth — ^Introduction — ^The lips ; the breath ; the saliva ; the palate ; the 

teeth ; toothache ; the gums ; pyorrhoea alveolaris ; stomatitis • • 210 

The tongue : furring of the tongue ; ulcers of the tongue ; white patches ; acute 
swelling of the tongue ; chronic swelling ; hypertrophy and atrophy of the 
tongue ; warts, fissures, and cicatrices ..... 222 

The (ri</2e<— Symptomatology — Ph3rsical examination — Causes of dysphagia : 
tumour ; malignant disease ; simple or non-malignant stricture ; spasm of 
the pharynx or oesophagus ; foreign bodies ; acute oesophagitis ; simple 
ulcer ; paralysis of the g^et ; dilatation or diverticulum of the gullet ; 
prognosis and treatment of dysphagia ..... 226 

CHAPTER IX 

THE ABDOMEN 

Introduction — Part A. Symptomatology : local symptoms ; fallacies in the 

diagnosis of acute abdominal pain ; general symptoms - . - 233 

Pftrt B. Physical examination : inspection ; palpation ; percussion ; mensura- 
tion ; fallacies in the diagnosis of abdominal enlargement ... 235 

Pftrt C Abdominal disorders, their diagnosis, prognosis, and treatment : routine 
procedure and classification — Causes of acute abdominal pain, with collapse : 
rupture of a cyst or organ, or perforation of the alimentary canal ; acute 
peritonitis ; rarer causes — Acute abdominal pain, without collapse ; colic ; 
rarer causes — Chronic abdominal pain : appendicitis ; chronic peritonitis ; 
movable kidney ; intestinal dyspepsia and intestinal catarrh ; enteroptosis ; 
incipient or obscure visceral or spinal disease ; diseases of the pancreas • 238 



xii TABLE OF CONTENTS 



PAGK 



Oeneralised abdominal enlargement: classifioation — Routine prooedare — ^Tym- 
panites ; gas in the peritoneum ; fluid in the abdominal cavity ; physical signs 
of fluid ; signs of ascites — Causes of ascites : portal obstruction ; cardiac 
disease ; kidney disease ; chronic peritonitis ; anaemia — ^Treatment of ascites 
— Clauses of encysted fluid in the abdomen : ovarian cyst ; rarer cysts - • 255 

Abdominal tumours — Method of procedure — ^Tumours special to the various 

regions of the abdomen ....... 262 

FlaUening or recession of the abdomen ...... 268 



CHAPTER X 

THE STOMACH 

Introduction — Part A. Symptomatology : gastric pain ; nausea or vomiting : 
Cyclical or recurrent vomiting ; hsematemesis ; other local symptoms ; 
general or remote symptoms ...... 269 

Part B. Physical examination : inspection ; palpation ; percussion ; motor 
insufficiency of the stomach ; bismuth meal ; examination of stomach 
contents ......... 279 

Part C. Diseases of (he stomach, their differentiation, prognosis, and trecUment : 
routine investigation and classification — Acute disorders : acute dyspepsia ; 
acute or subacute gastritis — Chronic disorders ; chronic djrspepsia (atonic 
and acid) ; gastralgia ; simple ulcer ; cancer of the stomach ; chronic 
gastritis ; dilatation of the stomach or gastric atony ; neurasthenic dys- 
pepsia ; gastroptosis ....... 285 

Dietaries and invalid foods — Artificial feeding of infants • - - 301 



CHAPTER XI 

THE INTESTINAL CANAL 

Introduction — Part A. Symptomatology : diarrhoea ; constipation ; abdominal 

pain ; remote or general symptoms ...... 306 

Part B. Physical examination : examination of the abdomen ; examination of 

the stools ; various intestinal and other parasites .... 307 

Part C. Diseases of the intestinal canal, their diagnosis, prognosis, and treatment : 
routine procedure ; classification of diseases — Causes of acute diarrhoea — 
Dysentery — Cholera — Causes of chronic diarrhoea — Psilosis or sprue — 
Tenesmus — Blood in the stools — Haemorrhoids — Intestinal worms — Con- 
stipation — Acute intestinal obstruction — Chronic intestinal obstruction • 314 



CHAPTER XII 

THE LIVER AND SPLEEN 

Introduction — Part A. Symptomatology : pain and tenderness over the liver ; 

jaundice ; icterus neonatorum ...... 339 

Part B. Physical examination : inspection ; palpation ; percussion ; fluid in the 

peritoneum - ........ 343 

Part C. Diseases of the liver: routine procedure and classification — Acute 
diseases : acute congestion of the liver ; catarrhal jaundice ; epidemic jaun- 
dice ; gall-stones and biliaiy colic ; diseases of the gall-bladder ; perihepa- 
titis ; abscess of the liver ; subphrenic abscess ; actinomycosis of the liver ; 
acute yellow atrophy — Chronic diseases : routine procedure and classifica- 
tion — Diseases in which the liver is normal or diminished in size : functional 
derangement of the liver ; atrophic cirrhosis of the liver — Diseases in which 
the liver is enlarged and painless : hypertrophic cirrhosis of the liver ; fatty 
liver ; lardaceous liver ; hydatid tumour of the liver — Diseases in which the 



TABLE OF CONTENTS xiii 

PAGE 

liver is enlarged and painful : ohronio oongestion ; cancer ; abscess — Rare 

tumours — Floating liver ....... 346 

The spleen — Introduction — Part A. Symptamatoloffy - - . - 370 

Fart B. Physical examination : palpation ; percussion ; surface landmarks ; 

diagnosis of enlargement - - - - • - - 371 

Part C. Diseases of the spleen : Causes of acute and chronic enlaigement — 

Irregular spleen — Wandering spleen — Atrophy of the spleen - - 373 



CHAPTER XIII 

THB UBINB 

Introduction — Part A. Symptomatology : alterations in the urine ; pallor of the 
surface and malaise ; renal dropsy ; general symptoms ; complications and 
secondaiy inflammations ; pain in the kidney ; ursBmia - • - 378 

Part B. Physical examination of the urine : a. Physical characers of the urine : 
appearance ; reaction ; specific gravity ; odour ; the diurnal quantity — 
h. Chemical examination of the urine : albumen ; nudeo-albumen ; mucin ; 
sugar ; urea ; uric (i.e., lithic) acid ; bile ; blood ; pus ; salts in the urine ; 
proteids in the urine ; other rare constituents — c. The urinaiy deposit : 
cloudiness of the urine ; microscopic specimens ; organised constituents ; 
ciystalline and inorganic deposits ...... 383 

Physical examination of Qie kidneys : landmarks ; palpation ; percussion ; other 

methods of examination - - - • • - '401 

Part C. Urinary disorders, their diagnosis, prognosis, and treatment: routine 
procedure — Classification — Albuminuria : acute nephritis ; chronic tubal 
nephritis ; chronic interstitial nephritis ; amyloid kidney ; renal congestion 
and its various causes — Hssmaturia, its forms and causes : renal calculus 
and renal colic ; injuiy of the kidney ; paroxysmal hemoglobinuria — Pyuria, 
its forms and causes : urethritis ; cystitis ; pyelitis — Altered specific gravity : 
caiises of diminution and increase of specific gravity ; polyuria ; diminished 
quantity of urine — Glycosuria ; temporary ^ycosuria ; diabetes mellitus ; 
diabetes insipidus — Retention of urine — Suppression of urine — Incontin- 
ence of urine : true incontinence ; increased frequency of micturition ; 
nocturnal incontinence — Cloudiness of the urine, and its causes — Renal 
tumours : hydronephrosis ; pyonephrosis ; perinephric abscess ; malignant 
disease ; cystic disease ; hyatid ...... 402 



CHAPTER XIV 

DISEASES PEOULIAB TO WOMEN 

Introduction — ^Part A. Symptomatology : list of local symptoms ; list of general 

symptoms — Case-taking ....... 435 

Part B. Physical examination : external examination ; vulvo-vaginal examina- 
tion ; bimanual examination ; instruments to aid examination - - 436 

Part C. Diseases of women, their diagnosis, prognosis, and treatment : routine 
procedure and classification of diseases — Diseases of the vidva ; leucorrhosa, 
of vaginal origin and of uterine origin ; dysmenorrhoea, spasmodic, in- 
flammatory, membranous ; monorrhagia and metrorrhagia ; uterine fibroid ; 
subinvolution ; the menopause ; maLgnant disease of the uterus ; extra- 
uterine pregnancy ; treatment of hsomorrhage — ^Amenorrhcoa : pregnancy 
— Pelvic pain : perimetritis (pelvic peritonitis) ; parametritis (pelvic cellu- 
litis) ; inflammation of the uterine appendages ; pelvic hsematocele ; uterine 
flexions and versions — Pelvic tumours and vaginal swellings : prolapse of the 
vaginal walls ; prolapse of the uterus ; inversion of the uterus — Disordered 
micturition ; painful defaecation ; painful sitting ; dyspareunia — Backache • 438 



xiv TABLE OF CONTENTS 

CHAPTER XV 

PYREXIA. MIGBOBIO DISEASES 

PACK 

Introduction — Definitions : acute specific fever ; infection ; contagion ; clinical 

characteristics of microbic diseases ; epidemic ; sporadic ; endemic - • 459 

Part A. SymptoffuUology : symptoms attending pyrexia ; incubation and other 

stages of acute specific fevers ; rigors ; delirium ; the typhoid state - • 460 

Part B. Physical examiruUion : clinical thermometry ; the temperature chart ; 
types of pyrexia ; subnormal temperature ; examination of organs ; ex- 
amination of blood ........ 468 

Part C. The diagnosis, prognosis, and treatment of microbic disorders : routine 
procedure ; classification — Oroup /. Exanthemata or eruptive fevers : 
introduction ; varicella or chicken-pox ; scarlet fever ; erysipelas ; small- 
pox ; vaccinia ; measles ; rotheln ; dengue ; typhus ; anthrax ; glanders — 
Oroup II. Continued pyrexia : list of fevers of a continued type ; enteric 
or typhoid fever ; diphtheria ; influenza ; rheumatic fever, pneumonia, and 
other inflammatory disorders ; whooping cough ; mumps ; glandular fever ; 
plague ; undulant fever ; yellow fever ; epidemic cerebro-spinal meningitis ; 
relapsing or famine fever ; thermic fever or heat-stroke ; kala-azar ; 
phlebotomous fever ; rat-bite fever ; Japanese river fever ; psittacosis — 
Oroup III. Intermitting pyrexia : list of fevers of an intermittent type ; 
ague ; remittent fever ; " blackwater " fever ; latent tuberculosis ; acute 
general tuberculosis ; visceral syphilis ; acute pysBinia or septicsemia ; sub- 
acute and chronic septic conditions (e.g., abscess, ulceration, etc.) ; the rarer 
causes of intermitting pyrexia ; trypanosomiasis - - - - 471 

General treatment of microbic disorders : immunity ; vaccine therapy ; remedial 
immunisation ; notification and isolation ; disinfection and prevention ; diet ; 
hyperpyrexia -.----.. 629 



CHAPTER XVI 

GENERAL DEBILITT, PALLOR, AND EMACIATION 

Introduction — Part A. Stfmptomatology : general debility ; pallor of the skin ; 

emaciation ......... 543 

Part B. Physical examination : examination of the viscera ; observations on the 

weight and the temperature ; examination of the blood ... 545 

Part C. Diseases which give rise to general debility, toOh or wOhout ancsmia and 
emacicUion, iheir diagnosis, prognosis, and treatment : routine procedure ; 
classification — Ancsmic disorders : chlorosis ; pernicious ansemia ; congenital 
anaemia ; syphilis ; plumbism ; latent tuberculosis or carcinoma ; chronic 
visceral disease ; haemorrhage and other causes of long continued drain ; J 
leukaemia ; chloroma ; Hodgkin^s disease ; splenic anaemia ; scurvy ; haemo- 
philia ; tropical diseases and parasites ; anaemias of childhood — Emaciation ;J 
malignant disease ; defective feeding and digestive disorders ; tuberculosis ; ] 
diseases of the pancreas and of the nervous sjrstem ; marasmus in childhood 
— Debility only : senile decay and arterial disease ; nephritis ; functional 
nervous diseases ; djrspepsia ; obscure abdominal or chest disease ; myx- 
oedema ; Addison's disease ....... 558 



CHAPTER XVII 

THE EXTREMITIES 

Introduction — Part A. Symptomatology : Pain in the limbs - - 699 

Part B. Physical examination : inspection of the limbs ; varicose veins ; oedema ; 

glandular swelling ; other local and constitutional signs - - - 601 



TABLE OF CONTENTS xv 

PAOB 

Part C. Diagnosis, prognosis, and treatment of diseases causing symptoms refer- 
(iNe to the extremities : routine prooeduie ; classification — Alterations in 
colour or contour of the extremities : erythromelalgia ; gangrene ; Raynaud's 
disease ; dead hands ; intermittent claudication — Diseases of the joints : 
acute gout ; acute rheumatism ; acute gonorrhodal arthritis ; acute rheuma- 
toid arthritis ; pysBmia and other constitutional conditions ; traumatism and 
extension from adjacent bone ; chronic gout ; chronic riieumatism ; rheuma- 
toid arthritis ; osteo-arthritis ; spondylitis deformans ; gonorrhoea! arthritis ; 
septic processes ; tuberculosis ; syphilis ; hysterical and neuropathic joint 
disorders — Diseases of the muscles : rheumatism ; new growths ; trichinosis ; 
myositis — Diseases of the bones : acute osteomyelitis ; rickets ; chronic oste- 
itis and periostitis ; tumours ; acromegaly ; achondroplasia ; pulmonary 
osteo -arthropathy ; osteitis deformans ; mollities ossium ; leontiasis ossea and 
other rare diseases - ,.•••.. 605 



CHAPTER XVIII 

THE SKIN 

Introduction — Part A. Symptomatology : pruritus .... 639 

Part B. Physical examination : necessary apparatus ; inspection ; palpation ; 

symmetry ; subjective sensations ; history ; etiology - - . 640 

Part G. Diagnosis, prognosis, and treatment of skin diseases : routine procedure ; 
classification — Group I. Dry Eruptions : wheals ; urticaria — macules or 
erythema ; serum disease ; roseola ; drug eruptions ; erythema multiforme ; 
rosacea ; lupus erythematosus ; erythema nodosum and other localised ery- 
themas — ^papules : acne ; prurigo ; scabies ; syphilis ; lichen planus ; keratosis 
pilaris ; milium ; lichen scrofulosorum ; adenoma sebaceum — scales ; 
psoriasis ; seborriioBio dermatitis ; syphilis ; exfoliative dermatitis ; pityriasis 
rosea ; pityriasis rubra pilaris ; ichthyosis ; erythrasma — Oroup II, 
Vesicular Eruptions : eczema ; herpes ; varicella ; sudamina ; hydrocystoma ; 
dermatitis herpetiformis ; pemphigus ; epidermolysis bullosa — Oroup III. 
Pustular Eruptions : impetigo ; syphilis ; sycosis ; boil ; carbuncle ; kerion — 
Oroup IV, Multiform Eruptions: syphilis; scabies — Oroup F. Nodular 
Eruptions : lupus vidgaris ; gumma ; new growths ; leprosy ; Bazin's disease ; 
moUuscum contagiosum ; mycosis fungoides ; leukaemia ; Yaws ; sporotri- 
chosis ; Madura foot ; blastomycosis— (Troup VI, Ulcers : inflammatory ; 
contagious ; neoplastic — Oroup VII, Excrescences : wart ; condyloma ; 
com ; papilloma lineare ; keratodermia ; acanthosis nigricans ; angiokera- 
toma— -(Traap VIII. Atrophies and Scars : scleroderma ; keloid — Oroup IX, 
Pigmentary and Vascular Changes : chloasma ; lentigo ; pityriasis versi- 
color ; moles ; purpura ; urticaria piginentosa ; xeroderma pigmentosa ; 
xanthoma ; morphoda ; oohronosiB— -Oroup X, The Sweat : anidrosis ; 
hyperidrosis ; bromidrosis ; chromidrosis — Oroup XI, Diseases of the 
Scalp and Hair : ringworm ; favus ; alopecia ; seborrhosa ; pediculosis ; 
canities ; hypertrichosis — Remarks on treatment of skin diseases - - 644 



CHAPTER XIX 

THE KBBV0U8 SYSTEM 

Introduction — Anatomical and pathological preliminaries — Part A. Sympto- 
matology : mental and motor defects ; nervousness ; pain and neuralgia ; 
headache ; disordered sleep ; vertigo ; subjective sensations ... 692 

Part B. Clinical investigation : mental and general symptoms ; pyrexia ; 
muscular system ; reflexes ; electrical reactions ; special senses and cranial 
nerves ; cutaneous sensation ; organic reflexes ; trophic changes ; vasomotor 
and sympathetic systems - - - - - - -711 



xvi TABLE OF CONTENTS 

PAOB 

Part C. Diagnosis, prognosis, and treatment of diseases of the nervous system : 
routine prooedure ; olassifioation — Group /. Generalised Neuroses : neuras- 
thenia ; hysteria ; hypochondriasis ; alcoholism ; drug habits ; collapse — 
Qroup II. Mental Symptoms : sudden and transient unconsciousness and 
its causes ; prolonged and complete unconsciousness (coma), and its causes 
— Partial mental defects : defects of speech, memory, and attention — acute 
perversions of the mind— chronic perversions of the mind : mania ; melan- 
cholia ; dementia ; special types of insanity — ^prognosis and treatment of 
insanity— hypnotism — mental deficiency in adolescence and in childhood — 
Group III, Intraorauial Inflammation : tuberculous meningitis ; acute 
meningitis ; posterior basic meningitis ; cerebral abscess ; sinus thrombosis 
— Group IV, Motor Disorders : Paralysis : hemiplegia ; cerebral tumour ; 
localisation of intracranial lesions ; hemiplegia in children — paraplegia : 
compression paraplegia ; spiual localisation ; myelitis ; spinal tumour,, 
haemorrhage, and pachymeningitis ; system lesions of the cord ; infantile 
cerebral and spinal paralyses ; multiple neuritis ; beri-beri ; functional para- 
plegia ; railwa^^ spine ; Caisson disease ; prognosis and treatment of para- 
plegia — brachiplegia ; amyotrophic lateral sclerosis — monoplegia; single 
nerve paralysis ; plexus paralysis ; spinal, cerebral, and functional mono- 
plegia — generalised paralysis ; toxic causes ; myasthenia gravis ; encepha- 
Utis ; intracranial, bulbo-spinal, and spinal lesibns ; Liandry*B paralysis — 
Inco-ordination and Gait : tabes dorsalis ; spinal pachymeningitis and 
tumour ; Friedreich's disease ; ataxic paraplegia ; cerebellar tumour — In- 
creased Muscular Action : tonic spasm ; writer's cramp ; cramp ; tetanus 
tetany ; hydrophobia ; Thomson's disease — ^tremors and clonic spasms 
paralysis agitans ; disseminated sclerosis ; functional, toxsemic, and oi^ganic 
tremors ; chorea ; myoclonus multiplex ; habit spasm ; clonic facial spasm 
torticollis ; post-paralytic spasms ; prognosis and treatment of tremor and 
spasm — convulsions : epilepsy ; hysteria ; intracranial and toxasmio causes 
Stokes- Adams disease ; convulsions in infancy and childhood — ^Muscular 
Atrophy : acute anterior poliomyelitis ; progressive muscular atrophy 
spinal and nerve lesions with amyotrophy ; idiopathic muscular atrophy 
arthritic amyotrophy — Group V, Pain and Sensory Symptoms : neuralgia 
sciatica ; migraine ; hemiansesthesia ; ansesthesia ; hypersBsthesia ; par- 
SQsthesia ; syringomyelia — Group VI, Cranial Nerves and Special Senses 
smell ; vision ; defects in the pupils ; oculo-motor defects ; ophthalmoscopic 
changes ; sense of taste ; facial paralysis ; hemiatrophy facialis ; deafness 
the ^osso-phaiyngeal, vagus, spinal accessory, and hypoglossal nerves 
bulbar paralysis — ^The Skxdl : hydrocephalus - - - - 721 



CHAPTER XX 

EXAMINATION OF PATHOLOGICAL FLUIDS AND CLINIGAL BAOTEBIOLOOY 

Methods of obtaining pathological fluids : paracentesis abdominis ; liver and lumbar 
puncture — how to examine pathological fluids ; characters of pathological 
fluids — Clinical bacteriology : methods and stains ; micro-oi^ganisms found 
in the sputum, false membrane, pleural effusion, pus, the stools, the urine, 
the blood, the cerebro-spinal fluid — Examination for spirochsete pallida - 896 

Formulffi of Useful Prescriptions ...... 908 

Index ------ ... 919 



LIST OF ILLUSTEATIONS 

PLATES IN COLOUR 

Plate I. — Small-pox - - - - -To face page 484 

Plate II. — ^Measles - - - - .... 488 

Plate III. — Blood Films - - - - , ., 562 

Plate IV. — Bacteria - - - - ,. „ 902 

IN THE TEXT 

PIO. PA.r.E 

1. Myzcedema ........ 18 

2. Exophthalmic GotTBE - - - - - - - 19 

3. Hereditary Syphilis • - • -20 

4. Attitude op Paralysis Aoitans - - 23 

5. PsEUDO -Hypertrophic Paralysis - - 24 
6 AND 7. Cretinism - - - - - - 27 

8. Cheyne-Stokbs Respiration - - - - - 31 

9. Superficial and Deep Bulness op Heart and Liver - - 43 
10. Diagram of the Cardiac Cycle - - - - - 45 
n. The Heart and Great Vessels in situ - 40 
12. Situation of Cardiac Murmurs - - - 47 
13 AND 14. Polygraph Tracings - - 49 

16. DuLNESS IN A Case of Rheumatic Pericarditis • - 53 
19. Chart of a Case of Malignant Endcoarditis - - - - 68 

17. Scheme of the Circulation of the Blood - - 73 

18. Propagation of Murmur of Aortic Stenosis - - 76 

19. ,, „ „ IN Aortic Regurgitation - - 76 

20. Various Murmurs met with in Mitral Stenosis - 78 

21. Pulse Tracings showing Efficacy of Bleeding - 87 

22. Pulse Tracings showing the Efficacy of Massage - - 87 

23. Tracheal Tugging -.....-- 93 

24. Normal Pulse Tracing ....-.- 100 
26. .. „ .. ... -100 

26. RiVA-Rocci Sphygmomanometer - - 101 

27. High Tension Pulse Tracing ...... 106 

28. Pulse Tracing showing Reduction of High Tension - - 108 

29. Low Tension Pulse Tracing ...... 109 

xvii 



XVlll 



LIST OF ILLUSTRATIONS 



Fia. 

30. Tracing of Water-Hammbr Pulse .... 

31. The Senile Pulse ---.... 

32. Abteeial Sclerosis ------. 

33. Anterior Thoracic Regions ..... 

34. Chest op Emphysema ...... 

36. Rachitic Chest ....... 

36. Pigeon Breast ....... 

37. The Lungs and other Viscera prom the Back 

38. Elastic Fibres ....... 

39. Charcot- Leyden Crystals- ..... 

40. Diagram showing the Production of RAles and Rhonchi 

41. Diagram showing Physical Signs op Pleurisy - 

42 AND 43. A Case op Pleuritic Effusion - . - . 

44. Chart op a Case op Acute Lobar Pneumonia - 

46. Diagram op the Physical Signs in Hydbopneumothorax 

46. Bronchial Cast ....... 

47. The Three Stages op Pulmonary Tuberculosis 

48. Laryngoscopy ....... 

49. The Larynx in Quiet Inspiration .... 
49a. „ „ IN Forced Inspiration .... 
60. „ „ IN Moderate Abduction .... 
51. „ „ IN Cadaveric Position .... 

52. „ „ DURING PhONATION - ... - 

53. ,, „ IN Bilateral Abductor Paralysis 

54. „ ,, IN Left Abductor Paralysis 

55. „ „ in Total Bilateral Paralysis 

56 AND 57. The Larynx in Partial Bilateral Abductor Paralysis 
58. Nasal Speculum ....... 

69. OIldium Albicans --....- 

60. Regions op the Abdomen ...... 

61. Vomited Material ....... 

62. Microscopical Appearances op the F^bces 

63. Head op the Tjbnia Mediocanbllata .... 

64. T-BNiA Solium 

65. Bothriocephalus Latus 

66. OxYURis Vermicularis 

67. ascaris lumbriooides 

68. Trichocephalus Dispar 

69. Ankylostomum Duodenale 

70. Area op Liver Dulness - 

71. Cholestbrin Crystals 

72. Tyrosin, Leucin, and Cystin 

73. The Stomach and Duodenum 

74. HooKLBTS prom a Hydatid Cyst 

75. Urinombter - 

76. Carwardinb's Sacoharimeter 

77. DOREMUS' Urbameter 

78. Renal Tube Casts - 



FAGK 

109 

112 

113 

124 

125 

126 

126 

128 

133 

133 

137 

141 

142 

145 

150 

156 

158 

179 

189 

189 

196 

195 

196 

196 

197 

197 

197 

200 

225 

237 

282 

309 

310 

310 

310 

310 

310 

311 

311 

344 

351 

351 

352 

367 

384 

388 

389 

396 



LIST OF ILLUSTRATIONS 



XIX 



FIO. 

79. Rbnal Epithelium ..... 

80. Bladder Epithelial Cells .... 

81. Appeabances of Red Blood Corpuscles and Pus Cells in the 

82. Urates -....-. 

83. Uric Acid Crystals ..... 

84. Triple Phosphates ..... 

85. Basic Magnesium Phosphate - - 

86. Neittbal Phosphate . . . . . 

87. Calcium Oxalate - ..... 

88. „ Carbonate ..... 

89. Eoo of Bilharzia Hjcbiatobia .... 

90. Chart from a Case of Septic Absorption 

91. Types of Pyrexia- ..... 

92. Chart from a Case of Scarlet Fever - 

93. Chart of Unmodified Small-Pox 

94. „ FROM A Case of Modified Variola 

95. „ ,, ,, of Malignant H-smorrhagic Small-Pox 

96. „ ,, ,, OF Measles - - - - 

97. „ „ „ OF Enteric Fever - 

98. „ „ „ OF Diphtheria 

99. Types of Pyrexia in Ague - - - - 

100. Types of Mosquito ..... 

101. Chart from a Case of Acute Miliary Tuberculosis - 



Urine - 



OF Visceral Syphilis 

OF Acute Septicemia 

OF Chronic Fymmia 

OF Malignant Endocarditis 



102. .. 

103. „ 

104. .. 

105. „ 

106. Wright's Capsule- ..... 

107. Antitoxin Syringe ..... 

108. The Tetanus Bacillus . . . . - 

109. The Typhoid Bacillus ..... 

110. gowebs' h.smoolobinometer .... 

111. Thoma-Zeiss HiSMocYTOMETER .... 

112. poikilocytosis ...... 

113. Parasite of Malaria ..... 

114. FiLARiA Sanguinis Hominis .... 
116. Trypanosoma in Blood of a Rat 

116. Blood Spectra ...... 

117. Spiroch-«tb Pallida (Treponema Pallidum) of Syphili:3 

118. A Case of Elephantiasis Telangiectodes 

119. A Case of Elephantiasis Lymphangiectodbs - 
120 AND 121. A Case of Erythromelalgia - 

122. Chart of a Case of Rheumatic Fever - 

123. A Case of Rheumatoid Arthritis 

124. Trichina Spiralis encysted in Muscle 

125. Achondroplasia ...... 

126 AND 127. Diagrams of the Common Situations of Certain Eruptions 
128. A Case of Erythema Iris ..... 



PAOB 

396 

396 

397 

398 

399 

400 

400 

400 

400 

400 

414 

450 

469 

475 

481 

482 

483 

488 

494 

500 

516 

518 

521 

522 

524 

527 

528 

534 

535 

536 

537 

547 

548 

551 

553 



556 
557 
569 
602 
603 
606 
614 
622 
630 
637 
643 
647 



XX 



LIST OF 1LLVSTRATI0N8 



KIO. PAGE 

129. Pedictjlus Corporis ....... 653 

130. Pediculus Pubis ---.---- 663 

131. acarus scabiei -...---. 654 

132. A Case op Tinea Circinata ...... 666 

133. Mycelium of Tinea Circinata ...... 667 

134. A Case of Verruca Necrogenica ..... 680 

135. MiCROSPORON Furfur ....... 684 

136. Small Spored Ringworm .---..- 687 

137. Large Spored Ringworm - ...... 687 

138. achorion schunleinu ....... 688 

139. Pediculus Capitis ....... 690 

140. Nits of Pediculus Capitis ...... 690 

141. Leptothrix --.-..--- 691 

142. Diagram of the Motor Neuron ...... 693 

143 and 144. Convolutions and Fissures of the Brain - - - 696 
146 AND 146. Localisation of the Chief Functions of the Cerebral 

Cortex - ........ 697 

147. The Chief Motor and Sensory Tracts .... 698 

148. Transverse Section of the Spinal Cord .... 700 
149 AND 160. Distribution of the Cerebral Arteries - - - 703 
161. Galvanic Battery- ....... 718 

152. Cortical Centres of Speech ...... 749 

153. Idbomotor Centres for Speech, Writing, etc. - - - 751 

154. Base of the Brain, showing Arteries and Cranial Nerves - 780 
155 AND 166. Segmental Algesic Areas .... 790, 791 
157 TO 160. Areas of Distribution of Cutaneous Nerves - 806, 807 
161. Pathology of Tabes Dorsalis ----.. 818 
162 AND 163. Reflex Arcs of the Movements of the Pupil • 870, 872 
164. Werner's Diagrams ...--.. 874 
166. Distribution of Cutaneous Nerves to the Head - - - 880 

166. Sense of Taste and Nerve Supply of the Palate - - . 882 

167. Course and Connections of the Facial Nerve - - . 884 

168. A Case of Facial Paralysis ...... 885 

169. The Auditory Apparatus ...... 888 

170. Wright's Pipette - - - - - - - - 906 



INTEODUCTION 



Those who ponder on general principles and inernods will have observed 
that a considerable change has gradually taken place during the last half- 
century in the methods of studying the science and art of 

EVOLUTION. 1- . « , 1 , 

medicme. Formerly, men were content to observe the symp- 
toms or effects of disease at the bedside and in the dead-house, and to 
speculate on the etiological connection of these two series of phenomena. 
Wherever the association of such phenomena during life and after death 
was sufficiently constant they were spoken of collectively as a " disease " 
when a group of symptoms without anatomical lesion constantly recurred, 
it received a name and place among the list of " disorders." Then each 
disease or disorder was taken as a separate entity, its anatomy, symptoms, 
diagnosis, and treatment were described, and its various possible etiological 
factors discussed ; and the result was known as '* Descriptive " or " Sys- 
tematic Medicine." The guiding principle of this descriptive process was 
the tracing from an assumed cause to a known effect. 

In later times great advances were achieved, almost synchronously, in 
two very different directions. On the one hand great improvements were 
made in the methods of observing and investigating the symptoms or 
effects of disease during life, and thus Clinical Medicine came into separate 
existence. This stage was marked by the appearance in this country of 
two very successful works — one by Dr. Samuel Fenwick, of London, on 
" Medical Diagnosis," first published in 1869, dealing with the symptoms 
and diagnosis of disease ; another by Dr. James Finlayson, of Glasgow, 
entitled " A Clinical Manual," first published in 1878, dealing with the 
methods of observing and investigating the symptoms of disease. On the 
other hand, with the extremely rapid growth of chemical, biological, and 
bacteriological sciences, and the elaboration of experimental methods in 
the investigation of disease processes, a new school of pathology arose, 
whose methods were based upon experiment, and whose leading principle 
was the artificial production of a definite cause and the observing of its 
effects. The extraordinary advances made by these means, and the new 

xxi 



xxii INTRODUCTION 

light thus shed upon the science of medicine during the last twenty years, 
form at once the wonder and delight of the civilised world. 

As a result of the movement to which I have referred, and the growth in 
the two directions named, treatises on Systematic Medicine, which attempt 
to deal at all fully with both the clinical and the pathological aspects of 
disease, have come to assume very considerable dimensions. In many of 
them there seems to be a tendency to become more and more pathological 
in their arrangement, and to treat diseases as separate entitiep, so that 
students of clinical medicine and busy practitioners, whose daily work 
consists of an endeavour to trace from effect to cause, have been heard 
to complain that they do not always find in them the clinical aid 
thev seek. 

Immediately after embarking on medical practice I realised, as probably 
many others have done, the importance for diagnostic purposes of review- 
ing the various diseases or pathological conditions which 
'""°™- might give riB« to a patient's leading symptom or symptoms, 
and being unable to find precisely the information desired in any of the 
current textbooks, I proceeded to keep a brief record of all the cases I 
met with arranged under the heading of their leading symptom. This book 
is based upon those records, which extend over many years, combined with 
the valuable knowledge imparted to me at the bedside by my teachers — 
more especially Dr. Charles Murchison, Dr. J. S. Bristowe, Professor 
J . M. Charcot, and Sir William Broadbent. Hospital cliniques, at first of 
a general and later of a more special kind, have always been at my com- 
mand ; but it was at the Paddington Workhouse and Infirmary that the 
idea of this work was conceived, its foundations laid, and the chief part 
of its " skeleton " constructed. It would be hard to conceive circum- 
stances better suited to the task, for our great poor-law infirmaries contain, 
as all the world now knows, a vast and almost unexplored field of every 
possible variety of disease, which can be studied from day to day fiom the 
beginning to the end of its course. 

As regards the plan and arrangement of this work, the subject will be 

approached from the gtandpoint of sjonptomatolog y. The principle 

throughout will consist of tracing from effect (sjmgtoms) to 

c ause (the m orbid process in operation). The order of sequence 

will be that which should be adopted in the examination of a patient. 

I Thus, the fe st^ chapte r will give a general scheme for the examination of 

a case, and will deal with certain general principles underlying methods of 

I observation, diagnosis, prognosis, and treatment. In the second chapt er 

the physiognomy of disease will be discussed. The succeeding c hapters 

will deal seriatim with the symptoms and signs referable to the several 



SPECIAL FEATURES xxiii 

organs or anatomical regions of the body, and the diseases which may 
cause those symprtoms. 

Each chapter will be divided into three, unequal garts. Part A. will 
treat of the s jfmyUm s which may indicate disease of the organ or region 
under discussion, the fallacies incidental to their detection, and a brief 
differential account of the various causes which may give rise to those 
s3rmptoms. Part B. will treat of the physical signs of disease in that 
region, and the various methods used to elicit them. Part C, which con- 
stitutes the major portion of each chapter, will be prefaced with a clinical 
classificatio n of the various maladies affecting that region, and a summary 
of the routine procedure to be adopted ; and this will be followed by a series 
of sections dealing with the several diseases , arranged according to their 
clinical relationships. For example, in Chapter III., on The Heart — 
Part A. describes and differentiates the various causes of breathlessness 
palpitation, precordial pain, and the other symptoms which may be 
indicative of heart disease ; Part B. describes percussion, auscultation, and 
the other methods of examining the heart ; and Part C. deals seriatim first 
with acute, and secondly with chronic cardiac disorders, classified and 
arranged on a clinical basis. 

Apart from the general plan and arrangement, there are two features 

special to this work. The first part of each chapter, dealing with symptoms 

and their causes, forms a feature on which great labour has 

FBATTOEs ^^^ expended. To make each list of causes complete with- 
out redundance, and to check the various data again and again 
in the light of experience, has involved an expenditure of time quite out 
of proportion to the space occupied. These lists will, I trust, be as useful 
to others as they have been to me in obtaining a clue to diagnosis. 

Another feature consists of the italicised paragraphs in Part C. standing 
at the head of each section, which deal with a separate malady. These 
emphasise the salient features by which a disease may be recognised and 
differentiated from others belonging to the same clinical group. They are, 
in fact, brief clinical definitions, and form, metaphoricaUy speaking, 
" sign-posts " or guides in the process of diagnosis. If, after carefully 
studying the lists of symptoms and their causes in Part A., and examining 
his patient (Part B.), the reader turns to these italicised paragraphs in 
Part C, the work will, it is hoped, serve as a " clinical index of diseases "; 
for by following the plan laid down he will shortly find himself reading a 
description of the diagnosis, prognosis, and treatment of the malady from 
which his patient is probably suffering ; while adjacent to this are the 
disorders which clinically, and very often pathologically, resemble it, and 
for which in practice it is apt to be mistaken. 



xxiv INTBODUGTWN 

Such an arrangement as that proposed must inevitably lead to some 
repetition, but this difficulty has been obviated to a certain extent by cross 
references. I would also ask the reader to remember that nothing fixes 
things so well in our minds, or aids us so much in tracing those analogies 
to which I shall shortly refer, as constantly looking at the same facts from 
a different point of view. 

An attempt has been made to present the various diseases in some kind 
of perspective by placing them as far as possible in order of importance 
and using different sized types. The relative importance of different 
subjects in medicine is largely a matter of opinion, and I cannot expect 
to escape criticism in this respect. 

It is a standing accusation against medical writers that they are care- 
less in respect to literary style, and I fear that I shall not be found an 
exception. I have striven to be intelligible rather than academic ; and 
in general I fear that I must plead guilty to having endeavoured to foUow 
the Duchess's advice to Alice in Wonderland, to " take care of the sense 
and the sounds will take care of themselves.'' When so large an area has 
to be covered, a certain amount of abbreviation is indispensable, and in 
order to condense my material, it has been my practice to adopt a numerical 
method of description. Some may take exception to this, though the 
student will find it to his advantage in the acquisition of knowledge. 

I may perhaps be pardoned for adverting to certain advantages which 
appear to me to be associated with the method that I have adopted of 

approaching clinical medicine. And first let me remark that 
this method of diagnosis is not what has been called a '* pro- 
cess of exclusion." It is a positive rather than a negative process, for by 
carefully considering the various causal diseases which may be in operation 
and balancing the evidence for and against each, the physician is guided* 
not to the least improbable, but to the most probable diagnosis. 

The advantages of passing in rapid review all the possible diseases which 
may give rise to a patient's leading symptom, are very obvious to those 
actively engaged in clinical work. It was Dr. Charles Murchison's method 
in his bedside teaching ; and another equally great clinician. Dr. Matthews 
Duncan, has aptly remarked : " If you do not know of a thing, you are 
quite sure not to suspect it ; and in all cases of difficult diagnosis, if you do 
not suspect the disease, you are almost certain not to find it." ^ But I am 
not aware that any work has yet been published which adopts precisely 
this plan of approaching clinical medicine. 

This plan gives, I venture to think, a truer view of nature's facts than 
one which deals with diseases as so many separate entities. We see a case 

* *' Clinical Lectures on the Diseases of Women," 4th edition, p. 15. 



ADVANTAGES xxv 

in all its clinical and practical bearings. We not only Icam that the diag- 
nosis of a patient's malady can at best be only a question of the greatest 
probability, but with almost mathematical precision we can also assess the 
probability or improbability of each of the other possible causes in opera- 
tion. We leam further that all diagnoses can only be provisional, and 
that the degree of probability of each possible cause changes from day to 
day, like the coloured pattern of the kaleidoscope, as the course of the 
malady unfolds itself before us. 

It is, moreover, in clinical work carried out on these lines — where diseases 
presenting analogous clinical phenomena are constantly being associated 
together from different points of view — that the role of the imagination, 
both in the investigation and in the treatment of disease, finds a legitimate 
place. The recognition of a clinical likeness between diseases has often 
led to the erection of a " working hjrpothesis " which by subsequent 
research has been found to be correct. Many of our greatest discoveries 
have been initiated in this way. It was, for instance, a process of this 
kind which led to the discovery that a large number of, perhaps all, 
pyrexial disorders are of microbic origin. There are still a number, 
notably measles, small-pox, and scarlatina, in which such a working hjrpo- 
thesis, based on clinical resemblances, forms at present the fidl extent of 
our knowledge ; but so precise are these foundations that the microbic 
nature of these diseases is never doubted. Hypotheses framed in this 
way should always be tested and confirmed in the laboratory and dead- 
house, whenever the morbid conditions can be produced experimentaUy, 
or when they are attended by fatal results. But unfortunately there are 
still a great many diseases, such, for instance, as the two great groups of 
clinical conditions we call hysteria and neurasthenia (conditions which 
form a not inconsiderable portion of the practitioner's daily work), which 
cannot, excepting in the most isolated instances, be observed in the dead- 
house, and which have not yet been produced in animals. In these cases 
the method of analogy or comparison to which I have just referred is not 
only a valuable means of investigation, it forms almost the only means we 
have. 

It is given only to few to devote the necessary time to laboratory 
research ; but all can study their cases at the bedside in the way indicated, 
and many a valuable and often unrecorded idea as to treatment will 
occur to the practitioner who thinks out and traces clinical analogies 
between diseases. 

There is yet another advantage which has always appeared to me to 
accrue, especially to the young observer, by this process of balancing 
evidence and comparing diseases. It not only impresses important facts 



xxvi INTRODUCTION 

upon his memory, but it constitutes one of the best possible means of 
training him to habits of accurate and complete observation, and of 
systematic and productive thought. The scope of his horizon is widened, 
his faculty of systematising his knowledge becomes by practice wonder- 
fully increased, and his reasoning powers strengthened and corrected. He 
finds intuitively that without accuracy in respect to the most minute details 
he may be led astray in the more important ones, that without system in 
the arrangement of his facts he will never be able to attach the proper 
significance and importance to each ; and finally, that without judgment 
in attaching due weight to each item of evidence, his conclusions may be 
erroneous although his premises and facts are correct. 

I have now described the scheme of this work, its purposes and scope — 
in a word, the ideal which I hoped to compass ; and I believe no one could 

approach a task of this kind without realising the re- 
sponsibilities and dimculties mvolved m its execution. 
Amidst the bewildering records of medicine there are many excellent 
treatises both on systematic medicine, the medicine taught in the schools, 
and on one or other of the several departments of clinical medicine. 
These deal with their respective subjects in a manner which I cannot hope 
to rival, and they have been to me an abundant source of instruction, but 
they have afforded me no exact precedent or guide along the path I wished 
to travel. The contemplation of the wide range of knowledge and ex- 
perience required, of the immense advances which have recently been 
made both in the theory and practice of medicine, of the supreme impor- 
tance of the subjects here dealt with> involving as they do questions of life 
and death, has filled my mind with a painful sense of the obligation im- 
posed upon me to sift my facts, and to cull my knowledge, truly, from all 
sources, but, before all, to obtain my material as far as possible by careful 
observation and patient thought from the book of nature which lay open 
before me from day to day at the bedside in infirmary, hospital, and 
private practice. 

In these circumstances I have gladly availed myself of the help and 
advice of many friends, and there are some to whom special^acknowledg- 
ment is due. In certain parts of the chapter on fevers, notably on scarlet 
fever, measles, diphtheria, and enteric fever, I have had much valuable 
advice and suggestion in the revision of the proofs from my old friend 
Dr. Foord Caiger. Similarly in the subject of aneurysm and in parts of 
the subject of pulmonary disease I am indebted to Dr. Robert Maguire, in 
parts of the chapter on diseases of the throat and nose to Dr. St. Clair 
Thompson and Dr. Scanes Spicer, in parts of the section dealing with 
serum -therapeutics to Dr. George Dean, in parts of the chapter on diseases 



RESPONSIBILITIES xxvii 

of the heart to Dr. Alexander Morison, and in parts of the chapter on the 
urine to Dr. C. 0. Hawthorne. The illustrations, with few exceptions, 
are taken from actual cases, and have been drawn specially for this book 
under my own supervision ; my grateful thanks are due to the artist> 
Mrs. Stanley Berkeley, a Royal Academy medallist, who has lent her talent 
to enrich these pages with drawings which are not only accurate but, as 
far as scientific drawings can be, artistic. Finally, it is difficult for me 
to express in measured terms my indebtedness to my wife, who has 
assisted me in the elaboration of this work during the greater part of four 
years. Her skill and knowledge have largely helped to give it such com- 
pleteness as it may possess ; her patient industry has afforded me not only 
assistance, but example ; and her companionship and encouragement have 
made many rough places smooth, and have often transformed what at times 
seemed to be a laborious and interminable task into a pastime. 

T. D. SAVILL. 
March, 1903. 



A SYSTEM OF CLINICAL MEDICINE 



CHAPTER I 

CLINICAL METHODS 

Prdiminary Definitions — Case-Taking — Methods of Diagnosis, Prognosis y 
and Treatment — Rules for Clinical Investigation, 

§ 1. DeftnitioiiB. — ^Disease is a departure from health, and is manifested in 
an individual during life by sjrmptoms. These are of two kinds — " sub- 
jective symftomSy^^ which are recognisable only by the patient, and present 
no external indication, such as pai^, itching, or a feeling of chilliness ; 
and " objective symptomSy*^ ^ which can be detected by the observer — e.g., 
abdominal enlargement or dulness on percussion. The word " symptom " 
is used in two senses. Sometimes it is used in a general sense to indicate 
all the subjective and objective evidences of a disease ; but more usually 
it is employed in a narrower sense, as synonymous with the subjective 
manifestations of a disorder. Confusion is obviated by using the term 
" subjective symptoms " when the latter sense is specially intended. 
Objective symptoms are usually spoken of as signs ; and those objective 
symptoms which are made out by physical examination are known as 
physical signs. 

Just as the value and significance of physical signs depend on the skill 
and experience of the physician who observes them, so the significance of 
subjective symptoms has to be weighed and considered in relation to the 
character and constitution of the patient who complains of them. Thus 
a certain symptom may appear trivial and unimportant to a patient of 
strong character not addicted to introspection, although serious disease 
may be present ; whereas in delicate women with susceptible nervous 
systems every subjective symptom, however slight, may cause great 
anxiety or exaggeration, and even real suffering. Submammary pain, for 
instance, in the first might indicate aneurysm ; in the second, hysteria. 

General {or constHutional) symptoms are those which relate to the whole 
body, such as debility or pyrexia. 

* These words " subjective " and " objective " are borrowed from philosophy. 
Subjective reality is reality which exists in the mind only, whei^das objective reality 
is that which can be demonstrated by means of tangible, visible, or outward signs. 

1 



2 CLINWAL METHODS [ § 2 

A UUent disease is one which is unattended by any very obvious symp- 
toms. Thus, we speak of latent puhnonary tuberculosa when a patient 
suffering from tuberculosis of the lung has none of the more usual and con- 
stant symptoms of that disorder. Physical signs are not necessarily 
absent in latent disease, but they are often difficult to detect. Some 
writers speak of a malady as being latent when the pain, which is usually 
a prominent feature of the disease, is absent. Thus, pericarditis is 
ordinarily attended by a good deal of pain, but this is absent in the latent 
form of pericarditis which frequently complicates rheumatic fever, and 
in the latent peritonitis which complicates enteric fever. 

A paroxysmal disorder is one which oomee on in the form of attacks separated by 
intervals of comparative health. Each attack or paroxysm consists of a stage of 
invasion (usually more or less sudden), leading to an acme, and followed by a gradual 
decline in the severity of the symptoms. As instances of paroxysmal disorders may 
be mentioned Paroxysmal Tachycardia, Angina Pectoris, Epilepsy, Nervous Faints 
and Flush Storms, and Paroxysmal Hsemoglobinuriaw 

The clinical features which all paroxysmal disorders present, and a close study of 
those features which admit of a pathological explanation, point to the probability of 
an origin in the sympathetic system, and especially its vaso-motor portion. 

§ 2. Case-Taking. — In clinical investigation, or case-taking, our object is, 
first, to elicit all the data of the case ; and, secondly, by reasoning based 
on those data to arrive at its Diagnosis, Prognosb, and Treatment. It 
will be found in actual practice that everything turns on the diagnosis ; 
that is our first and principal object ; the prognosis and treatment follow 
from this. 

The investigation of a case consists of two parts : (A) The Interrogation 
of the Patient, and (B) the Physical Examination. Students should 
always accustom themselves to learn all that is possible by interrogation 
before proceeding to the physical examination. 

A. By Interrogation of the Patient we learn — 

(a) What is his chief or dominant symptom ; 

(b) The facts concerning the present iUness ; 

(c) The patient's previous history ; and 

(d) Hid family history. 

Throughout the interrogation of the patient it is well to follow three 

GENERAL RULES : 

(1) Avoid putting what barristers call " leading questions " — i.e., questions 
which suggest their own answer — e.g., "Have you had a pain in the 
back ?" suggests an obvious answer to the patient. It might be put thus : 
*' Have you had any pain, and if so, where ?" The patient should be 
encouraged to tell his own story, without interruption. Moreover, the 
very words he uses should be recorded in inverted commas, and on no 
account should the words of the patient be translated into scientific terms. 
Some say that leading questions are permissible when the patient is very 
ignorant and stupid, but these are the very cases in which leading questions 



S 8 ] OASE'TAKINQ 3 

should be specially avoided. The only legitimate way of putting a leading 
question is in an alternate form — e.g., " Have you suffered from diarrhoea 
or constipation ?" Time, patience, and tact are necessary to elicit the 
true facts of the case, without irrelevant detail. Our object is to learn 
what the p&tient feds and knows, not what he thinks of his disease ; and 
our patience is often sorely tried by a long story of his own or his previous 
doctors' views on his case. Our record should be comprehensive. Including 
all important data, negative as well as positive, yet concise — i.e., excluding 
irrelevant facts. Only experience and a knowledge of medicine can teach 
us what is or is not relevant. The beginner, however, should strive after 
completeness rather than conciseness. 

(2) A chronological order should always be adopted, both In eliciting and 
in recording the facts. Nothing is more wearisome than to wade through a 
mass of verbiage which mixes up dates. Dates should be recorded always 
in the same terms. It is very common, for instance, to read in students' 
reports that " breathlessness began in the year 1892," " palpitation started 
when the patient was aged forty," " the dropsy came on three years ago." 

(3) Always adopt a kindly and sympathetic manner. Not only is it our 
bounden duty to be considerate and patient with those who suffer, but by 
entering into the spirit of the patient's sufferings we can often get at more 
important facts, and a truer narration of them, than can one whose harsh 
or abrupt manner causes the patient to shrink up like an oyster into its 
shell. Put your questions in as simple and non-technical a form as possible, 
and be sure that the patient attaches the same meaning to the words as you 
do. Much will depend on the tact of the physician, and two very good 
rules may here be added — viz.. Never put questions bearing on venereal 
disease before the husband or wife of the patient ; never inquire concerning 
a family history of consumption or cancer before a patient whose illness 
is likely to be of that nature. 

(a) The Chief or Cardinal Symptom. — The first question to ask a 
patient should always be the same : " What do you complain of ?" Special 
attention should be paid to the symptom for which the patient seeks 
advice or is admitted to hospital, because it is this symptom which guides 
most of our subsequent inquiries. It should always, as far as possible, 
be recorded in the patient's own words. This book is based upon the 
patient's cardinal symptom; and in the following chapters I shall, after 
each cardinal symptom, allude to the principal conditions for which it 
may be mistaken. The best way to avoid error in this respect is to 
verify your observations by repeating your examination again and again. 

(b) History op the Present Illness. — It is better to investigate the 
present illness first, before the previous and family histories, because it is 
closely connected with the patient's disease, and because we are tracing 
backwards from effect to cause. A good question to start with is : " When 
did you cease work ?" or, " When were you last quite well ?" Remember 
that the present illness dates from this to the time when the patient came under 
observation. Our questions should be directed to ascertaining three facts 



4 CLINICAL METHODS [ § 8 

of importance — viz., the precise manner of commencement of the disease, 
whether sudden or gradual ; the date when the patient ceased to work ; 
and the date when he took to his bed. Then the evolution of symptoms 
can be traced step by step in the order of their development — always in 
chronological order. It is useful also to know whether he has recently been, 
or is now, under medical treatment, not only because the symptoms may 
have been modified in this way, but also because one of the most important 
ethical principles of the medical profession may be involved.^ In all of 
these inquiries the three general rules above given apply (p. 2). 

(c) The Previous History of the patient bears largely on the etiology, 
or causation, of his illness, and comprises two orders of facts — viz., (1) those 
relating to any illnesses the patient may have had before the present one ; 
(2) those concerning his personal habits and surroundings, 

(1) iJnder the former heading, note in chronological order all ailments 
the patient has suffered from prior to the present one, with the dates of 
their occurrence and their duration — e.g., contagious diseases of childhood ; 
and especially such ailments as venereal disease, rheumatism, and gout. 
If the attacks have been at all obscure, it is desirable to add a few of the 
leading symptoms to prove the nature of the alleged attacks, and in such 
instances inverted commas should be freely used. For instance, " rheu- 
matism " is a vague term which may mean any disease attended by pains 
in the limbs, such as alcoholism, syphilis, tabes dorsalis, or neurasthenia. 
The subject of syphilis should always be approached with delicacy in the 
case of women. Indirect information may often be gained by inquiring 
for prolonged sore throat, followed by loss of hair, by eruptions, or pains 
or swellings of the cranial or other bones. In married women a series of 
miscarriages or still-births, or children born with eruptions or snuffles, 
may have the same significance. 

(2) The occupation, home surroundings, and previous habits as regards 
exercise and food should be inquired into. The daily amount of alcohol 
taken, and its kind (wine, beer, or spirits), should always be noted ; and 
also the time of day at which it was taken, because far more harm may bo 
done by " nips " between meals (without ever getting actually drunk) 
than by ten times the quantity taken with meals. Finally, we should 
ascertain whether the patient has resided abroad, especially in malarial 
districts. In females, the previous state of the catamenia, and the number 
of pregnancies, miscarriages, or still- births, should be noted. 

(d) The Family History may, like the previous history, have a causal 
relationship to the patient's malady. The age and state of health if 
living, age and cause of death if dead, of near blood relations, should 

* By-law CLXXV. of the Royal College of Physicians of LoudoD runs as follows : 
' • No Fellow, Member, or Licentiate of the College shall officiously, or under colour of 
a belSevolent purpose, offer medical aid to, or prescribe for, any patient whom he knows 
to be under the care of another legally qualified Medical Practitioner." This is perhaps 
the most important guiding principle in tlie ethics and etiquette of the medical pro- 
fession. On the other hand, this law gives us no proprietary right in a patient because 
we have once prescribed for him or his family. He ceases to be our patient directly he 
ceases our treatment for that particular ailment. 



§2] GASE'TAKIN.O 5 

always be noted — i.e., father and mother, brothers and sisters, sons and 
daughters. Inquiry should also be made as to whether any members of 
the family (parents, grandparents, brothers, sisters, uncles, aunts, or 
cousins) have suffered from consumption, cancer, acute rheumatism, gout, 
nerve diseases, insanity, asthma, heart disease, apoplexy, and especially 
those diseases to which the patient himself seems liable. 

B. The Physical Rraminatian (i.e., the State on Admission, or the 
Present Condition) may with advantage be prefaced by a few general 
remarks on how and what to observe. 

(1) Here, again, having learned by interrogation our patient's chief 
complaint, we should ask ourselves, Is there any striking or pre- 
dominant SIGN OR appearance (Latin fades) ? The importance of 
INSPECTING our patient cannot be overestimated. In these days of 
scientific instruments we are too apt to forget the use of our faculties. 
By simply using our eyes many important data may be learned besides the 
colour of the skin, the general nutrition, the attitude or decubitus, and 
the facial expression. For instance, the manner in which a patient answers 
questions is often the first clue to hysteria, and a peculiar mode of speech 
is one of the pathognomonic symptoms of general paralysis of the insane, 
disseminated sclerosis, and other diseases. Moreover, with experience we 
can by thb means form a conclusion as to the kind of patient we have to 
deal with. Again, never be in a hurry ; it is only by taking time that we 
can fully appreciate all the points presented to our view. This habit of 
" observing " the patient is only developed by long practice ; but it will 
never be developed if the young physician allows himself to be infected by 
the hurry of modem times. 

(2) It is important always to commence our examination with that organ 
TO WHICH THE SYMPTOMS ARE MAINLY REFERABLE. Some teachcrs direct 
their pupils to examine and report on the physiological systems always in 
the same order (first the heart, then the lungs, then the digestive system, 
and so forth), whatever may be the malady. But such a course has, to 
my mind, three objections : (i.) The student goes about his work in a 
mechanical fashion ; (ii.) if the patient suffer from some serious disorder, 
such as peritonitis, he may be seriously injured by a thorough investiga 
tion of the chest and other parts ; and (iii.) in many cases it is a waste of 
time to examine all the organs with equal thoroughness. The same 
educational advantages and experience can be obtained by the other 
method, and in that way we come to the most important facts first. As a 
general rule, the most important data should be mentioned first. 

(3) In all cases every organ in the body should be carefully 
EXAMINED ; for although we may find in one physiological system sufficient 
mischief to account for the patient's symptoms, the other organs may 
reveal changes which considerably modify our treatment, our prognosis, 
and even our diagnosis. Whatever order is adopted, the student should 
not wander from organ to organ, but examine each physiological system 



« CLINICAL METHODS [ § 2 

thoroughly before proceeding to the next. It is well to get into the habit 
of adopting some such order of physical examination as the following : 
F%r9ti note the general condition ; secondly ^ examine the organ chiefly 
affected ; thirdly, the other organs in the following order : Thorax (heart and 
lungs), Abdomen (alimentary canal, liv^r, spleen, and genito-urinary 
system), Head and Limbs (nervous and locomotor apparatus). Further 
details are given in the scheme below, but for the thorough investigation 
of the organ chiefly affected reference must be made to the chapter dealing 
with the diseases of that organ. 

The examination should always be carried out gently, and without undue 
exposure. In serious cases, especially when the heart or lungs are involved, 
it is often well to postpone a thorough examination of some organs, so as 
not to risk harming the patient by exposing or fatiguing him. At the 
same time, the young physician should never allow modesty to prevent 
his making a thorough examination. This rule is especially necessary in 
patients of the better class, but a little firmness, tact, and a courteous 
demeanour will generally enable him to perform what is a duty both to 
himself and his patient. 



:{m;i:h> 



OF CASE-TAKING. 



A. INTERROGATION OF PATIENT, 

(a) The patient's chief or Cardinal Symptom. 
(h) Data concerning the Present Illness. 

(c) The patient's Previons History. 

(d) The Family History. 

B. PHYSICAL EXAMINATION (i.e., Present CondUionr-Give Date).^ 

(a) The general condition may be summarised mainly under three head- 
ings : (i.) The Physiognomy or expression (especially in acute 
disease (Chapter II.) ; (ii.) The Decubitus, Attitude, or Gait, 
especially in chronic disorders (Chapter II.) ; (iii.) The Nutrition, 
General Conformation, and any Eruption on the Skin (Chapter 
XVIII.). The temperature should be taken ; and any bed-sores 
noted. 

(^) Chest. 

I. Cardio- Vascular System. (Chapters III. to V.) 

Symptoms. — Breathlessness, palpitation, cardiac pain. 
Physical Signs. — Pulse : rate, rhythm, tension, arterial wall. 
Heart : apex-beat, percussion area, auscultation, dropsy. 

^ This scheme gives only the chief points which should be noted about the different 
physiological systems, with the object of excluding disease. For an exhaustive 
examination, such as must be made of the organ to which the patient's symptoms 
are mainly referable, the student should refer to the chapter dealing with the diseases 
of that organ. 



§ 2 GA^E'TAKINQ 7 

II. Respiratory System. (Chapters VI. and VTI.) 

Symptoms, — Cough, expectoration, dyspnoea, pain in chest. 
Physical Signs, — Rate of respiration, inspection, palpation, 

percussion, auscultation. 
Examine throat and noso. 

(c) Abdomen. 

III. Alimentary Canal. (Chapters VIII., IX., X., and XI.) 

Symptoms, — Appetite, discomfort after food, nausea, pain, 
state of the bowels, colour of motions. 

Physical Signs, — Examine mouth and tongue. Physical 
condition of abdomen as regards distension, and presence of 
fluid or tumour (inspection, palpation, and percussion). 

IV. Liver. (Chapter XII.) 

Symptoms, — Pain, jaundice. 

Physical Signs. — Size (palpation and percussion), surface (if 
accessible), tenderness. 

V. Spleen. (Chapter XII.) 

Any enlargement (palpation and percussion) or local pain. 

VI. Urinary System. (Chapter XIII.) 

Symptoms, — Any undue frequency of, or difficulty in, mic- 
turition. Any dropsy or pain. 
Physical Signs — 

(i.) Urine : quantity, colour, reaction, specific gravity, 
albumen, blood, sugar, deposit (microscopical ex- 
amination), 
(ii.) Kidney, — Any enlargement, mobility, or tenderness. 

VII. Generative System. (Chapter XIV.) 

Menstruation, frequency, duration, quantity, intermenstrual 
discharge. 

{d) Head and Iambs. 

VIII. Nervous System. (Chapter XIX.) 

Sym/pioms, — Intelligence, sleep, neuralgia, etc. 
Physical Signs, — Muscles : paralysis, spasm, tremor, char- 
acter of walk. Reflexes y deep and superficial. 
Sensation for touch, pain, temperature. 
Cranial Nerves, — Vision, pupils, movements of eyes, fundi. 
Movements of face, tongue, and palate. Hearing. Smell. 
Taste. 
Sympathetic System.— Flush storms, trophic lesions, obscure 
sensations. 
(e) Blood. 

In anaemic and some other cases the blood must be examined 
(Chapter XVI.). 



8 CLINICAL METHODS I § 8 

Progress of Case. — ^Notes (daily of acute or febrile cases, twice a week of 
subacute, and once a week of chronic cases) should be made of the progress 
of the case ; and much care is required here to avoid redundancy on the 
one hand, and on the other to record completely all important changes, or 
any fresh symptoms, and the effect of the treatment adopted. In acute 
febrile cases there ought to be a daily note, and the pulse, respiration, and 
temperature should be noted several times daily. In chronic cases it will 
be sufficient to note, once a week, the persistence of the prominent symp- 
toms or any change in the symptoms. In all cases any sudden change in 
the patient's symptoms or general condition should be noticed at once. 
Each note should have special reference to the previous one ; and before 
taking a fresh note, the previous one should be read over. The treatment 
and its effects should always be incorporated ; thus, if the patient has been 
ordered diaphoretics or purgatives, record should be made of the state 
of the skin or bowels. 

History Sheets, Charts, Diagrams, etc.— A history sheet for recording the history of 
a patient should be ruled with one vertical line down the page one-thiid from the left- 
hand margin, so as to give space for information learned subsequently. It should 
have printed headings and spaces at the top, thus : 

D'agnosis. (Space here for primary and secondary disease, filled in by physician 

afterwards. ) 



Name Age Sex Ocoapation 

Address Date of admission 

Chief symptom on admission 

Date of discharge ' 



Temperature charts are of the greatest use to record the temperature and other 
features of diurnal variation 

Outline diagrams of the various regions of the body are now prepared, and are 
very useful. 

A kind of shorthand code for physic il signs is advocated by some authors, and. when 
once learned, may be useful in saving time and space. 

§ 8. Examination of Children and Infants. — Here the same general rules apply as to 
interrogation and physical examination, and we should first endeavour to ascertain 
the child's leading symptom, either from the patient or the relatives. There are 
however, certain additional rules upon the adoption of which much of our success 
with children will depend. 

1. First endeavour to establish friendly relations with your little patient. • This may 
be done sometimes by appearing not to notice the child when you first enter the room ; 
after a while it may make advances and investigate your watch-chain or ring. A child 
dislikes being starod at. Time should always be given for the child to become accus- 
tomed to your presence, and anything like abruptness will defeat your aim. 

2. The questions put to the child should always be of the simplest character — e.g.^ 
" Where does it hurt you ?" From the mother you may learn the age up to when the 
child remained healthy, the symptoms of the present and previous illnesses. In the 
case of an infant ask whether is was a full-time child, if bom with instrumental aid, 
whether it was bom healthy, or whether it developed a rash or " snuffles," and whether 
breast or bottle fed. If the child is past early infancy, the same questions may still be 
put, and in addition inquire when it began to walk, and when dentition commenced. 



$4] METHODS OF DIAGNOSIS 9 

Carefully inquire as to its present and past diet, as to its appetite, and the state of the 
bowels. Ask also how long it sleeps, bearing in mind that children require much more 
sleep than adults. Then inquire for any recent illness in other members of the family. 
Physical Examination. — Valuable as aiierUive observation may be with adults, it 
becomes quite indispensable with children, who cannot accurately describe their 
sensations. Much may be learned while you sit and allow the child to get accustomed 
to your presence. Notice its expression, the brightness of its eyes, its attitude, the 
colour of its skin, the state of nutrition, its size as compared with age, its movements, 
the condition of its lips (moist or dry), the character of the breathing, the sound of its 
voice. If it cries, inquiry should be made whether this is constant or only at times. 
Congenital syphilis may be plainly depicted on its face or skin. If the child be asleep 
when first you enter, do not wake it, but notice all the above before it is disturbed. 
The limbs of a healthy child should be constantly on the move ; drowsiness, dulness, 
and listlessness are signs of pyrexia, and especially that of the contagious fevers. 
The hands are instinctively moved towards a seat of pain — e.g., the head in meningitis 
The state of the temper is altered in the prodromal stage of most diseases ; but it is 
markedly peevish in the prodromal stage of meningitis. For other facial alterations, 
see Faciei (§ 12). When the child is undressed for examination, the back of the chest 
should be examined first, while the child looks over the mother's shoulder at someone 
who attracts its attention with a bright object or a bunch of keys. The binaural 
stethoscope is the most useful under these circumstances. Percussion should be 
delayed until the end of the examination. 

§ 4. Methods of Diagnosis, Prognosis, and Treatment. — ^Diagnosis, prog- 
nosis, and treatment are the objects we had in view in eliciting all the facts 
concerning the patient by the process of " Case-taking." Of these three, 
Diagnosis — which, as the Greek woid (hicuyvfoais) implies, means the dis- 
tinguishing or discernment of the disease — is by far the most important. 
Everything necessarily hinges on that, because without the recognition 
of the disease, rational prognosis and treatment are impossible. It will 
be well, therefore, to consider how the data we have elicited may be 
utilised in order to arrive at a diagnosis. Several different methods are 
employed : 

The method usually adopted, which is the outcome of the student's 
studies in systematic medicine, is to erect a hypothetical diagnosis, and 
to see whether the patient's symptoms tally with the description of the 
disease. When a child, for instance, with disorderly movements comes 
before us, the diagnosis of chorea at once occurs to our minds. The age of 
the patient, character of the movements, and all the obvious features of 
the case appear to correspond with that disorder. It does not seem 
necessary to consider any other suggestion. This method answers well 
enough in straightforward, well-marked, typical cases ; but in cases 
presenting anything unusual or atypical considerable difficulty may be 
experienced. 

Another method of making a diagnosis is by a process of exclusion ; that 
is, after studying the diseases which might possibly be in operation, we 
arrive at our diagnosis by excluding those which the disease least resembles. 
In 3uch diseases as enteric fever, where the symptoms are few in number, 
this may be the only method possible. The patient, for instance, is 
suffering from a moderate degree of pyrexia, the illness came on gradually ; 
that is all we may know about the case. There are many possible causes 



10 CLINICAL METHODS [ § 4 

of such a condition, but we arrive at the conclusion that it is probably 
enteric fever, because all the other possible diseases are rendered im- 
probable for one reason or another. 

The third method consists of noting the cardinal symptoms and balancing 
the evidence for and against all the possible causes which might give rise to 
it. In this method, after having elicited all the facts of the case, we return 
to the patient's cardinal symptom, enumerate in our own minds the various 
causes which might give rise to that symptom, and balance the evidence 
adduced by the other facts of the case for and against each one in turn. 
It may strike some as being a little tedious, but it is not so when we have 
got into the habit of employing it. It is certainly the one best adapted 
for the elucidation of obscure or atypical cases ; and under all circum- 
stances it presents a truer picture to our mind, because diagnosis can 
never be a matter of absolute certainty. At most a diagnosis is only a 
strong probability, and this method enables us to ascertain the exact 
amount of probability in each disease. Even in the simplest and most 
typical cases it is a good mental exercise for us to keep in mind the other 
lesions which might produce the same symptom, and then we are always 
on the lookout for possible errors, and ready at any moment to review 
the diagnosis — a correct mental attitude when in presence of Nature's 
phenomena. The chapters which follow are based on this method. 

ExAHFLB. — Let us suppose, for instance, that the patient, a pale young woman, 
aged twenty-three, comes to us complaining of Tomiting blood t.e., hematemesis). 

First, we ascertain and verify this, the leading symptom, and find that she has really 
vomited a considerable quantity of blood. 

Secondly, we interbooatb her as to the history of her present illness, her previous 
and family histories, and we find that she has suffered for several years from symptoms 
pointing to dyspepsia, and that latterly there has been severe pain in the epigastrium. 
There are always four features we have to investigate about every pain — its position, 
character, degree, and constancy ; and we find that this epigastric pain is a sharp pain, 
not constant, but coming on Portly after taking food, and that it is followed and 
relieved by vomiting. The other details of the case we will omit for the sake of brevity. 

Thirdly, we proceed to the physical examination, first of the abdominal organs, 
but this reveals nothing abnormal. Then we go through the other physiological 
systems in order, observing (a) her General Condition (noting, for example, how pale 
and thin she is, and how weak she seems) ; (6) examining the Chest (oardio- vascular 
and respiratory systems) ; (c) the Head and Limbs (nervous system) ; (d) the Blood 
must also be examined, because anaemia (poverty of blood) may be inferred from the 
pallor of her skin. 

Having elicited all the data (taken the case) by interrogation and physical examina- 
tion, we return to the cardinal symptoms — ^haematemesis ' — ai\d consider its various 
causes (sec the section on Hsematomesis) seriatim, taking the most probable cause in 
this case first. 

^ Here there was no difficulty about identifying or selecting which was the chief or 
roost important symptom ; but in another case uie anaemia (or the vomiting or epi- 
gastric pain) might he the more serious or prominent symptom, the haematemesis 
consisting, perhaps, of a few streaks of blood. Then we should deal with the anaemia 
in the same way as haematemesis is here dealt with. Sometimes a good deal depends 
upon our choice of which is the " leading symptom." for it is not always the most 
prominent which is the most serious and important ; and by an error in this respect 
we may bo led far afield of the true disease. Sometimoa. howovor, it is useful to 
change the point of view we take of the case, by regarding it from another standpoint 
or leading symptom. 



§4] METHODS OF DIAGNOSIS; PROGNOSIS 11 

(a) SiMFLB Ulcer of thb Stomach. 

For : (L) The profuseness of the hsematemesis ; (ii.) the character of the pain 
(brought on by food, relieved by vomiting) ; (iii.) the history of dyspepsia ; 
(iy.) the age and sex of the patient. 

Against : (i.) No tenderness in the epigastrium 

(b) Cancer op the Stoiuoh. 

For : (i.) The vomiting of blood ; (ii.) pain in the stomach ; (iii) palbr and 

emaciation ; and so on. 
Against : (i.) The blood vomited was too profuse, and had not the character 

special to cancer (coffee grounds) ; (ii.) the pain was only produced by 

food, and entirely disappeared after vomiting ; (iii.) age of patient much too 

young. 

(c) Portal Obstruction. 

For : (i ) The profuseness of the hsematemesis. 

Against : (i.) Absence of abnormal signs in the liver ; (ii.) absence of ascites, 
piles, and other symptoms of portal obstruction. 

(d) Other and less probable dlagnoses can be discussed in like manner, though 

each of these may be more summarily dismissed thus : Vicarious menstrua- 
tion would not account for the dyspepsia, acute epigastric pain, and other 
symptoms. Leucocythamia, Scurvy, and oiher blood conditions, if present, 
would present the other symptoms of those maladies ; and so on. 

It follows, therefore, that the balance of evidence is in favour of (a) Simple Ulcer 
OF the Stomach, partly because of the weighty arguments in its favour, and partly 
because the only argument against it is not vital, for tenderness may be absent when 
the ulcer is situated on the posterior wall of the stomach. Indeed, if a numerical 
value were given to each of the ** reasons ** for and against, it would be possible to 
express the precise degree of probability in each disease in the form of a mathematical 
ratio. This method may at first sight seem tedious, but after a little practice it 
becomes automatic and extremely simple ; and it takes much less time than is here 
implied. 

Prosnosis (from the Greek word TrijoyvaxTts:) is a " foreknowledge " of 
the events which will happen — t.e., of the probable course the disease will 
run. Nothing but wide experience, combined with careful and minute 
observation, will enable a physician to prophesy with any approach to 
accuracy. It will, however, be useful to bear in mind that the prognosis 
of a case depends upon four circumstances — viz., (1) the usucU course, 
duration, and event of the disease in operation (phthisis, for instance, 
runs a prolonged course, and until lately the event was almost invariably 
fatal) ; (2) the presence or absence of untoipard symptoms (e.g., profuse 
hsemoptysis in phthisb) ; (3) the presence or absence of complications 
(which are sometimes more fatal than the disease itself — e,g,, enteric and 
many other fevers are fatal chiefly by their complications) ; and (4) the 
causes which are in operation, including among the predisposing causes 
such data as age and sex (bronchitis, for example, in middle life is not a 
serious affection, but in infancy and old age it is one of the most fatal 
diseases in the Registrar-General's returns). More reputations are wrecked 
on the rock " Prognosis " than on any other. 

As practical hints to the young physician, I would advise him — (1) Never 
to commit himself to a prognosis unasked, or before the effects of treatment 
have been noted. (2) It is also well to impress upon the friends that a 
'* physician " cannot hope to be also a " prophet "; and that prognosis 



12 CLINICAL METHODS [ § 5 

may depend on many factors in the case which are not yet revealed. The 
medical work in connection with life insurance is largely a question of 
prognosis. 

Treatment is what the patient comes to us for ; and it may be of three 
kinds : (1) In Radical treatment (also called Curative or Rational) our 
object is to cure the patient of his disease by the removal of the cause. 
This is the only truly scientific treatment, and it is based mainly upon a 
knowledge of the pathology of the malady. (2) Symptomatic treatment ia 
directed only to the relief of the symptoms. In some incurable maladies 
symptomatic treatment is the only kind that is possible, and all that we 
can do is to ease the passage to the grave. But in the practice of busy 
practitioners, the trouble and time needed for thorough investigation 
often lead to the adoption of the latter at times when a more radical treat- 
ment would be possible. There is an unfortunate tendency to fall into 
a routine of symptomatic treatment which we should constantly guard 
against. Both Radical and Symptomatic treatment may be either internal 
or external on the one hand, and either medicinal or dietetic and hygienic 
on the other. (3) Preventive treatment has within the last quarter of a 
century developed almost into a separate science, the science of Hygiene 
or State Medicine. 

§ 5. General Rules in Clinical Investigation. — There are certain habits 
which the student should strive to cultivate when he comes to the practical 
aspect of his profession ; and he should remember Thackeray's saying : 
" Sow an act and you reap a habit ; sow a habit and you reap a character ; 
sow a character and you reap a destiny." Clinical medicine depends 
more than anything else on ac<jurate, complete, and well-directed observa- 
tion, and there are five hints I would give to the student in this connection, 

1. Avoid superficiality in your observations. Do not try to see many 
cases in one day, but rather one or two cases continuously from day to day, 
so that you may follow a given malady throughout its entire course. It 
is of more value to follow up one case in this way than to see a dozen on 
one occasion only. Practical knowledge must be acquired gradually. 
The thought will often occur to the student how slowly he progresses with 
his clinical knowledge. This is partly real, partly apparent. It is partly 
apparent because a student does not realise at the time the value he derives 
from listening, for example, to the same cardiac murmur over and over 
again. It is partly real because it is only by patiently devoting the 
necessary time to the study of the same case from day to day that he will 
learn to make his observations adequate, thorough, and precise. That 
is why many a brilliant intellect falls behind, and many a plodder comes 
to the front in our profession. It is vain to attempt to substitute genius 
for patient industry in this arena. You must learn for yourself the effects 
of this or that line of treatment ; learn to correct and control the observa- 
tions you make one day by your observations of the morrow ; and above 
all, try to learn what is the sequel or termination of the case, especially 



S 6 1 GENERAL RULES 13 

in such instances as may lead you to the dead-house. There, more than 
anjrwhere else, the most brilliant diagnosticians learn from their own errors 
more than from a multitude of successful cases. 

2. Do not strive after whU is rare and curious. It follows, as a matter of 
course, that, other things being equal, a fact is more important in propor- 
tion as it is common. Moreover, by studying only the exceptions to a 
rule, our minds will have a distorted view of clinical phenomena. Do not 
therefore, be led astray by those pedants who seek after the singular and 
uncommon. It is well to see rare cases when the opportunity offers, by 
all means, but be careful that you mentally register them as rare. 

3. Do not study only acute and severe cases. It is true that in acute 
diseases there is often more to be done, more heroic and decisive effects to 
be produced, or apparently produced, and therefore more credit and 
renown to be obtained. But we shall find in actual practice not one- 
tenth, perhaps not one-hundredth of our patients will be suffering from 
these complaints. Our success, therefore, in practice, whether measured 
by that laudable satisfaction at having done one's duty, or by the pecuniary 
reward of which every earnest labourer is worthy, will depend very much 
on our experience of, and our ability to treat, chronic and what we are too 
apt to call trivial complaints. For one case of Graves' or Addison's 
disease, the student will, I venture to think, have a hundred cases of 
dyspepsia, chronic rheumatism, or chronic bronchitis. In the treatment 
of such complaints the greatest judgment and thoroughness are some- 
times needed. No sudden or startling effects can be produced. Chronic 
diseases require chronic remedies, and it is only by experience that one can 
learn to produce those gradual effects which lead to a successful issue. 

4. Be accurate in your observations. State facts precisely as you find 
them, no matter whether they accord with your hjrpothesis or not ; and 
state only what you find and know to be the truth. The study of clinical 
medicine, like the study of any other of Nature's phenomena, should 
inculcate in the mind of the student a love of truth. It is impossible to 
have any dealings with Nature without learning that truth is the key 
to the discovery of her secrets. Accuracy is one form of truth, and it is 
only by repeatedly going over your observations, and sifting the patient's 
statements, that you can insure accuracy. 

5. Be systematic in the arrangement of your data^ for it is only by a 
systematic arrangement that you can attach the proper significance and 
importance to each, and get a firm grasp of the whole case. Nothing, for 
instance, is more liable to confuse and to prevent you from coming to a 
correct conclusion than wandering from one date to another without regard 
to the chronological sequence in the history of an illness. And again, in 
physical examination, nothing is so likely to lead you astray as wandering 
from organ to organ without first completing the examination of each. 



§ 6. Classiflcation of Diseases — ^Method of Procednre. — It has been cus- 
tomary, and the practice is convenient, to classify diseases into two great 



14 CLINICAL 'METHODS [ § 6 

groups — Constitutional and Local. Local diseases are those in which the 
principal, and perhaps the only, lesion is localised in one organ or situa- 
tion, e.g,, facial neuralgia, ringworm. Constitutional diseases are those 
in which the disease has manifestations of general distribution, e.gr., acute 
rheumatism, typhoid fever, and pyaemia. 

It is convenient for clinical purposes to preserve this division, but the rapid advance 
of pathology has gradually transferred disorders from the " local " to the ** constitu- 
tional " group. A large number of diseases formerly believed to be lesions of local 
origin (such, for .nstance, as pneumonia, endocarditis, and peritonitis) are now known 
to be due to some general morbid process, toxic or microbic, which, reaching the blood, 
is carried by the circulation all over the body and causes a special local manifestation 
in one situation. 

From a pathological standpoint diseases are sometimes divided into two groups — 
Oi^anic, those in which some anatomical change is found after death ; and Functional, 
those in which no structural alteration is found. The anatomical or structural change 
is spoken of as the '* lesion." The word *' functional " must not be regarded as 
synonymous with " hysterical" 

Now it so happens that local disorders are very often met with as com- 
plications or effects of constitutional or general conditions ; and since in 
clinical work we are engaged in tracing from effect to caiuie, we shall, in 
the following chapters, take the local diseases which are manifested by a 
lesion localised in some particular organ first, and the constitutional con- 
ditions afterwards. 

When a patient applies to us, if, as the result of our inquiries, we find he 
is suffering from a symptom localised to some organ (e.gr., pain in the liver) 
turn to the chapters relating to the diseases of the organ (one of the 
Chapters IIL to XIV.). 

If, on the other hand, he has no localised symptom, but complains of 
malaise, feverishness, or a sense of " bodily illness," turn to the chapters 
on constitutional diseases (Chapters XV. to XIX.). 



CHAPTER II 

THE FACIES, OR EXTERNAL APPEARANCE OF DISEASE a 

In out scheme of case-taking it will be remembered that the first step in 
physical examination was to observe the patient's general condition ; and 
it will also be remembered how great was the importance of an adequate 
inspection of the patient while he was telling us the story of his illness. 

Some diseases can be identified almost at a glance, before the patient 
opens his lips, such, for instance, as Chronic Alcoholism, some manifesta- 
tions of Hereditary Syphilis, Graves' Disease, Cretinism, Myxoedema, 
Facial Paralysis, and Hydrocephalus, when these conditions have passed 
beyond the incipient stage. The existence of others can be very strongly 
suspected, such as Rickets, Postnasal Adenoids (mouth-breathing children), 
and Chronic Bronchitis with Dilated Right Heart. 

But, apart from these, much may be learned from the first glance at a 
patient — from his decubitus (the way he lies), from his attitude or gait (if 
he be able to leave his bed), from the expression of his ^ace, the colour 
of his skin, and from the general conformation of his body — without the 
employment of any special methods of apparatus for diagnosis. It is to 
be feared that as scientific methods become more and more perfect, these 
means, which constitute one of the most useful and important aids to 
diagnosis and prognosis to the experienced busy practitioner, are apt to 
be neglected. But, on the other hand, students and young practitioners 
had better not attempt " lightning diagnoses," or they will certainly fall 
into the most serious errors. Some men, it is true, seem to be specially 
gifted in this way ; but it is only by long experience and the possession of 
special faculties that they can accomplish such feats. 

It is a fundamental rule that your patient should face the light at all 
medical interviews. Similarly your own chair should be in the shade, lest 
the patient should read too readily what is passing through your mind. 
It is surprising what important clues can be obtained by an intelligent 
inspection of your patient, both as to his character and his disease. 

The facies of disease may be summarised under three headings : (A) The 
Physiognomy of Disease. (B) The Decubitus, Attitude, or Gait. 
(C) Alterations in the General Conformation of the Body. 

^ The Latin word facies signiiiea an appearance, form, or shape. 

15 



16 THE FACIE8 OF DISEASE [§J7,8 

Hints to be derived from an inspection of the hands are given under 
Diseases of the Extremities (Chapter XVII.). The various diseases will 
be only mentioned here. The description and differentiation of the several 
afiections referred to will be entered into more fully in the chapters which 
follow. 

(A) The Physiognomy in Disease. 

An observant physician can obtain important clues to diagnosis by the 
physiognomy — i.e., the aspect and expression of the patient's face — even 
apart from the insight which can be gained by this means into his character. 

§ ?• In Acute Diseases more can be learned from the position in which 
the patient lies (i.e., his Decubitus, § 14) than from the physiognomy or 
expression of his face. But it is worth remembering that the face assumes 
an anxious expressioUy which is very characteristic in pericarditis, peri- 
tonitis, and severe pneumonia, also during attacks of angina pectoris. 
The supervention of actUe pericarditis in the course of rheumatic fever is 
often unsuspected, as there may be no local symptoms ; but it may be 
recognised by this anxious expression, the dilated nostrils, and the flush 
upon the cheeks, which were (probably) at our last visit so pale. In acute 
croupous pneumoniaj again, the appearance is very distinctive. The 
flushed face, hot dry skin, widely dilating nostrils, the eruption of herpes 
beside the mouth, and the profound disturbance of the pulse-respiration 
ratio (1:2 instead of 1 : 4, which is the normal), form a picture which 
greatly aids the recognition of the disease. The Fades Hippocratica — a 
facies or appearance, of which the description has been handed down from 
Hippocrates — is the forerunner of death from exhaustion, such, for in- 
stance, as the final stage of cholera, and wasting disorders. The temples 
are hollow, the eyes sunken, the eyelids slightly parted, the eyes glazed, 
and the lower jaw droops. The Risus Sardonicus is a fixed grin, met with 
typically in tetanus. The corners of the mouth, which twitch at intervals, 
are drawn upwards as in laughter, and the features assume a fixed sarcastic 
expression. 

§8. A few Chronic Diseases may be enumerated in which the physi- 
. ognomy is characteristic. 

(i.) The aspect of a phthisical or tuberculous patient differs in the pre- 
monitory and advanced stages, (a) Before any evidences can be detected 
by physical examination of the chest, the patient has the appearance 
which is loosely described by the laity as " delicate." The skin is fine 
and soft, and the fresh, rosy colour of the cheeks is out of keeping with the 
dark rings aroimd the sunken eyes. But it is by the deficient chest 
measurements and sloping shoulders that the " strumous diathesis," as 
this tendency or predisposition to tuberculosis is called, makes itself 
especially manifest. The shoulders slope, and the transverse diameter is 
deficient in proportion to the antero-posterior (see Chapter VI.). Some- 
times such patients are plump and rosy ; nevertheless, they have a deficient 
chest measurement, (b) When the disease is advanced, the phthisical 



§ 9 ] SWELLING OF THE FACE AND NECK 17 

patient often presents an appearance that enables the physician to hazard 
a diagnosis almost without further investigation. The pale, emaciated 
face, with sunken eyes, the circular crimson flush of hectic fever on the 
cheeks, the wasted body, bathed from time to time in sweat, the hoarse 
voice and easily-provoked dyspnoea, collectively form a picture which ifi 
very characteristic. 

(ii.) Chronic bronchitis with dilated right heart is another condition of 
extremely common occurrence in the practitioner's daily practice, and 
the picture these patients present is very characteristic. The florid 
'* healthy " looking cheeks, the pulsating jugulars, in a person over forty 
(more often of the female sex) is very typical. 

(ill.) In chronic alcoholism there is a pufliness of the face and a congested 
watery look about the eyes (" a blear-eyed look "). The eyelids are puffy, 
80 that the person is described by sailors as having " an eye like a poached 
egg." The cheeks and nose are often red, and dotted with stellate venous 
capillaries. The belly is corpulent ; and on holding out the hands and 
spreading the fingers, they are seen to be affected with fine small rhythmical 
tremors. The whole picture is unmistakable, though the eyes alone will 
tell the tale. 

§9. SweUing ol the Face and neck, if associated with oedema of the 
limbs and tnmk, may be part of a generalised dropsy. In the dropsy of 
renal diseasCy on account of the looseness of the cellular tissues around 
the eyelids, the swelling is most obvious in that situation. The pufliness of 
the eyelids due to renal disease is, however, greater in the morning than 
in the evening, and in this way may be distinguished from a similar con- 
dition due to arsenical poisoning or whooping-cough. The dropsy of 
cardiac disease is more diffuse. 

A swollen, oedematous condition of the face, accompanied frequently by 
a troublesome redness, coming on after meals, is a symptom for which 
dyspeptic patients often seek advice. It also forms part of that trouble- 
some condition urticaria factitiosa. A swelling of the face is also apt to 
occur with different forms of erythema, and is generally worse after meals. 
In chlorosis and severe ansemia the pallor of the skin may be associated 
with some oedema. 

Chronic cedema around the eydids must not be mistaken for myxoedema. 
It is a not infrequent sequel to recurrent eczema, or repeated attacks of 
er3rsipelas, in that situation. It is also met with in nervous or hysterical 
conditions, and in vaso-motor derangements, when it is liable to transient 
exacerl)ations. 

(Edema confined to the head and neck is found in those rare cases where 
there is pressure on the veins within the thorax, especially the superior 
vena cava, as in cases of mediastinal tumour ; or with tumours within the 
skur. 

Myxcedema may often be recognised by a glance at the patient's face 
^nd hands (Fig. 1). There is a solid oedema and pufliness of the face — the 



18 TBE FACIES OF DISEASE [ !10 

body and limbs being also affected — but it does not pit on pressure. The 
vacant, stolid look, fiushed cheeks, '^scanty hair, and slow speech are 
equally typical of this disorder. The hands are flat, coarse, and swollen 
(see § 420). In acromegaly the jaws, lips and end of the nose are thickened 
and enlaced {g 449). 

§ 10. Tlie Complexion and colour of the face will repay careful insper^- 
tion, for thereby the trained obser\-er will acquire some useful hinta. Thus, 
the pallor of syphili.'f or tubercle, and other anceniic conditious, is often 



He. 1.— UTXaDUA,— The patient »>• & man atiAd thirty, who nag Admitted Into tha PsddlnEton 
IiiDrmuy la November, ISS7, pnwentlog all the luiul lymplunu of the dtieue. Ela tnove- 
menla and laeuta] proctuea were eitremely alow ; average temperatuie »7-2 ; the quantity 
ol area paated waa leu than halt tha normal. There wu a t«ndenry to liicinorrhagea (iwv 
further partlcnlan In Hed. Soc. Proc., vol. xl.). 

very striking. So also is the pallor, or rather sallowness, of aortic valvular 
disease ; the dead white or waxen puffy appearance of parenchymatous 
nephritis ; the greyish pallor of chronic interstitial nephritis ; the charac- 
teristic yellowish hue of chlorosis ; the primrosf colour of that happily 
much rarer condition, pernicious antemia.i The deep yellow to greenish- 
yellow colour of jaundice ; the dull earthy look of malarial cachexia, cancer, 

• It ie ODly by Iohr iMperience that one is enabled to distinguish these t«6neinentB 



i H ] THE FACE IN DETAIL 10 

and chronic abdominal disease ; and the purple (or cyanotic) appearance o{ 
the cheeks and lips in mitral and congenital heart disease, are still more 
distinctive. A famt ydiow tinge with pallor occurs with old age, early 
catarrhal jaundice, choUemia and severe ansamias. Dark rings around 
the eyelids appear in states of fatigue ; they often indicate want of sleep, 
or indigestion, and may be so pronounced in malarial conditions as to 
resemble the ecehj'mosis of a bruise. Bronzing is seen with Addison's 
disease, arsenical poisoning, htemochromatosis, and in half-castes. 

Seborrhcea oleosa of the scalp gives rise to greaaineta of the face ; and 
this, with the erythema which frequently accompanies it, produces an 
appearance somewhat resembling a badly polished copper kettle. A 
greasy complexion of this kind is 
a great affliction to some young 
and otherwise attractive women, 
who might easily be rid of it by the 
cure of the scalp lesion. A muddi/ 
sallow complexion may be associ- 
ated with dyspepsia, when the lips 
are usually dry. 

g 11, The Face in Delail merit« a 
little closer study, and, first, that 
most eloquent portion of it, the eyes. 

(i.) The eyes may be protuberant 
as a whole (Froptosis), as in Graves' 
disease, intra- ocular tumoor, or 
tuemorrhage or thrombosis of the 
cavernous sinus- In protuberance 
due to acute blood diseases the 
ophthalmoscopic appearance may 
be normal. Protrusion of the eye- 
balls is one of the most constant 
symptoms of Oraves' disease. An 

eauallv common ara of this dis- Fia.2,— EiopHiHAunoooiTKiioraves'DiiftMe). 
^, . .. ° , , , From Byiom Brammll'a " Atlu of CllnlMl 

order is a goitrous enlargement of uedtdne." 
the thyroid gland, and therefore the 

malady is also called Exophthalmic Goitre (see Fig. 2). The appearance 
of protrusion may be caused by loss of intra-orbital fat. The eyeballs 
may recede in paralysis of the cervical sympathetic, in wasting diseases, 
collapse, and the diseases which lead to collapse. The pallor of aneemia 
is seen in the conjunctivse, and in the sclerotic, or white of the eye, the 
tinge of jaundice can often be detected when the yellow colour of the skin 
is so slight as to escape detection. The sclerotic may be yellow also in 
severe annmia and in old people ; it may be bluish in congenital heart 
disease, and in the rheumatic diathesis. The " arcus senilis " is a white 
ring of opacity in the cornea, just within its peripheral margin. It is 



20 THE FACIES OF DISEASE [ | IS 

usually believed to indicate senile degeneration of the arteries and other 
tissues of the body, but I never found it so among the old people in the 
Paddii^ton Workhouse and Infirmar}'. In adults vho are subjects of 
hereditary syphilis, the comece may present struB, or the appearance of 
ground glass (Fig. 3), due to interstitial keratitis. Alterations of the jAtfU 
are dealt with elsewhere. 

(ii.) The lifs may show the pallor of aneemia on the one band or the con- 
gestion or cyanosis of cardiac disease on the other. The mouth is held 
open when adenoids are present, in idiocy, cretinism, and certain paralyses. 
Fissures and mucojia tubercles may indicate that syphilis ia in operation. 
Stellate cicatrices around the lips are a record of previous or hereditary 
syphilis. Dryness of the lips 
occurs with fever and gastric 
disturbance. The position and 
movements of the mouth are 
characteristic in facial and bulbar 
paralysis, in the Landouzy- 
Dejerine type of myopathy, and 
in thetremorsof general paralysis 
of the insane. 

(iii.) The teeth may present 
the evidences of pyorrhoea or of 
hereditary syphilis, in which 
disease, as Hutchinson has 
pointed out, the permanent in- 
cisors (that is to say, when the 
child has reached the age of 
seven) are characteristically 
" P*f>S^<l " — '■^■' narrower at 
the cutting edge, and notched 

Fig. 3.— HebeDRaBT Stmius.— Showina thelnUr- (^" *'^ § l*'^)" 

BtlU«lker«tlU«»ncl "pegged teeth "iJlHeredllary (iv.) Depression of the bridije 

srphiUs. ,' , ' '^ .. , J ■ . 

of the nose, if marked, is due 

to chronic rhinitis in childhood, usually of syphilitic origin. In such cases 
the nose is characteristically broad and flat, or small and " snub," like 
a button, the opera-glass nose of Foumier. The end of the nose is 
enlarged in acromegaly and myxtedema. 

(v.) The eon lamy levesl disgnostia evidence of lupua erythem&toBDB, circulatory 
disturbances, and the tophi of gout. 

(vi.) Defective development ma; be i«cogniaed by " stigmata," such as epirjinthic 
fold, liare-lip, oleft palate, occeesoiy auricles, and dermoid cysts. 

§ 12. The Phyaiognomr of Childhood requires considerable experience to 
appreciate it fully ; then it lends us mvaluable aid. 

(i.) Congenital typkUis gives to an infant a very characteristic, pinched, 
wan, or " senile " face. The complexion is ashy-grey, the skin is " drawn " 
and it may be flaky or parchment-like. The eyes and cheeks are so hoHow 



§18] VARIATION a IN THE FORM OF THE SKULL 21 

that the nose seems unduly prominent, and thus gives to the infant the 
appearance of a little wizened old man. 

(ii.) When an infant is experiencing fain the face will sometimes give 
a clue to its situation. Thus, a wrinkling of the forehead or frown is 
indicative of pain in the head ; a drawing-up of the mouth at the comers, 
producing marked naso-labial folds, points to severe abdominal pain ; a 
dilatation of the nostrils and elevation of the eyebrows may suggest intra- 
thoracic discomfort ; and in tabes mesenterica and other chronic wasting 
diseases the face gradually assumes a fixed or contracted condition, in 
which the angles of the mouth are depressed. 

(iii.) Nothing is more characteristic than the listless and apathetic facies 
of children suffering from the early stages of fever. 

(iv.) MotUh'breathing children (due generally to postnasal adenoids), 
have a very characteristic expression. The broad bridge of the nose and 
open mouth give to them a vacant, stupid appearance, which sometimes 
belies their intelligence, though sometimes they are, in fact, mentally 
backward. 

(v.) The fontaneUes afford information as to the general condition of a 
child. A depressed fontanelle is an untoward sign in all acute illnesses of 
childhood — e.g., the diarrhoea and vomiting of infancy. The fontanelle^ 
bulge in inflammation of the meninges, and this is a useful diagnostic 
feature between true meningeal affections on the one hand, and fevers, 
fx>ncho-pneumonia, and other diseases with cei*ebrdl symptoms on the 
^ther. The fontanelles are tense and bulging in all diseases causing 
increased intracranial pressure — e.g., cerebral tumour. Normally, the 
anterior fontanelle should be closed between the ages of one and a half 
and two years, and the posterior at birth. In rickets the former is late 
in closing. 

S 18. Variation! in the Form ot the Skoll aro met with in several complaints, and 
chiefly in childran, b-Dcauso cases of marked deformity of the head seldom reach adult 
life, except in the shelter of an asylum for the insane. The following variations are 
noteworthy : — 

(L) Aaymmtiry m^y bo congenital, due to a diffioult labour, or acquired in early 
life from the continual nursing of the infant on one arm. The head is flattened on 
the side it rests on A course of nursing on tho obhor arm will correct the deformity 
in the most surprising way. 

(ii). In hydrocephalua (§ 625) the head is large out of all proportion to tho face, and 
the forehead overhangs the face. 

(iiL) In rickets the skull is large and square, but the forehead rises straight up and 
doei not overhang. There aro often bosses in tho frontal and piriotal regions. 

(iv.) In hereditary ayphUis the bones around the anterior fontanelle are thickened, 
and there are irregular areas of thickening and thinning (cranio-tabos), especially 
behind the ears. The condition resembles that found in rickets, with which it not 
infrequently ooeziBte. 

(v.) In microcephaly the forehead is receding and the cranium very small. The 
children are mentally defective. In scaphocephaly the head is elongated and its 
lateral diameter diminished. Defective mental development may co-exist with other 
** stigmata of degeneration/* such as high arched palate, accessory auricles, etc. 

(vL) In adidts signs of infantile malformations may be found, and localised thicken- 
ings may also be seen in osteitis deformans, leontiasis ossea, and after injury. 



22 THE FACIE8 OF DISEASE [ § 14 

(vii.) In acromegaly (§ 449) the lower jaw is enlarged and often the nose also. The 
face is ovoid with the long transverse diameter below. 

(viii.) In osteitis deformans (Paget's disease) the face is ovoid but with the long 
transverse diameter above. The hands and feet are also big and clumsy, but the skin 
is normal. 

In various diieaief of the ner?oiu system the face presents a pathognomonic ex- 
pression. Thus in Bell's or facial paralysis the face is distorted, and so also in that 
rare condition facial hemiatrophy. The expression is vacant in idiocy, some hysterical 
subjects, and early disseminated sclerosis. A smooth, expressionless appearance 
(differing from the preceding in that there is a lack of mobility) is very characteristic 
of paralysis agitans, and among rarer conditions, of double facial paralysis, the myo- 
pathies affecting the face muscles, scleroderma, and Raynaud's disease (on acoount 
of the scleroderma present). Bulbar paralysis gives a very characteristic, mournful, 
or sullen appearance to the face. In this disease the orbicularis oris is paralysed, and 
allows the lower lip to pout ; while the weakness of the zygomatici results in a drooping 
of the comers of the mouth, such as wo usually associate with sorrow or suUenness 
of temper. In a more advanced stage the saliva dribbles out of the mouth. Certain 
spasms and tremors are recognised at a glance (§ 594). 

(B) Decubitus (in Acute Conditions) and Attitude (in Chronic 

Diseases).^ 

§14. Decnbiius signifies the position which a patient tends most con- 
stantly to assume, and it often gives a valuable clue to the disease, more 
especially in the diagnosis of Acute Diseases, and sometimes as to their 
probable issue as well. For example : 

(i.) Sitting up in bed, propped up with pillows, on account of inability to 
breathe in other positions (orthopnoea), is characteristic of the extreme 
breathlessness which occurs in advanced cardiac, pulmonary, or renal disease. 

(ii.) Lying on one side is characteristic of considerable pleural efiusion or 
pneumonia on that side, as in this position free play is given to the healthy 
lung. When a phthisical patient always lies on one side, we may suspect 
a cavity, bronchiectasis, or empyema of that side. A patient curls up on 
one side in colic and in certain forms of meningitis. 

(iii.) The dorsal decubitus — 1.6., lying on the back — is seen ingrave 
illnesses attended by marked prostration, (a) In the '' typhoid state " 
the limbs are stretched out and completely relaxed. The typhoid state, 
so called from its occurrence in tjrphus and tjrphoid fevers, is a condition 
of profound prostration, attended by unconsciousness or muttering 
delirium, sordes on the teeth, and a dry, cracked tongue. (6) If the prostra- 
tion be due to peritonitis, the legs are drawn up, so as to relax the abdo- 
minal muscles ; and for the same reason the breathing is thoracic and the 
abdomen is quite still. The greater flexion of one leg may give a clue as 
to the side on which the trouble exists. 

(iv.) Opisthotonos is an arching of the back which occurs in some con- 
vulsive and spasmodic disorders. It may be so great that only the head 
and heels touch the bed. It is met with in tetanus, hystero-epilepsy, and 
strychnine poisoning. 

^ The various characteristic gaits are described under Diseases of the Nervous 
System. 



116] THE ATTITUDE 23 

(v.) Retraclvm of the head m cbaraoteristic in ceiebro-spinal and post- 
basal meningitis. It is also met with in infants witb digestive disorders or 
febrile states, in dyspncea due to laryngeal obstruction, and in rare cases 
of cervical caries. 

(vi.) Reslkaaness occurs in many disorders, acute and chronic, and is 
generally a grave sign in the former — e.g., in acute pericarditis. Some- 
times, as in children, it is an indica- 
tion of severe pain. Carphatogy 
(Kap^os = the clothes, kiytiv — to 
pluck), or floccitatio, is the picking 
at the bedclothes so obaracteristic 
of the " typhoid state." The hands 
seek after imaginary objects. StA- 
aullv* tendinum is the muscular 
twitching or tremor which occurs 
-"Ifl^TEe same state. Both of these 
imply extreme cerebral depression. 
They are met with in the malignant 
forms of the acute specific fevers, 
and are of the gravest possible import. 

§ IS. The Attitude which is involun- 
tarily assumed by a patient suffering 
from certain cluonic diseases, if be be 
able to leave his bed, is very charac- 
teristic. Thus : 

(l) In paralysis agitans the bead, 

neck, and thorax are bent forwards, 

the arms are bent at the elbows, the 

body moves stifSy " as if made of 

glass," and the patient has t^e 

characteristic " festination gait " 

(Fig. 4). The disease is recognisable 

at sight by the smooth, expressionless 

face, fixity of gaze (always looking 

forwards), the forward bending of the 

body, tremors of the hands, and tbe _ „ . , „ 

, ' ' , ■ , ., ■■ . . . Fig- *.— The attitude typical of Paealtbib 

short steps which the patient takes AoiIAHSiCroiaapluteicBstbrU.PuilRiclier. 

as he shuffles along, (ii.) Tbe attitude 

assumed by children sufiering from post-diphtheritic'paTali/sis is somewhat 
similar to the preceding, and is so characteristic that one cttn often detect 
the disease as the patient enters the room. Tbe bead hangs forward from 
weakness of the neck muscles, and tbe " flabbiness " of all the move- 
ments is peculiar, (iii.) The rigidity of the spine in rheumatoid arthritis, 
osteo-arthritis, and spinal caries, gives a stifiness and awkwardness to all 
the movements which is very noticeable. 



24 THE FACIB8 OF DI8BASB t } 16 

(iv.) Duchenue'tt yteado-hyperirophic pandgait (Fig- 5) U » oompu&tjvoljt ram con- 
dition, but the »rohing forwards of the baok. prominenoa of the buttooks, Bcapule. 
and calvM, and inability to rise from a iccumbent postnis without the aid of the 
hands, ara qnita pathognomonic. 



(C) The Qeneral Cohporhatiom. 

g 16. Under this heading we note (a) whether the patient exhibits any 

lose of flesh {Emaciation, in^) ; (b) whether he piesente any increase in 

volume (General Enlaroehbnt, § 17) ; or (c) whether he presents any 

DEFORHiry or Dwarfism (§ 19). 

Here we shall meet with several important 
diseases affecting the skeleton and general 
growth of the individual, especially Hered- 
itary Syphilis. The various causes of such 
alterations will only be mentioned here. They 
will be described and difierentiated under 
the Diseases of Eztremitiea, and elsewhere. 

Variations iw Health. — The terms 
" Emaciation " and " General Enlargement 
of the Body " are only relative. The 
healthy man should have an elastic skin, 
firm muscles, and a slight amount of sub- 
cutaneous fat ; but individtial variaHona are 
BO great that no definite standard can be set 
up as normal. Health in the wiry, nervous 
man is consistent with a spareness that 
would indicate disease in his stouter and 
more phlegmatic brother. The same holds 
true with regard to age. A child has an 
amount of fatty covering that would be 
abnormal in adolescence ; an old man has 
atrophy of the soft parts and prominence of 
the bones which in the middle-aged man 
could only accompany serious disease. The 
question of build is very largely one of 
hereiUi/. Stout parents generally have 
children who t«nd to become stout, and trice 
vena. 

(a) Emaciation is necessarily attended by 
more or less weakoess, and the subject is dealt 
with under General Debility (Chapter XVI.). 

Flj. K,— PsEDDO-EVFRRTEOPHia PARiLYSiBot Duchanns-— Thl» patlBttt 1* a boy, atied nine yetis- 
The lUiutratlOD ■haws w«J the two moat charactsriatlc teaturca of Uis dknua— uunely, 
*™ Ba'UBemDDt ol the calves aail battooka, and tha (trching Inwarda ol the back (lotdtMls). 
The dltBUe la often combined, a* hen, with true mDMUlar atiophy In oUnr parta— «.f ., the 
■hoolder girdle— «nd ther«rore the scapula project. The cbUd abo eihlblted the tyi^cal 
mumer of EBttloji up from the prone pualtloa. Tlie child seemed Darmal udUI lie bejan to 
walk at two yean, wheo It wii noticed he " lilted Itli leiv too high." 



$S 17.18] GENERAL ENLARQEMENT— OBESITY 25 

The chief causes of debility with emaciation are as follows : Malignant 
disease, digestive disorders and privation, diabetes, various nervous dis- 
orders, chronic Bright's disease, syphilis, tubercle, and pancreatic diseases ; 
and in children, tabes mesenterica, defective feeding, diarrhoea, and 
hereditary syphilis. 

In advanced life the first cause which occurs to our minds, if the patient 
has lost flesh, is cancer ; in middle age, diabetes ; and in younj adults, 
tuberculosis. In tuberculosis of the lungs or elsewhere, emaciation may 
occur before any physical signs can be detected ; indeed, loss of flesh 
which is accompanied by an intermitting pyrexia generally means latent 
tuberculosis. In infancy the two most common causes of acute or rajyid 
wasting are Defective Feeding and Gastro-Intestinal Catarrh. The two 
most common causes of slow, progressive, or chronic wasting in infants are 
tuberculosis of the intestine and mesenteric glands, and Hereditary 
Syphilis (§§417 and 404). In hereditary syphilis the child may be born 
quite healthy in appearance, but often soon begins to waste, the face 
presenting a wizened " old man " aspect. 

§ 17. General Eniargdment of the body is much less often met with than 
diminution. It occurs in Obesity y Generalised Dropsy (see §§ 9 and 21), 
Myxcedema (see § 9, and General Debility, § 419), and Acromegaly,^ It is 
probable that the giants of old were specimens of acromegaly. These 
affections will be described and differentiated elsewhere, but since the 
treatment of obesity has unfortunately been allowed to get into the hands 
of charlatans and patent-medicine vendors, it will be well to add a few 
remarks on the causes and treatment of that condition. 

§ 18. Obesity ia veiy largely a question of heredity, and no amount of dieting will 
make any difference in some people. In others it is an indication of luxurious or 
sedentary living, or of indulgence in alcohol. Women frequently become obese just 
about the menopause. Sometimes it is found in chronic cerebral disease, such as 
idiocy or tumour, and, more rarely, in tumours of the adrenal bodies, associated with 
sexual precocity.^ The pathological causes of obesity come under two headings : 
(L) excessive intake of those food-stuffs known to produce fat ; and (ii.) deficient 
oxygenation. It is probably due to the latter cause that persons with persistent low 
tension are apt to become fat. Both causes may be in operation. Successful treat- 
ment must therefore depend either upon diminution of intake or increase of 
oxygenation. 

Tbeatmxnt. — Our first duty when consulted about such cases is to examine every 
organ in the body, especially the heart, lungs, and liver, because excess of subcutaneous 
fat is often attended by a similar deposit of subpericardial fat ; and, if due to alcohol, 
by fatty degeneration of both heart and liver. Chronic bronchitis and emphysema 
are also frequently followed by obesity from deficient oxygenation. If no serious 
lesion be present, there are at least five methods of reduction : (1) To limit the amount 
of fluid taken with meals ; (2) Banting*s system consists in excluding all fats, sugars, 
and starches from the diet, green vegetables and lean meat alone being allowed ; 
(3) Ebstein's system only excludes all sugars and other carbohydrates ; (4) OerteFs 
system is the most complete, and consists in (i.) slowly climbing mountains for several 
hours daily, inspiring with one step and expiring with the next ; (ii.) food mainly 

^ [ have also met with general enlargement of the extremities in certain rare cases 
presenting vaso-motor symptoms. 
* Guthrie and £mery» CUn. Soc. Trans.. 1907. 



26 THE FACIB8 OF 'DISEASE [ § 19 

nitrogenous, with small quantities of fats and starches ; and (iii.) the fluid limited to 
1} pints in twenty-four hours (see Chapter III., { 51). (5) Some eckses of obesity may 
be successfully reduced by limiting the food entirely to one pound of lean meat or fish a 
day, divided into four meals, taken without fluid ; between meals the patient should 
drhik as much hot water as possible by constantly sipping it If the patient will co- 
operate, this method is very successful,^ but the diet is a Spartan one. Thyroid or 
strychnine, either separately or together, are also of value in obesity, especially in 
tiiose oases occurring about the menopause when the apparent obesity is often due in 
reality to a myxoBdematous deposit. 

Adiposis Dolorosa ^ is a rare variety of obesity described by Dercum. It is character- 
ised by the local deposition of fat in the form of tender adipose tumours. The 
condition spreads and becomes more general, the hands, feet, and face escaping. 
Pains, both constant and paroxysmal, occur in various situations, associated with 
great muscular weakness and areas of partial loss of sensation. Professor Stockman 
contends that the condition is common, and is a chronic subcutaneous fibrosis, which 
in Dercum*8 cases was accompanied by much subcutaneous fat. The fibrosis is 
a chronic inflammatory change secondary to acute or chronic infections. It is curable 
by massage, and plenty of daily fresh-air exercise.^ 

§ 19. Dwarflim, or diminished stature, may arise from any cause which affects the 
growth of the bones of the trunk or limbs, whether local or constitutional. The 
commonest causes of a stunted condition of the body, n order of frequency, are : 

(i.) Bickets, — In this disease there is curving of the long bones, together with altered 
epiphyseal growth. This results in " bandy legs," ^* knock-knee," and other familiar 
deformities (see Chapter XVII., § 447). 

(ii.) Hereditary Syphilis, the means of recognising which are fully given in 
CTuipter XVI., f 404. 

(iii.) Curvature of the Spine, which may take three forms : (i.) kyphosis {i.e., the 
convexity projecting backwards), usually due to tuberculous or other disease of the 
vertebrse, or to laxity of the ligaments, as in rickets. The latter disappears when the 
child is held up by the shoulders, (ii.) Lordosis {i.e., a forward projection), usually 
compensatory, or the result of muscular weakness ; and (iii.) scoliosis (a lateral curve). 
All these may diminish the stature, but they differ considerably in importance. A 
certain amount of scoliosis is normal to nearly everyone, and the kjrphosis of muscular 
weakness is common enough in old age, as a consequence of which our stature becomes 
slightly less in advancing years. It is the angular kyphosis which is so serious, as 
indicating organic diseases of the bodies of the vertebrae. 

(iv.) Cretinism (§ 138) is a peculiar stunting of the growth which is endemic among 
children in certain districts. The appearance is so distinctive that typical cases can 
be recognised at a distance (Fig. 6). The face is broad and flat, and joined almost 
without a neck to the body. The skin and hair are coarse, the hands broad and 
stumpy, the stature stunted, for even when twenty years of age a cretin may be only 
3 i'eet high. It is due to a perverted or diminished action of the thyroid gland, and 
recovery usually results and is maintained while thjrroid extract is being given (Fig. 7). 

(v.) Mongolism is a condition of defective development met with chiefly in the 
last children of long families. It is differentiated from cretinism by the fine hair, 
clear complexion, broad head, and liveliness of manner. The name is derived from 
their resemblance to the Mongolian races. The eyes are oval and slant upwards at 
the outer angle, the little finger tends to curve inwards ; they often squint, and are 
the subjects of various ** stigmata '* of *' degeneration." 

(vi.) Achondroplasia, — A rare condition somewhat resembling, and formerly con- 
fused with. Rickets (see § 449). 

(vii.) Osteomalacia, when this disease involves the spine (§ 449). 

(viii.) Infantilism is due to a loss or perversion of internal secretions, the usual 
changes, both sexual and physical, which normally occur at puberty failing to take 

^ A case is published in the Lancet, 1893, vol. ii., p. 133. 

' Dercum, Iniemat, Joum, Med. Set., 1892, p. 521 ; and Brit. Med. Joum., 1889» 
vol. ii., p. 1553. 
3 Brit. Med. Joum., 1911, vol. I, p. 352. 



i II ] DWARFISM 21 

place, and the patient retaining the stature, featnces, and voice, and often the mental 
pn>cliTitie«, of a child. In oases with pancreatio insufficiency diarrhcea ie pieeent 
These forms of iofaiitiligia cnn be treated with good roeulta bj thyroid and panoteatic 
oxtnwtB. Under the name progeria Haatings Gilford has described a condition in 
which infantilism is associated with premature dec&j, the appearance, attitude, and 
state of nutrition of the dwarf beooming senile, and degenerative ohangea occaiting 
in the vessels and viscera. A cachectic type of infantilism is described in which the 
development is arrested owing to chronic infection such aa tuberculosis, syphilid and 
c«rdiac disease, or drags such as alcohol, tobacco, lead, mercury, or morphia. 



Kg. S. — Gate ol CftniKlSii under the care of W. Rushtoa Parker.— The child, aged aix, preseatel 
the duTMterliUc Mpect ol a cretin— vli., aunkeu nose, ■wallen mooth, gmBll eyee widely 
apart, coane hair, and stumpy Umba. Fig. T iliaws Um urns child alter ali moottu' treat- 
mgnt vlUi thytoid gland (S giaini dally). 

(iz.) In addition to the foiegolog there aie certaui ran conditions, of which the 
celebrated Tom Thamb and his wife, and the race of pigmies of Africa met with by 
Sir H. H. Stanley' and others, are examples, in which the skeleton and the organs aie 
diminished in size, but theii proportions maintained. Such caaea, however, seem to be 
functionally normal in every respect- 
Some of the diseases above refened to bebng so distinctly to tbs domain oE suigery 
that reference must be made to other works for their differentiation. Others will be 
deMribed under IHseases of the Extremities. 

' F. C. tjhrubeall, Lajiat, vol. i., 1003. 



CHAPTER III 

DISEASES OF THE HEART AND PERICARDIUM 

There are three noteworthy facts in connection with the diseases of the 

circulatory system. First, the left side of the heart is stronger and 

much more prone to disease than the right ; secondly, the arteries are, in a 

corresponding manner, much thicker and more often diseased than the 

veins ; and thirdly, heredity plays a very prominent part in chronic 

disorders of the heart and arteries. 

The saying of Bjomson that *' herodity is a condition, not a destiny," ^ applies hero ; 
for although its application is chiefly ethical, it may be employed in a physical sense 
also. Careful living may do much to counteract the hereditary tendency to early 
death from chronic cardio-vascular disease. 

Following out the plan adopted in this work, we shall consider : — 
First, the Symptoms which lead us to infer the presence of cardiac 

disease ; 

Secondly, the Physical Examination of the patient ; and 

Thirdly, the Differentiation of the Various Diseases which affect 

the heart and pericardium, their diagnosis, prognosis, and treatment. 

PART A. SYMPTOMATOLOGY. 

The general symptoms {e.g.y breathlessness, dropsy, etc.) of cardiac 
disease, as distinct from the local signs referable to the heart, should be 
studied very carefully, inasmuch as the gravity of any given case depends 
not so much on the local signs present as on the general condition of the 
patient. 

The Three Cardinal Symptoms of diseases of the heart and peri- 
cardium are Breathlessness, Dropsy* and Cyanosis. To these may be 
added Palpitation^ PrsBCordial Pain» Syncope, sometimes Coagli» and in 
acute affections, Pyrexia and its concomitant symptoms. Sadden Death 
is more frequent in disorders of the heart than in disease of any other 
viscus, and it is sometimes unattended by any previous manifestation of 
heart disease. 

§ 20. BreathlessnesSy or Dyspnoea, is a constant symptom in all diseases 
in which the heart is unequal to the work demanded of it. Breathlessness 

1 " The Heritage of the Kurte," 

28 



§ 20 ] BREATHLES8NES8 29 

may be present without cardiac disease ; but it may be affirmed that no 
serious affection of the Cardiac Wall can exist without some degree of 
breathlessness. It may be only on exertion, such as walking up a few 
stairs, but it can always be elicited in some degree. The slightest degree 
of dyspnoea may be detected by observing that the scaleni and lower 
edges of the stemo- mastoids are brought into play at the end of 
inspiration. 

Severe disease of the Valves of the heart may, however, exist for many 
years — provided the obstruction so caused is adequately compensated for 
by increased growth in its muscular wall — without the patient having any 
noteworthy symptoms, or even being aware of i(3 existence, until the 
cardiac wall begins to degenerate and its cavity to dilate. Then, as time 
goes on, breathlessness is sure to appear, and it is for this s^Tiipt^m that you 
are generally consulted in heart cases. In the later stages it becomes so 
pronounced that the patient is unable to breathe when lying down, and 
night after night is passed sitting upright in a chair, or, at best, propped 
up with pillows in bed. This degree of breathlessness is known as 
orthopnoea.^ Towards the end, in a certain number of cases, a larger 
proportion in my experience than is generally supposed, some degree ol 
Cheyne- Stokes respiration may be observed. 

Causes of Breathlessness (Dyspn(ea) . — Difficult breathing may arise 
in five different groups of disorders. ^ 

1. Caidiac Disease. — The dyspnoea of heart disease has no intrinsic 
features which distinguish it from that due to other causes, except that 
it is apt in some cases to be paroxysmal. There is, however, usually a 
history, or evidence, of some of the other symptoms of cardiac disorder. 
In cardiac valvular disease the amount of breathlessness present and the 
distance a patient can walk without producing it are, of all symptoms, 
the most valuable indications as to the amount of inadequacy of the 
cardiac muscle (cardiac failure) present in any particular case. 

2. Embarrassment of the Heart by Neighbouring Structures, such as 
a dilated stomach, ascites, mediastinal tumours, or obesity. Murchison 
used to teach that dyspnoea and nearly all the symptoms of cardiac disease 
(excepting cyanosis) may be produced by dyspepsia without any structural 
disease of the heart. 

3. Laryngeal or Tracheal Obstruction. 

4. Pulmonary Disease, of which emphysema is the most conmion. 

5. Toxic or Hsemic Conditions, the most frequent of which is certainly 
anaemia. Deficient aeration and other poisonous conditions of the blood, 
such as uraemia (chronic Bright's disease), diabetes, and all pyrexial states, 
may be attended by dyspnoea, caused in this way. 

^ This word implies veiy urgent dyspncBa— ^p^os, Greek, erect 
3 This does not include l^e dyspnoea associated with vaso-motor spasm or with 
yaeo-motOT paresis and states of low arterial tension, such as may be met with in 
great prostration or bodily fatigue. This kind of dyspnoea, I have observed, has for its 
chief feature a sighing character of the [respiration, |and long-drawn sighs occur eveiy 
lew seconds. 



30 DISEASES OF THE HEART AND PERICARDIUM [ §80a 

Causes of Breathlessness which are ajd to be overlooked, — ^The differentiation of the 
various forms of cardiac disease will be given in the following pages ; but, supposing 
a patient over thirty-five or forty, who complains of breathlessness, presents no 
definite signs of cardiac or pulmonary disease, nor any evidences of dyspepsia or 
anaemia, then there are certain conditions which should be suspected : 

1. Oardiao Enfeeblement or Fatty Degeneratioii, in which case the sounds and impulse 
would be very feeble, and the other signs mentioned in § 62 should be present. 

2. Arterial Sclerosis, in which case the radials would be hard and cord-like, but 
smooth, unless atheroma were also present, and the arterial tension high (excepting in 
the very last stage of the disease). Here, also, there would be giddiness, especially 
on assuming the erect posture, and the other symptoms mentioned in § 67. 

3. Aortic Stenosis, the murmur of which is sometimes very^difficult to^detect, 
especially when attended by cardiac enfeeblem^it. ^ 

4. Deep-seated Aneurysm of the Aorta and other Intrathoracic Tamonrs may 
give rise to the breathlessness and general symptoms of heart disease without thu 
physical signs. In such cases tho dyspnoea may be paroxysmal. 

5. Coronary Obstruction (i.e., diminution of the calibre of the coronary arteries by 
atheroma, calcification, or other disease). In this obscure condition the patient 
probably complains also of " dizziness in the head '" on suddenly assuming the erect 
position, from the incapacity of the heart to pump the blood to the head. But this 
condition can never be more than suspected during life. 

In a patient under thirty-five or forty the three following causes of Unexplained 
Breathlessness may be suspected : 

6. Cardiac Syphilis may be imattended by any signs or symptoms, excepting breath- 
lessness (§ 41). Happily the condition is very rare. 

7. Adherent Pericardium, also, is often unattended by any physical signs ( § 38c). 

8. Latent Polmonary Disease, and especially latent pulmonary tuberculosis, should 
always be suspected in cases of breathlessness without obvious cause. 

9. When severe dyspnoea sets in suddenly in the course of cardiac or Acute Renal 
Disease, or during an attack of scarlatina^ the chest should always be carefully 
examined, because double hydrothorax may set in rapidly without any general dropsy 
or other warning symptom, as in a case mentioned by Osier, and a similar one which I 
have had the opportunity of observing. 

10. Disease of the costo-chondral or vertebral joints, which is known by pain on 
pressure over the joints. 

§ 20a. Paroxysmal Dyspncsa is that form of dyspnoea which occurs in attacks from 
time to time. It is apt, as above mentioned, to occur in some cases of cardiac disease, 
especially in the last stages of aortic regurgitation, and in any given case our attention 
should first be directed to the heart. But there are several other conditions which 
one would suspect in a patient in whom the chief or only symptom consists of paroxysms 
of breathlessness. 

1. Aneubysm and other Intrathoracic Tumours may give rise to paroxysmal 
dyspnoea before other signs can be made out. 

2. In Asthma, laryngismus stridulus, and whooping-cough, the attacks of breath- 
lessness are typically paroxysmal. 

3. Paroxysms of dyspnoea occurring at night are often one of the first symptoms of 
Chbonio Bsight*s Disease, and are spoken of by the patient as asthma. 

4. Neurotic DYSPN(EA.^-Some neurotic patients are liable to attacks or paroxysms 
of panting respiration, resembling the panting of fear. It usually ceases when the 
patient converses with you, and is, of course, unattended by any signs in the 
lungs. 

5. LiNOUAL Varix — I.e., a varicose condition of the veins at the root of the tongue — 
may give rise to severe paroxysms of dyspnoea.^ 

6. Foreign Bodies in the trachea and retropharyngeal abscess in children, and 
polypi or papillomata of the larynx in adults, give rise to paroxysms of dyspnoea. 

^ A case of paroxysmal dyspnoea, cured by the removal of a lingual varix, is pub- 
lished by M. P. Mayo Collier in the West Lond. Med. Chir. Soc. Trans., 1897, p. 206. 



^att.tl^ nHETNE-STOKES RESPIRATION— DROPSY 31 

7. Saddon dyapiKBa. ooming on daring vomiting, ia the main indiofttian of thst 
nre accident, Ruptdrb of tbb <Esofb*git9. This dy apnoeft Ib due to pnenmothomT, 
and bj promptly opening tbe thorftz on th&t iide the patient's life might be eaved.^ 

6. Enlargement of tiie Ththcs Gi-and in the condition known as Lvuphitish. 
or Btatiu lymphaticus. in which there is gonoral hyporplaaia of lymphatic Btructnre. 
Hseociated with a persistent thymus, may cause paroxysmal dyspncea, to which Ilio 
name " thymic asthma " has been given (} 20). 

t>. The laryngeal crisBs of tabes dorsalis may t«ke the form of paroxysmal dyapncea. 

§ sob. Oberns-Stokea Bespiratlcni (so called after its lirat obeerveis) consista, in its 
typical form, of a setiaa of eight or ten rapid inspirations gradually incieaeing ui depth 
and rapidity, and then dying gradually away, each series being separated by a pause 
of five to thirty seconds (the stage of apncea), in which there is hardly any respiratory 
movement (Fig. S). 

In a modified form, without the apncea pause, Cheyne-Slokcs breathing is by no 
moans infrequent. It seems to indicate a want of harmony between the caidiac and 
the VBSO-mot«r regulator mechaniHia. It is usually a serious symptom, and appeared 
in the groat majority of those of my cardiac patients in the infirmary who were closely 
observed totmriU the end of lift. It has less significance at the extremes of life, for it 
may be olwerved during sleep in normal infants, and is compatible with a hale old age. 
Another (xception to Uie unfavoumbln import of Chcync-StokeB breathing occurnd 



Fig. fl. — CuEVNE-STOKK RespikaTiON. — Besplritory tracing a[ CheyDe-.Stukei breathing, for 
■rhich (he author Is Indebted to Dr. C. O. Hawthorne, who took (tie trsdng from a cue of 
cerBbral embolism mider his care In the Western InArmary, Olasgow. 

under my notice in the case of a focal lesion of the pons, producing crossed hemiplegia, 
in which it per8ist«d with only occasional intermissions during the last nx months of 
the patient's life. Its principal catue* are as folbws : 

1. Carduo D19BASB, whlch is certainly its commonest cause. 

2. Ubxmia. 

3. Apoplexv. 

4. TuBBHcuLous Mbninoitis, and other states of cerebral congestion or com- 
pression. 

5. AsTKRUi. ScLBBOSis (used in its widest sense). 

6. 8CH3TROKK. 

Thus it will be seen that the three pathological conditions in which it is apt to 
ocour are : States of cardiac failure ; states of cerebral congestion ; and toxio blood 
conditions. ' - , 

§ 21. Dropsy is a chronic efEusion of fluid into the subcutaneons 
tissue (when it is known as anasarca or cedema) or into the serous cavity 
(as in hydrothorax, hydropericardium, ascites). The former. Anasarca, 
is the variety of dropsy we are now concerned with, for It ia a very constant 
feature of some forms of cardiac disease. General anasarca has to be 
difierentiated from myxcedema, in which the swelling is harder, aod doea 

' A few cases of this accident have been recorded. If it were recognised, the thorax 
might |be opened without fear on the side of the 'pneumothorax, and the cesophagus 
■titched. Bee DiscnsBJon at Roy. Med. Cliir. Soo. in spring of 1900. 



32 DISEASES OF THE HEART AND PERICARDIUM [ § 21 

not pit on pressure. It is best to apply the pressure over a bone, such as 
the lower end of tibia on its inner aspect. 

Causes, — The causes of localised dropsies are given in Diseases of the 
Extremities (§ 425). There are three varieties of general anasarca, which 
differ from each other both pathologically in their origin, and clinically in 
the course which they pursue. 

1. Cardiac Dropay (1) starts, and throughout the case predominates, in 
the most dependent farts, that is to say, in the legs if the patient has been 
walking about, or in the back if he has been lying in bed. On inquiry, 
the patient may complain that the ankles swell towards evening around 
the top of the boot. (2) Other signs and symptoms of cardiac enfeeble- 
ment or dilatation are present ; and perhaps those of valvular disease as 
well. (3) In the history of the case dyspnfpa will have f receded the 
dropsy. 

Dropsy does not occur with equal frequency in all foims of cardiac 
valvular disease. It is common in disease of the mitral valves, but rare 
in aortic disease, at any rate until quite the end. The dropsy which com- 
plicates pulmonary disease has the same features as cardiac dropsy, because 
it is the resulting cardiac dilatation which prcduces the dropsy. 

2. Hepatic Dropsy (1) always begins and predominates in the abdomen 
(ascites), although the legs may swell subsequently by reason of the 
pressure of the fluid on the veins within the abdominal cavity. (2) There 
may be also enlargement or other signs of the liver affection which has 
given rise to the condition ; and if these be absent some other cause of 
obstruction to the portal vein should be sought (Chapter XII.). (3) The 
dyspnoea will \iQ,vQ followed the abdominal enlargement. 

3. Renal Dropey is (1) general in its distribution from the beginning, 
occurring in the legs and eyelids at the same time ; though it is probable 
that the oedema round the eyes on rising in the morning first attracts 
the attention of the patient or his friends. (2) Examination of the urine 
leveals the features of renal disease (Chapter XIII.). (3) The patient 
presents a characteristic pale or waxy appearance. 

In some cases of general anasarca associated with albuminuria, the 
question arises whether the dropsy is of renal or cardiac origin. This may 
sometimes be answered by finding the liver enlarged, for this is a natural 
sequence of cardiac valvular disease, but not of renal disease. 

Prognosis, — The dropsy of cardiac disease is probably due to the back- 
ward pressure within the veins, and its occurrence is therefore an indication 
and a measure of the amount of obstruction to the circulation on the 
right side of the heart. 

The treatment of all forms of dropsy should be directed to the removal 
of the cause. But even if this be not removable, the dropsy may frequently 
be alleviated. The limbs should always be rested, raised to the same 
level as the body, and kept warm. The additional support of a well- 
adjusted flannel or stocking bandage is a great comfort to the patient, and 
helps to prevent further effusion. Diuretics and diaphoretics should b^ 



§ 82 ] DROPS Y--PALPITATION 33 

employed. These failing, we may (a) employ Southey's trocars, the 
patient being wrapped in blankets and the fluid allowed to slowly drain 
away ; or (h) make punctures in the skin of the limb with a small two-edged 
scalpel. Six or eight punctures are sufficient, the positions of the veins 
being avoided. Dropsical limbs have a tendency to the development of 
eczema, erythema, cellulitis, and epidemic exfoliative dermatitis, so that 
strict asepsis should be observed in these procedures. 

Obscurh Causes of GsNisaAL Anasabca. — If, in a patient who complains of 
dropsy, no ma^ed evidences of cardiac, renal, or hepatic disease are discoverable, 
the following causes may be auspecUd : 

1. Amemia is not infrequently attended by some swelling of the ankien at the end 
of the day. This may appear quite early in chlorosis, but is rare in pernicious annmia. 
Swelling of the feet and ankles may be present in the last stages of many exhausting 
diseases, such as phthisiB, in septic states, and in cases of insufficient nutrition and 
old age. Other d^ective blood conditions, such as leukemia, may also be accompanied 
by dropsy. 

2. In Fatty Heart anasarca is not a prominent symptom, but a slight degree is 
frequently present. 

3. Among the less frequent causes of dropsy in this country are Beri-Beri (§ 462) and 
Epidemio Dropsy. In Beri-Beri there are symptoms of peripheral neuritis. Epidemic 
dropsy is an acute infectious disease met with in the tropics, with dropsy but no 
albuminuria. 

4. General oedema, without urinary changes, following a gastro-intestinal upset, 
has occurred in young children. Some have been cured by hypodermic injections 
of adrenalin ; other cases have been fataL Milroy described a hereditary oedema in 
which a solid oedema of the legs existed from birth, unattended by danger to life. 

§ 22. Palpitation is the sensation of *' fluttering in the chest " experi- 
enced by a person when he is conscious of the beating of his heart. It 
arises under two sets of conditions It is said to be Symptomatio when 
a cause can be assigned to it, such as heart disease, flatulent dyspepsia, 
anffimia or intrathoracic tumour. It is said to be Idiopathic when no 
organic cause can be discovered to account for the symptom (compare also 
Paroxysmal Tachycardia, § 40). 

Symptomatic Palpitation may arise from (a) causes referable to the 
heart itself (causes 1 to 3) ; or (b) morbid conditions outside the heart 
(causes 4 to 9). 

1. Most Stmotnral Diseases of the Heart, especially such as are attended 
by rapidity and irregularity of its rhythm, are attended by palpitation. 
When patients consult us for this sjmiptom, we should therefore first make 
a thorough examination of the heart and pericardium. 

2. Palpitation is also the leading indication of the firritaUe Heart, in 
which there may be no discoverable structural disease. Irritable heart 
is found in young men who have overtaxed their strength in athletics or 
military work, and occasionally in young women. Palpitation is its most 
obvious symptom, with a very quick pulse, or one which easily becomes 
rapidy and sometimes with high arterial tension. Breathlessness, sleepless- 
ness, incapacity for prolonged exertion, and nervousness, often accompany 
the palpitation. Hypertrophy is a common result; and unless rest be 
ordered the heart will become dilated. Complete rest is the chief indication 

3 



§«B] DSOFST—PALPITATIOX J3 

employed. These failing, we may (a) employ Sonrtiev-'s trocars, the 
patient being wrapped in blankets and the fluid allowipd to sloiriy dnin 
away ; or (6) make punctures in the sldn of the limb with a small two-ed^ed 
scalpel. Six or eight punctures are sofficient, tiie pesitioos of the v^ns 
being avoided. Dropsical limbs have a tendency to tbe dereh^Nneat of 
eczema, erythema, cellulitis, and epidemic ezfoUatire dermatitit, so thai 
strict asepBis should be obaerred in these procedaies. 



I CAussa ov GEixaAi. Axasaxca. — If, in a pMient who comflama of 
dropsy, no maHcod evideiiMs of Midiac, noal, or twpMJt^ iliwi are diwoivnUr, 
the following caosen msj be nupteUd : 

1. AniMBia is not iofreqneatlj att<aded bj sonw ivcUing of tha anklet ai tbe ^hI 
of tha day. Thia may appear quite eaily in cUonMu, but is nta in pwniirio— an ■■la 
Swelling of the feet and anUee may be ptMent in tlie laat rtagea of aaiiy exhanttiiig 
diaoaoos, saoh aa phthisis, in septic states, and in ossrs of inmilficinit niitntiaa aod 
oldaga. Other defective IJood cooditions, such aa kmkKmia, may abo be acoompaiuNl 
by dropay. 

2. la Fat^ Hsart anaearca is not a pcDmioMtt symptom, but a sl^tf ilaKreF is 
freqaeatly pr iwo nt. 

3. Among the lesB freqnent oanses of dropayin this eoimtryBieBwi-BMi(|MX)aad 
■sUeiniB Diopar. In Beri-Bwi iiien are symptoma of psnpbenl nearitB. EpidBBk' 
dropi? is an acute infeotioos disease met with in the tropic*, with dtopey bat no 



4. GensTsl cedema, withont niinaiy chaogea, following a gaatro-intrstioal apse*. 
baa ooeamd in yonng childmn. Some have bem cored by hypoderBue injeetioot 
of adrenalin ; other cases have been fataL Milniy Jeaiiibud a heiedilaiy inliiiaa id 
which a aolid cedema of the legs existed from birth, nnatteadcd hy danger to lifp. 

§ 22. PalldUtion is the sensation of " fluttering in the chest " experi- 
enced by a petBon when he is conscious of the beating of his heart. It 
arises under two sets of conditions It is said to be Symptomatic when 
a canse can be assigned to it, such as heart disease, flatolent dyspepsia, 
antnnia or intrathoracic tumour. It is said to be Idiopathic when no 
organic cause can be discovered to account for the svroptom (compare also 
Faroxyanial Tachycardia, } 40). 

Stmptomatio Palpitation may arise from (a) causes referable to the 
heart itseU (causes I to 3) ; or (fr) morbid condirions outside the heart 
(caoses 4 to 9). 

I. Most Stnwttml noonico &t ttw Heart, especiaUy such as are attended 
by rapidity and irregularity of its rhythm, are attended by { 
When patients consult us for this symptom, we dtould therefore first n 
a thorough examination of the heart and pericardium. 



34 DI8EA8E8 OF THE HEART AND PERICARDIUM [§28 

for treatment, and is generally successful. Irritable heart is, in my belief, 
in some cases a sjonptom of neurasthenia (^.t;.). 

3. Various Nervous CaoMS, such as fright, fear, or other emotion, 
especially after an exhausting illness, give rise to palpitation (compare 
Paroxysmal Tachycardia, § 40). 

4. In Aii»iiiia the palpitation is a freqaent and often distressing feature. 

5. In Dyipeptia palpitation is very often present. In such oases it frequently 
occurs at night, especially after taking a heavy meal. It may, in these circumstances, 
be acoobtipanied by' morbid dreads— c.^r.. of impending death — by breathlessness, 
cardiac pain, and by other cardiac symptoms. 

6. Certain Looal Oonditioni, such as thoracic or abdominal tumour, or dilated 
stomach, which hamper the heart's action, may produce palpitation, although the 
heart be healthy. 

7. The excessive use of Certain Dmgi or Articles of Diet, notably tobacco, tea, 
coffee, and alcohol. 

8. In 0raves' Difease (exophthalmic goitre) violent palpitation and greatly increased 
rate of the heart are prominent features. In quite a number of my cases this and 
the other nervous symptoms of the disorder had existed for many months, or years, 
before the two diagnostic features — thyroid enlargement and exophthalmos — became 
obvious. Graves* disease should always bo suspected in cases of persistent palpitation 
for which no cause can be made out. 

9. In Hyitsrioal subjects palpitation is a symptom often complained of, and 
occasionally it takes the form of a definite and somewhat alarming attack (see a case, 
§40). 

§ 28. Pain in the Chest is not always present, even in grave cardiac 
disease. A feeling of discomfort or constriction, or a sense of suffocation, 
is a symptom frequently present when the action of the heart is deranged 
by functional or structural diseases — oftener perhaps by functional. The 
importance of pain as a symptom of heart disease lies in the fact that the 
onset of discomfort or pain, together with breathlessness, after slight 
exertion, suggests the presence of cardiac trouble even when physical 
examination reveals little or nothing. 

To avoid certain yofiocie^, ascertain if there be tenderness on pressure. 
If so, the lesion is probably a neuralgia of the intercostal nerves, or the 
inframammary fain so common in hysteria. The latter may sometimes 
be distinguished in this way from pain of cardiac origin, but occasionally 
can only be recognised by the presence of other hysterical stigmata. Pain 
in the prsecordial region is not infrequently associated with lithsBmia, and 
may be attended by tender spots over the ribs at the apex. Empyema or 
other abscess in the chest when approaching the chest wall may cause pain 
and tenderness on pressure. 

There are Four Groups op Causes which may lead to preecordial pain : 

(a) When praecordial pain occurs as the result of Stnietiiral Disease of 
the Heart, it usually consists of a diffuse dull aching, most severe at the 
apex. As in other organs having a serous covering, pain is more often 
present when that covering is inflamed (pericarditis) than when the sub- 
stance of the organ is affected. But pain may be altogether absent ; and 
it is surprising what serious valvular derangement of the heart may exist 
without the occurrence of pain. 



$84] PAIN IN THE CHEST— SYNCOPE 35 

(6) Caidiac Pain of Fnnctioiial Qri^in may be due to (i.) pressure upon 
the heart by a distended stomach or abdomen ; the differential features 
of this pain are — it is greatest at the base of the heart, aggravated by the 
recumbent posture, and associated with dyspnoea, (ii.) Reflex Pain may 
be referred from stomach (chiefly) or uterine disorders (occasionally), 
(iii.) Nervous Pain due to profound grief, sudden fright, or other violent 
emotion, is of a sharp character, referred to the praecordium. It is frequent 
in the debilitated, especially after prolonged nerve strain. 

(c) Various Organic Affections outside the Heart and Pencardinm 
may give rise to praecordial pain ; thus we may have intercostal neuralgia, 
especially the neuralgia which precedes and follows herpes zoster ; pleuro- 
dynia^ and many pleuritic affections. Pain in the chest is also present in 
spinal caries and carcinoma of the vertebrce, and when tumours erode the 
bones. The crises of locomotor ataxy may cause pain in the chest. 

(d) Afigiiift Pectoris is a condition manifested by paroxysmal attacks 

of extremely severe constricting pain in the chest, with a sense of suffocation 

and other symptoms (see § 41). 

But in cases of nnezplained pain in the chest, and in the absence of cardiac signs, 
mediastinal tumour or aneurysm of the aorta, either of the arch or of the descending 
aorta, ^ should always be suspected. 

In the treatment of prsBCordial pain an endeavour should be made to 
ascertain and relieve the cause, but much relief may be obtained tempo- 
rarily by the application of an opium or belladonna plaster, belladonna 
liniment, or glycerine of belladonna. 

§ 24« Syncope is suspended animation due to anaemia of the brain. It 
is often preceded by giddiness, nausea, and a feeling of faintness. The 
face is ashy pale and the pulse and respiration feeble. Its advent is usually 
sudden, but recovery, after the attack has lasted some minutes, is gradual. 

Diagnosis, — Syncope has to be distinguished from epilepsy minor, which 
it resembles in many respects. First, epilepsy minor (petit mat) is usually 
preceded by an aura, though this is evident to the patient only. Secondly, 
its advent is more sudden than S3aicope, and the return to consciousness 
equally sudden and complete, for the patient in petit mal can go on with 
his usual avocations immediately afterwards. Thirdly, syncope rarely 
occurs without some definite determining cause, although it may be of a 
trivial nature — such, for example, as a heated room, or the sight of blood. 
Finally, in epilepsy minor there is generally a history of major attacks at 
some time. 

Causes, — Syncope nearly always arises from either structural or func- 
tional derangement of the heart — more frequently the latter. A careful 
examination of the heart should always be made, because, as an indication 
of Structural Disease, syncope is a symptom of considerable gravity ; 

^ In a case of aneurysm of the descending thoracic aorta which I have recently seen, 
abnost the only symptom or sign, besides breathlessness, during eighteen months — ^up 
to the time of sudden death from rupture of the aneurysm into a bronchus — was 
continuous pain in the praecordial region. It extended round from the back on the 
left side, and was thought to be intercostal neuralgia. 



30 DISEASES OF THE HEART AND PERICARDIUM [ § 24 

whereas the nervous faints of Functional Derangement are of com- 
paratively little moment. 

(a) The Nervous Faints due to functional derangement of the heart 
are happily the more frequent. They occur chiefly in young, anamic, 
and nervous females ; who, when exposed to grief, bereavement, or any 
sudden emotion, or too hot rooms full of vitiated air, develop the familiar 
" fainting attack." Slight transient syncopal attacks are, indeed, one of 
the " stigmata " of the hysterical diathesis (§ 524). 

(b) As a symptom of Stractural Heart Disease, syncope is a much 
more serious matter. It is a not infrequent symptom in any form of 
cardiac disease attended by enfeeblement of the heart's action, and is 
serious as indicating weakness of the cardiac wall. It is more often met 
with in aortic than in mitral valve disease. It may be the first and only 
symptom of fatty, fibroid, or other degeneration of the heart (§ 52). 
Syncopal attacks, preceded by giddiness, may arise in old people who are 
the subjects of arterial thickening and degeneration, this being the cause 
of what is known as " senile syncope." So important is it to distinguish 
between the two kinds of fainting attacks that their differential features 
are given in a table. In both there is a pallor of the surface, and there may 
be feeble pidse, though the pulse in nervous faints is sometimes unaltered. 
Both recover best in the recumbent position. 

Other less common or obvious causes of syncope : 

(a) Acting directly through the Heart. — (L) Latent organic disease of the heart, such 
as fatty degeneration, which should always be suspected in obscure cases, or Stokes- 
Adams disease (§ 58) ; (ii.) compression of the heart, as by corsets or by mediastinal 
tumour ; (iii.) profuse internal hsBmorrhage ; (iv.) drugs and asthenic poisons acting 
on the heart. 

(6) Acting through the Nervous System. — (i.) Emotions and fatigue ; (ii.) violent 
injury or operation ; (iii.) irritant poisons, or injury to the intestines. 

(c) Acting through the Blood and Bloodvessds. — (i.) Annmia, debility, hunger, or 
starvation ; (ii.) increased peripheral resistance in the arteries, with insufficient cardiac 
hypertrophy ; (iii.) diminished resistance in the peripheral and splanchnic arteries, 
such as occurs with excessive heat, as in hot rooms or Turkish baths ; (iv.) suddenly 
assuming the erect posture, as in jumping from bed, may produce syncope in the aged ; 
(v.) sometimes, in addition to the preceding, the splanchnic veins aro suddenly dilated 
by emptying the bladder, and this leads to ansemia of the brain and syncope. 

Prognosis. — Syncope in the young is, as we have seen, usually a neurosis, 
whereas in the aged it generally means cardio- vascular degeneration. In 
the former, therefore, it is usually as trivial as in the latter it is serious — 
the gravity depending upon the nature of the lesion. 

Treatment (see Causes above). — Place the patient immediately in a hori- 
zontal position, with the head low. This may be most readily done on 
the floor, but if there is little space, instruct the patient to bend forward 
and lower the head between the knees. Apply ammonia to the nostrils, 
throw cold water on the face, and, in severe cases, apply a mustard-plaster 
over the heart. If recovery does not promptly take place, and the pulse 
be very feeble, a hypodermic injection of 15 or 20 !\ of ether or brandy, or 
3 or 4 IH^ of liq. strychninflB, may be resorted to. For further treatment, 
see Collapse. 



H25,26J 



COUOH— CYANOSIS 



37 



Table I. 



Gardl&C Syncope, atwodated with structural 
Deningemeut of the Heart. 



Usually adults ; both sexes equally 
affected. 

Biay come on without any apparent 
determining cause, or after excessive 
exertion. 

Not accompanied by emotional mani- 
festations. 

May be f ataL 

Evidences of caidio-vascular degenera- 
tion and its causes. 
If no signs, suspect fatty heart. 



KeZTOUB Faints, iu which only the Nervous 
Apparatus of the Gardlo- Vascular System 
is deranged. 



Females, young or at menopause. 



Some determining cause always present 
(e.gr., emotion), acting on the nervous 
system. 

Often preceded or followed by crying 
or laughter, and other emotional 
symptoms. 

Never fatal. 

Sometimes other evidences of the hys- 
terical diathesis — e.g., hemiansesthesia, 
ovarian tenderness, globus. 



§ 25. Cough is a symptom which belongs more especially to diseases of 
the lungs (§ 70), but it is met with in diseases of the cardio-vascular system 
under two circumstances. Firstly, the lungs are very often involved 
secondarily to the heart, especially when the right side is diseased, and 
then the patient has the cough usual to pulmonary disorders. Secondly, 
when the aorta, by its enlargement, presses on the trachea, or on the 
recurrent laryngeal nerve, a peculiar dry, brassy, or, as it is aptly called, 
" gander " cough is present, which is so characteristic as to be in itself a 
diagnostic feature of aneurysm of considerable value. In pericarditis 
cough may be troublesome. 

§ 26. Cyanosis (Kudveo^y blue) is lividity of the surface of the body. 
It is not one of the most common symptoms in heart disease, but it is one 
of the most serious and unmistakable evidences of enfeebled or retarded 
circulation. It is generally most pronounced on the lips, fingers, nose, 
ears, and toes, and the skin may vary in colour from faint purple to almost 
black. When only a slight degree of cyanosis is present; it may be 
detected by closely examining the roots of the nails. Cyanosis is an 
indication of deficient aeration of the blood, which may be due to (1) stag- 
nation of the blood in the capillaries ; (2) defective oxygenation of the 
blood ; (3) abnormal compounds of the haemoglobin. 

Generally speaking, the first is the most common cause in cases where 
the heart is at fault ; the second where the lungs are defective ; and the 
third where there is disorder of the digestive tract. It should be remem- 
bered, however, that when the heart is involved the lungs become affected 
later, and that the first and second causes are to be foimd in association 
in many cyanotic conditions. 



38 DISEASES OF THE HEART AND PERICARDIUM [ SS «7, M 

In the first class the causes to be looked for are : 

1. Deficient via a tergo, as in failing compensation towards the termination of many 
cases of heart disease, or of diseases in which the heart is secondarily afiected — 
e,g., cirrhosis of the liver, profound tozsemia. 

2. Constriction of arterioles, as in angio-neurotic cyanosis, exposure to cold and 
a few other conditions. 

3. Obstruction to the flow of blood through a part, as in thrombosis, when the 
cyanosis is usually localised. 

4. Increased concentration of the blood, as after comparative dehydration from 
profuse diarrhoea or sweating, and in conditions in which the polycythemia depends 
on some defect in the circulatory system necessitating an increased number of cor- 
puscles to provide a sufiicient supply of oxygen to the tissues — e.g., congenital heart 
disease. It is also seen in erythremia (see below). 

In the second class there are four subdivisions : 

1. Failure of venous blood to reach the lungs, as in some cases of congenital heart 
disease where the blood is in part " short-circuited " through a patent foramen ovale. 
Unless a considerable amount of blood is so short-circuited no cyanosis may be 
apparent, or perhaps only the roots of the nails will show the characteristic bluish 
tinge. 

2. Obstructed flow in the pulmonary cireulation. This is rare but may occur in 
congenital pulmonary stenosis, and when a mediastinal tumour is pressing on any of 
the pulmonary vessels. 

3. Deficiency of lung surface available. This is met with in emphysema and in a 
variety of other conditions of lung disease and of pressure on the lung with collapse 
of the lung. Pneumonia, phthisis, tumour, and sudden or chronic pleural efiFusions 
are examples of this class. 

4. Deficient entry of oxygen. Under this heading come cases of stenosis and 
obstruction of the bronchi or trachea, as in syphilis, spasm, impaction of foreign 
bodies, and pressure of tumours, such as aneurysm and goitre. Here also come cases 
of cyanosis due to absence of the proper proportion of oxygen in the atmosphere, as 
on the tops of mountains or in very ill- ventilated rooms. 

§ 27. Eryihrnmia (Synonyms : Vaquez' disease, polycythemia vera, splenomegalic 
polycythemia). — ^This is a disease in which there is an overgrowth of that part of 
the marrow in which the red celb are formed. There is (i.) increase in the number of 
the red cells, which may be as many as 13,000,000 per c.mm. There is an increased 
viscosity of the blood, and later an increase in its volume, (ii.) The patients are easily 
recognised by the redness of their complexions, which often deepens to cyanosis, 
especially in cold weather. All the superficial vessels are dilated, (iii.) The spleen 
is very laige, frequently reaching to the pubis, (iv.) Subjective symptoms are head- 
ache, vertigo, pains in the limbs, and dyspnoea. A variety is described without 
enlarged spleen, but with high blood-pressure and arterio-sclerosis. The patients 
usually die in six to eight years from syncope or cerebral hemorrhage ; many of them 
in [asylums. 

The Treatmenl must have reference to the cause ; but in several cardiac 
conditions cyanosis, if unaccompanied by dropsy, is a distinct indication 
for venesection. But when marked anasarca is present, it indicates 
generally that the venous stasis is too great to admit of relief by this 
measure. In erythraemia bleeding gives temporary relief when the blood- 
pressure is high ; when the blood-pressure is low its action is not so 
certain. Inunction of mercury over the spleen is useful, and the iodides, 
nitrites, and other drugs have their advocates. Arsenic is contra-indicated. 

§ 28. In the third class come two rare diseases : sulph - hemoglobinemia and 
methemoglobinemia. 

Snlph - hnmoglobinsBmia (Synonym: Enterogenous cyanosis). ^ — This disease has 
hitherto been named according to each observer's idea of ito etiology, without 

1 Wcit and Clarke, the Lancd, Feb. 2, 19 J7. 



{ 89 ] 8UDDBN DBA TH 39 

dJBoriminating it horn the not dissimilar condition, methemoglobinemia. The most 
prominent symptom is (i.) cyanosis of a greyish hue, combined with pallor ; (ii.) some 
form of intestinal disorder, usually constipation, occasionally alternating with 
offensive diarrhoea ; (iii) extreme weakness ; the patient may appear to be on the 
point of deaUi for long periods of time. The etiology is uncertain but the disease 
seems to be associated either with the presence of conditions (possibly bacterial) 
which allow of the formation of some easily assimilable compound of sulphur which 
is not normally present, or else with lesions of the mucosa of such a nature that the 
normal sulphuretted hydrogen of the intestine is given a chance of combining with 
the blood. The prognosis is good if the morbid intestinal condition reacts satisfac- 
torily to treatment. Intestinal antiseptics must first be tried, and if these fail operative 
measures may be adopted. 

Mettusmoi^Mnnmia is a condition in which methemoglobin is found in the blood. 
The most prominent symptom is (i.) cyanosis ; the tint is a bright blue and there 
coexists marked pallor, (it) Offensive diarrhoea, (iii.) Weakness, dimness of vision, 
vague pains, and a feeling oif collapse. There are from time to time exacerbations of 
all symptoms with extreme dyspnoea, and at such times the patient seems to be at 
the point of death. There may also be periods, varying from a few minutes to hours, 
during which the cyanosis entirely disappears, (iv.) There is usually an ante- 
cedent history of drug-taking, or of working in mines, or in the manufacture of 
explosives. The drugs or fumes which give rise to this type of cyanosis are aniline 
derivatives ('* antikanmia " and ** daisy " headache powders, antipyrin, veronal, 
sulphonal) and benzene compounds. Pot. chlorate and some other drugs have 
a similar effect, but are less often found to be in operation. In another class of case 
there is no drug history, and bacteria have been isolated. In two recorded cases the 
organism was of the ooli group ; in one it was isolated from the blood, and in the 
ot^r from a pelvic abscess. In some cases of poisoning when a large dose has been 
taken, as with suicidal intent, Uie onset of the illness is very acute. 

The diagnoaia must be based on the history and the peculiar cyanosis, but can only 
be verified by spectroscopic examination of the blood (Fig. 118). The prognosis is bad in 
acute cases ; in others it depends on the ease with which the intestinal disorder can be 
treated, and on the discovery and cessation of any causative drug. As regards ireo^ 
merU, the cause must be removed. Quebrachu, a drug which is credited wiUi 
increasing the oxygen capacity of the blood, appeared to have immediate good effects 
in one case.^ ^e usual measures for intestinal antisepsis should be tried, and 
operative procedures may be required. 

A Sallow Hue of the skin is characteristic of aortic valvular disease, 
which in this respect presents a marked contrast to the plethoric florid 
appearance of patients with mitral valvular disease. This sallowness is 
distinguished from jaundice by the absence of the yellow colour from the 
eyeballs and the absence of bile in the urine. True jaundice, however, 
does arise in cardiac disease as a symptom of the hepatic congestion, which 
is met with more often in mitral than in aortic disease. 

Pyrexia and its concomitant symptoms (see Chapter XV.) are present 
in most of the acuU disorders of heart and pericardiima. The temperature 
in malignant endocarditis is of an intermittent or remittent type, with an 
irregular range, such as that met with in other forms of septicsemia. 

§ 29. Sudden Deaib, or death, say, within a few hours of the apparent 
commencement of the illness, is a frequent mode of termination of 
disease of the heart, and it may be the first symptom of disease of this 
organ. The chief conditions under which sudden death occurs are as 
follows. The first six of these have reference to the cardio- vascular system. 

* Matthews, the Practitioner^ 1911. 



40 DISEASES OF THE HEART AND PERICARDIUM [ {{ 80. SI 

1. Among the various fonns of cardiac valvular disease, sudden death 
is more frequent in aortic than in mitral disease. But sudden death, 
and, in general terms, the prognosis, depend more upon the condition 
of the wall than of the valves. 

2. It is liable to occur in all forms of primary disease of the cardi^ic 
waU — 6.^., fatty and fibroid heart (§ 52). 

3. It is a very common termination to aortic aneurysm (§ 53). 

4. A patient may die with the first attack of Angina Pectoris (§ 41). 

5. Sudden profuse hcemorrhage, internal or external. 

6. Pulmonary efnholism — e.g., from air in the veins (as in the per- 
formance of transfusion), or clots passing through the heart. 

7. The conditions which cause Coma may also result in death, which 
is relatively sudden (§ 530). 

8. Nerve diseases which in their progress involve the medulla ter- 
minate suddenly ; and thus, among the rarer causes, atlanto-axoid disease 
and syringomyelia may be mentioned. 

9. Sudden emotion, injuries to the head, and other conditions acting 
on the nervous system by shock (§ 528). 

10. Suddenly-acting poisons, such as prussic acid, a large dose of 
morphia or carbolic acid, aconite, veratria, etc. 

11. Sudden rupture of a large cyst, an internal organ, acute disease of 
the suprarenals, or other cause of Collapse (§ 168). 

12. Foreign bodies in the trachea, or other causes suddenly stopping 
the respiration (cuphyoDia). 

13. Acute pulmonary oedema (§ 84). 

14. Lymphatism. 

f 80. Lymphatiim {SkUiM LymphaUcua) is a rare condition frequently unrecognised 
during life, but it is important as being a cause of sudden death. There is overgrowth 
of the thymus gland and of the lymphatic tissues throughout the body. There may 
be no symptoms, the first evidence of the existence of the condition being death after 
a trivial shock, such as a plunge into a cold bath, a hypodermic injection, or the first 
touch of the knife in a minor surgical operation. Occasionally death is pieceded for 
months by attacks of dyspnoea, cyanosis, syncope, and convulsive seizures. The 
physical signs are often indefinite, consisting only of hypertrophied tonsils and 
adenoids, and the patient is flabby and pale. In other oases the enlarged thymus 
causes dulness over the upper part of tiie sternum, the spleen is palpable, and there 
may be overgrowth of adenoid tissue at the base of the tongue. Subjects of this 
diathesis must be guarded against any sudden shocks, or exertion, and must be warned 
against rapid movements of the head and swallowing large imchewed morsels of food. 
Operative measures which aim at drawing up the thymus from the thoracic inlet have 
been successfully performed in Germany in a few oases, but the danger of death under 
operation has made surgeons reluctant to touch these subjects. X-ray applications 
have been reported as successful in some oases. 

PART B. PHYSICAL EXAMINATION, 

§ SI. Landmarks of the Ghest. — ^There is a ridge on the sternum formed 
between the manubrium and the gladiolus which can always be felt, 
opposite the second costal cartilage (c. c.) ; and the other ribs can be 
counted from the second one. The nipple is usually situated just external 



§82] PALPATION AND THE LOCALISATION OF THE APEX 41 

to the fourth costal cartilage, near its junction with the rib ; it should 
correspond to a vertical line dropped from the middle of the clavicle. 
At the back, the lotoer angle of the scapula is near the seventh rib ; and 
the scapular line is a vertical line drawn through the inferior angle of the 
scapula. The position and relations of the heart can be studied in Fig. 11, 
which is a sketch taken from the cadaver. The various regions of the 
thorax named for convenience of reference are given in Fig. 33 in the 
chapter on Pulmonary Diseases. The ordinary methods employed for 
the physical examination of the heart, and the pericardial sac within 
which it is suspended, are Inspection, Palpation, Percussion, and 
Auscultation. Modern surgical methods enable us occasionally to employ 
the method of Aspiration under due precautions, and Radiography is 
of assistance in certain cases. Becent methods of investigating the con- 
dition of the right auricle are referred to in § 35. 

Inspeetion* — Note, first, the attitude of the patient, and the amount of 
dyspncea present. Note also if there be any visible pulsation of the 
arteries and veins at the root of his neck. In some cases it is desirable to 
take a side view, and slight deviation from the normal can often be better 
observed by looking over the patient's shoulder. 

Secondly y most useful information may be obtained by simply observing 
the aspect and appearance of the patient, for the pallor or sallowness of the 
skin in cases of aortic valvular disease presents so marked a contrast to 
the florid cheeks of mitral disease as to form a most valuable aid to diagnosis. 
Notice also, if the dropsy of the ankles or back, which sooner or later 
attends mitral disease, is present. 

Thirdly, carefully observe that part of the chest wall which lies in 
front of the heart. It is important to notice if there be any undue 
pulsation or bulging in any part of the chest. The forcible displaced 
apex-beat of cardiac hypertrophy ; the wavy, difiuse pulsation of cardiac 
dilatation and pericardial effusion ; the epigastric pulsation and throbbing 
jugular veins in cases of dilated right ventricle ; and the heaving carotid 
arteries in cases of aortic regurgitation, may each afiord us valuable hints 
as to the direction of our further inquiries. 

§ 82. Palpation and the Localisation of the Apex (see Figs. 9 and 12).— 
The apex-beat is the farthest point to the left at which the cardiac impulse 
is distinctly felt, and after inspection, by which it can frequently be seen, 
should be first palpated by the flat of the hand, and then localised with the 
finger tips. In an adult male it is normally situated in the fifth interspace 
about 1} inches below and i inch to the inner side of the nipple line, 
at a distance of about 3 inches from the mid-sternal line. These and other 
cardiac measurements vary with the age^ and proportions of the patient — 

^ The position of the heart is considerably modified in childhood. The left border 
comes oat to the nipple line, and the ri^ht border extends to the riffht edge of the 
Btemom ; the apex beats almost directly below the nipple, behind the mth rib, or may 
be in the fourth interspace. 



42 DISEASES OF THE HEART AND PERICARDIUM [ § SS 

facts which are apt to be forgotten. The most external portion of the 
apex-beat should be marked by a dot with an aniline pencil. The 
localisation of the apex is a most important matter, and there are three 
principal features to observe about it — its POsmoN, its fokoe, and its 
EXTENT. You may also note in passing whether a thrill can be felt with 
the flat of the hand. It is important to bear in mind that the apex-beat 
is considerably modified if the apex happen, as it not infrequently does, 
to pulsate ^precisely behind a rib. It is only when the apex beats in an 
intercostal space that these three features can be satisfactorily made out, 
and this sort of fallacy should be remembered and allowed for. It can 
sometimes be felt more distinctly when the patient is asked to lean forward. 
In dextro-cardia the apex is on the right side. 

In HYPERTROPHY of the left ventricle the apex-beat is displaced down- 
wards and outwards, and the cardiac impulse is forcible and heaving. 
In hypertrophy of the right ventricle there is pulsation in the epigastrium 
and in the lower interspaces, but the apex is in its normal site. With 
DILATATION the impulse is diffuse and wavy. 

The apex is displaced downwards in cases of emphysema or pleurisy 
with effusion ; if the latter be on the left side, the apex may even be 
displaced beyond the right border of the sternum (see Fig. 42). The 
apex is displaced ujnoards in pericardial effusion, retracted lung, abdo- 
minal tympanites, or with any abdominal tumour pushing up the 
diaphragm. The apex-beat is obscured by very muscular or adipose 
chest walls, or emphysema. It is feeble with fatty heart ; wavy in 
pericardial effusion. With pericardial adhesions there is a systolic 
retraction of one or more interspaces. 

Thrills. — Of endocardial thrills the presystolic thrill fdt at the a'pex, 
due to mitral stenosis, is the most common. More rarely there is also a 
thrill in the pulmonary area (Fig. 12), due to mitral stenosis. The systolic 
thrill at the aortic area due to aortic stenosis, when present, is very marked. 
A diastolic thrill can be felt over the manubrium in advanced cases of 
aneurysm or aortic regurgitation. Mitral regurgitation is occasionally 
accompanied by a systolic thrill at the apexy which is the commonest thrill 
felt in children. A widespread thrill may be present with pericarditis. 

A presystolic thrill at the fifth costo-chondral junction is very rare, and indicates 
tricuspid stenosis. Aortic regurgitation is occasionally accompanied by a pre83rBtolio 
thrill at the apex. 

§ 88. Percussion of the superficial area of the prsecordial dulness — 
i e., area not covered by lung. In mapping out this area, the percussion 
stroke should be very much lighter and more superficial than that applied 
when examining the lungs, or the liver, or the spleen, and other deep- 
seated solid organs (see Fig. 9). The superficial area which is here referred 
to is a triangular one, with the apex upwards. The measurements of the 
dull area in a person of average size are 3J inches transversely, from the 
mid-sternal line ; and 2J to 3 inches vertically along the left border of 



I U 1 PERCVSBIOH 4$ 

the sternmu. Its boundaries are given in Fig. 9. The percussion note 
over the sternum is very different to that elicited over the chest i>eside it — 
it is of a much higher pitch — consequently, we cannot compare the per- 
cussion note in these two situations. We ought, tJierefore, to percuss 
upwards and downwards in a vertical line along the sternum to ascertain 
if any part of it is duller than normal. 

The »,m& ol deep-staled canliac dulnew U } inch la^er on enoh side, and 1 inch 
htilgei upwards, than the aaperfioial ana. Its limilB are considered by most physicians 
to be less oortain, and therafore less useful for di^nosis, than the superficial area. 
In some schools, however, it has nupeiseded the superficial canliao dulness, and is held 
to denote more accurately the variations in size of the heart. 

Method. — The student should lose no opportunity of fshcobsino the HoauAL 
heart and of attending to the following poinU : (i) Having frH localUtd (Ac apex- 



Fig, fl.— 8upertl(ilsJanilDBepDnln«M0fH«artwidUTer.— The guperflclal area of laidlm 
dnlaeu i> a triangular one, witli tbe ap«x upwards. The meaiuiements ol Chli area in a 
penon □( averaca tlie are 3| inche« traniveiaeLy. uid 2) to 3 iuirheg vertically along the left 
border otthe sttmnm. The right bordfiT beglni at the level ol the Joartli eoilai cartOati, and 
eomapondi to a vertical line drawn slightly to the left of the middle line ol the iteranm. 
lilt left limit ttirta from the oame point, and runs ontwarda along the lover border u[ tile 
fourth costal <:artllage to nearlj' Ita JnncClon with the rib, then bending downwards to apex- 
beat. The lower limit l> contlnnoua with the liver dulnew. 

beai, begin outside the cardiac area in a. perfectly resonant area. Tlie middle fingef 
of the left hand should be placed flat and ^Tndy upon the chest wall parallel to the 
margin of duhiess to be made out, and movod \ inch at a time, always paraUd to that 
Tnargin. towards the centre of the heart, (ii.) Use only one finger — the second of the 
tight hand — as a hammer, making a short sharp tap with the finger lip. The per- 
cQsging finger should rebound immediately — " staccato." as pianists say. The 
movement should be made from the wrist, or from the knuckle (metacarpo 'phalangeal 
joint), as in playing the piano, and the tap should be a light one. (iii.) By listening 
attentively to Urn sound elicited, it will be notictrfl that it is dull and fiat over the 
heart, like that produced by striking any solid object ; but louder and more resonant 
outside the area, like the sound produced by striking an empty barrel. It is only 
possible to define in this way the right, tho api>cr, and tho loft limits of the dull area, 
bocause at tho lower limit the cai'diac duliiess ia continuous with that uf the liver. 



4t DISEASES OF THE HEART AND PERICARDIUM [ § 84 

Mark with a blue aniline pencil the right or sternal border in two places. The curved 
upper and left border of the dulness should also be marked by a pencil in two positions 
— viz., close to the left side of the sternum, and in another place near the nipple ; 
these can then be joined and continued to the apex- beat. 

Fallacies. — It should be remembered that cardiac enlargement may 
be obscured by the hyper-resonance of emphysematous lungs, and under 
these circumstances enlargement of the heart or pericardium is very 
difficult to make out. We have then to rely upon other means than 
percussion. On the other hand, cardiac enlargement may be simulated 
by a fibrous retraction of the left lung, the heart, nevertheless, remain' ng 
of normal size ; or, thirdly, the heart may be displaced by an aneurysm or 
other mediastinal tumour pushing forward, and making the prwcordial 
area appear larger. One or other border of the area of dulness may be 
obscured by pleuritic effusion. Ascites, pleural effusion, or abdominal 
distension may actually displace the heart (see case in Fig. 42, § 84). 

The boundaries of the praecordial dulness are of great importance — so 
much so that we are enabled, as we shall see, to classify both acute and 
chronic diseases of the heart by the presence or absence of enlargement. 

The CHIEF CAUSES OP ENLARGEMENT of the prsBcordial area of dulness 
are two in number — effusion into the pericardium, and enlargement 
of the heart. The latter may be due to hypertrophy or to dikUationy or, 
more commonly, to a combination of the two. This enlargement may 
involve any one, or more than one, of the cavities of the heart. 

§ 34. For Auscultation much practice is required, and once more I 
must warn the student never to miss an opportunity of listening to the 
sounds of the heart, particularly the normal sounds. The whole cardiac 
cycle — i.e.y contraction (systole) and dilatation (diastole) — occupies about 
one second (Fig. 10). The first sound is due to the contraction of the 
ventricular muscle or to the closure of the mitral and tricuspid valves 
(or to both), and occupies about ^*^ second ; then comes a very brief 
interval, say ^',y second ; followed by the second sound (jjf second), which 
is due to the closure of the aortic and pulmonary valves ; and, finally, 
the diastolic interval {{'q second). (Fig. 10 should be studied carefully 
by the student.) 

Methods. — If no stethoscope is handy, cover the patient's skin with a soft hand- 
kerchief, preferably silk, and apply the ear ; but a stethoscope localises the sounds 
better. Personally, I prefer the old-fashioned wooden stethoscope, if the earpiece 
fits my ear well. But the binaural stethoscope is very useful for examining infant-s, 
or whenever there is any noise in the room or in the street, though it always has the 
disadvantage of giving more resonance tones (echoes arising in the cup and tubes). 
Place the small end of the stethoscope on the chest over the apex-beat, so that the rim 
touches all round, and then adjust your ear to the stethoscope, not the stethoscope to your 
ear. The common fault is to allow one side of the chest end to be raised off the chest 
in the process of adjusting the stethoscope to the ear. Do not allow the weight of 
your head to rest on the stethoscope ; it pains the patient, and you do not hear as well. 
It is a good plan to keep your fingers on the pulse (wrist or carotid) whilst auscultating. 

Listen, first, to the sounds at the apex and all round its neighbour- 
hood. Notice that the first sound is normally longer and duller than the 



§»4] 



AUSCULTATION 



45 



second,! and that the two sounds somewhat resemble lubb (yV second), 
<i^P (A second). Then, secondly, listen at the base ; place the instrument 
over the second right intercostal space, close to the sternum, over the 



NORMALI ^yg^ 
SOUNOSj \ J / 



VENTRICULAR 



_i- 



SYSTOLE. 



DIASTOLE. 




of cardiac cycle 



closure of 

mitral & 

tricuspid 

valves 



of cardiac cycle. 



closure 
aortic h 
pulmonary 
valves 



OTHER 
tVENTS 



) 



MURMURS. 



THEIR 1 
SIGNIFICANCE/ 



expansion 
of aorCa. 



Illllinniiih 



SYSTOLIC 
MURMUR 

^^ • 

O 

nr^itral 

Iregur^iCaCion 
or 
dorDic 
sDenosis. 



aortic 
recoil. 



ricH 
ar 



lau 
;uL. 

isystole 




llliuaj. 



DIA5T0UC 
MURMUR 

9^ m 

O 

ft 

MBS • 

3 

aortic 
regurg^. 



PWSrSTOLIC 
MURMUR 



3 

o' 
CO- 



mitral 
stenosis. 



:j)jf. 



Fig. 10. — Diagram of a Cirdiac Cycle, showing various events and ttieir duration, how the 
different mnrmuis are produced, and their clinical significance. The student should study 
this and Fig. 12 very closely. 



aorta. Thirdly, listen over the pulmonary area, between the second and 
third left spaces ; and, fourthly, listen over the tricuspid area, at the left 
side of the fifth costo-chondral junction. The student will notice that 

^ The first and second sounds correspond to G and B-flat respectively, below |the 
middle octave. 




le bod; o[ ths 4th Don. Vert. 



Root of R. lung. 



11. — The BMrt Uld QreKt Veuela in Bltn, via\ )uiig8 turned l»el[, skctrJied from tiit 
pBdkver Bifht ventricle forniB neater part of the interior lorface of the heart. Above 
and to right ol thla la the right auricle, into vhlch the luperlor vena cava openi, which collects 
the blood from the two Innominate veloi. PaHlng out from and above the right ventricle 
Is the pulmonarr artery, above which again it the remslnt of the ductna arterloaiu, connecting 
" — '"■ "■« arch oJ the aorta. Jmtto the left ol the pulmonary artery the left aurlcnlar 



appendix peepa round the comer. The arch 
left ventricle (which 1> at back, and therefore only 
upper convexity arlae 



.In Older the in 
trachea la aeen behind the veaaela, and 
Ft paaalng down Id front ol th 



margin of heart), and froi 
-tery, left carotid, and Intt anbclavlan. 
phrenic and vsel nervet are leen at the tidei, thme 



5H] 



AUSCULTATION 



the actual position of a valve (Fig. 11) does not correspond precisely with 
the portion of the m&ximum intensity of the sounds produced at that 
orifice (Fig. 12). This should always be the order of investigation, and 
by listening in this manner, we are enabled to make two important observa- 



Flg. 12. — DiAO&Aa aHowmo t 



\ Bitnatioii o 



B OudUc T&lVM A 



) THK pOlltlOIL i: 



p - Pnlmooaiy oriflca, at level at upper border ol third ]«ft coatal wrtllage. 

s = Aortic orlDce at level of lower border of third leftRoaUl cuilbiee. 

n - Kltr«l orifice »t level of lowat border of lomth left cottsl cartUige. 

I ^ Triciuirid orl£c« at level ot [onrth Intacepace, lying obllqnely behiad the etemum. 

The potltloni where the eoiuidt prodnced at the varloiu orlBcee are beit heard are Indicated 
by the lett«ii encloied In cltclei. The arrows mark the direction In whicb mocmun produced at 
Um oaiMpondlDS orlfieM are conducted. 

H. Ultra! mnrmnn ara b«(t heard at Vtit mitral arsa — i,t., the apex. 

A. Aortic mannim are best heard at the aorUc area— <.<-, aecoad right eo«eal oarUlage. 

p, Palmonary mncmDra are beat heard at the pulmonary area — i.e., lecond left intercostal spare. 

T, Tricutpid manuDn are best heard at the trlcnipld area — 1.(.. atlovprend ot fltcrnuin. 

tiona : (i.) The presence or absence of a mukmur (peri- or endo-cardial) ; 
(ii.) whether either sound is unduly shortened, prolonged, accentuated, or 
duplicated. 

If a murmur or bntU be discovered, there are four qualities to be observed 
concerning it : (i.) Its time (i.e., whether it replaces the first or second 



48 DISEASES OF THE HEART AND PERICARDIUM [§85 

sound) ; (ii.) its position of maximum intensity ; (iii.) the direction in which 
it seems to be conducted (i,e., continues to be audible) ; and (iv.) its quality 
as regards roughness. These may be briefly summarised as Rhythm, 
Position, Conduction, and Character. A systematic method of this kind 
is easily acquired, and the habit will afterwards be of the greatest use. 
It is by the cultivation of such habits that the good clinical observer is 
made. 

Alterations of the Heart Sounds and their Significance. 

1. Murmurs heard with the first sound are systolic in rhythm ; murmurs 
with the second sound are diastolic (see Fig. 10). There are four funda- 
mental facts which the student must never forget, viz. : 

Systolic m. at apex continued into axilla —mitral regurgitation ; 

Presystolic m. limited to apex = mitral stenosis ; 

Systolic m. in aortic area, conducted along carotids = aortic stenosis ; 

Diastolic m. at aortic area, conducted down sternum = aortic regurgitation. 

Stenosis {oTevoot, to contract) indicates obstruction or narrowing of 
an orifice ; regurgitation indicates a backward flow from imperfect closure 
of the valves. 

2. Accentuated second sound in the aortic area, at the base of the heart, is met with 
when the arterial tension is high (§ 61), or in aortic aneurysm. In the pulmonary 
area an accentuated second is due to increased blood-pressure in the lungs, as in 
mitral valve disease. 

3. A reduplicated second sound at the b€ise of the heart is found when the aortio and 
pulmonary valves do not close S3mohronously, as when the pressure in either the 
arterial or the pulmonary system is unduly high (as in 2). When heard a little to the 
right of the apex it is very characteristic of mitral stenosis. A reduplicated first at the 
apex is sometimes found with high arterial tension. 

4. Short, dear, sharp sounds are found with cardiac dilatation, while fedU sounds 
occur with fatty or fibroid heart. Emphysema, excess of adipose tissue, and pericardial 
effusion, obscure the sounds, and give the impression of feebleness. 

6. A prolongation of the first or second heart sound is sometimes spoken of, but 
it is difficult to know where to draw the line between a prolongation and a murmur. 
A ** booming " first is found with hypertrophy. 

Fallacies. — Under ordinary circumstances the respiratory do not 
interfere with the cardiac sounds, but if they do, the patient should be 
asked to stop breathing for a few seconds. It is often wise to do this 
in any case, because sounds originating in the bronchi or pleura may be 
mistaken for cardiac murmurs, but they cease when the patierU stops breathing. 
On the other hand, if a murmur be very feeble and doubtful, the heart 
sounds may be exaggerated by causing the patient to take some exertion, 
such as running upstairs (see § 47 for variations in murmurs). 

§ 85. The Pulse affords one of the best possible indications as to how 
the heart is performing its work, as to what remedies are indicated, and as 
to how the therapeutic measures we have already adopted are answering 
their purpose. The pulse also gives an important clue as to the nature of 
the cardiac lesion ; thus, in mitral regurgitation the pulse is usually rapid, 
of low tension, and may be irregular, whilst in mitral stenosis it is regular, but 



§36] 



THE PULSE 



49 



small, thready, and incompressible ; in aortic regurgitation it presents a 
collapsing (^'water-hammer") character, whilst in aortic stenosis it 
presents exactly the opposite feature, being sustained. The pulse will 
be dealt with fidly in a separate chapter (§ 55), but there are three important 
hints which may be mentioned here — viz., (1) Do not examine the pulse 
until the nervousness at first excited by your visit has passed ofiE ; (2) gener- 
aUy keep your fingers on the pulse while auscultating the heart ; (3) in all 
cardiac cases the rate, rhythm, force, and tension of the pulse should be 
frequently noted. 




Fig. 13. — SimultaneouB tradngB firom the jugular and radial poises from a patient with a normal 
heart. The jogolar pnlse is of the anrioular form, and shows a large wave (a) due to the 
aaride. The rhsrthm is regular. The space b represents the period of yentricular systole. 
{J)f. Jamet Maekmtie.) 

The pulsation of the jugular veins in the neok may give valuable assistance in 
determining the condition of the auricles of the heart. The poltobaph is an 
instrument by which one can obtain simultaneous parallel records of the action of the 
jugular (venous) pulse and the 
radial (arterial) pulse. The 
venous tracing reveals the con- 
dition of the right side of the 
heart just] as the tracing of 
the artery (or of the cardiac 
apex) reveals the condition of 
the left side of the heart 
(Fig. 13). The interpretations 
of tiie records in cardiac disease 
can only be correctly judged by 
the expert skilled in their em- 
ployment. The venous tracing 
shows in normal conditions two 
waves. The first (a) is duo to 
contraction of the right auricle, 
and is followed by a depression 
indicating the relaxation of 
ihe auricle. The depression 
is broken by a small rise 

(e), probably communicated to the jugular vein by the carotid. The second wave 
(v) represents the ventricular contraction. The interval between the first and second 
waves occupies about one-fifth of a second, the time of the wave of contraction passing 
from auricle to ventricle. The venous tracingshows a definite change when auricular 
fibrillation (f 50) supervenes. The first auricular wave is replaced by numerous tiny 
waves (fibrillation), duo to the undulatory independent twitchings of the muscular 
fibres in the right auricle ; and the tracing shows only a ventricular wave (Fig. 14). 

4 




Fig. 14. — Simultaneous toaciugs of the Jugular and radial 
pulses firom a patient with auricular fibrillation. The 
jugular pulse is of the ventricular form, and there is an 
absence of the] wave {a), due to the auricle, preceding 
the carotid wave («) as in Fig. 13. The rhsrthm is 
irregular. The space B represents the period of ventri- 
cular systole. (Dr. James Maekemie.) 



60 2)18EA8£!8 OP fHH HEARf AND PEMtCARbtUM [ JJ a6, $7 

Tho ELECTBO-OABDiooBAM shows the Contractions of tho heart. The electrical 
discharge which is set up by contraction of tiie cardiac chambers is conducted to a 
string placed between the poles of a magnet, and the movements of the string are 
projected on to and recorded on a photographic plate. 

PART a DISEASES OF THE HEART AND PERICARDIUM : THEIR 
DIAGNOSIS, PROGNOSIS, AND TREATMENT, 



§ 86« Glassiflcatioiu — For practical purposes, diseases of the heart and 
pericardium are best grouped into Acute and Chronic ; and the latter 
may be subdivided into those attended by erUargement of the prcBcardial 
didneas and those not necessarily so attended. 



Aeute. Chronic. 

AREA OF DULNESS INCREASED. 

I. Cardiac hypertrophy. 



I. Acute pericarditis. 
II. Acute endocarditis. 

III. Neuro-palpitation (paroxys 

mal tachycardia). 

IV. Angina pectoris. 



II. Cardiac dilatation. 

III. Hydropericardium. 

IV. Congenital heart disease. 
V. Aortic aneurysm.! 

AREA OF DULNESS NOT 
NECESSARILY INCREASED. 

I. Chronic valvular disease. 
II. Fatty heart. 

§ 37. Routine Procedure. — First : What is the Patient's '' Leading 
Symptom " ? It may be that the patient voluntarily complains of one 
of the symptoms discussed in Section A, and in this way has directed 
our attention to his heart. If not, we must ascertain, without putting 
" leading questions," what is his " chief symptom." Breathlessness is 
the most constant symptom in cardiac disease, and in more advanced 
stages we meet with dropsy and cyanosis. 

Secondly : Having obtained this clue we follow it up by asking a few 
details, in chronological order, of the History of the Illness. In this 
way we ascertain whether the disease he acute or chronic — a most important 
matter, because for clinical purposes diseases of the heart and pericardium 
may be primarily divided into acute and chronic. The Previous and 
Family Histories may also be inquired into. In all cardiac cases it is 
important to know whether the patient has ever had acute rheumatism, 
this being the most frequent cause of cardiac valvular disease. Ascertain 
also if there be any heart disease in the family. 

Thirdly : The Examination of the Heart, and especially the decision 
as to whether there is any enlargement or not. The routine method consists 
of the following procedures : — 

^ This is not a disease of the heart proper, but is included here because its existence 
is often revealed by finding enlargement of the prsecordial dulness, or dulnees above, 
meiging into that of the heart. 



SS8] ACUTE PERICARDITIS 51 

1. An examination of the apex- beat (by inspection and palpation) ; 

2. The mapping out of the area of pracordial dulness (by percussion) 
(see Fig. 9) ; 

3. Listening to the heart sounds (auscultation) ; and 

4. The examination of the pulse. 

The chest should always be stripped and a thorough examination made. 
An attempt to examine a female patient should never be made without 
the removal of the corsets. The patient should be examined both in the 
recumbent and the erect posture. 

If the sjrmptoms of which the patient complains point to some Chronic 
Caidia3 Disease — i.e,, they have come on gradually and are unattended by 
pyrexia or other constitutional disturbance — the reader should turn to the 
Chronic Diseases (§ 42). 

If, on the other hand, the disease is of an Acute character — i.e., it has 
come on recently or suddenly, and is perhaps attended by pyrexia and 
other constitutional symptoms — it is one of four diseases : I. Acute 
Pericarditis ; II. Acute Endocarditis ; III. Paroxysmal Tachy- 
cardia ; or IV. Angina Pectoris. 

I. The patient is in evident distress, and the prcecordial area q/* dulness is 
increased, the shape of the duiness being pyramidal, toith the point upwards, 
and the temperature is elevated. The disease is probably Acute Pericarditis. 

§ 38. Acnte Pericarditis is an acute inflammation of the pericardial 
sac. The disease has two stages : the first precedes, and the second 
follows, the efEusion of fluid into the pericardial sac. It is not infrequently 
met with as a primary afiection. It supervenes during the course of 
many different diseases, and the symptoms of these may mask its onset. 
Rheumatic fever is certainly its most common cause, and it should be 
remembered that it may be the first manifestation of this affection. 
We should always examine the heart daily in rheumatic fever, and in 
acute renal affections, because in these acute pericarditis may come on 
insidiously, without pain or tenderness, its advent being maiked perhaps 
only by the occurrence of delirium, so rare otherwise in acute rheumatism. 

Symptoms, — (1) The patient wears an anxious, troubled look, and the 
cheeks are flushed or pallid ; there are fever and a rapid pulse ; the 
breathing is rapid, and he complains of severe pain over the heart (occasion- 
ally referred to the abdomen), increased by pressure, movement, or respira- 
tion. (2) Physical Signs. — The prsecordial dulness is only slightly increased 
at first, but a loud, harsh double friction sound, " to and fro," like a saw, 
is heard on auscultation. This may be distinguished from a murmur 
produced within the heart by (i.) always being double (i.e., accompanying 
the movements of the heart) ; (ii.) the second part of the rub is continuous 
with the first, without any diastolic pause ; (iii.) it is often loudest at the 
root of the great vessels, over the third left costal cartilage ; (iv.) it varies 
in its character from time to time, and is increased by gentle pressure with 
the stethoscope ; (v.) pressure will also elicit another differential character 

HARVARD uNivERsrrr 

fCHOOLOF MEDICINE AND PUBLIC HiALHI 

LIBRARY 



62 DISEASES OF THE HEART AND PERICARDIUM [ § 88 

— viz., that the disease is usually accompanied by tenderness, as well as pain. 
The differentiation between peri- and endocardial murmurs is so important 
that it is also given in a tabular form below (p. 55). To distinguish peri- 
cardial from pleuritic friction is very easy, because the latter ceases if the 
patient holds his breath. Note that as the efihision occurs the murmur 
becomes less distinct, but it is again intensified as the effusion clears up. 

(3) Second Stage, or stage of pericardial effusion. The inflammation 
may subside, but more frequently, in the course of a day or two, effusion 
of fluid occurs, and the pain and tenderness diminish. The rub becomes 
less audible, though it can still be heard at the base of the heart. The 
temperature may fall a little, but the breathlessness and other symptoms 
continue. A troublesome cough is frequently added, and dysphagia and 
vomiting sometimes occur. The increased area ofdul/ness, due to pericardial 
effusion, may be greater than the enlargement from any other cause, 
(i.) It is of triangular shape, with apex upwards, reaching to the third, 
or even second, costal cartilage, (ii.) As the root of the heart is fixed to 
the pericardium, when the sac fills the whole heart becomes raised, and, 
therefore, the apex beats above and to the left of its normal position, (iii.) The 
dulness extends to the left of the apex-beat. There is progressive weakening 
of the heart sounds at this time, because they are transmitted through 
fluid. It is possible by the height of the dulness along the sternum, which 
should be watched each day, to determine the amount of fluid present. 
Ewart describes a square patch of dulness with absence of R. M. at the 
base of the left lung. 

Etiology, — Pericarditis may attack any age and either sex, but is almost 
always preceded and cau^d by some other disease. It is doubtful if 
idiopathic pericarditis ever occurs. The causes of pericarditis may be 
ranged under five heads : (1) Injury, (2) Certain acute infections : acute 
rheumatism, pyaemia (staphylococcal, streptococcal, pneumococcal), scarlet 
fever, variola, typhus, typhoid, and influenza (Barlow), and some consti- 
tutional diseases — Bright's disease, scurvy, gout. (3) Chronic infections — 
e,g,y tubercle. (4) Morbid growths — e,g., cancer. In the two last the 
process tends to be subacute, and is accompanied by a large amount of 
fluid. (5) Extension from adjacent organs, amongst which may be men- 
tioned pleurisy or pleuro-pneumonia, especially on the left side ; intra- 
thoracic aneurysm (pericarditis may be the precursor of rupture into the 
pericardium) ; solid intrathoracic tumours ; perforating ulcer of the oeso- 
phagus ; various diseases below the diaphragm — e,g,, abscess or hydatid 
of the liver. 

Course and Prognosis, — The duration of acute pericarditis with effusion 
varies widely, but it averages about fifteen to twenty-five days. It may 
undergo resolution with or without the formation of adhesions (Adherent 
Pericardium, § 38c below) ; or result in chronic effusion (Hydropericardium, 
§ 45) ; or become purulent (Pyopericardium, § 38a below). Pericarditis 
with effusion is always a serious malady, but the prognosis depends much 
on the disease which it complicates, the general condition of the patient, and 



S»8] ACUTE PERICARDITIS B3 

the evidences of cardiac embarrassment — namoly, dyspnoea and cyanosis 
with feeblBseas, rapidity, and irregularity of the pulse. Pericarditis com- 
plicating rhenmatism, like the olher complications of that dieease, tends 
to vecovpr. but it may leave a weakened heart, and lead to cardiac 
dilatatiun. In renal disease it is a (terions though often latent affection ; 
and in pyemia, when it is generally purulent, it adds to the gravity of that 
mHoub disorder. In infancy and in debilitated patients it is alec grave. 

Diagnotii. — The diagnosis from acute endocarditis has been considered 
above, and in Table II., p. 55. It is distinguished from dilatation by 
the following points : the left border of the dulnesa in pericardial effusion 
extends beyond the apex-beat, and the apex-beat may be displaced 
upnrards ; the right border of dnlness has a convex outline and the cardio- 



tlg, IB. — DiAOiuk noH A Case or Bheciiitio Pebioardttib n . 

tweDt7-wven. The ditrk uea inilleBtM pnccordlaL dulcsaa. The lugei — _,^ 

■hwUng bIvm Uw vra over which the pericardial [rictlon could be heard (londneu ii Indicated 
by the dgpUu of the shudlng). It 1> uaually tauKlit that one of the [eatnret dlKlnsuUhlnK 
perl- trom endo-cardlal mnnnnn it the limitation ot the roTmei ta the precordial region . 
but I have numy Umea utiafled myieif that thli li not lo. and thli case li one ot leveml 
examplea I have met with TfliiOed by aulnpay. Thlicsue watanderthe careol Dr. W.H.Ord 
when I wM hlB honae-phytldan. 

hepatic angle at the right fifth intercostal space is dull (Rotch's sign). 
X-ray examination shows obliteration of the normal space between the 
diaphragm and the heart, and sometimes the heart outline can be made out 
distinctly within that of the distended pericardium. 

Treatment, — In the inflammatory stage the patient should be kept in 
bed absolutely without movement, on light fluid diet ; and cotton-wool, 
a poultice, or warm fomentation applied to the prtecordium. This usually 
gives more relief than the ice-bag which is recommended by Dr. Lees, 
though this undoubtedly relieves the symptoms. If the distress is great, 
wonderful relief is obtained from four or live leeches over the pnecordium. 
If cyanosis, orthopnoea, and irregular pulse are present, indicating con- 
siderable cardiac embarrassment, bleeding (4 to G ounces) is a prompt and 
efficacious measure. Opium (gr. ^ quartis horis], or morphia hypodermi- 



54 DISEASES OF THE HEART AND PERICARDIUM [ §88a 

cally, is of great value for the pain and distress. Small doses of chloral 
may be given for the restlessness if the circulation is well maintained. 
Effervescing salines should be administered. Digitalis is given in small, 
frequent doses for cardiac failure, and stimulants, ether, and strychnine, 
according to the state of the pulse. The effect of digitalis must be very 
carefully watched, lest it increase the cardiac embarrassment. For hyper- 
pyrexia and delirium some recommend the graduated bath, but the 
necessary movement is a grave objection ; and we have remedies quite as 
valuable in antifebrin, phenacetin, aconite, quinine, and opium. 

Tf&Ument for the cause of the pericarditis should be combined with 
the foregoing — e.g., sodium salicylate combined with alkalies for acute 
rheumatism ; diuretics and hot-air baths for renal disease ; quinine in larger 
doses for pysemia. In the stage of effusion free blistering promotes 
absorption, but it must be remembered that renal disease is a contra- 
indication to blistering. If the effusion becomes chronic, potassium 
iodide (gr. v. t.i.d.) and diuretics may be given (P. 55). Iodine paint and 
other local counter-irritants are also useful. 

Pabacbntesis PsRiGARDn. — If, at any time, the effusion be considerable, and the 
cardiac embarrassinent veiy great, as evidenced by severe dyspnoea, and a rapid, 
irregular, low-tension pulpo ; if leeches and bleeding have failed to give relief, explora- 
tion with a hypodermic syringe, under strictly antiseptic precautions, may be practised 
io ascertain (he nature of the fluid. If clear fluid be found, paracentesis should be 
performed, and the ope ration may be done without fear, if rigid antiseptic precautions 
be employed, and the point of the trocar kept away from the viscus. Incise the integu- 
ment in the fifth left interspace, close to the sixth rib, 2 to 2^ inches to the left of the 
middle of the sternum (in an adult of average size). Lisert the trocar and cannula 
perpendicularly to the surface ; withdraw ^e former directly it pierces the wall. 
Eight or twelve, or even forty ounces (in a chronic case) may be thus gradually removed. 

§ 88a. Pyoperioarditii. — Sometimes in debilitated children and in the course of 
scarlatina, in phthisis and empyema, always in the pericarditis of pyaemia, and under 
some other conditions, the fluid in the pericardium takes on a purulent or sero-purulent 
character. This condition is sometimes revealed (as in a collection of pus in other 
parte of the body) by the occurrence of (1) shivering attacks, (2) profuse perspirations, 
and (3) a temperature with wide variations in the coursa of a few hours, in addition 
to the clinical features of acute pericarditis above described. But it is very difficult 
to diagnose, because the friction sound is usually absent. It is usually fataL 

Pyopericarditis is the form which pericarditis frequently assumes in infancy, and 
is then extremely difficult to diagnose. In addition to the small measurements with 
which we have to deal, the left lung may become adherent to the chest wall early in 
the disease, and so prevent the recognition of the enlargement of the prsBcordial dulness. 
It is only by the profound disturbance of the circulation, the progressive weakness 
with anaemia and leuoocytosis, that we can assume the presence of pus. 

Pyopneumocardium is a rare condition in which air reaches the pericardial sac from 
the lungs or stomach. 

HcBmopericardium is very rare. Aneurysm of the first part of the aorta or of the 
cardiac wall, rupture or wounds of the heart, scurvy and other blood diseases, may 
lead to sudden death owing to the sudden influx of blood into the pericardium. A 
small amount of bleeding may be seen in the pericarditis due to Bright's disease, 
malignant growths, and tubercle. 

Treaiment, — Quinine in large doses, phenacetin, and like remedies, may be ad- 
ministered, but a large hypodermic syringe, rendered thoroughly antiseptic, should 
be very carefully introduced whenever the existence of pyopericardium is suspected. 
If the fluid withdrawn be of a purulent nature, paracentesis, or, better still, free 
drainage, should be e£fected. 



M t86, 88c 1 P Y OPE RICA RDlTlS^LA TENT PERICA RDITIS 55 

§ 88&. Latent Perioarditif — i.e.* perioarditis without symptoms (though not neces- 
sarily without physical signs). In most patients in whom we find a pericardial 
effusion a history of acute pericarditis is obtainable ; but it is a faxit not sufficiently 
recognised that pericarditis may have come on quite insidiously, without any acute 
symptoms. The effusion may bo discovered when examining tiiB heart as a matter 
of routine, or perhaps not until the autopsy. Moreover, I have, in the post-mortem 
room, on more than one occasion foimd a totally adherent pericardium in a patient in 
whom the most careful inquiry had failed to reveal any 33rmptom3 pointing to the 
heart during life (§ 47). It is a latent pericarditis of this kind which ordinarily com- 
plicates RxNAL DissASE. In AouTB Rheumatism also Us advent may he inikaUd 
only by delirium or votniting ; and Gouty persons also may be attacked by this latent 
disease after exposure to chill. 

Pericarditis occasionally results in Adherent Pericardium. 

{ 88e. Adherent Pericardiiim may exist in two forms : (i.) The internals in which 
the visceral and parietal layers become joined, so that the heart is shut up, as it were. 
in a box. and is incapable of much hypertrophy. The symptoms are those of grave 
cardiac failure, which usually come on severely, and often end fatally at about puberty, 
when the heart should increase proportionately with the general development. 

(IL) External, in which the pericardium is adherent to the surrounding structures, 
the pleura, mediastinum, and diaphragm. The symptoms are those of cardiac 
embarrassment out of proportion to the signs of heart disease found. The signs are 
many, but not very reliable. They are (1) a systolic tug at the apex ; (2) fixity of the 
cardiac apex during respiration and with change of position ; (3) systolic recession 
along the attachments of the diaphragm, either in front along the lower costal border, 
or behind under the eleventh and twelfth ribs ; (4) signs of hypertrophy, greater than 
can be accounted for by the severity of any valve disease which may be present ; 
(5) pulsus paradoxus, or stopping of the pulse during inspiration. Cardiolysis or 
removal of ribs has been succemfnlly performed for this condition. 

We now pass to the other acute disorders — viz., II. Acute Endo- 
carditis ; in. NEURO-PALprrATiON ; and IV. Anoina Pectoris. 

II. The prcBoardial area of dolneM is not neoeisarily inereased, the 
jxUient is in evident distress, his temperature is elevated, and on attsctd- 
toting the chest there is a murmur added to the heart sounds — the disease is 
probably Acute Endocarditis. It is not always easy to distinguish 
endocardial from pericardial murmurs (see table below). 

Table II. — ^Diagnosis of Endocardial from Pericardial IUurmurs. 



Endocardial Murmurs. Pericardial Murmurs. 



1. May accompany first or second sound 
only, or both. If double, there is 
always a short interval of silence 



Always double, and can be heard 
throughout the diastole, as well as 
the systole, without any interval 



between the two bruits. between the two bruits. 

i 

2. Loudest in one of the valvular ; Usually loudest over third left costal 

areas. | cartilage (root of big vessels). 

I 

3. May be conducted into the axilla, i Mostly confined to the praacordium. ^ 

or along the aorta and carotids. 



4. Usually no pain or tenderness. 



Usually accompanied by pain. 



* For an exception to this, see Fig. 16, p. 53. 



56 DISEASES OF THE HEART AND PERICARDIUM (§89 

§ 89. Acute Endocaiditii is acute inflammation of the valves of the 
heart. It is usually attended by an almost imperceptible enlargement 
of the precordial dulness^ because a degree of dilatation or myocarditis 
is associated with it. In a very large proportion of cases it complicates 
some other disease ; and, like pericarditis, it is very frequently associated 
with acute rheimiatism ; it may even be the first evidence of that disease. 

There are two varieties of endocarditis, commonly known as Simple 
and Malignant, and there are three groups of symptoms found with each. 

In Simple or Benign Endocarditis, as in the other variety, (1) the 
characteristic feature is the devdopnerU of a murmur^ usually heard 
loudest at the apex because the mitral valve is the one most frequently 
involved in acute rheumatism ; but it may be heard in any situation, 
depending on the valve affected (see p. 73), and it may be single or double 
in rhythm. The murmur has to be diagnosed from that of pericarditis 
(see table above), and, if possible, from that due to old valvular disease. 
In the acute disease the murmur is usually softer and heard over a more 
limited area ; in old valvular disease it is harsher, and is conducted in 
different directions (vide Cardiac Valvular Disease, § 47). The previous 
history, and the presence of cardiac dilatation, may also aid us consider- 
ably. The other physical signs which are present are a weak, diffuse 
impulse and weak cardiac sounds. 

2. The Constitutional Symptoms may be so few and slight that at the 
time they may pass almost unnoticed. But since simple endocarditis 
usually complicates some other disease (e.g., acute rheumatism), the 
constitutional symptoms largely depend upon the severity or mildness of 
the primary disease. The onset of the endocarditis in these circumstances 
may be suspected when there is a sudden increase in the rapidity of the 
heart, and an additional rise of temperature without apparent cause. 
Palpitation may be present, but pain and distress about the prsecordium 
are generally absent — a feature worth bearing in mind. In the rare 
instances in which acute endocarditis occurs primarily, the temperature 
is irregularly intermittent (100*^ to 102*^ F.). The presence of such a 
pyrexia, and the absence of physical signs, excepting those referable to the 
heart, are the only data upon which we can rely for the diagnosis of the 
disease. 

3. Emboli do not usually occur, at any rate, imtil very late, in simple 
endocarditis attacking a heart previously healthy. But when it attacks 
a heart the seat of old valvular mischief — known sometimes as Recurrent 
Endocarditis — the temperature may vary from 100° to 102*^ F. for days, 
weeks, or even months, and emboli may arise in various situations from 
the separation of the inflammatory material on the valves. Rigors, with 
tenderness and enlargement of the spleen, may indicate embolism of that 
organ ; sudden hemiplegia or other nerve troubles may point to embolism 
in the brain ; sudden occurrence of bloody albuminous urine, with a rigor, 
point to embolism in the kidney ; sudden blindness, to embolism of the 
central artery of the retina ; sudden pain and tenderness in a leg or 



§ 89 ] ACUTE ENDOCARDITIS 57 

arm may indicate plugging of one of the arteries, in which case the pulsation 
will be absent below the blockage ; and sudden abdominal pain with 
vomiting and collapse may follow embolism of the mesentery. 

Causes of Benign Endocarditis. — A history, or evidence at the time, of 
the causes of endocarditis may help us in the diagnosis, (i.) Undoubtedly 
the most common of these is rheumatic fever, old or recent, and it shoidd 
be remembered that acute endocarditis may arise quite early in the course 
of the disease, before the joint lesions are manifest. Exposure to cold is 
mentioned as a cause, but the endocarditis in such cases is probably of a 
rheumatic kind, (ii.) Chorea, scarlatina, typhoid, and many other bac- 
terial infections, may give rise to endocarditis, (iii.) It is also an occasional 
complication of syphilitic,^ cancerous, and other cachectic conditions, 
chronic alcoholism, and renal disease, (iv.) Valves deformed by acute or 
chronic endocarditis are predisposed to acute inflammation, and the 
recurrent endocarditis above referred to thus arises, (v.) The patient is 
generally yoimg, rarely older than thirty-five or forty when attacked by 
endocarditis for the first time, (vi.) Heredity is an important predisposing 
factor. 

The Diagnosis of benign endocarditis has been referred to above (under 
the constitutional symptoms), and it is not usually difficult. It is most 
important, however, to distinguish the two forms of endocarditis, as they 
differ so widely in their duration and fatality. Malignant or ulcerative 
endocarditis differs clinically (1) in the greater severity of the constitutional 
sjrmptoms, which may present all the features of septiceemia or of the 
typhoid state ; (2) in the wide range of the temperature in the course of 
twelve or twenty-four hours, and the occurrence of severe rigors and 
sweats ; (3) in the invariable occurrence of systemic emboli, which may be 
of an infective character. When, however, malignant endocarditis super- 
venes on a previously damaged heart the diagnosis may become extremely 
difficult. 

The Prognosis, though the malady may last for many weeks, or even 
months, is favourable as regards life, but the damage to the cardiac valves 
is generally permanent, and then the prognosis turns on many important 
considerations (§ 50). 

Treatment should be directed primarily to the disease of which endo- 
carditis is a complication — salicylate of soda, for instance, for rheumatic 
fever, though this drug is usually thought to have no control over the 
cardiac lesion. Perfect rest — hardly allowing the patient to turn in bed — 
is absolutely essential. This not only favours the subsidence of the 
inflammation, but prevents the violence of cardiac action, which separates 



^ H. L., a lad aged fiftoen, was admitted into the Croydon Hospital in 1882 with 
intense chlorosis, intermitting pyrexia, and a loud endocardial murmur. The cause 
of his ilbiess was obscure during life, but he died gradually of asthenia. After death 
gammata were found involvng the cranial and other bones. There were striae in 
the cornea, and other evidences of syphiUs, and abundant evidence of acute recent 
endocarditis, and a generalised endarteritis. This case is referred to at greater length 
io the Clinical Journal, December I, 1897. 



58 DISEASES OF THE HEART AND PBSICARDWM lfa9a 

the fragments from the valves and leads to embolism. Aconite is of 
groat value to slow and steady the heart. In this and other respects the 
treatment is mucU like thai of pericarditia (g 38), though the local treatment 
has less eSect in endocarditis. Stimulants and digitalis are indicated only 
if the heart's sction is very weak and irregular, and they should be given 
with great caution, for fear of stimulating the heart too much and promotiitf^ 
embolism. 

3 89ii. Ulcnatin or KtUgnuit Sndocudllii (SynoDymn — Infective Endocarditis). 
— In this form the endocardium is much moie Eeriousl; affected, for there is mor^ 
deetniction of the valves and adjoining surfaces, so thtA large ulcers may be produced, 
and the valves may be periorated, or even completely disappear. The vegetations, 
too, are much larger. 

It seema doubtful if the disease ever occurs as a primary affection, but it ii rather 
a septicnmia or blood infection, in which the heart valves form a nidu« for the oiccu- 
lating orgMtisma. The micio-organisms most commonly found are staphyl-Kocci and 



Fig. 16.— Chart of Hallgnaut or Uleerattve BndoeardlUi. 

atroptococci, pneumococci, and, more rarely, gonococci, bacilli ooli communes, typhoid 
and influenza bacilli. It is, therefore, usually a complication of such dieeaacs aa 
pneumonia, eiysipelaa, acplic wounds, abscesses, meningitis, gonorrhoea, dysentery, 
or puerporal fever. It is met with more isiely after chorea, scarlatina, and rheuma- 
tism, diseaaea in which simple endocarditis is so common ; and with extreme rarity 
after tubeniulosis, diphtheria, and variola. Thtre is a marked piedisposition for the 
disease to attack a heart which ie already the seat of chrooio endocarditis. (1) Th« 
Contlitutitmal Syinptmn' vary considerahly, but are usually grave, rompHsing intenso 
anEsmia, great prostration, and, in (n) the Typhoid caritty, the early supervention of 
somnolence and muttering delirium. In (bj the Septic varidy (such as arises wiUi 
acuta necrosis, the puerperium, or an external wound) the mind remains quite clear 
to the end. but rigors and sweats are prominent, simulating ague or pyemia. The 
spleen is usually enlarged, and petechial rashes are fairly Iniquent. The fever is high. 



§ 40 ] MALIGNANT ENDOCARDITIS— TAOH YOARDIA 59 

and may be continuous, but it more often runs an irregularly intermittent course, 
which may extend over weeks or months. (2) Generally there is a Cardiac Murmur, 
but a careful examination may be necessary, and occasionally — in cases free from old 
valvular mischief — ^there is none ; so that theoccurrence of embolism may be the first 
symptom to draw attention to the heart. (3) The Emboli may be simple blockings 
of an artery, as in simple endocarditis, but they may become abscesses, which in turn 
form sources of septic infection in the lung and elsewhere (Symptoms of Embolism, 
see p. 56). 

Course and Varieties. — ^The severity and duration of the disease vary widely. 
Those cases coming on without previous cardiac mischief usually run a rapid and 
acute course of five or six weeks. Varieties (a) and (6) vide supra, (c) The Cardiac 
group (Bramwell) — ^those in which previous chronic valve disease exists — run a 
prolon^d course of many months, up to a year or more ; rigors are often absent, 
and it may be very difficult from the symptoms to decide if malignant endocarditis 
is present or not. Between these extremes every grade is met with, but in the 
end the disease is almost always fatal, (d) There are certain ah?rrant forms marked 
by the predominance of such symptoms as jaundice, diarrhoea, parotitis, profuse 
sweatings, various eruptions, or pyrexia of a continued type. 

The Diagnosis from enteric, ague, acute miliary tuberculosis, acute lymphadenoma, 
cerebro-spinal meningitis, and pysamia may be very difficult. An intermitting or 
remittent temperature, rigors, emboli, peteohise, pallor of the face, and the var3ring 
character of a cardiac murmur, are points in favour of ulcerative endocarditis. In 
enierie the onset of the fever is gradual ; rigors and sweats rare or absent. The 
ineffioaoy of quinine serves to differentiate it from ague. Local lung symptoms aid 
the diagnosis of acute miliary tuberculosis. In pycsmia the cause is probably apparent, 
and the rigors and sweatings are more frequent. 

Treatment must be conducted on the same general lines as that of the benign variety 
{q.v.), the precautions as to rest and stimulants applying, if possible, with greater 
force. On tiieoretioal grounds it would be well to administer abundance of nutriment 
and to try antiseptic remedies, such as quinine in full doses, antipyrin, antifebrin, 
sulphocarbolates, guaiacol, and the like. The recognition of the fact that malignant 
endocarditis is part of a septicsamia has led to more rational methods of treatment. 
Cases of recovery by the use of antistreptococcic serum have been reported, but this 
treatment has been generally disappointing, because of the large number of different 
organisms which may cause the disease. The method introduced by Sir Almroth 
Wright promises greater success, and some encouraging results have been attained by 
its use. A culture of the infecting micro-organism is obtained from the patient's 
blood, and horn it a vaccine is prepared. This is injected subcutaneously, the fre- 
quency and dosage being controlled by estimating the opsonic index (Chapter XX. ). 

There are two other, rarer, heart disorders which arise very suddenly, 
and in these also the area of prsdcordial dnlness is not necessarily increased 
— (in.) Paroxysmal Tachycardia, and (IV.) Angina Pectoris. These are 
paroxysmal disorders without Elevation op Temperature. 

§ 40. The jHiHent is suddenly seized with an attach of " jxUpitatian,'^ but 
WITHOUT ANY DEFINITE PAIN IN THE CHEST — the disease is probaUf/ 
Paroxysmal Tachycardla (Neuro-palpitation). 

(m.) Paroxysmal Tachycardia (idiopathic tachycardia, heart hurry, neuro- palpita- 
tion, hysterical or nervous palpitation) is a term somewhat loosely applied to signify 
a quick pulse, but, unlike bradycardia (slow-pulse), which has no meaning in itself, 
the term ** tachycardia '* should only be employed to denote a special disease with 
characteristic symptoms. Tachycardia proper, or paroxysmal tachycardia, is now a 
recognised, though not very common, condition. It consists of a series of paroxysms, 
coming on at intervals, with abrupt onset, lasting for a few minutes to several hours, 
during which the rapidity of the pulse may amount to 200. It returns to a normal 
rate just as abruptly as it started. Sometimes there is no subjective distress, but it 
may be accompanied by a sense of constriction and suffocation, and the attack may 



60 DISEASES OF THE HEART AND PERICARDIUM [ § 40 

commence with a " sinking ** in the epigastrium. The face wears an anxious, terrified 
look, and the patient may complain of ** flushing " of the general surface, with a feeling 
of heat or " pins and needles " all over. This is usually followed, in all the cases 
which I have seen, by pallor of the skin, a feeling of coldness of the extremities, with 
tremor, or actual shivering. Such are the symptoms of a typical attack of Paroxysmal 
Tachycardia, though the details may vary in dififeient patients. The attacks return 
at varying intervals (days, weeks, or months), and are often determined by some 
emotioal cause. ^ 

The Diagnosis from Angina Pectoris is given under that affection (§41). 

Causation, — ^The disease is not limited to any special period of life in women ; it 
may occur at any time from childhood to late middle age. In men it occurs usually 
from fifteen to twenty-five years. No cause has been discovered, either in the heart 
or other organs. In some cases the disease appears to be due to a disordered nervous 
condition, either in the vagus or in the sympathetic, probably the former.^ An 
attack may be brought on by mental or physical strain in those who are subject to 
the disease. It may also be associated with hysteria ; the case I have narrated in 
the footnote below was associated with many of the symptoms of that malady, and I 
have known many other cases of tachycardia similarly associated. Compare also 5, 
p. 61 (angina vaso-motoria). All the facts point to that form of the disorder 
being an angioneurosis in which dilatation of the peripheral vessels suddenly occurs 
under any abnormal strain. The polygraph recoids show two forms, one in which 
the auricle beat is in normal position ; and one in which the auricular beat is 
absent. 

The Prognosis depends upon the frequency and duration of the attacks. The 
conditio^, it would seem, can only be temporarily cured, though patients may live 
for years. Br. H. C. Wood cites a case of a physician who suffered from it for forty- 
three years. In the emotional variety recurrence of the attacks may be prevented 
by avoiding the cause. 

Treatment. — For an (Utack a full dose of digitalis in brandy and water is recom- 
mended by some ; others recommend that the patient should forcibly close the 
glottis and make a strong expiratory effort. Some patients obtain relief by strong 
coffee or by iced water. Ammoniated tincture of valerian is very efficacious. Tincture 
of sumbul, spirit of ether and of chloroform, sal volatile, and bromide of ammonium, 
are also useful. A seizure of this kind may frequently be cut short or averted if the 
patient can be induced to take some form of muscular exercise. Electrical stimulation 
of or pressure upon the vagus in the neck, may arrest an attack. 

In the intervals, regular occupation, the avoidance of the various causes which 
are known to produce an attack, and attention to the general health, are advisable. 
Sodium salicylate and bromides relieved a case of Sir Clifford AUbutt's, with gouty 
family history. Probably bromide in some form is the most useful medicine. 

^ The following may be quoted by way of illustration. In May, 1887, 1 was hastily 
summoned to one of the nurses in the Infirmary, who had, two hours before, witnessed 
for the first time in her life the death of a patient. She was a healthy youns woman 
of twenty- five, in whom there had been previously no manifestations of hysteria. 
The solemnity of the scene in which she had just played her part was well calculated 
to have a very powerful emotional effect upon a novice, and she thereupon burst 
into a flood of tears. From this she recovered sufficiently to play the organ for 
prayers, but in the middle of the service she was seized with violent palpitation of the 
heart, accompanied by a pain over the apex, a sensation of " pins and needles " down 
the arms and legs, and a sense of impending suffocation. I found her in a state of 
collapse and general tremor, and unable to remember what had happened. The 
pulse was beating 120 per minute, respiration sighing, and the surface of the body 
and limbs pale, cold, and covered with a profuse cold perspiration, having previously 
been, I was told, suffused with marked general redness. There were no physical signs 
of cardiac or other visceral disease. I administered 30 trains of bromide of poti^h, 
16 erains of chloral, and 3 m Hq. atrychninae. She gradually rallied, and presently 
sank to sleep, and the next morning she was herself again. 

^ The clinical phenomena are best explained by the hypothesis that there is a 
sudden lowering of the general blood-pressure, due to an equally sudden and wide- 
spread paralysis of the vaso- motor nerves of the peripheral arteries. 



S41] ANGINA PECTORIS 61 

IV. The piUienty probaUy a maley at or 'past middle Ufe, is suddenly seized 
with a severe " constricting " pain in the chest, accompanied by a sense 
of suffocation — the disease is Angina Pectoris. 

§ 41. Angina Pectorii is a paroxysmal affection in which the attacks consist of 
severe cramp-like pain in the region of the heart, attended by a sense of suffoca- 
tion and impending death. The classical and severe tjrpe of this affection is, 
happily, very rare, but milder attacks, known as ** pseudo-angina '* are not un- 
common. 

Symptoms, — (1) An attack comes on quite suddenly, often after some exertion (at 
any rate, on the first occasion), and consists of acute pain in the h<rart, which radiates 
down the arms, especially the left arm. The site of the pain, Mackenzie points out, 
is over the distribution of the four upper dorsal nerves, and across the chest ; the skin 
may be hyperalgesic over this area. The face is expressive of the torture which the 
patient suffers, and at first is of a deadly pallor.^ The limbs also are pale, benumbed 
and often covered by a clammy perspiration. The patient is restless in his endeavours 
to assume a position of comfort. The sense of suffocation, of bodily discomfort, con- 
striction of the chest, and of impending dissolution is extreme. The attack lasts 
from a few minutes to one or two hours, or more, and is liable to be aggravated if the 
patient ventures to move from the position of ease which he may have assumed. 
In a certain proportion of the cases death closes the scene. (2) The heart's action, 
when examined, is sometimes found to be unaltered, though palpitation may be com- 
plained of. In those cases which I have observed during the attack, the pulse was 
notably slow and feeble ; and this is generally a marked feature in cases about to be 
fatal. It may be irregular, and in some cases it is increased in rapidity. There may 
be no murmur or physical signs of any kind referable to the heart, but more usually 
some form of aortic valvular mischief is present (see Etiology, p. 62). (3) The mind 
remains clear throughout, so that the patient appreciates fully the horror of his 
position. Many cases are accompanied or succeeded by a profuse flow of urine ; 
others by profuse perspiration. Among the less frequent symptoms are tonic muscular 
spasms, convulsions, and vomiting. The limbs and other parts which were the seat 
of pain may afterwards feel " numbed." (4) In by far the larger number of cases 
the patients are of the male sex, and advanced in life. Out of 88 cases collected by 
Sir John Forbes, 80 were men, and 72 of these were over fifty years of age. The 
disease also appears to affect by preference persons among the wealthier classes of 
society, and, for some inexplicable reason, as Fagge and Pye-Smith point out, persons 
who have been possessed of unusual mental capacity. 

Varieties, — 1. When discoverable cardiac lesions are present, the disease is known 
as Symptomatic Angina Pectoris, 

2. Idiopathic Angina Pectoris is that form in which no such organic cause can be 
detected. 

3. Pseudo-Angina Pectoris is a term loosely employed to designate any attack of 
cardiac pain and palpitation — e,g,, the anginoid attacks accompanying flatulent dis- 
tension of the stomach. Walshe and others describe under this term a minor form of 
attack of frequent occurrence, consisting of more or less severe pain, referred to the 
region of the heart, with palpitation, ** coming on either without cause or after 
exertion, or through overeating, or indigestion, or flatulent distension of the stomach, 
or a variety of other fimctional disturbances."^ 

4. Hystarical Angina Pectoris is a term sometimes empbyed erroneously for the 
condition described under Neuro-palpitation or Paroxysmal Tachycardia (§ 40). 

5. Angina Vaso-motoria is a term applied by Nothnagel to oases somewhat resembling 
true angina pectoris, excepting that the symptoms of vaso-motor disturbance — ^pallor 

^ This pallor of the surface is generally succeeded by a reddish, or sometimes 
cyanotic, tint of the same parts, as I have several times observed in patients at the 
Infirmary during the attacks. [Trousseau (Clin. Lect. New Syd. Soc, vol. iii.) and 
Anstie (Trans. (3in. Soc., vol. iiL) have also noted this stage.] The succeeding stage 
of cyanosis is due to the paraljrtio dilatation which sometimes follows the spasm of 
fcho ftfteriolofi. 

2 Walshe, " Diseases of the Heart," fourth edition, p. 209. 



62 DISEASES OF TUE HEART AND PERICARDIUM [ § 41 

followed by cyanosis, coldness, and numbness of the extremities — predominate over 
the symptoms referable to the chest. ^ 

Diagnosis. — (1) It is important to distinguish the different forms of '' anginoid 
attack " grouped under ** Pseudo-Angina Pectoris " from true angina. Among the 
features which sometimes enable us to distinguish pseudo-angina from the graver 
form of disease are the following : (L) They come on at any time of life, whereas true 
angina is confined to persons of the male sex over forty- five years of age ; (ii.) they may 
occur in either sex, the hysterical form being specially liable to afifect young women ; 
(iii.) thoy may come on spontaneously, without previous exertion (though this is not 
constant) ; (iv.) they often appear after meals, and are nearly always associated with 
some gastric derangement, such as dilated stomach, flatulence ; (v.) the pulse of pseudo- 
angina is usually rapid and regular, never slow ; and the sounds and boundaries of 
the heart are normal. Nevertheless, pseudo-angina, like true angina, may or may not 
be associated with cardiac lesions. (2) Attacks of Paroxysmal Tachycardia are not 
difficult to differentiate from true angina, on account of the great rapidity and the 
regularity of the pulse, and the normal arterial tension. (3) Biliary Colic has occasion- 
ally to be diagnosed from angina, but here the patient advanced in years is usually of 
the female sex, and the condition is speedily followed by jaundice. (4) The diagnosis 
from the other causes of prsecordial pain has already been given (§ 23). 

Etiology. — ^The immediate cause of an attack is usually some undue exertion. 
After death it is said that no structural disease of the heart and arteries may be 
found, although far more frequently the heart walls are found to be degenerated, flabby, 
or fatty, with or without other changes in the cardio- vascular system. 

The clinical and anatomical antecedents of angina are the following: (1) Fatty, 
or fibroid, or granular degeneration of the heart muscle is said to be the most frequent. 
(2) Aortic valvular disease, especially stenosis ; mitral disease is rare. (3) Advanced 
atheroma or calcification of the aorta. (4) Aneurysm or dilatation of the aorta, 
especially of the root within the pericardial sac. (5) Atheroma of the coronary 
arteries, calcification, or some other disease of these structures ; and this may in some 
cases lead to embolism or thrombosis, and thus to a more or less localised degeneration 
of the cardiac muscle (Kemig). (6) Arterial sclerosis (using that term in its widest 
bense to indicate any thickening and rigidity of the arterial walls). (7) Gumma of 
the heart wall, in wMch circumstances the patient may be young. ^ 

Angina Pectoris has been regarded as the result of disease of the coronary arteries, 
but it is now generally believed to bo due to a sudden demand for increased effort on 
the part of a damaged heart. In, at any rate, a certain proportion of cases this sudden 
demand consists of an abrupt increase in the peripheral resistance by contraction of the 
peripheral arterioles. It appears that for the production of the attacks of angina the 
combination of these two factors is necessary. Neither of these can alone produce a 
paroxysm ; for, as Bioadbent (*' Heart Disease ") points out, high arterial tension is 
extremely common, alone ; so also is a degenerated heart wall — yet angina is raro. 
When, however, the two are present in combination, a third or determining cause 
{e.g., some unusual exertion, or a further increase in the blood-pressure), supervening 
suddenly, may produce an attack of angina. 

Prognosis. — True angina is an extremely serious condition. The patient may die 
in a paroxysm. The attacks are sure to return, though this may not happen for some 
years. When there is no marked arte rio- sclerosis and there is response to treatment. 



^ Dr. James Mackenzie considers this is a condition of true angina occurring in sub- 
jects of low blood-pressure who are liable to feel the cold. 

^ Dr. Sidney Phillips {Lancet, 1897, vol. i., p. 223) has collected a valuable series of 
cases, and from these it would appear that, if small and situated elsewhere than in 
the loft ventricle, a gumma of the heart may give rise to no svmptoms, until by its 
growth it produces sudden death. It is not, therefore, possible to diagnose cardiac 
syphilis with certainty. Its existence, however, may be suspected in presence of 
angina pectoris and a rapid, irregular pulse, especially if these occur in a person under 
middle age, and if no other cause for these symptoms can be made out. If these be 
present, even in a slight degree, in syphilitic persons, they should be regarded with 
grave apprehension ; and the disappearance of these symptoms under antisyphilitio 
treatment renders the diagnubis highly probable. 



§ 48 ] ANOINA PECTOEIS—CHBONIC DISEASES 63 

the outlook is good. In women who have had long strain, as in nursing sick relatives, 
both mental and physical exertion must be prohibited, and in such oases complete 
recovery is usual. The existence of a cardio-valvular lesion does not materially 
modify the prognosis ; the condition of the cardiac wall is our best guide to the prob- 
able oouise of a case (§ 50). 

Treaimenl. — (a) For the Attacks. — ^Amyl nitrite, 3 to 5 minims, inhaled, generally 
gives prompt relief, a method of treatment for which we are indebted to Sir Lauder 
Bnmton. Sufferers should carry about with them glass capsules containing this 
quantity, which can be broken into the handkerchief. ^ The remedy hastens the advent 
of the second stage of arterial dilatation, and the attack passes off. For a more lasting 
effect, nitroglycerine may be given internally, -j Jg drop every one to four hours, in 
tabloids, pushed to tolerance to A drop. All the nitrites have a similar action in 
dilating the peripheral arteries ; and lately advantc^ges have been claimed for erythrol- 
totra-nitrate, in that its effects are more permanent, 1 grain administered in 1 drachm 
of absolute alcohol, suitably diluted, being said to have effects lasting four to five 
hours. It is reported to have relieved cases in which other remedies have failed. A 
hypodermic injection of a full dose of morphia, if the last-named remedies are not at 
huid, generally gives some relief ; and in very severe cases chloroform, inhaled to 
complete ansBsthesia, has been recommended. If this be combined with a dose of 
morphia, ite effects become more prolonged. Hot drinks and large doses of oxygen are 
useful. In some cases of ** Angina Vaso-motoria," warm baths givo great relief. I 
have not tried this treatment in cases of true angina, but, judging from the good 
offiects I have observed in other conditions of vascular spasm, this method of treatment 
would be very efficacious in cases where movement is not harmful to the patient. 
Mustard plasters and warm fomentations to the epigastrium may be tried, either 
during or between the attacks. In two cases of somewhat severe pseudo-angina I 
found that the following draught, carried by the sufferer in his pocket, and taken at 
the outeet of an attack, was attended by prompt relief : Tinct. lobeliae seth., tnxx. ; 
spiritus otheris, inxx. ; liquoris morphinse, inxx. ; aquae chloroformi, ^i* 

(6) Between the Attacks, — It follows from the above remarks on the etiology that the 
indications for treatment lie in two directions — to relieve excessive tension or any 
tendency to vascular sjM^m, and, if possible, to restore the damaged heart. If the 
main element of the case is cardiac onfeeblement, this should receive our special 
attention, on the lines mentioned elsewhere (Treatment of Cardiac Valvular Disease). 
If, on the other hand, the peripheral resistance is excessive, our treatment should be 
directed to reduce it. The pulse should be examined many times, and under different 
conditions, during the day, and if the tension is very high, much may be done, even 
though the arteries be diseased (§ 61, High Tension). Erythrol-tetra-nitrate and nitro- 
glycerine are hero again valuable remedies, not only to relieve, but to prevent the 
occurrence of the attacks, and these may be combined with various cardiac tonics, 
such as iron, nux vomica, and especially arsenic. Digitalis and stimulants may be 
administered on the same principles as in cardiac valvular disease. To insure rest at 
night chloral, gr. v., may be given. 

Much may be done by regulating the mode of life, and avoiding those things which are 
known by experience to induce the seizures. Repose of mind and body must be strictly 
enforced. Other determining causes met with are exposure to cold, indigestion, dilatation 
of the stomach by too heavy meals, and a sudden alteration of posture by the patient. 
Such conditions must be avoided, as also any unnecessary or sudden exertion or emotion. 

CHRONIC AFFECTIONS OF THE HEART AND PERICARDIUM. 

§ 42. CAassifloatiim. — Chronic Disorders of the heart and pericardium 
may follow an acute attack of the conditions described in the previous 
sections, as, for instance, when chronic valvular disease dates from an 
acute endocarditis which has complicated rheumatic fever or scarlatina 
in early life. But a considerable proportion of the disorders which afiect 

* This remedy seems to lose it« effect when preserved in the ordinary way in a bottle. 



64 DISEASES OF THE HEART AND PERICARDIUM [ { 48 

the heart are chronic from the beginning ; they start insidiously, and are 
unaccompanied by any marked constitutional symptoms. 

For clinical purposes, the chronic disorders of the heart and pericardium 
may be divided into those attended by enlargement of the area of dulness 
and those not necessarily so attended. 

(a) Chronic Diseases attended by enlargement of the area of prsecordial 

dulness. 

I. Cardiac hypertrophy. 
II. Cardiac dilatation. 
III. Hydropericardium. 

IV. Congenital heart disease (laie). Mem. Aneuiysm, and other 
Mediastinal Tumours (see footnote to table on p. 50). 

(b) Chronic Diseases not necessarily attended by enlargement of 

the area of preecordial dulness, the diagnosis of which 
may depend mainly on auscultation. 

I. Valvular disease. 
II. Fatty or fibroid heart. 

It is important to bear in mind that valvular disease, though not per se 
giving rise to an enlarged area of prsecordial dulness, is so often associated 
with hypertrophy or dilatation that it is usually attended by enlargement 
of the prflBCordial dulness. 

Method of Procedure. — It will be remembered that the routine examina- 
tion of the heart consisted of (1) inspection ; (2) palpation ; (3) percussion 
of the preecordial dulness ; and (4) auscultation. The student should bear 
in mind the vekiioxxa faUacies which may give a false impression of cardiac 
enlargement, and also those conditions, such as emphysema, which obscure 
an enlarged heart (§ 33). If the area of dulness is not increased, turn 
to §47. 

Group A. — The patient complains of some of the subjective symptoms 
pointing to chronic cardiac disorder^ and, on examination of the heart, 
the area of dulness is found to be increased^ chiefly in the transverae 
direction — the disease is probably Hypertrophy, Matation, or Hydro- 
pericardium. 

I. The APEX beats below Us normal ^position ; the impulse is forcible 
and heaving ; on auscultation, the first soutid is dull and prolonged. There 
is Hypertrophy op the Heart. 

§ 43. Hypertrophy of the Heart, and the dilatation which not infre- 
quently accompanies or follows it are certainly the commonest conditions 
which produce an increased area of prsecordial dulness. 

Cardiac Hypertrophy is an increase of the muscular substance of the heart, 
and its weight, which is normally about 8^ ounces in women and 9 J ounces 
in men, may be increased to 10 or 12 ounces, and on rare occasions to 15 or 
20 oimces. Its signs are as follows : (1) The increase in the prflecordial 



§ 48 1 SIGNS OF HYPERTROPHY OF THE HEART 65 

dulness is in a transverse direction — towards the left if the left ventricle 
be hypertrophied, towards the right if the right ventricle ; (2) the apex 
beats below its normal position ; (3) the impulse is unduly forcible, heaving, 
Of thrusting ; (4) on auscultation, the first sound is muffled, less audible, 
and prolonged. The pulse is firm, strong, and bounding. 

Sym^ptoms may be altogether wanting if the hypertrophy accurately 
compensates for the obstruction in the circulation which has caused the 
hypertrophy. The patient may, indeed, be unaware of any cardiac dis- 
order. But generally, on inquiry, he will complain oi a " thumping " in 
his chest and '* throbbing " in his head, occasionally of breathlessness and 
precordial distress. 

Etiology, — Hypertrophy, and the dilatation usually accompanying it, is 
the result of some obstruction in the circulation, either in the lungs (such 
as bronchitis and emphysema) or in the general circulation (such as cardiac 
valvular disease, or arterial thickening). It is an illustration of the 
physiological law that increased use leads to increased growth. The part 
of the heart which chiefly undergoes hypertrophy will depend on the 
position of the obstruction ; and the signs met with in addition to those 
above mentioned will vary accordingly. Thus, there will be three sets of 
symptoms : (a) Signs of hypertrophy of the heart ; (6) signs of enlarge- 
ment of the cavity specially involved ; and (c) signs and symptoms of the 
cause. The following causes will be more readily understood by consulting 
Fig. 17 (p. 73), and it must be remembered that the enlargement is never 
in actual practice strictly limited to one chamber of the heart. 

(a) Hypertrophy op the Left Ventricle is indicated by enlargement 
of the area of dulness, chiefly towards the left ; the apex beats below and 
to the left of its normal position ; the pulse is strong unless modified by 
the presence of a valvular lesion, and the carotids may be seen to pulsate. 
This condition may arise under ten different causes : 

(i.) MUral regurgitation, in which case there would be a systolic apical murmur, and 
the other features given in § 47. 

(iL) Aortic stenosis or regurgitation, which may be recognised by a basal murmur 
of systolic or diastolic rhythm, and other characters given in § 47. The hypertrophy 
resulting from regurgitation may be greater than that due to any other cause {cor 
bovinum of the ancients). The heart may weigh in these cases 20 to 30 ounces, or 
more. In roguigitant lesions a certain amount of dilatation always accompanies 
hypertrophy, and the condition is then known as ** eccentric " hypertrophy. In 
these cases the dilatation is compensatory, and produces no untoward symptoms. 
True, or, as it is called, " concentric," hypertrophy, unaccompanied by any dilatation, 
is only met with in aortic stenosis and Bright's disease. 

(iii.) Aneurysm of the aortic arch, if unattended by valvular disease or renal mischief, 
does not per se cause cardiac hypertrophy ; but it is nearly always so attended, and 
thus becomes a fairly frequent cause of hypertrophy of the left ventricle. If the 
aneurysm involves the first half of the areh. it produces marked physical signs ; if the 
second or third part, pressure symptoms arise without signs (§ 53). 

(iv.) Prolonged high Hood-pressure — and thus its numerous causes (§ 61) — 
may lead to hypertrophy of the left ventricle. It is probably in this way that 
chronic Bright's disease is so frequently accompanied by hypertrophy of the left 
ventricle. 

(v.) Widespread thickening of the peripheral arterioles is invariably followed sooner 
or later by a certain degree of hypertrophy of the left ventricle (arterial sclerosis, § 67). 

5 



66 DISEASES OF THE HEART AND PERICARDIUM [§48 

(vi.) Disturbed innervation, such as attends the " irri table heart," Graves' disease, and 
nouTo-palpitation, in time results in moderate hypertrophy, chiefly of the left ventricle. 

(vii.) Pericardial adhesions, unless they are few or filamentous, or unless there is 
universal internal adhesion, so that the heart cannot expand, is a doubtful cause. 

(viii.) Excessive, muscvlar exercise, whether athletic or laborious, may produce 
liypertrophy, and in support of this statement it may be mentioned that the normal 
incr&ase with age is more noticeable in men than in women. 

(ix.) Cardiac fibrosis (sclerotic myocarditis) is a i-are condition, which may be 
associated with a certain amount of hypertrophy. 

(x.) Increased density of the Uood is a cause of hypertrophy which is not mentioned 
among the lists usually given ui textbooks, but which, nevertheless, must be of con- 
siderable potency. It is estimated that 99 per cent, of the work done by the heart is 
employed in overcoming the resistance due to capillarity in the arteries and capillaries, 
and it follows, almost of necessity, that if the density of their fluid contents be increased , 
the resistance will be increased proportionately. 

Obscure Causes, — If in a given case of cardiac hypertrophy careful 
examination reveals no valvular mischief, and no obvious cause can be 
made out, the physician should always suspect obscure aortic aneurysm, 
OBSCURE RENAL DISEASE, or widespread arterial thickening. 

(6) Hypertrophy of the Right Ventricle is indicated by enlarge- 
ment of the area of dulness to the right ; throbbing and pulsation in the 
lower left intercostal spaces and epigastrium (and if accompanied by 
dilatation, pulsation also in the veins of the neck) ; a violent but more 
diffuse cardiac impulse ; and, on auscultation, accentuation of the second 
sound over the pulmonary valves. The degree of hypertrophy present may 
he measured by the degree of the second and fourth of these symptoms : in tliia 
way we measure the efficiency of compensation (§ 50). 

It may be due to three important causes : 

(i.) Pulmonary diseases attended by obstruction in the pulmonary circulation, of 
which bronchitis and emphysema are certainly the most frequent. This combination, 
a very common one, is identified by a history or evidence of lung mischief (§ 93). 

(ii.) Mitral stenosis is the next most common cause, and should be borne in mind 
even in the absence of a presystolic murmur (§ 47). 

(iii.) Mitral regurgitation is followed by hypertrophy of the right ventricle, due to 
the congestion of the pulmonary circulation. 

(c) Hypertrophy of the Left Auricle is always attended by dilata- 
tion. It is a difficult condition to detect, because the palpable and visible 
pulsation in the third left interspace, when present, though due to this 
cause, may admit of other explanations. 

It may arise in mitral regurgitation, but its chief cause is mitral stenosis. In the 
latter condition, palpation generally reveals a thrill over the apex, and careful auscul- 
tation may detect the presystolic or mid-diastolic murmur (§ 47). 

Hypertrophy of the Right Auricle is not recognisable clinically. 

(d) Extreme Hypertrophy op Both Auricles and Ventricles arises 
in congenital heart disease, but may be confined to the right side, since the 
valvular lesions are mostly on that side. 

Prognosis and Treatment. — Cardiac Hypertrophy is in itself essentially 
a conservative process for some condition which causes obsti-uction in the 
ciivulation. It is Nature's method of compensating for the obstruction, 
and it is well to promote it up to a certain point. 



§44] CAUSES OF HYPERTROPHY OF THE HEART 67 

1. I/the cause he removable, the prognosis is favourable. Our treatment 
in such cases should therefore be directed to the removal of the cause — 
e.g,, high blood-pressure, which can be reduced. 

2. If the cause be fwt removaUey the prognosis of the case depends on 
our being able first to maintain the compensatory hypertrophy, and, 
secondly, to relieve the heart of part of its work, so that the hypertrophy 
does not go beyond what is necessary. To accomplish the first, we should 
endeavour to promote the general nutrition by tonics and hygienic 
measures, and by regulating the bowels with mild saline laxatives, and 
similar remedies. In order to relieve the heart of part of its work, and to 
aid the systemic circulation, baths, massage, passive and active move- 
ments, are of the greatest use (see § 51). 

3. The existence of cardiac hypertrophy adds an element of risk to a 
person's life in three ways. In the first place, hypertrophy infallibly 
indicates that there is obstruction somewhere in the circulation, and 
this, whatever it be, is in itself an injury to health, and may shorten life. 
Secondly, a far more important consideration is the increased liability to 
cerebral hsBmorrhage, and vascular rupture elsewhere. Thirdly, high 
arterial tension is an almost invariable accompaniment of cardiac hyper- 
trophy, and this causes a continual strain upon the peripheral vessels, 
which results first in arterial hyperrayotrophy and later in arterial sclerosis, 
the serious consequences of which are indicated elsewhere (§ G7). 

II. The area of dulness is increased ; the posiUon of the apex-beat is 
INDEFINITE ; the impulse is diffuse and toavy ; on auscultation^ the first sound 
is short and sharp. The disease is Cardiac Dilatation. 

§ 4/L Cardiac Dilatation (one form of " Cardiac failure ") is an indica- 
tion that the heart is " failing " to keep pace with the extra demand 
made upon it, that the reserve power of the muscle wall is becoming spent. 
The heart as a whole possesses a certain amount of reserve power, but 
certain foci of muscle fibres may show signs of exhaustion before others 
(§§ 50 and 58). In ordinary circumstances the heart first hypertrophies, 
then dilates. Hypertrophy and dilatation are usually associated, but 
if the nutrition of the body or of the heart is faulty, the heart begins to 
dilate from the outset, without any preliminary hypertrophy. 

The Physical Signs of cardiac dilatation resemble those of hypertrophy 
in several ways, and, like it, (1) the area of dulness is increased chiefly in 
a transverse direction, to the right or to the left, according to the side of 
the heart which is dilated. But there are three important features 
specially belonging to dilatation : (2) The cardiac impulse is wavy and 
diffuse, and is displaced outwards rather than downwards ; it may be so 
feeble as to be hardly perceptible. (3) On auscultation, the first sound 
at the apex is clear and sharp, resembling the normal second sound in 
character. Murmurs may be present from coexisting valvular disease, 
but a systolic murmur — the " murmur of dilatation " — may sometimes 
be heard apart from actual valvular disease, because the auriculo-ven- 



68 



DISEASES OF THE HEABT AND TEEICARDIUM 



[§44 



tricular orifices, by reason of the dilatation, allow a reflux of the blood. 
(4) The pulse is feeble, rapid, irregular, and sometimes intermittent (see 
also Table III.). 

Table III. — Diagnosis of Typical Cabdiac Hypertrophy from 

Typical Dilatation. 



Apex-Beat and 

Impulse : Displaced 

in Both. 



J^ Forcible, heaving, 
Pi tbiUBting ; below 
S and to 1. of normal 
"C (1. ventricle) ; in 
^ epigastrium (r. ven- 
S tricle). 

n 



Percussion. 



( 



L. V. : Area 
increased trans- 
versely to the 1. 
IR. V. : Area 
increased trans- 
versely to the r. 



Auscultation. 



General Symptoms. 



) 



Sounds muffled, 
prolonged, and 
forcible. 



(May be absent; or 
symptoms of high blood - 
pressure. 



o 

I 



Feeble, irregular, 
undulatory, difFuse. 
If r. ventricle — pul- 
sation in the epi- 
gastrium and veins 
of the neck. 



( 



L.V. : Area 
increased trans- 
versely to the 1. 

B.V. : Area 
increased trans- 
versely to the r. 



I 



Systolic'^ 
murmur at 
apex, at one 
stage. 

Systolic 
murmur in 
tricuspid 
area, at one 
stage. 



o ' 



o » 

» St 
* ST 

8* 
P 

a 



r Dynpnoea, cough, cyan- 
osis, and other signs of 
lung congestion. 

Dropsy, scanty higli- 
coloured albuminous 
urine, enlarged liver, as- 
cites, and other signs of 
congestion of organs. 



Towards the end, when cardiac failure is extreme, foetal rhythm, gallop rh3rthiii, 
and " delirium cordis " may occur. In foetal rhythm the long and short pauses are 
almost identical, so that the first and second sounds can scarcely be distinguished ; 
in gallop rhythm there is rapidity of action, together with a distinctly reduplicated 
second sound. In delirium cordis the heart is so rapid and so irregular that it is 
practically impossible to make out the relations of sounds and murmurs. 

It is, however, by the presence of certain symptoms that the existence 
of cardiac dilatation (or failure of compensation) generally becomes 
manifest. In hypertrophy, as we have seen, there may be no symptoms 
at all ; but with dilatation the patient complains of : (1) Heart symptoms, 
such as breathlessness on little or no exertion, palpitation, and prsBcordial 
distress. (2) There may also arise a number of symptoms referable to other 
parts, in consequence of the delay in the circulation, such as anasarca, 
ascites, and symptoms of congestion of the lungs, liver, and kidneys. 
These will be described under Cardiac Valvular Disease, where the means of 
detecting which cavity is chiefly involved are also given (see also Table III.). 

The Causes of Cardiac Dilaialion are of extreme importance as bearing 
on the prognosis and treatment of cardiac valvular disease and other 
circulatory disorders. The clinical conditions which produce dilatation 
are practically identical with those which produce cardiac hypertrophy 
(§ 43), when they are persistent and are associated with some condition 
which impairs the nutrition of the heart (see (6) below). Undoubtedly the 
two commonest causes of cardiac hypertrophy and dilatation are Cardiac 
Valvular Disease and Chronic Bronchitis with Emphysema, and 
these are the possibilities which should first suggest themselves to the 
mind in a case where dilatation is evident. The former will be fullv 
discussed in the following section. 



§ 45 ] CARDIAC DILATATION^HYDROPERICABDIUM 69 

Chronic Bronchitis^ with its usual accompaniment of Emphysema, pro- 
duces in time a dilated Right Ventricle. This latter is recognised by two 
very characteristic local signs, in addition to the breathlessness, etc., 
above mentioned — viz. : (i.) epigastric pulsation ; and (ii.) pulsation 
in the jugular veins. The clinical picture presented by this frequent 
pathological combination is very characteristic — the florid face and 
plethoric build ; the easily excited breathlessness and constantly recurring 
cough, enable us to recognise the condition almost at a glance. The sub- 
ject will be more fully discussed under Cardiac Valvular Disease (§ 47). 

The essential or pathological causes of Dilatation may be arranged under four 
headings : 

(a) Any condition which persistently prevents the complete emptying of the cavities 
of the heart (see Causes of Hypertrophy) will produce compensatory hypertrophy with 
dilatation, which will be exactly proportional to the increased resistance in the circula* 
tion, provided none of the circumstances mentioned under (6), (c), or {d) beloW are 
also present. If any of these circumstances aro in operation, dilatation or failure 
may be initiated without previous or accompanying hypertrophy. Moreover, the 
supervention of any of these in the course of a cardiac case may at once disturb a well- 
balanced compensatory hypertrophy, and serious symptoms may immediately appear. 

(6) Any failure of general ntUrition, or vitality, may entail a weakened cardiac wall, 
which will perhaps yield even under normal circulatory conditions. Such, for instance , 
may be caused by exposure, insufficient food, alcoholic excesses, old age, various 
fevers (especially rheumatic fever, typhus, typhoid, and malaria), various blood 
conditions (such as pernicious anaemia, scurvy, chlorosis, leukemia, etc.), and cachectic 
conditions (such as syphilis, tubercle, and cancer). See Causes of Pyrexia and of 
Anaomia (Chapters XV. and XVI.). 

(c) Local impairment of the mttrition of the heart wM may result in dilatation without 
hypertrophy, even with normal circulatory resistance. Myocarditis, for instance, and 
the conditions which accompany peri- and endo-caiditis (which lejkd sometimes to 
acute dilatation) ; or the more gradual degenerations which ensue on sclerosis and other 
diseases of the coronary arteries ; or fibroid and other degenerations of the cardiac 
wall (see Fatty Heart). Prolonged fatigue may also act locally by overtaxing the 
heart muscle. Any of those may upset the balance of a well-adjusted hypertrophy. 

{d) Any sudden strain on an apparently normal heart may produce acute dilatation. 
Thus, severe and sudden grief, fright, or anxiety may damage the heart through its 
nervous apparatus, and severe muscular exertion in athletes or others who have not 
had any previous training may cause the heart to give way and dilate. Instances of 
the latter are met with in hill-climbers who are *' out of form," and others who take 
sudden and unaccustomed exercise. Breathlessness may date from incidents of this 
kind, from which the patient may never, or only with difficulty, recover. 

The Prognosis and Treatment of Cardiac Dilatation are fully dealt with under Cardiac 
Valvular Disease (§ 47). 

III. The area of dulness is increased upwards, atbd its shape is pyra- 
midal, with the point upioards ; the apex-beat is raised, and the impulse is 
weak and undulatory ; on auscuUation, the sounds are feeble. The disease 
is Hydropericardium. 

§ 45. HydroperioArdinm is a chronic effusion of fluid into the pericardium. (1) The 
shape of the dulness is very characteristic, being pyramidal, with the narrow end 
upwards. (2) The apex of the heart is raised, and to the right of its normal position, 
because the roof of the pericardium is raised by the fluid, and takes the heart with it. 
(3) For the same reason, the left margin of praecordial dulness extends beyond the apex- 
beat. (4) On auscultation, the heart sounds are distant and muffled. There may be 
irregularity and rapidity of the pulse, and difficulty of breathing from the impeded 
action of the heart and lungs. 



7) DISEASES OF THE HEART AND PERICARDIUM [ § 46 

Etiology. — Chronic effusion into the pericardium may originate in one of three ways. 

(1 ) Ab the result of Acute Pericarditis (§ 38), of which a history is generally obtainable, 
but by no means always (see Latent Pericarditis, § 386). Most authors draw a dis- 
tinction between chronic pericardial effusion of inflammatory origin and simple 
dropsy of the pericardium (hydropericardium proper). But the physical signs are 
practically indistinguishable ; for the diagnosis of the former we depend mainly on the 
history of it having commenced as an acute affection, and on the absence of anasarca. 

(2) True hydropericardium seldom occurs excepting as part of a general dropsy due 
to renal or caidiao disease, and therefore the urine should be carefully examined. 
In these circumstances the effusion gives relatively litUe inconvenience to the patient, 
because it takes place so gradually that the parts have time to adapt themselves to 
the stretching they undergo. (3) If hydropericardium be not preceded by pericarditis, 
or be not part of a general dropsy, new growth or tubercle, although rare, should 
always be suspected. In these circumstances, if a little fluid be withdrawn by a hypo- 
dermic syringe (p. 54), it may be blood-stained (cancer), or contain bacilli (tubercle). 

The Diagnosis from Cardiac Dilatation should be readily accomplished by the shape 
of the dulness, which is square instead of pyramidal in dilatation ; and by the heart 
sounds, which are clear and sharp in dilatation, muffled in effusion. X-ray examina- 
tion is of assistance. Pleuritic effusion is attended by pulmonary symptoms. 

The Prognosis of hydropericardium depends on it€ causation, being favourable in 
Cause 1, adding only a little to the gravity of the primary malady in 2, and being 
almost necessarily fatal in 3. 

Treatment. — ^The treatment of inflammatory effusion is dealt with in § 38. If part 
of a general dropsy, our efforts must be directed to this. Counter-irritants are some- 
times useful. Paracentesis should not be considered imless the cardiac embarrassment 
is very ui^nt, because of the danger of withdrawing a large amount of fluid suddenly 
from the pericardial sac. 

IV. The prcecordial percussion area is considerably and irregularly 
increased : the impulse is forcible and heaving, 

(a) The area is distorted at^ somewhat square ; on atiscuUationy there 
is a loud murmur, probaUy loudest in the pulmonary area. The disease is 
Congenital Heart Disease (see below). 

(b) The UPPER PART of the area is ifhcreased transversely, and there is 
dulness over the sternum — it is probably an Intrathoracic Tumour. 
If on auscultation, the second sound at the base is reinforced and sharp, or 
replaced by a diastolic murmur, it is probably Aneurysm of the first part of 
the Arch of the Aorta (§ 53). 

§ 46. Congenital Heart Disease is another chronic form of cardiac disorder attended 
by increased praecordial dulness, but it is comparatively rare. There are three 
cardinal signs produced by it : (1) The prsecordial dulness is very considerably in- 
creased, the normal shape is distorted, and it may extend considerably beyond the right 
border of the sternum, because the commonest form of the disease results in immense 
hypertrophy and dilatation of the right ventricle. (2) Palpable and sometimes 
visible pulsation over almost the whole of the cardiac area may often be detected for 
the same reason. (3) A loud, rough systolic murmur can generally be heard, loudest 
in the third or fourth interspace, close to the left of the sternum, and it is often easily 
heard in the back. These signs in a child who has a tendency to cyanosis are almost 
certainly due to cardiac malformation. (4) Dyspnoea is also fairly common, and may 
be either persistent or paroxysmal. The condition, however, may remain latent for 
many years, until exertion or some illness reveals its existence. The diagnosis is 
sometimes a matter of difficulty. Other symptoms arise as the disease progresses — 
thus, general cyanosis, reaching a very extreme degree ; coldness of the extremities ; 
syncope and epileptiform attckcks ; a low temperature of the surface generally (because 
the blood is iwor iu oxygen), although not of the interior of the body (Peacock) ; 
drubpy occatiioually ; haemorrhages fix^m the lungs ; and symptums of congestion uf 



§ 47 ] CONGENITAL HEART DISEASE— CARDIAC MURMURS 71 

the other viscera. Dilatation of the conjunctival vessels is often observed, and 
clubbing of the toe and finger ends. Headache is often present, and convulsions are 
not unknown. Backwardness or precocity, and sometimes more grave mental 
defects, become evident as the child grows older. It is important to remember that 
very loud bruits may mean but slight abnormality, whilst very severe diesase may be 
unaccompanied by even a slight murmur. 

Etiology. — Congenital disease of the heart arises under two conditions : (1) Inflam- 
matory affeciion-8 attacking the foetal heart in utero may lead to stenosis of the orifices, 
almost invariably on the right side of the heart, which is in contradistinction to the 
loft-sided lesions of extra-uterine life. (2) An arrest of the closure, which normally 
takes place shortly after birth, of either the ductus arteriosus, foramen ovale, or the 
ventricular septum. Whatever the cause, the commonest lesion is a narrowing of the 
pulmonary artery or pulmonary valves,* which probably results in the venous blood 
making its way through the foramen ovale or ventricular septum from the right to the 
left side of the heart, the septum also deviating to the left. Stenosis of the aortic 
orifice is much rarer, but in that case the arterial blood finds its way through the same 
orifices from the left to the right side of the heart. In either case three events happen : 

(1) Deficient oxygenation, and probably admixture of venous and arterial blood; 

(2) the right ventricle takes an equal share with the left in the work of the heart, and 
consequently it hyi:ortrophies and dilates ; and (3) the ductus arteriosus remains 
patent, to compensate for the insufiiciont delivery of blood into the aorta or pulmonary 
artery, as the c€kse may be. It is only occasionally possible to suggest the precise 
nature of the lesion during life, but this, although it is a matter of great interest, is 
not always of great moment. 

Prognosis, — ^The condition may remain latent for many years, though f«w marked 
cases survive to adult life. The prognosis is serious in proportion to the degree of 
dyspnoea and cyanosis, pointing to deficient aeration of IJie blood, and in proportion 
to the other symptoms of " cardiac failure " (§ 60). 

The Treatment is the same as that of Cardiac Dilatation, bearing in mind that rest 
IB of primary importance (§51). 

We now turn to those Chronic Heart Diseases in which the area of 
dulness is not necessarily increased, and which depend mainly on Auscul- 
tation for their diagnosis (Table IV., p. 72). 

V. On auscultation^ one or both of the heart sounds is heard to be acconi' 
panied by a murmur, or bruit. Pericardial friction having been excluded, 
the Valves of the heart are diseased — with certain exceptions or faUacies 
{such as hwmic murmurs), which wiU be described, 

§ 47. Chronic Endocarditis — Cardiac Valvular Disease — Cardiac Mur- 
mors. — ^Disease of the valves of the heart is the commonest of all cardiac 
disorders, and it is revealed on auscultation by the presence of a bruit or 
murmur which is added to, or replaces, one or both of the heart sounds. 

Method of Procedure, — In order to arrive at a diagnosis, it will be remem- 
bered that four features must be carefully investigated in any given murmui 
— namely, its rhythm, position, conduction and character (§ 34). 
The last named is relatively least important. In order to be quite sure of 
the rhythm of a bruit, it is often convenient to place the fingers on the 
carotid artery whilst auscultating the chest. 

^ Some observei's maintain that the primary mischief is always the non-closure of 
the ductus arteriosus or foramen ovale or ventricular septum, narrowinff of the aorta 
and pulmonary arteries being secondary. But the view above stated is the more 
probable, because a small leakage through oiio of those orifices is a by no means infre- 
quent occurrence without symptoms during life 



72 



DISEASES OF THE HEART AND PERICARDIUM 



[§47 



A cardiac murmur may arise in three ways. It may arise outside the 
heart — e.g., from roughness of the pericardium ; it may be of h^mio or 
FUNCTIONAL ORIGIN ; or it may arise within the heart from organic disease 
OF THE VALVES (which chiefly concerns us now). 

The characters of pericardial murmurs have already been given (§ 39) ; 
and their diagnosis from endocardial murmurs (Table II., p. 55). 

H^Mic, or functional, Murmurs are frequently heard in ansemia and in 
soma other blood conditions (see Chapter XVI.). They are usually systolic 
in time. They are rarely double, and never diastolic alone. They are 
usually heard loudest in the pulmonary area. A single murmur of pre- 
systolic or diastolic time is a certain indication of organic disease at one 
of the cardiac orifices. 

Organic Murmuis are those which are produced by organic disease of 
the valves (cardio- valvular disease). Valvular disease may be due to 
several lesions (§ 49), but the commonest one in early life is endocarditis 
(acute or chronic), and in older persons chronic degenerative change. 
The effect is a thickening or puckering of the valves and ring, which results 
in one or both of two conditions : (a) Stenosis — i.e., a narrowing (orcvooi, to 
contract) ^of the orifice, which prevents the blood flowing freely through it ; 
or (6) Regurgitation, in which the valves are incompetent and allow a reflux 
of the blood to take place from imperfect meeting and closure of the cusps. 
The remote effect of these two conditions is practically the same — viz., 
a retardation or obstruction to the circulation of blood through that orifice. 

It simplifies matters very much that cardio-valvular disease arising 
after birth is practically confined to the left side of the heart — i.e., to the 
mitral and aortic orifices. Thus it happens that there are four principal 
cardiac lesions — Mitral Regurgitation, Mitral Stenosis, Aortic Re- 
gurgitation, and Aortic Stenosis. 



Table IV. — Differentiation of Cardiac Valvular Diseases. 









Ausculta- 
tion. 

Systolic 

murmur 

conducted 

into axilla. 


Appear- 
ance of 
Patient. 

Florid. ' 


Pulse. 

Irregular, 

rapid, and 

compressible. 


Other Symp 
to the ] 

Dropsy, v 
' enlarged 
' liver and 
ascites, etc., 


ioms special 
Disease. 




' Mitral 
(apical 
murmurs). 


' Regurgi- 
tation. 


with signs of 
• congestion 


« 

■ , 

> 

• 

1 O 




^ Stenosis. 


Presystolic 
murmur. 


Patient 
young. 


Regular, small, 
and moder- 
ately firm. 


Hcemopty. <^ «»^°*- 
sis ; emboli, j 


Aortic 

(basal 

murmurs). ' 

1 


'Regurgi- 
tation. 


Diastolic 

murmur 

conducted 

down 
8ternum. 


SaUow. 


•• Water- 
hammer," 
rapid and 
compressible. 


i Throbbing ^ 
1 of arteries 
of neck, 

1 


with symp- 
toms of 
cerebral 
1 aneemia and 


1 




^ Stenosis.^ 


Systolic 

murmur 

, conducted 

into vessels 

of the neck. 


Heart 
, lesion of 

; the 
aged. 

1 


Slow, regular, 

smsdl and 

hard. 


No special j ^ta 
symptoms, j a'^w^cks. 



^ Real aortic stenosis is very rare, but atheromatous roughening is very common. 



J 471 SYSTOLIC MUBUURS 73 

The Btudent shuulcl otutly Fig. 10, p. 4JS, so as to thoroughly compreheaU thu various 
eventa which oocur dniing one complete contnction and dilatation of the heart (a 
,QB_ cardiac cycle). Uo should also liear iu mind that 

the left Bide of the heart is behind the right, and 
that the left ventricle comes neareat to the surface 
only at the apex, immediately behind or just below 
the fifth rib (Figs. 11 and 12, p. 46). He should 
also remember that a cardiac murmur ia not pro- 
duced in a diseased orifice, but by the eddies in 
the blood-stream beyond. For theae leasous a 
mununr is not always heard budest directly over 
the orifice diaeaaed. The student may also consult 
the accompanying diagram of the circulation. 

Diagnosis of Cardiac Honnnn. — The first 
thing to determine is whether a given 
murmur is related to the first or second 
sound of the heart — i.e., whether its rhythm 
is systolic or diastolic — and this will form a 
convenient basis of classification of cardiac 
murmura. 

A. Systfdic Hnnunn' — i.e., bruits added 
to or replacing the first sound — may be 
produced by the following causes, which are 
mentioned more or leas in order of frequency : 
Hiemic conditions (see above, and AntemJa, 
§ 402), mitral regui^itation, aortic stenosis, 
aortic aneurysm, tricuspid regurgitation, 
pulmonary stenosis, congenital heart disease, 
and cardio- pulmonary conditions. 

1. In Mitral Bworgitatioa the systolic 
murmur is characterised by (i.) being 
loudest at the apex ; (ii.) being conducted to 
the axilla, and also audible behind, at the 
angle of the scapula ; and (iii.) owing to the 
resulting hypertrophy of the left ventricle, 
the apex is displaced downwards and out- 
wards. There is accentuation of the second 
sound in the pulmonary area, due to the 
congestion in the pulmonary circulation. 
The pulse is soft, there is a characteristic 
florid physiognomy, and a tendency to 
<EoS dropsy. 

ng. 17. — Schems oltbe Clrculatloa of the Blood. — The anperiar aod inferior veiis cav»(6) bring 
tha blood back from the organa and tluues into the right anrlcle (1). Theni^e It outei Into 
the right Tsntriela i%), through the pnlmoiury artery 17) ir 
lung) br th« pDlmaDarr veins <B|. It puaee tJuoiigb U: ' 
ftnd li diitribnted br meuu of the sorts (S. &) and thi 
or tha body. Notlog that the blood trom the itom&cli 
baton Joining the genenl circulation. (From Huxley 



74 DISEASES OF THE HEART AND PERICARDIUM [ § 47 

General Symptoms of Mitral Regurgitation arise when there is failing 
compensation ; and two events take place, which, in order of occurrence, 
are (1) dilatation of the left ventricle and pulmonary congestion ; and 
(2) dilatation of the right ventricle, 

1 . The symptoms of dilatation of the left ventricle have been already 
mentioned (p. 67). Pulmonary congestion is revealed by laboured breath- 
ing, cough, expectoration of mucus, sometimes tinged with blood, or actual 
haemoptysis. The physical signs are abundant mucous rales, and some- 
times scattered patches of dulness at one or both bases. Pulmonary 
apoplexy may be suspected by sudden increase of dyspnoea, accompanied 
by continuous hsemoptysis. 

2. Dilatation of the right ventricle, consequent on the congestion of the 
pulmonary circulation, sooner or later produces the following symptoms 
and conditions : 

(i.) A tricuspid bruit is sometimes heard (see below, p. 75). 

(ii.) Pulsation in the epigastrium and in the veins of the neck. 

(iii.) Dropsy, which indicates congestion of the whole venous system. 
Cardiac dropsy starts and predominates in the legs or the hack, whichever 
may happen to have been in the most dependent position. The skin is 
tense, and is very liable to be attacked by erythematous, erysipelatous, 
and inflammatory conditions (cellulitis, ulcer, etc.). Ascites in varying 
amoimt is generally present. It is often an early and prominent sign in 
mitral stenosis. Cyanosis and a general lividity of the surface are conse- 
quences of the same venous stasis. A case of mitral disease, therefore, 
presents a marked contrast to one of aortic disease, where the countenance 
is pale and sallow. 

(iv.) Engorgement of the liver is evidenced by pain and tenderness in 
that region, and jaundice of the skin and conjunctivae. The organ is 
enlarged, and it may extend even to the umbilicus. Sometimes pulsation 
of the liver may be made out by placing one hand on the epigastrium, and 
pressing the other beneath the back in the dorsal region. In cases of 
dropsy with albuminuria, when we are in doubt whether the dropsy is of 
renal or cardiac origin, hepatic enlargement is a valuable diagnostic aid, 
for its presence is very usual in cardiac cases, but it is not one of the 
consequences of renal disease. 

(v.) Indigestion — i,e,, want of appetite, a sense of discomfort in the 
stomach after meals, nausea or actual vomiting, with streaks of blood, 
indicate congestion of that organ. 

(vi.) Albuminuria, with high-coloured scanty urine of high specific 
gravity (and possibly casts in long-standing cases), points to congestion 
of the kidney. 

(vii.) Splenic enlargement and tenderness are the only indications of 
congestion of that organ. 

la. A Murmur of Dilatation, systolic in rhythm, haviug all the above characters, 
and, like it, due to mitral regurgitation, may occur without definite disease of the 
valve, when the left vciUridc becomat dilated, and the muscular ring ai\>uud the valve 



S 47 ] SYSTOLIC MURMURS 76 

faiU to complete the closure of the mitral valve. This oondition is especially apt to 
occur io the aged when dilatation of the left ventricle supervenes on hypertrophy. It 
alao occurs with chronic renal disease, arterio-sclerosis and ansemia. 

II. Aortic Stenocds is another lesion producing a systolic bruit. True 
stenosis of the aortic orifice is not common, but a roughness, or the presence 
of vegetations on the inner surface of the valves, may produce the same 
bruit. The latter is mostly found in old people on account of the degenera- 
tive changes, and a systolic murmur thus produced is of relatively less 
serious import. 

This murmur is characterised by (i.) being loudest at the second right 
interspace ; (ii.) it is conducted up to the vessels in the neck, and is audible 
in some cases also at the apex (Fig. 16) ; (iii.) it is usually harsh, sometimes 
musical, but in many cases it is barely audible ; (iv.) the pulse is small, 
sustained, and slow, sometimes anacrotic (§ 59). A systolic thrill is some- 
times felt over the base of the heart. 

General Symptoms are almost wanting in aortic stenosis — other than 
occasional pain, pallor or sallowness of the face, and faintness or giddiness 
— until perhaps the mitral valve, owing to backward pressure, gives way 
(see Mitral Kegurgitation, p. 73). 

The detection of aortic stenosis is sometimes as difficult as mitral stenosis, and 
the characteristic murmur may be absent. It may then be suspected when the 
patient, generally an elderly man, presents persistent dyspnoea, bradycardia, nervous- 
ness, and occasionally anginoid attacks, which are not otherwise accounted for. In 
true stenosis the second sound is short and not very loud ; whereas in cases of high 
arterial pressure with systolic murmur the second sound is loud. The apez-beat in 
stenosis is displaced downwards. 

ILL In AoBTio Aneurysm a systolic murmur is the most common one heard 
Accentuation of the aortic second sound is the most constant physical sign (§ 53). 

IV. Tbictjspid Beotjboitation takes place when that orifice is diseased or dilated. 
Some maintain that if the valve be healthy, though dilated, no bruit can be heard, 
but it is certain that in cases of confirmed bronchitis a murmur is often present which 
comes and goes under treatment, and which is not found to be attended with any 
marked changes in the tricuspid valve after death. The murmur is characterised by 
(i) being heard best at the tricuspid area — i.e., on the left side of the lower part of the 
sternum ; (iL) it may be heard as far out as the right nipple ; (iii.) the pulse is of low 
tension, often irregiilar ; (iv.) owing to the accompanying hypertrophy or dilatation 
of the right ventricle, the area of dulness extends to the right, and there is epigastric 
pulsation ; and (v.) there is also pulsation of the veins of the neck, due to regurgitation 
into them, which is distinguished from the undulation seen in simple engorgement by 
the fact that the pulsation is not obliterated, but is rendered more distinct when the 
finger is placed on the external jugular vein, emptying the vein by the finger, and 
noting that it fills from below. 

Oeneral Symptoms, as above indicated (p. 74), result from tricuspid regurgitation. 
By far the commonest cause is Chronic Bronchitis, which thus presents a clinical 
picture (p. 69) readily recognised. 

V. PuLMONABY STENOSIS is practically unknown, unless it be part of congenital 
malformation of the heart This murmur is systolic in rhythm, loud and harsh, and 
is heard over a very wide area, but most distinctly in the second left interspace. 

Fallacies in the Diagnosis of Systolic Murmurs. — 1. Ilamie murmurs (§ 402) 
are undoubtedly extremely common, and sometimes vciy difficult to distinguish from 
thowf of cardiac valvular disease. 



7(1 DISEASES OF THE HEART AND FERICARDIUM [ f 47 

2. A ayslolic murmur audible in the aortic arta, and having all the chsroctera of It. 
above, is due not go often to aortio steuoaia a« to (i.) roughening oE the valve id old 
people from atheroma or oaloareoug deposit; (ii.) gimple incompdtnce of the aortic 
valvcB may produce both a systolic and a diastolic murmur ; (iii.) atheroma, witli 
dihiaiion of the aorta, may also produce a syBtolic or a double bruit : then there is a 
ringing second sound in addition. 

3. A ajslolio murmur heard best at the second left interspace is Bomctimea present 
in iiiitrai rfgargilation with a hypertrophiod left auricle. It must not be mistaken for 
pulmonary stenosis. 

4. The " milk-ipol " murmur is due to a localised thickening of the visceial peri- 
cardium, appearing aa a glistening white spot near the centre of the anterior surtac-- 
of the heart. Usually it is unattended hy symptoms, but it may bo of importance 
clinically, forit iaapt to bo mistaken for valvular disease. The " milk-spot" murmur 
(based on twenty-tbrec observations, verified by autopsy, at the Paddingtoa Infirmary) 
is generally » prolonged rough bruit, systolic in time, though occisieiially double ; it 
in ttriiMy localised to a circle of 1 or 1 J inches radius, whoso cent™ is situated in the 



Fig. H —The lyitoUc raurmur ol aortic Fig. IB.— Tlis disitoUc mnimur el »ortlC 

(tenoil* liBpth el ihadiog indi- reRurgltatlon. Depth ol shading 

rates intensity ol murmur, indicates Inlenalty el muriDtu'. 

third left intersliaoe, cIo.ho to the sternum, which is also its position of maximum iu- 
tensity, Anither important feature is that at one lime it m very rough and loud, and 
a day or so later it may have completely disappeared. These features, and the 
absence of the concomitant symptoms of cardiac s'.'.Kular disease, or of chlorosis. 
enable us to differentiate the milk-spot murmur from other conditioua. It was foimil 
more often in hyportrophied hearts than in those of normal size. It has been variously 
attributed to tight -lacing, the soldier's shoulder straps, and other lesa probable causes. 
The condition is more frequently met with in adult or advanced life. A history of 
perioarditia waa obtainable in only one of the twenty -three cases, 

5. A cottgeniUd murmur, usually systolic and localised t« the base, has been known 
— in rare cases — to porsiat throughout life in some persona who have never experienced 
any other manifestation of cardiac disease, although they have lived to a good old age. 

0. A systolic murmur heard shortly after the first sound may bo heard at the apex 
at one stage of mitral stenosis (itiackenzie}. 

7. Cardio-pulmonary or Cardio-respiratory murmurs are also rare, and aro probably 
produced by the expulsion of air from the adjacent lung tissue by tlio raovementa of 
the hoart. They do not indicate any canliao lesion, and the lung may also lie healthy ; 



§47] DIASTOLIC MURMURS 77 

but they are sometimes associated with phthisis when the cavity in near the heart. 
They are heard in various parts of the antero-lateral region of the chest. Thoy have 
a blowing, whiffing, or " sipping " character, are usually systolic in rhythm, and in 
rare cases double, though the systolic element is always loudest. Often they are not 
loudest at the apex, and come rather between the two sounds than with the first 
sound. Sometimes they disappear when the patient alters his position or stands up. 
When he stops breathing, they may be weakened, abolished, or unaltered. 

B. Mnrmnn heard in the diasMic interval may occupy either (a) the 
first half of that interval, replacing, accompanying, or following the 
second heart sound (Dictstolic murmurs) ; or (b) they may occupy the 
second half of the interval, preceding and leading up to the first heart 
sound (Presystolic murmurs) (see Fig. 20). 

Murmurs of the first kind are produced, in order of frequency, by aortic 
regurgitation, aneurysm, and pulmonary regurgitation ; murmurs of the 
second kind are mostly due to mitral stenosis, very rarely to tricuspid 
stenosis. 

I. In Aortic Begorgitatioii the murmur is diastolic (Ventricular Dias- 
tolic), ^ and is (i.) audible in the aortic area (second right space), but it is 
often loudest at the third left intercostal space ; (ii.) it is conducted down 
the sternum, and audible at the apex (Fig. 19). It is, therefore, one of the 
loudest and most widespread of murmurs, (iii.) Owing to the amount of 
dilatation and hypertrophy of the left ventricle, the apex is displaced 
downwards and outwards more than in any other form of valvular disease, 
(iv.) The pulse is the characteristic " water-hammer " (§ 62). The face 
is pale, and the carotids visibly pulsate. Capillary pulsation is generally 
present, and is detected by drawing a line across the forehead, or by 
lightly pressing on the finger-nail or on the lips with a glass slide ; the 
alternate blush and pallor due to the pulsation in the capillaries is thus 
well brought out. So great may this be that a pulse is sometimes com- 
municated to the veins on the dorsum of the hand. 

General Symptoms in aortic regurgitation : (i.) Pain about the chest, 
often of an anginoid character, may be complained of before compensation 
fails, or true angina may be present, (ii.) The anaemia is greater in this 
than in aortic stenosis. Faintness, giddiness, frontal headache, and dis- 
turbed sleep are common, (iii.) Dropsy is rare, as death usually occurs 
before the mitral valve yields sufficiently to produce the necessary back- 
ward pressure. Embolism sometimes occurs, though not so often as in 
mitral stenosis. 

II. In BGtral Stenosis the murmur is presystolic in time. It occurs 
during the contraction of the auricle, and is known, therefore, as the 
auricular systolic or A. S. murmur. It is heard (i.) at the apex, and 
(ii.) over a very limited area, (iii.) The murmur is rough or rumbling, 
and crescendo in character, running up to a loudly accentuated first sound, 
(iv.) A reduplicated second sound is heard best just to the right of the 



^ Diastolic murmurs are sometimes spoken of as V.D. murmurs, being produced 
during the ventricular diastole. Similarly, presystolic murmurs are spoken of as A.S. 
murmurs, being produced during the auricular systole. 



78 DISEASES OF THE HEART AND PERICARDIUM [ § 47 

apex.i (v.) On palpation, a characteristic sigji in this heart lesion is the 
presystolic thriU, It may be/efe even before the murmur can be heard — 
i.6., before the number of vibrations per second are sufficient to produce 
a musical note. In the later stages it disappears altogether, (vi.) The 
apex-beat is not displaced to the left ufdess regurgitation he also 'present ; 
but the prsBCordial area of dulness is increased to the right, owing to the 
hypertrophy and dilatation of the right ventricle, (vii.) The pulse is 
small and of fair tension, until compensation fails. 

In the later stages of mitral stenosis the presystolic murmur disappears, 
and sometimes a mid-diastalic or an early diastolic murmur is heard 
(Fig. 20). This diastolic murmur has a diminuendo character, and is 
only audible near the apex. Sometimes the second sound is absent at 
the apex. 

Later still, there may be no murmur at all, and then the characteristic 
** slapping " (short, sharp) first sound and irregular rhythm of the heart 

form the sole auscultatory signs. This 
^"^ I" e^ i« s«* I** form of cardiac valvular disease is 
diastole| [DtASTOLgl [diastole I commoner m women, and, m my 
— '*"iwi I Ki^ I illliih^ I experience, in children. 

^ ^ ^ General Symptoms. — (i.) Pulmonary 

Fig. 20.— Three murmun may be met with congestion (p. 7^, ante) IS especially 

ill Mitral Stenosis, which may oc- «^,«*^,^« . «^«„««„««4.i„ k «>.>-» ^^*^ro;« :« 
cupy different parU of the diaatoiic in- common ; consequently haemoptysis is 

f*r?''»i^^*?;j; ther^rore be called the more frequent in this than in other 
(a) LATi, (6) MID, and (c) early dia- . i. , t ... v i i- 

sTOLio MURMiTRs. The late diaatoiic forms of valve disease ; (u.) emboli are 

• — i.e.y preBystolic — murmur is the i t ^ /••• \ j 

commonest : the early dJastoiic ig least ^Iso more frequent; (ill.) dropsy IS 
frequent. The redupUcation of the rare until the end, but, on the failure 

second sound has been omitted for the . . i n i 

sake of clearness. of the right ventricle, all the symp- 

toms of right ventricular dilatation 
appear. Liver enlargement is more common, but cyanosis and dropsy 
are less common in mitral stenosis than in regurgitation. 

III. In Aortic Aneurysm a diastolic murmur is sometimes heard, but the murmur 
is usually systolic in time. 

IV. Tricuspid Stenosis is a raro condition, but it is occasionally met with in 
young women, and is recognised by (i.) a presystolio murmur, heard loudest over the 
fifth right costal cartilage, close to the sternum, (ii.) Dropsy precedes the pulmonary 
engorgement, but in other respects the consequences are the same as those of regurgi- 
tation through this orifice. 

V. Reouroitation through the pulmonary artery is practically never met with, 
excepting either as an accompaniment of congenital malformation of the heart, or as 
part of a general valvular inflammation in acute ulcerative endocarditis. 

Fallacies in the Diagnosis of Diastolic Murmurs. — 1. A diastolic murmur due 
to aortic regurgitation may be heard at the apex. It must not be mistaken for mitral 
stenosis. In addition to the fact that the aortio murmur is heard louder at the base 

^ This so-called * reduplicated second " is supposed to be due to a short diastolic 
murmur following the second sound, because it is heard at the apex, where the pul- 
monary second is said not to be audible ; and because, if due to asynohronous closure 
of the aortic and pulmonary valves, from the high pressure in the pulmonary circula- 
tion, one would expect it to be heard in mitral regurgitation, and in the later stages of 
mitral stenosis, in both of which it^ absent. 



§ 48 1 DIASTOLIC M URM UBS 79 

than at tho apex, it has a uniform character, whereas a mitral diastolic murmur is 
broken, of varying intensity, and the pulse and other symptoms are different. 

2. A prtsyiclic apical murmur is occasionally heard with aortic regurgitation 
(Austin Flint murmur). It is diagnosed from that due to mitral stenosis by its not 
being followed by an accentuated first sound, by the position of the cardiac impulse, 
and by the absence of the other signs of mitral stenosis. 

3. Mitral stenosis is the most difficult form of valvular disease to detect in the 
second or third stages, when the characteristic murmur may be altogether absent. It 
may, then, be strongly suspected when there is — (i.) a loud, clear, sharp first sound 
at the apex, with marked accentuation of the pulmonic second sound ; or (ii.) hyper- 
trophy of the right ventricle, chronic pulmonary catarrh, and hi^moptysis, especially 
if the second sound is reduplicated or absent at the apex. 

C. Double Mnrmnrs may be produced by a combination of any of the 
above systolic and diastolic murmurs. 

(a) Double murmurs most audible at the base (other than hsBmic) : 

1. Combined Aortic Obstruction and Regurgitation is the most 
common condition, and causes a loud double see-saw murmur, heard best 
in the second right interspace. 

II. Aneurysm of the Aorta may be attended by a double murmur 
having the same characters as in disease of the aortic valves. This is 
heard loudest in the second right interspace, but it may also be heard at 
the back, to the left of the fourth dorsal vertebra. 

III. A double murmur occasionally occurs in the dilated aorta of the 
age<l, but with less marked features. 

IV. A double murmur, loudest in the pulmonary area, nsually indicates Congrnitat. 
Hkart Disease. 

(6) A double murmur most audible at the apex may be heard when both 

Mitral Regurgitation and Stenosis are present. It consists of a 

systolic bruit followed by a long diastolic murmur almost filling up the 

diastole. 

Fallacies in the Diagnosis of Double Murmurs. — 1. When a double murmur 
can be heard both at the base and apex, do not imagine that mitral regurgitation 
exists, as well as aortic disease. Remember that a systolic mitral and a systolic 
aortic may be alike in character, and that aortic murmurs can often be heard at the 
apex, as well as the base. To arrive at a conclusion is often very difficult, but one 
must rely on the position in which the murmur is loudest, and on the other features 
which distinguish mitral and aortic lesions. 

2. When a double aortic murmur is present, the lesion may be regurgitation, or 
stenosis, or both together. A diagnosis is made by examining the pulse (§ 62), tho 
rhythm of the thrill, if one is present, and the position of the apex- beat. In regurgi- 
tation the apex is displaced farther downwards and outwards than in any other form 
of valve disease. In aortic stenosis the left ventricular wall is hypertrophied, with 
but little enlargement of the cavity, and as emphysema is so often associated with it, 
the apex may bo hard to find. 

3. Murmurs of pericardial friction may easily be mistaken for a double aortic 
murmur. 

4. Hcsmic, cardio-pulmonary, and milk-spot murmurs are occasionally double. 

§ 48. General Symptoms of Cardiac Valvular Disease. — The first 
effect of valvular disease is hypertrophy of the heart, as already mentioned, 
and so long as there is adequate compensatory hypertrophy there may be 
no concomitant symptoms at all. 



80 DISEASES OF THE HEAUT AND PERICARDIUM [§49 

But, sooner or later, in most cases hypertrophy f»ives way to dikUation, 
and then a series of characteristic symptoms ensue. Those special to each 
form of valvular lesion have been referred to in the preceding section. 
Certain general symptoms are common to all formes of chronic valvular 
disease, 

1. Breaihlessness on walking uphill, or even on very slight exertion, is 
a very constant feature. No serious enfeeblement of the heart wall or 
disturbance of its function can exist without this symptom ; and it cannot 
be too much insisted on that breathlessness is not only a symptom, but, 
in general terms, is a measure of the extent of the cardiac failure. 

2. Dropsy occurs early in mitral, late in aortic, disease. 

3. Palpitation is of less diagnostic import, for it may occur without any 
organic heart change, and is not always present with valvular disease. 

4. Pain is by no means always present in cardiac dilatation, but few 
cases run their entire course without considerable prsecordial discomfort. 
Pain is a fairly common feature of aortic disease, and sometimes amoimts 
to angina. 

5. Insomnia, in advanced cases, is frequently a very troublesome 
symptom. Sometimes the patient, when dropping off to sleep, suddenly 
starts with the terror of suffocation, and gasps for breath. Headache and 
delirium are also met with in advanced cardiac disease. The former is 
occasionally due to temporary high tension, but both are more often due 
either to pyrexia or to a toxic condition of the blood from failure of the 
emunctories. In either case free purgation is indicated. 

6. Embolism may occur, having all the features described under Acute 
Endocarditis (§ 39). It is most frequent in mitral stenosis, and next in 
aortic disease. 

§ 49* The chief Cause of cardiac valvular disease in youth is acute endo- 
carditis, which has a special tendency to attack the mitrcU valve, and in 
advancing years the chronic degenerative changes, which attack the aortic 
orifice. 

1. Acute Endocarditis of rheumatic origin is by far the most frequent 
cause, and a large majority of " heart cases " date their symptoms from 
an attack of that disease in youth or early adult life. Scarlatina and the 
other acute specific fevers, and all causes of acute endocarditis (§ 39), play 
their part, but the other specific fevers are infrequent relatively to acute 
rheumatism and scarlatina. 

2. Chronic Endocarditis may come on insidiously, especially under the 

influence of certain poisons, chief among which are alcohol, sj'philis, and 

gout, and especially if these be combined with hard labour. Under such 

circumstances, the lesion usually affects the aortic orifice. But chronic 

endocarditis more often supervenes upon acute endocarditis — an attack 

of which may have been overlooked. 

Dr. C. O. Hawthorne has done good service in drawing attention to the fact that 
endocarditis may start with an apparently trivial attack of Rubactite rheumatism, the 
child complaining of nothing but slight pains in the limbs, accompanied pethaps with 



S 50 ] PROQNOaiS OF CARDIAC VALVULAR DISEASE 81 

a slight sore throat, not of sufficient gravity for him to be kept in bed. Parents of 
children whose antecedents are rheumatic should be warned not to treat such symptoms 
lightly. 

3. Degeneraiive changes {e.g., atheroma) are the lesions chiefly met with after middle 
life. They af^t essentially the aortic orifice, either by injuring the valves or by 
causing dilatation of the aorta, which, extending to the situation of the valves, prevents 
them from meeting during the diastole. 

4. Any prolonged high tension — cgr., that which accompanies arterial sclerosis — may 
lead to valvular strain, usually aortic. Persistent obstruction in the lungs (e.^., 
chronic bronchitis), or in the general systemic circulation, may have the same effect 
as persistent high tension on the right or left side of the heart respectively. 

5. Extensive or prolonged miiscular exertion may, it is believed, lead to valvular 
mischief — at least, there is no other mode of explaining the fact that a large number 
of athletes have sclerosis of the aortic valves. In rare circumstances a sudden strain 
may lead to rupture of a valve. 

6. Congenital conditions are referred to in § 46. 

§ 50. Tlie Prognosis of chronic heart disease is but ill-understood if the 
conclusions are based only on hospital cases. They need to be followed 
from beginning to end as in private practice or infirmary work. It is quite 
certain that many patients have disease of the heart for years without 
knowing it. It is also certain that the first symptoms very often date 
from the patient knowing that he has cardiac disease, and unless there are 
special reasons- to the contrary, a patient should never be informed of its 
presence. 

Cardiac disease may terminate life in three ways : (i.) By sudden death 
— this may result either from syncope, or from rupture of the heart, or, 
as some say, from cardiac anaemia, due to non-filling of the coronary 
arteries; (ii.) by the occurrence of complications, especially bronchitis, 
and other pulmonary affections ; or (iii.) by asphyxia, from dropsy of the 
pleura, often combined with congestion of the lungs. 

The probable course and duration depend upon many considerations, 
but on nothing more than the condition of the cardiac waU (No. 3 below), 
and this should be the object of the most thorough investigation. 

1. The presence of certain Cardiac Symptoms is in itself an indication 
that the reserve power of the cardiac muscle is overdrawn — e.^., palpita- 
tion, dyspnoea, increased by emotion or exertion, cardiac pain, syncopal 
and anginoid attacks. In actual practice the prognosis is good in pro- 
portion to the amourU of exercise a patient carh take toithout froiucing 
breatMessness.^ Syncope and anginoid attacks usually indicate serious 
cardiac embarrassment. Palpitation and cardiac pain are less serious 
indications; "Delirium cordis" and Cheyne-Stokes breathing are very 
grave (§§ 206 and 44). 

2. The Condition of the Pulse is of considerable value in prognosis, but 
it has to be judged in connection with the valvular lesion. Irregularity 
is a grave indication except in mitral regurgitation ; in aortic disease it is 
very serious. Persistent irregularity with rapidity is always a bad sign, 
and may indicate the onset of auricular fibrillation (see below). 

^ Mackenzie states : ** The simple test is to observe how the heart responds to 
effort. . . . Heart failure is first exhibited by a diminution of the work force of the 
heart, and this is shown by a restriction of the field of effort." 

6 



82 DISEASES OF THE HEART AND PERICARDIUM [§60 

3. The Physical Signs of Cardiac Hypertrophy and Dilatation given in 
Table III., p. 68, will help us to gauge the amount of dilatation — i.e., 
failure, or hypertrophy — i.e., compensation which is present, by means of 
a careful examination of the apex- beat, by percussion, and auscultation. 
If emphysema or other condition prevents us obtaining reliable conclusions, 
it is worth remembering that a regularly acting heart with an apex in the 
normal situationy justifies (with possible exceptions in mitral stenosis) a 
fairly good prognosis. 

For purposes of prognosis — and, indeed, for treatment also — cases of 
cardiac valvular disease are best divided as follows : In the first stage 
there is efficient hypertrophy, with or without compensatory dilatation (in 
regurgitant lesions dilatation is also a compensatory process and aids the 
heart). In this stage the patient may not come under notice at all ; 
both the valvular mischief and the hypertrophy may be discovered 
accidentally. 

In the second stage the dilatation increases, and some of the symptoms 
referable to the heart, above mentioned, are sure to be present. The 
dilatation, however, is not sufficient to produce pulmonary or systemic 
engorgement. The characters of the murmurs vary as years pass, owing 
to changes in the cardiac muscle, and hence in its contractile force. 

In the third stage there is advanced dilatation, with thinning of the wall 
and congestion of the lungs (in aortic lesions), of the general venous 
system (in mitral lesions), and finally of both. 

" Auricular fibrillation " may supervene, and is a sign of the gravest 
import. Fibrillation is a condition in which the various muscular fibres 
of the heart contract rapidly and independently of each other. Owing 
to the resulting conflict of action of the different fibres the normal con- 
tractile wave from auricle to ventricle via the auriculo-ventricular bimdle 
of His is suspended, and the chambers of the heart tend to dilate. When 
fibrillation occurs in the ventricle it leads to death ; when it occurs in the 
auricle, the normal stimulus of the contraction wave is replaced by rapid 
and irregular stimuli, which in turn affect the ventricular rhythm. In 
most cases of cardiac failure the onset of auricular fibrillation is evidenced 
clinically by a pulse of rapid and disorderly rhythm — i.e., no two successive 
pulse beats or intervals are alike. In cases of heart-block the pulse is 
slowed. In mitral stenosis the onset of auricular fibrillation is evidenced 
by the disappearance of the presystolic murmur. Other clinical signs of 
auricular fibrillation are an absence of the auricular wave in tracings of the 
jugular vein and of signs of an auricular systole in an electro-cardiogram. 
The patient is usually conscious of a fluttering or thumping sensation 
about the heart and an aggravation of his other symptoms of cardiac 
failure. Fibrillation is met with chiefly in two classes of cases — (1) those 
with a history of rheumatic fever, and (2) elderly patients with fibroid 
degeneration of the heart. Dr. Mackenzie finds that 70 per cent, of cases 
of cardiac failure in general practice are due to the onset of auricular 
fibrillation. 



§50] PROONOSIS OF CARDIAC VALVULAR DISEASE 83 

f 4. The presence of signs of venous obstruction as a measure of backward 
pressure — viz., pulmonary congestion, dropsy, lividity of the lips and 
fingers, enlargement of the liver and spleen, and albuminuria — is un- 
favourable. But the gravity is very different in mitral and aortic lesions 
respectively.' In mitral cases a moderate degree of these symptoms 
indicates only moderate cardiac failure, and it by no means follows that 
the heart is beyond redemption. But if they occur in aortic disease they 
show that the final stage is reached, and that the patient will probably not 
live many months. When general venous congestion exists, the relative 
amount of urine passed day by day is a good measure of the strength of the 
heart and the improvement made — a fact which is not generally appreciated. 

5. Concerning the Nature of the Valvular Lesion as bearing on the 
pn^osis, some difference of opinion is expressed as to the relative im- 
portance of aortic and mitral lesions. My own experience is that a 
moderate degree of aortic stenosis is the most favourable form, and if well 
compensated may give rise to little or no inconvenience ; the patient 
generally dying of some intercurrent malady. Next in order comes mitral 
regurgitation, then mitral stenosis ; the most serious being aortic re- 
gurgitation, the valvular disease which most frequently ends in sudden 
death. Combined lesions of stenosis and regurgitation are naturally more 
serious than single ones, and the gravest of all valvular lesions is double 
aortic disease. 

In Aortic Regurgitation, the measure of the amount of regurgitation, and 
therefore the prognosis, depends upon the clearness with which one can 
hear the aortic second sound (as distinct from the murmur) in the carotid 
arteries, and on the degree to which the pulse collapses. In Mitral Re- 
gurgitation a loud muxmnT/oUomng the first sound is more favourable than 
a weak murmur, or than one which replaces or accompanies the first sound. 
In Mitral Stenosis a faint or absent second sound is a grave sign. Apical 
murmurs due to dilatation can generally be made to disappear undei* 
treatment. 

In Double Aortic Disease it is important to note which is the louder, the first or thu 
second of the two bruits. If the first be the louder, it indicates considerable compen- 
sating hypertrophy of the left ventricle, and the prognosis is more favourable ; but 
if the second (the regurgitant) bruit be the louder, it probably indicates a weakened 
ventricle, which allows a large reflux of blood, and the prognosis is as grave as well 
can be. 

6. The Primary Cause of the valvular mischief influences the prognosis to some 
extent. Injury and congenital mischief, both happily rare, are very serious. Kheu- 
matism is grave in proportion to its tendency to recur. In general terms cases due 
to acute endocarditis in early life are much more favourable than the degenerative 
changes (accompanied perhaps by an alcoholic or syphilitic taint) supervening during 
middle liiPo. 

7. Age is not a very important factor. Valvular lesions in childhood are more 
Toad'ly compensated, but at the same time advance more rapidly. Mitral stenosis 
coming on in childhood is much graver than when it supervenes in the adult, and 
generally terminates fatally before the age of twenty-one. On the other hand, aortic 
regurgilation due to endocarditis in youth is compatible with a long and useful life ; 
but when coming on in middle or advanced life, it is generally due to degeneration and 
dilatation of the aortic orifice — a condition of far graver import. 



84 DISEASES OF THE HEART AND PERICARDIUM [ f 51 

8. The Temperament, Habits^ and Means of the patient will naturally influence his 
future. Want of rest and sleep, the presence of worry and other causes of nerve 
strain, seriously affect the prognosis in all forms of cardiac disease. The prognosis ia 
bad in the intemperate, and those who lead irregular lives. It is also unfavourable 
in the destitute, and in those who are compelled to work hard for their daily bread. 
Nevertheless, complete idleness is equally bad, and a patient should b^ encouraged to 
do as much as he is able without fatigue. 

9. Finally, before hazarding a prognosis in any given case, the Effects of TreeUment 
should always be watched, for it is sometimes truly wonderful how the skilful adminis- 
tration of digitalis, and the application of modem methods of treatment, will some- 
times seem to snatch the patient from the very jaws of death. The existence of an 
organic murmur without change, and not requiring active treatment for two years, 
justifies a favourable prognosis. 

§ 51. The Treatment of Chronic Heart Disease (including Cardiac 
Dilatation or Failure and Valvidar Disease) may be considered under three 
heads : (a) When compensation is fully established ; (b) when compensation 
begins to fail ; (c) when compensation has broken down. 

(a) When there is eflficient compensation, no symptoms are present and 
no active treatment is needed, but much may be done to prolong the 
patient's life, and to avoid the supervention of cardiac failure. Subjects 
of chronic valvular disease should be enjoined to lead quiet, regular, and 
orderly lives. They should be warned particularly against the dangers 
of any sudden, imusual exertion, such as running to catch a train. With 
regard to exercise, it may be said, in general terms, that the patient himself 
is the best judge, provided always that he does not exert himself sufficiently 
to cause palpitation, severe dyspnoea, or prsecordial pain. Some sports 
are more peimissible than others ; thus cricket, tennis, and golf may 
usually be enjoyed, whilst football, racing, and rowing must generally be 
forbidden. Climbing, especially to high altitudes, must be disallowed. 
Alcohol, tobacco, and tea are all myocardial poisons if taken to excess, 
and should be used only in strict moderation. The skin should be kept 
active by the daily bath, and the bowels regular by means of purgatives 
if necessary. Whenever possible, a means of livelihood should be chosen 
in which the heart is subjected to but little strain. A sedentary occupation 
with moderate exercise in the intervals, is more suitable than that which 
entails earning a living literally by the sweat of the brow. Lifting or 
carrying heavy weights, climbing ladders, wielding heavy hammers, and 
physical labour in constrained positions, are liable to overtax the powers 
for compensation of the cardiac muscle. Meals should be regular, and 
heavy meals should be avoided. The diet should be easily assimilable, 
and contain only a moderate amount of fluid. Anything requiring pro- 
longed digestion disturbs the night's rest, so that it is sometimes a good 
rule to allow nothing solid after 2 p.m. in those who have a tendency to 
indigestion or gastric disturbances. A small quantity of stimulant with 
meals may be called for, but should not be used unnecessarily, because of 
the reaction afterwards, and of the tendency to excess, which exists in 
cardiac cases. 

{b) When compensation is beginning -to fail, the condition of the heart 



Itt] TREATMENT OF CARDIAC VALVULAR DISEASE 85 

should be noted frequently ; rest, drugs, and exercises being prescribed in 
accordance with the variations in the circulation and the capability of 
response to treatment by the cardiac muscle. 

Drugs. — In cardiac failure, especially when the pulse becomes feeble, 
rapid, and irregular, digitalis is par excellence the remedy. It is especially 
indicated in failure of the right heart and in mitral regurgitation, whetlier 
primary or secondary to aortic lesions. It is contra-indicated when there 
is full compensatory hypertrophy, and the pulse is fairly strong, regular, 
and slow, or if vomiting is present. The recent work of Dr. James Mac- 
kenzie has thrown much light upon the action and modes of administration 
of digitalis. It slows the heart, and improves contractility and con- 
ductivity; in overdoses it induces heart-block. It should be given in 
large doses (,"^i. daily) to get the muscle thoroughly under its influence ; 
the dose is then reduced to the minimum which experience and careful 
observation proves to be capable of maintaining the regularity and slow- 
ness of the pulse. It is especially useful in auricular fibrillation, except 
where there is pyrexia or fibroid degeneration, when the muscle does not 
respond to the drug. It should be continued for a considerable time in 
smaller doses in the form of a tonic. Strophanthus and other cardiac drugs 
are less efficacious than digitalis. The action of digitalis and many other 
cardiac remedies is expedited by an occasional dose of calomel. Formulae 
54, 57, 59, 67, and 84 are useful. In aortic valvular disease and in the 
early stages of mitral stenosis, digitalis is not so valuable a drug; but in 
the later stages of these affections, when compensation begins to fail and 
signs of auricular fibrillation are present, digitalis gives relief. In aortic 
cases, where the blood-pressure is high, or where angina is ^resent, the 
vaso-dilators are often of most use, such as nitroglycerine (in the form of 
liquor trinitrini \[\i. t.i.d.), or er3rthroltetra-nitrite, sodium nitrite, and sal 
volatile. Belladonna is sometimes useful if there is relaxation of the 
vessels. Among the cardiac tonics strychnine, nux vomica, iron, and 
arsenic are the most valuable in the order mentioned.^ 

The various symptoms may be met by appropriate remedies. For the 
jndmonary congestion, squills and stimulating expectorants are indicated. 
For breathlessness, spirits of ether or of chloroform and ammonia are 
useful. Nitroglycerine is useful where breathlessness is associated with 
high tension, which may accompany cardiac hypertrophy ; and at the 
same time it cures the headache and sleeplessness due to the same cause. 
Ether m^xx. to xl., or strych. sulph. gr, ^V hypodermically, are useful for 
the paroxysms of dyspnoea. Cough is relieved by drinks of hot milk, and 
drugs such as codeia, small doses of opiimi, and chloroform or ether. For 
jHdjniation alcohol is a most valuable cardiac stimulant, and relieves the 
breathlessness as well. Unfortunately, patients soon find this out for 
themselves, and thus cardiac valvular disease is a not infrequent cause of 

^ Cane-sugar in the form of glebe granulated sugar in doses of 1 to 5 ounces twice 
or three times daily is strongly recommended in failing myocardium, from whatever 
cause, by Dr. Goulston, {Brit. Med. Journ,, March 18, 1911) and Dr. Carter Brit. Med. 
Jaum., November 26, 1911). 



86 DISEASES OF THE HEART AND PERICARDIUM [ § 61 

chronic alcoholism, especially among women, who take it secretly, during 
the night, when the palpitation is most apt to come on. The exact dose 
should therefore be carefully prescribed, and the quantity should always 
be moderate. Other causes of palpitation which may be present should 
be treated (§ 22). For sleeplessness opium or morphia hypodermically is 
useful ; in mitral disease, however, where the liver is congested, opium is 
better avoided, and other drugs employed, such as potassium bromide, 
sulphonal, trional, and paraldehyde. I have not found small doses of 
chloral do harm, as some maintain. The hcBmoptysis of heart disease is 
best left alone, as it relieves the congestion. The gastric symptoms 
may be relieved by acting on the congested liver with calomel, i to 1 grain 
every night, with sodium sulphate and sodium bicarbonate (30 grains in 
2 ounces of hot water) in the mornings. Digitalis must be stopped if it 
causes sickness. It may be necessary to give predigested food. For the 
treatment of syncopal attacks and pain, vide §§ 24 and 23. Formula 56 is 
useful. 

Massage and Systematised Exercises, — At one time rest was regarded as 
imperative for all forms of cardiac disease. But the advance of physio- 
logical knowledge has shown what an important part the skeletal muscles 
play in the circulation of the blood, by squeezing the fluids out of the soft- 
walled veins and lymphatics, while they cannot compress the lumen of the 
firm-walled arteries. There are three varieties of this treatment, which 
are invaluable for different degrees of cardiac failure. Fir sty for the worst 
cases, gerUle nwssagey combined perhaps with passive movements. These 
are available where any kind of voluntary movement on the part of the 
patient is attended with breathlessness. The great value of properly 
regulated massage in cardiac failure is well seen in the case from which the 
tracings in Fig. 22 were taken. Secondly^ slow volurUary movements of 
flexion and extension on the part of the patient while standing or sitting. 
In the Nauheim system these vohmtary movements are gently resisted 
by the operator — "resistance gymnastics" — see Formula 114. These 
movements, combined with baths (see below), constitute the essence of the 
Schott system. Thirdly, OertePs method, which consists of three parts : 
First, reducing the amoimt of fluid taken to 31 ounces per diem (to include 
the amount contained in the solid food) and promoting perspiration ; 
secondly, a diet largely consisting of proteids ^ ; and thirdly, graduated 
exercise in the form of walking uphill, each day a little farther. Cases 
attended by plethora and obesity are the most suitable. 

Baths, such as those in use at Nauheim, may be usefully added to the 
preceding. They act by relaxing the arterioles of the skin directly, and 

* Oertel's dietary is as follows : — Morning : 6 ounces of coffee, 3 ounces of bread. 
Noon ; 3 to 4 ounces of soup, 7 to 8 ounces of roast meat or poultry, salad or green 
vegetable, a little fish, 1 ounce of bread or farinaceous pudding, 3 to 6 ounces of 
fruit ; no liquid (excepting in hot weather, 6 ounces of light wine). Afternoon : 
6 ounces of tea or coffee (1 ounce of bread occasionally). Evening : one or two lightly 
lH)iled eggs, 1 ounce of bread, salad, fruit, sometimes a small piece of choose, 
G to 8 ounces of light wine, with 4 to 5 ounces of water. 



SU] 



TREATMENT OF CARDIAC VALVULAR DISEASE 



87 



the arterioles of other parts reflexly. By these means blood is transferred 
from the venous to the arterial system, and its flow accelerated (F. 113), 

(c) When compensation has broken down and marked cardiac failure 
is present, absolute rest is necessary. The patient is usually imable to lie 
down, but has to be propped up with pillows, and in severe cases sleep can 
be obtained only when the legs are hanging down. In severe failure of the 

V.' 



B 




Fig. 21.— TracingB A and B show the efficiency of bleeding. A shows the flat top of high tension. 
B was taken Immediately after 6 ounces of blood were removed, and shows Uie reduction 
thus effected, and also the senile character of virtual tension. The patient was about fifty- 
seven years of age, and suffered from cardiac valvuUr disease with recurrent high tension 
(with headache, ete.). The urine was always normal. Some years later he was brought in 
with apoplexy and died. 

right heart, as indicated by orthopnoea, lividity, distended jugular veins, 
the liver dulness extending well below the costal margin and the cardiac 
dulness extending far to the right, venesection is called for, and brings 
prompt relief. The abstraction of from 5 to 10 ounces of blood is usually 
sufficient ; its efficacy is shown in Fig. 21, above. Three to six leeches may 
be applied to the right lower ribs in children, in whom venesection is more 
difficult to perform. The dropsy may require special treatment, such as 




Fig. 22. Pulse tracings C and D are taken by a Marey's sphygmograph (in which the momentum 
of the lever is greater and the excursion larger, than those taken by Dudgeon's). C (which 
shows simply high tension) was taken before, and D (which shows the reduction of tension) 
was taken directly after maitiitge — massage and passive movements. The patient was a 
man aged sixty-five, under carefor arterial sclerosis, and these tracings show the efficacy of 
massage in relieving the heart. 



draining the legs by Southey's tubes (§ 21) or multiple superficial incisions. 
Aspiration of a pleural effusion or paracentesis abdominis may be neces- 
sary. Diaphoretics are of little use in cardiac dropsy. Cardiac tonics, 
such as digitalis and caffein, should be employed in conjunction with 
diuretics, calomel, and hydragogue cathartics, such as pulv. jalapae co. 
and cream of tartar. The digitalis, squill, and calomel pill is useful at 
this stage ; so also Formula 55. Diuretin and theocin-sodixmi acetate arc 



88 DISEASES OF THE HEART A^D PERICARDIUM [ § 52 

valuable drugs when dropsy is excessive. A salt-free diet should be 
ordered. The readily difiusible stimulants such as spirits of nitrous ether, 
alcohol and sal volatile are of great value. 

VI. On auscultation, no murmur can he heard, and the heart sounds are 
very feehle ; the impulse is so weak thai it cannot be localised. Fatty 
or Fibroid Degeneration of the heart toaU may be strongly suspected. 

§ 52* Fatty Heart in its clinical sense indicates enfeeblement of the 
cardiac wall. A better term for it would be Cardiac Enfeeblement, or 
Primary Cardiac Failure. Examples have now been given of all the various 
physical signs liable to be found in the heart by means of inspection, 
palpation, percussion, and auscultation. But, supposing the most careful 
examination reveals no physical signs, although, by reason of certain 
subjective symptoms, we believe the patient to be sufEering from cardiac 
disease. Fatty or Fibroid Degeneration op the Cardiac Wall should 
be suspected. The diagnosis often rests on a process of exclusion, and the 
two forms are clinically indistinguishable from one another. 

Its detection is often a matter of some difficulty, but the disease may 
be suspected (i.) when the pulse and heart impulse are feeble, and the heart 
soimds perhaps inaudible ; (ii.) if the patient be subject to attacks of 
fainting or of dizziness; and (iii.) if he be subject to palpitation and 
breathlessness. The patient may experience no symptoms at first beyond 
a tight feeling across the chest on exertion ; later, he may have dyspnoea, 
especially at night or after movement. The pulse may be either very 
quick or very slow, intermittent, or irregular, due to extra-systoles. The 
disease is more frequently met with in persons past middle age, and if 
unaccountable fainting attacks occur for the first time at this age period, 
fatty heart is the most probable cause. Some oedema of the ankles may 
also be present, (iv.) The heart sounds are not usually accompanied by a 
murmur, for even if valvular mischief exist, the force of the heart may not 
be sufficient to produce a bruit.* With the onset of cardiac dilatation the 
area of prsBcordial dulness may be increased, but it is often obscured by 
emphysema of the lungs, which is itself one of the causes of fatty degenera- 
tion. Later on, anginoid and epileptiform attacks, or the syndrome known 
as Stokes- Adams disease (§ 59) are not uncommon. 

The Prognosis is extremely grave. Fatty heart is one of the commonest 
causes of sudden death. The earlier stages of the malady are insidious, so 
that by the time pronounced symptoms appear irreparable mischief may 
be done. The patient may die in one of the syncopal attacks, or, if not, 
he will rarely live for more than six to twelve months after definite symp- 
toms have set in, such as dyspnoea, Cheyne - Stokes respiration, or a 
continually irregular pulse, especially the pidsus alternans. In the early 
stages of cardiac degeneration plenty of fresh air exercise and good sleep 
are essential for increasing the reserve power of the unaffected muscle 
fibres, and if the patient responds to this treatment he may live for many 
years (Mackenzie). 



§58] FATTY HEART 89 

Diagnosis, — In the early stages it may be impossible to distinguish 
Fatty Heart from Cardiac Dilatation, especially when emphysema is 
present, preventing accurate percussion. In dilatation there is nearly 
always anasarca, fluid in the serous cavities, and congestion of organs. 

Treatment consists of (i.) perfect rest, both of body and mind, and 
avoidance of anything like excitement ; (ii.) stimulants in small and fre- 
quent doses — ammonia, alcohol, ether, combined with plenty of easily 
assimilated nourishment, and potassium iodide where the arterial system 
is affected, (iii.) Cardiac tonics, and especially strychnine, arsenic, and 
quinine, combined with plenty of fresh air. Digitalis should not be given 
if there be no signs of dilatation and the pulse be slow. It is, however, 
of great value in the opposite conditions, (iv.) The heart may be relieved 
of some of its work by passive movements, massage, and other measures 
described under Cardiac Valvular Disease, due care being exercised; 



CHAPTER IV 

ANEURYSM OF THE AORTA AND OTHER INTRATHORACIC 

TUMOURS 

Anatomy. — The mediastqiain is the irregular space in the chest which lies between 
the two pleural sacs. For descriptive purposes it is divided into four parts — viz., the 
middle mediastinum, which is occupied by the heart and pericardial sac ; the anterior, 
which is the space in front ; the posterior, the space behind ; and the superior, the 
space above the pericardial sac. The most important structures contained in those 
spaces are : The thymus or its remains ; the arch of the aorta with its branches 
(innominate, left subclavian, and carotids) ; the superior and inferior venae cavte, 
with the innominate and azygos veins ; the pulmonary vessels, the trachea and bronchi ; 
the vagus, recurrent laryngeal, phrenic, and splanchnic nerves ; the cardiac and pul- 
monary plexuses ; the roots of the lungs ; the oesophagus, thoracic duct, lymphatic 
glands and vessels, and loose cellular tissue (Fig. 11). The lymphatic glands are 
important on account of the occurrence of lyrapho-sarcoma and other glandular 
enlargements which may form mediastinal tumours. 

DuLNESS WITH AN IRREGULAR OUTLINE is referred to in the italicised 
remarks on diagnosis preceding § 46. 

If, on percussing over the sternum, ^ or just beside it, the preecordial 
dulness is found to be increased irregularly upwards — the morbid con- 
dition may be Pericardial Effusion, Enlargement of the Left 
Auricle, Retraction of the Lung, an Abdominal Swelling pushing 
UP THE Heart as a Whole, or Aortic Aneurysm or some other 
Mediastinal Tumour. The two last named are generally to be dis- 
tinguished sooner or later by the presence of pressure symptoms (p. 93). 
If possible, a skiagram should be taken. 

Iff on auscultation over the abnormal dulness near tlie base of the hearty 
there is a reinforced or ringing second heart sound — perhaps a 
systolic or diastolic murmur — the disease is probably Aneurysm of the 
Aorta. 

§ 53. Intrathoracic Aneurysm. — ^Aneurysm of the aorta is undoubtedly 
the commonest of intrathoracic tumours. In regard to the anatomy 
of this serious and important malady, the student should study Fig. 11 

The arch of the aorta is the favourite seat for aneurysmal dilatation. 
Its shape and the fact that it is subject to continuous strain make it sur- 

^ Remember, in percussing over the sternum, the note elicited is of a much higher 
pitch than that just beside the sternum. 

90 



1 5S ] INTRATHORACIC ANEURYSM 91 

prising that the malady is not even more frequent. Any part of it may 
be affected — the ascending, transverse, or descending part of the arch. 
The dilatation may assume either a fusiform or saccular shape, the former 
being the more frequent. Fusiform dilatation arises as a rule in the first 
part of the aorta, and may lead to stretching of the valves and aortic 
incompetence. The fusiform aneurysm gives rise to practically no physical 
signs, and the ensuing description refers, unless otherwise stated, to 
saccular aneurysm. It may make its way in various directions, and it 
is extraordinary how bones, cartilages, and other hard structures, may 
become eroded and absorbed under its pressure. One of the earliest 
results of aneurysm near the root of the aorta is cardiac hypertrophy, but 
this may not occur at all when it involves other parts. According to its 
position, aneurysm of the aorta may be either very easy or very difficult 
to detect. If it involves the first part of the aorta, near the yron^ of the 
chest, it is soon revealed by definite physical signs. If the second or third 
parts of the arch are involved, and the tumour extends backwards, there 
may be no physical signs, and even the pressure symptoms may be obscure. 
Thus the clinical manifestations belong to two categories — physical signs 
and pressure symptoms ; and we have two varieties of aneurysm : (a) The 
aneurysm of physical signs, when the first half of the arch is involved ; 
(6) The aneurysm of symptoms (that is, pressure symptoms), when the 
SECOND HALF of the arch is involved. 

The Symptoms Common to aortic aneurysm in all positions will be con- 
sidered first, because these are the symptoms which will probably first 
attract our notice. Then we will turn to certain others special to the first, 
second, and third parts of the arch respectively. 

Symptoms Common to All Positions : 

1. Dyspnoea is often one of the earliest complaints which the patient 
makes. When it is due to pressure on the trachea, as in aneurysm affecting 
the transverse portion of the arch, it is persistent and stridulous in char- 
acter. When it is due to pressure on the anterior pulmonary plexus, as 
in aneurysm of the first part of the arch, it is often paroxysmal. 

2. Cough is generally present and has a characteristic brassy sound 
(gander cough). Pressure upon the recurrent laryngeal nerve is common, 
with consequent paralysis of the left vocal cord, and there may be hoarse- 
ness or even aphonia from the same cause. Paralysis of the left vocal cord 
in the absence of central nerve lesions, practically always means aortic 
aneurysm. Laryngoscopic examination should be a matter of routine 
in all suspicious cases, because abductor paralysis occurs before com- 
plete paralysis, and the former may be unattended by any alteration of 
voice. 

3. Pain in the chest is another common symptom. It may occur in 
attacks of an anginoid character, shooting down one or both arms, usually 
the left, especially in aneurysm of the first part of the arch. The pain 
may be neuralgic when there is pressure on nerves ; or it may be of a dull 
boring charact>er when due to erosion of bone, such as occurs in connection 



92 ANEURYSM OF THE AORTA [ f 6S 

with aneurysm of the descending arch.^ Short of definite anginoid attacks 
of this kind, patients with aortic aneurysm are liable to feelings of suffo- 
cation, constriction, or " spasm " in the chest, and nameless dreads come 
over them from time to time without cause. Such attacks may in many 
cases be brought on by bending the head backwards, or by any movement 
which stretches the neck. I have known patients with dilated and rigid 
aorta suffer frcm the same symptoms. 

4. A reinforcement of the aortic second sound is the most constant of 
the auscultatory signs of aortic aneurysm. It is sometimes spoken of as 
a " ringing " second soimd. 

5. The diastolic shock or thud is an equally important sign. It is felt 
by the hand or the stethoscope, and is synchronous with the second sound. 

6. Inequality of the radial pulses is a fairly frequent symptom. It is 
present whenever the aneurysm is so placed as to cause a difference in the 
arterial pressure in the great vessels which spring from the aorta. The 
typical aneurysmal pulse occurs in the one just beyond the sac, and its 
characteristic is a loss of the pulse wave, the blood flowing in one continuous 
stream. 

7. Inequality of the pupils occurs frcm pressure on the sympathetic. 
In the early stage the irritation of the nerve causes dilatation of the pupil 
on the same side. Later on there is paralysis, with contraction of the 
pupil, accompanied sometimes by vascular dilatation and unilateral 
sweating of the face and neck. 

8. The heart may be displaced when the aneurysm is large, usually to 
the left. It is sometimes hypertrophied. 

(a) Sjonptoms peculiar to aneurysm of the ascending or first part o! 
the arch. Aneurysm of this part of the arch is usually easy of detection, 
and in marked cases the Physical Signs are unmistakable, (i.) On auscul- 
tation, an accentuated second soimd is usually to be heard ; and in a large 
number of cases, where the dilatation involves the valvular orifice, a 
diastolic murmur is also heard. Over the site of the aneurysm a systolic 
murmur is always present, and this is frequently present also at the aortic 
area. Thus, a double murmur at the aortic area is found in many cases, 
(ii.) Any percussion dulness present is continuous with that of the heart. 
It usually extends to the right of the sternum, b\it this depends upon 
whether the aneurysm makes its way forwards or not. The left heart 
gradually hypertrophies, (iii.) On palpation, the diastolic shock is very 
characteristic. Sometimes there is a thrill felt also in the suprasternal 
notch, (iv.) When the aneurysm is so large as to form a tumour, the 
swelling expands laterally with each systole of the heart. The accompany- 
ing erosion of the sternum may be very painful, (v.) The right bronchus 
may be pressed upon, leading to diminished or absent respiratory murmur 
(R. M.) of the right lung. In severe cases there may be pressure on the 
superior vena cava, with oedema of the neck and arms, (vi.) The dyspnoea 

^ A case is mentioned in the footnote to §23 in which this was almost the only 
symptom. 



}sa INTRATHORACIC ANSUSYSM D3 

is paioxyamal ; and the right tecuireitt laryngeal nerve may be involved, 
with right laryngeal paralysis. 

(6) The symptoms of aneurysoi of the second oi transrene part ol the 
arch may be equally easy to detect when it makes its way forwards. 
But when the posterior part is affected it may present considerable diffi- 
culty in diagnosis, especially from other intrathoracic tumours, (i.) The 
dyspnma may be either paroxysmal or continuous, with inspiratory stridor, 
owing to the pressure upon the trachea, (ii.) Pressure upon the left 
bronchus may lead to diminished breath sounds in the left lung, and 
^mptoma {2) and (5) above are specially marked in aneurysm of the 
transreise arch, (iii.) Tracheal tugging is a very characteristic sign of 
aneurysm in this situation. Standing behind the patient, hold the cricoid 
between the finger and thumb, and press gently upwards, the patient 
sitting in a chair erect with the chin up (see Fig. 23). In this way the 
pulsation is transmitted by the trachea to the hand, (iv.) The physical 
signs — which are in this situa- 
tion less marked, or may be 
absent — consist of a thrill felt 
on palpating the suprasternal 
notch ; dulness on percussion 
over the manubrium, con- 
tinuous with that of the heart, 
and extending from the middle 
line to the left of the sternum ; 
and auscultatory signs are de- 
scribed above — (a) (i.). 

(c) The symptoms of aneu ■ 
rysm affecting the dMcendini; 
aorta may be very obscure, 
(i.) Intense pain in the back is 
the most common symptom, 

and there may be no other for a long time [case in footnote, g 2:}). The 
pain may pass to the side, following the course of an intercostal nerve, 
(ii.) Other pressure symptoms, such as dysphagia, from pressure upon the 
(esophagus ; wasting, from pressure upon the thoracic duct ; disease of 
the left lung, from pressure upon its bronchi ; and any of the other symp- 
toms mentioned on p. 91. (iii.) If the swelling enlarges, physical signs to 
auscultation and percussion may become apparent in the left (occasionally 
the right) scapular region ; and in advanced cases there may even be a 
pulsating swelling without the knowledge of the patient. Osier found 
that in such cases there is absence of pulsation in the femoral arteries. 

Etiology.— (I) Aortic aneurysm is far more frequent in men than in 
women, especially those in the prime of life — namely, between the ages of 
thirty-five and fifty. (2) It is especially frequent among soldiers and 
those who do laborious work. This liability has been attributed to the 
wearing of belts and the like, but it is probably due to the fact that these 



94 ANEURYSM OF THE AORTA [ § 6S 

classes are subjected to sudden and severe muscular exertion and heart- 
strain at certain times. It also occurs among blacksmiths for the same 
reason. 

(3) Both syphilis and alcohol are potent agencies in the production of 
arterial degeneration. Alcohol acts probably in two ways — partly by 
predisposing to degeneration of the aortic walls, and partly by over- 
stimulating the heart from time to time. 

(4) As an exciting cause some cases of aneurysm date from a period of 
overexertion, exposure, and destitution, or from an injury. 

Diagnosis, — The diagnosis of a deep-seated aneurysm is sometimes as 
difficidt in the early stages as it is easy when the aneurysm is situated 
superficially. The diagnosis from cardiac vcdvular disease and other 
causes of cardiac hypertrophy (§ 43) is made by the occurrence of the 
pressure symptoms. Many of the local signs of a saccular aneurysm may 
be produced by a dilated and rigid aorta, but here the pressure symptoms 
are wanting. The throbbing aorta of aortic regurgitation is apt to be mis- 
taken for aortic aneurysm, and it is sometimes impossible to differentiate 
these conditions. The throbbing aorta in Graves' disease and severe cases 
of anaemia may also give rise to difficulty. Mediastinal growths, on the 
other hand, may have the same pressure symptoms as aneurysm, and may 
only be diagnosed by the absence of the physical signs referable to the 
heart. There is no murmur on auscultation over the dull region, the area 
of dulness is usually not so limited or defined, there is usually no expansile 
pulsation over the tumour, and there are signs of collateral circulation. 
Finally, the course of mediastinal tumours rarely lasts longer than eighteen 
months. Radiography is very valuable in the diagnosis of the presence 
and nature of intrathoracic tumours. 

Prognosis, — By treatment much can be done to prolong life, and the 
patient may live a good many years if his occupation does not necessitate 
much exertion. Death may occur in four ways — from rupture, exhaus- 
tion, cardiac failure, or complications. The rupture usually leads to a 
sudden and copious hcemorrhage, which terminates life ; but sometimes 
there is a slight leakage, which may recur at intervals of a few days. 
With aneurysm of the ascendirhg aorta rupture usually takes place into the 
pericardium, pulmonary artery, or superior vena cava ; with aneurysm 
of the transverse arch, into the trachea (a very frequent situation) or into 
the bronchi ; and, when the descending aorta is involved, the blood usually 
finds its way into the pleura or oesophagus. The process may be so 
gradual that there is no sudden onset of symptoms, such as dyspnoea, or 
cyanosis, or bleeding, and death may not take place for some time. But 
generally, as in the cases just narrated, it is copious and sudden, death 
speedily ensuing. The severity of any case is measured to some extent 
by the amount of dyspnoea present and the rapidity of the evolution of 
symptoms. Other consequences or complications are due, for the most 
part, to the effects of pressure — such as collapse or a low form of pneumonia 
of the lung, hydrothorax, and oedema of the head and neck. 



§ 64 ] OTHER MEDIASTINAL TUMOURS 96 

Treaiment, — The indications are three in number : (a) To lower the blood- 
pressure ; (6) to slow and steady the heart ; and (c) to increase the blood 
coagulability in the hope that laminated clot will form in the sac. Absolute 
rest in bed must be enjoined. This alone may accomplish very con- 
siderable relief, and there is no doubt that some of the extraordinary 
results claimed foi certain remedies have been due to rest. Much can be 
accomplished by diet. It should be of the smallest quantity consistent 
with life. Tufneirs'dietary^ is based on this fact, and in it only 8 ounces 
of fluid and 10 oimces of solid are allowed per diem. It must be persevered 
in for three to six months. The good derived from this dietary mainly 
depends on the reduction of fluid. Drugs should be employed to steady 
the heart and reduce the tension (Pulse, § 61). There is, however, one 
remedy which is undoubtedly capable of materially improving thoracic 
aneurysm — viz., iodide of potassium in large and gradually increasing 
doses, commencing with 20 grains, three or four times a day. 

Calcium chloride in large doses, in view of its known power to increase 
coagulation, is worthy of trial. The digestive organs often need attention. 
For the pain, morphia, atropine, or belladonna, internally or in the form 
of a plaster, are used ; if of anginoid character, nitroglycerine. Even if 
the dyspnoea is very urgent, do not perform tracheotomy imless it is due 
to bilateral laryngeal paralysis. If there be an external swelling, some 
elastic support is needed. Calomel is valuable for high arterial tension ; 
aconite for palpitation. For venous distension or severe dyspnoea vene- 
section may be performed. Surgical measures have been adopted from 
time to time in the treatment of superficial aneurysms, but they are not 
free from danger. Of such we may mention acupuncture, galvano- 
puncture, and the injection of coagulating fluids such as perchloride of 
iron (a dangerous procedure). Distal ligature of one of the great vessels 
sometimes leads to improvement, especially if it is involved in the 
aneurysm. 

Other Mediastinal Tumours. 

§ 64. The Symptoms of Mediastinal Tnmonr belong to three categories — namely, 
(a) the signs of displacement of organs ; (b) the physical signs of tumour ; (c) the 
symptoms of pressure. There are also {d) certain symptoms special to the different 
kinds of tumour. 

(a) The displacement of organs is sometimes the first intimation we receive. The 
liver is rarely displaced, but the lungs and heart are often pushed to one side, and the 
apex- beat may be found in the axilla. 

(6) The physical signs of tumour appear sooner or later on the anterior or posterior 
aspects of the chest, and consist of : (1) Dulness on percussion, corresponding to the 
position of the tumour ; (2) auscultatory signs, which differ somewhat with the 
position and nature of the tumour. If it be solid, the breath sounds will be tubular 
and perhaps differ on the two sides, and there may be an increased conduction of the 
heart sounds. If it contain fluid (such as aneurysm or, more rarely, hydatid) there 
will be a diminished respiratory murmur, and in the case of aneurysm a characteristic 

^ The solids may consist of wcll-cookod meat or fish and biscuit, and for the fluid 
10 ounces of milk are permitted per day. From 12 ounces to 18 ounces solid may bo 
permitted, but the fluid must not exceed 16 ounces. It must be combined with 
absolute rest, and drugs are better avoided. 



96 ANEURYSM OF THE AORTA [§54 

murmur (§ 53). (3) Ausculto-percussion will aid in dofining the boundaries of the 
tumour. (4) Radiography is used for defining the nature and position of mediastinal 
growths. 

(c) The 83rmptoms of mediastinal tumour which are due to preMure on the various 
structures around are as follows : 

(1) Dyspnoea always appears sooner or later, and may be of a type peculiar to 
mediastinal tumours when there is pressure upon the trachea ; it has a stridulous 
character, which resembles tubular breathing heard without the aid of the stethoscope. 
The breathlessness is often paroxysmal or asthmatic when there is pressure upon the 
heart and cardiac plexuses ; or it may be of a Cheyne-Stokes nature. But the char- 
acter of the dyspnoea depends upon whether it is the heart, the great vessels, the 
bronchi, or the nervous apparatus of the heart, lungs, or laiynx, which is pressed upon 
by the growth of the tumour. • 

(2) Cough, sometimes of a laiyngeal brassy character, is also present, and it is 
accompanied by expectoration if , as is usual, there is also bronchitis or congestion of 
the lungs. There may be laryngeal paralysis from pressure upon the recurrent branch 
of the vagus, and hoarseness, or even aphonia, may result 

(3) Cardiac and circulatory symptoms, such as palpitation, cyanosis, or a difference 
in the pulses of the two sides in the neck or radial arteries. There may be signs of 
collateral circulation, with enlarged superficial epigastric and mammary veins. 

(4) Dysphagia, from pressure on the gullet, is present chiefly with posterior media- 
stinal growths. 

(5) Inequality of the pupils may appear, owing to pressure on the sympathetic. 
Usually the pupil on the affected side is contracted from paralysis of the sympathetic, 
but it may be dilated during the stage of irritation. 

(6) Pleuritic effusion occurs if there be pressure on the thoracic veins or if there be 
growth in the pleura. 

(7) The inferior vena cava is rarely compressed, but lividity or oedema of the head, 
neck, and arms may occur from pressure on the superior vena cava. 

(8) In suspected tumour of the anterior mediastinum, it is well to remember that 
when the head is thrown back, the veins of the neck become distended, owing to the 
increased thoracic pressure producing venous obstruction. Dyspnoea is marked, and 
the sternum may bulge forward. 

(9) Pain down the arms and in the back occurs when there is pressure on the spinal 
nerve trunks. 

{d) Causes. — There are certain symptoms which are special to the nature and 
situation of the tumour. There are five clinical groups of tumours, in addition to 
aortic aneurysm. 

I. Malignant Tumours, which may be primary or secondary. If, in addition to 
the above physical signs, the expectoration present a constant prune-juice character, 
aud if on paracentesis a bloody fluid is drawn off, the presumption is strongly in favour 
of malignant tumour. The fluid may contain colls recognisable as malignant. Out of 
520 cases of mediastinal tumour, Hare^ found 134 were cancerous. Cancer of the 
mediastinum is the commonest mediastinal tumour, because it is usually secondary 
to cancer of the lung or oesophagus. In the latter case it is situated in the posterior 
mediastinum. Primary cancer, as of a bronchus, is rare, and tends to affect secondarily 
the anterior mediastinal glands. Sarcoma, especially lympho-sarcoma, may start in 
the mediastinal glands as a primary growth, or originate from the pleura and from 
the thymus remains. Primary sarcoma is most frequent in the anterior mediastinum. 
If secondary in origin (as when the abdominal viscera are the seat of the primary 
tumour), it occupies chiefly the posterior mediastinum. In primary mediastinal 
sarcoma enlargement of the glands in the neck and elsewhere may occur. 

II. Innocent Mediastinal Tumoubs, though more rare than the foregoing, are some- 
times found in the mediastinum — e.g., fibroma, dermoid cyst, hydatid. lipoma, gumma, 
and enchondroma, the latter growing from the sternum, are also occasionally met with. 

III. Enlabgement op the Mediastinal Glands. — ^With these there is often 
dulness posteriorly in the upper half of the interscapular space, but occasionally there 

^ Hare (" Mediastinal Tumours," Philadelphia, 1889) found out of 520 cases, 134 
were cancer, 98 sarcoma, 21 lymphoma, 7 fibroma, 11 dermoid, 8 hydatid, 115 sup- 
purative mediastinitis. 



§54] MEDIASTINAL TUMOUR 97 

is dulness over the sternum. Paroxysms of coughing, *' oroupy " or like whooping- 
cough, may be present, together with stridulous breathing from pressure upon the 
trachea. The eausta of enlarged bronchial glands are : 

(a) As described above, malignant dUeaae of the glands is the most common cause 
of enlargement. 

(6) TtAarcU, which is generally secondary to tubercle of the lungs. It is more 
common in children than in adults. The condition may be suspected when con- 
current disease of the lungs is present, and symptoms such as the above, arise. If the 
glands suppurate, sweatings and intermittent temperature become more pronounced 
than when the lung only is diseased. An abscess may form and open into a bronchus 
(compare IV. below). 

(c) Lymphadenoma (Hodgkin's disease) may start in the anterior mediastinal glands. 
Hare mentions twenty-one cases which ho included under the names " lymphoma '' 
(lympho-sarcoma) and " lymphadenoma.'* Lymphadenoma cannot be diagnosed 
with certainty from lymphoma unless the ordinary symptoms of Hodgkin's disease be 
also present — viz.. (i.) enlargement of the glands in other parts of the body; (ii.) 
attacks of pyrexia. 

(d) Bronchitis and the pneumonia which complicates measles, influenza, and whoop- 
ing-cough, are often attended by enlargement of the bronchial glands, which may 
occasionally be recognised behind the sternum in children. 

(e) Whooping-cough, without bronchitis or other disease of the lungs, may give rise 
to swelling of the bronchial glands, although the condition may be hard to make out. 
Some observers consider that it is the pressure of these glands which causes the 
paroxysms of whooping-cough. 

IV. SuppiTRATiVE MEOiASTnoTis (absccss of mediastinum) lb a rare condition 
which may afifect the anterior or posterior mediastinum, or both, but more often the 
anterior. (L) The most prominent symptom is pain, in the site of the inflammation, 
or passing down the nerves pressed upon. (iL) Dulness, with cedema and redness, may 
be present over the upper part of the sternum if the disease be in the anterior region, 
or over the dorsal spines if in the posterior mediastinum. Pulsation communicated 
from the aorta may be present, and lead to a diagnosis of aneurysm, but the pulsation 
is not expansile, and fluctuation may be felt, (iii.) Pyrexia is present, usually of a 
hectic type, with the rigors, sweats and weakness which attend all deep-seated inflam- 
mations, (iv.) The presence of leucocytosis is an important diagnostic feature. The 
causes of the acute form of mediastinitis are trauma, erysipelas, and the eruptive 
fevers. The chronic form is usually due to tuberculous disease. It may rupture in 
various directions. 

V. Enlarosmbkt of the Thymus. — A certain degree of enlargement is normal to 
childhood, and may cause dulness over the manubrium. It begins to decrease after 
the second year of life, and should have disappeared by adult life. In the status 
lymphaticus (§ 30) the thymus persists in adult life. An enlarged thymus is also 
foequently found in Graves' disease, and rarely in Addison's disease, myxcedema, 
mjrasthenia and rickets. Inflammation, oedema, and tubercle may afifect the gland. 
Tumours may occur — cysts, sarcoma, rarely epithelioma, lymphoma and lymph- 
adenoma. 

Prognosis, — In all cases of intrathoracic tumour which are large enough to produce 
symptoms the prognoss is unfavourable. Moreover, all of these conditions entail 
much sufifering to the patient. Malignant tumours are fatal in six to twelve months, 
depending upon the site and progress of the growth. Innocent tumours may last for 
a long time. Syphilitic, tubercubus, and simple inflammatory glandular enlarge- 
ments may recover under treatment, but even in these no confident prognosis of 
recovery can be given in any case. Suppurative mediastinitis may open externally, 
and run a course of a few days or weeks only ; other cases are chronic, and last for 
yearsp or lead to pulmonary gangrene and oUier serious complications when the pus 
bonows into adjoining organs. An enlarged thymus may lead to sudden death 
&om pressure upon the trachea. 

Treatment in intrathoracic tumour is almost wholly palliative. For aneurysm, 
see § 53. Abscesses, hydatids, or growths connected with the sternum may be dealt 
with by the surgeon in some cases. 

7 



CHAPTER V 

THE PULSE AND ARTERIES 

§ 66. The Meaning of " The Pnlie."— By the term *' pulse " is understood the expansile 
sensation communicated to the finger by the alteration in the shape of the artery, 
due to the momentary increase of blood -pressure which takes place during the systol<3 
of the heart, and which is transmitted to the periphery in the form of a wave. It has 
been shown that there is no dilatation of the artery ; the increased output of blood for 
the moment raises the blood-pressure, and alters the shape of the channel from an 
oval to a circle. The examination of the pulse is of extreme importance, not because 
it has a set of diseases of its own, but because it affords us so many valuable practical 
hints about the diseases of other organs, and about the general condition of the 
patient. " Many of the indications obtained from the pulse do not depend upon a 
comprehension of the circulatory conditions which the varieties of the pulse denote, 
or, indeed, upon a knowledge of the circulation at alL Observant physicians before 
the time of Harvey could gauge thoroughly the state of the patient in fever from the 
pulse, and it is not for the purpose of estimating the movement of the blood that we 
ourselves, in a case of fever, count the beats and note their force and volume. We 
calculate from the data thus obtained the strength of the sufferer, and the effect upon 
him of the disease. On the other hand, it is only through a knowledge of the con- 
ditions which govern the circulation that such facts as the connection between kidney 
disease and cerebral h»morrhage can be understood, and that the prognostic signifi- 
cance of the hard pulse, which betrays this connection, can be appreciated." ^ 

For the production of the pulse three factors are requisite : (i.) The con- 
tractions of the ventricle, which determine the frequency and rhythm of 
the pulse, and to a large extent its force ; (ii.) the elasticity of the large 
vessels ; (iii.) the peripheral resistance found in the arterioles and capillaries. 
These three factors must always be considered in studying the pulse. 

§ 56. dinioal Investigation. — ^It is preferable not to examine the pulse 
until the preliminary excitement occasioned by the doctor's visit has sub- 
sided ; and in all accurate records the pulse should be noted under similar 
conditions as regards the posture of the patient, time of day, relation to 
meals, etc. 

The radial pulse is the one usually selected for examination, since it is 
easily accessible and lies against a bone. But the pulse can be observed in 
other situations — e.gr., the temporal, dorsalis pedis, or popliteal arteries. 
Three fingers should be placed along the course of the artery, the index 
finger next the heart, and allowance shoidd be made for much adipose 
tissue. The different means of eliciting the several features will be dealt 
with below. When feeling the pulse, its special features may often be 

1 Sir William Broadbent. " The Pulse." first edition, p. 76. London. 1890. 

98 



i M ] CLINIC A L IN VEST 10 A TION 99 

brought out more fully by holding up both wrists with the fingers on the 
pulses. Only experience and comparison between all types of pulse can 
give to the physician the necessary aptitude for observation and correct 
inference. It is impossible here to enter upon all the complex data of the 
circulation, but the leading practical points which are of use in clinical 
work will be indicated. 

A complete observation of the pulse should comprise six features, the 
first four being the most important. 

1. Rate and Rhythm (i.e., regularity). — The rate of the pulse per minute 
is easily calculated by the watch, and in making this obserx^ation it should 
be remembered that a physiological acceleration occurs after any exertion, 
excitement, or after a meal, or may even be caused by nervousness on 
the visit of the doctor. The pulse is faster in the evening than in the 
morning, and it is faster by about eight beats per minute in an upright 
than in a recumbent posture.^ If the pulse be irregular, the type of the 
irregularity (vide infra) must be noted. 

2. The Farce or strength of the pulse depends largely upon the force of 
the heart beats, and is best measured by its com'preasibUity — the finger 
next the heart presses the vessel until the wave is no longer appreciable 
to the other fingers. By the amount of pressure required to obliterate 
the wave, the force with which the blood is propelled from the heart can 
be estimated. A " full bounding pulse " is one which has strong pulsations, 
but it is not necessarily one of high blood-pressure. Indeed, a full bounding 
pulse may occur in fevers where the blood-pressure is generally low. The 
strength of the pulse is measured by the force or strength of the pidse wave. 

3. The Character of Each Beat is observed by noting (i.) whether the 
pulse wave rises suddenly or gradually ; (ii.) the duration of the beat, 
whether long or short ; and (iii.) whether the decline is abrupt or gradual. 
It is important to note the presence or absence of dicrotvtm, which is a 
marked feature in low tension (see § 62). 

4. The state of the blood-pressure or arterial tension is perhaps the 
most important pathological feature of the pulse, and it is estimated by 
the degree of fulness of the artery between the pulsations. Normally the 
vessel is hardly felt between the beats if the wall is healthy. The vessel 
should be rolled transversely under the fingers, and, if the arterial tension 
is high, it stands out like a cord between the beats. 

5. The Size of the Artery and the State of its Walls will require fuller 
consideration later on, but it is important to note these features, because 
an artery of small size may give the impression of a weak pulse. The 

^ The pulse is faster in the female than in the male, and it varies considerably at 
different a^, tiius : 

in the foetus and new-bom infant its average rate is 140 per minute. 

Under 1 year „ „ 120 

Under 8 years „ „ 100 

From 7 to 14 „ „ 90 

From 14 to 21 „ „ 80 

From 21 to 65 , „ 70 

In old age ,. ,, 80 



100 THE PULSE AND ABTERIES [JM 

thickneaa of the wall must also be noted, because a thick-walled artery 
may give the impreBsiou of high arterial tension. 

6. The piUae of both Radial Arteries should be compared, so that any 
abnormalities may be detected. It should be part of the routine to 
examine both pulses, as by this procedure we may detect the existence of 
unsuspected disease, such as aneurysm or other intrathoracic tumonra. 
Abnormalities such as a more or leas superficial position of the radial on 
one aide or the other exist more frequently than is supposed. 

It will be advisable to consider the Pulae under five headings : ■ I. 
Rapidity; II. Infrequency; III. Irregularity; IV. High Blood-Pressure 
(or Arterial Tension) ; V. Low Arterial Tension, They are relatively of 
very different importance. Altoi-ations of tension are of the greatest 




Fia. H. FiQ. as. 

Fl«. M.— NOKMAL PHLSS TEioiSQ, taken wltb tbe »othQr'i modiflcMion ot Dndgton _ „,_^ . 

graph. Bate eg ; pceuDie (boat ! ooncea. Fig. ES.— -Norual PVlSI TkaCiXo (Fig. £4) 

"1, with th« namw of the iirindp«[ pftTta. The dletolic (or Jiortlc) notch indlatea 

~ of Uie sigmoid viivea, and therefore the lenoluation ol the ventricular >r>ta1e and 

jicement of the ventricular dlutole. The diailolic line li that part of the tracing 

froiD the dicrotic notch to the nent percusilon vave. 

moment, and irregularity comes next. The caosei of these will be 
considered ; their treatment, with the exception of high and low tension, 
belongs to the causal conditions. 

The Sphvohoobafr is an inBtmmont eniplojod to obtain a record on paper of tho 
characteTa of the palge. The linit one uBod was that of Mare;. In this instruniont a 
pad placed over the pulse is connected with the short arm of a lever ; tho long arm, 
which magnifies the pulse wave, is sharpened to a point, and makes a tracing on 
smoked paper. 

The handiest instrument, however, is that of Dudgeon. This is n littlo instrument 
which is strapped on to the wrist. Some years ago Weiss mode for mo a modification 
of the latter whioh can be used without a strtip — on appendage which I regard as un- 
necessary, since the instrument can more readily, with a little practice, be steadied 
and adjusted by the hand of the operator. The manipulation of any of these instru- 
ments is easily acquired by experience. The chief precautions are : (i.) To place the 
pad exadly over the artery, and it is of gieat assistance if the course of the Teasel has 
been pravioDsly marked by an aniline pencil \ (ii.) the omounl of prteaun uned, and 
the adjustment of the instrument, should be suoh as to obtain Uie most graphic 

The SPBYGUOOitAU or sphygmographic tracing is very useful as a gmphic record 
of the pulse, and to show the progress of the case from day to day ; but it does not 
tdl na as much as the ednoated finger, and its readings can never bo quite aocuiate 
because the exact amount of pressure exercised by the pad upon the artery cannot bo 
known. Figt. 24 and 26 represent a normal pulse tracing, the principal named porta 
of which it consiita being indicated in the latter. (1) Tbe jurautioa wave is abrupt 
and vertical in proportion to the force of the ventricular oontiootion and invaraely 



157] 



RAPID PULSE 



101 



proportional to tho peripheFal rosiBtanoe. (2) The tidal wave is prominent in pro- 
portion to the amount of peripheral resistance and the force of the ventrioolar con- 
traction — ».«., when the arterial tension is high. When the peripheral resistance is 
very low Uiere may be no tidal wave. (3) The dicrotic wave is pronounced and the 
aortic fioM more marked in proportion as the peripheral resistance and the heart force 
(i.e., tho arterial tension) aro low. 

Many instnimonte have been devised for tho measitremekt of the BLOOD-PtiESSUBE, 
tho most accurate of them would seem to be RrvA Rocci's Sfhyomomanometeb, a 
modification of which is shown in tho accompanying figuro (Fig. 26). Hill and 




Fig. 26.~Riva Bocci's Sphyomomanombtbr. 

The armlet should be wrapped round the patient's arm above the elbow (the arm Bhoold either 
be bare or at most covered only by a thin shirt) ; the armlet ihoald be ittrapped on, and it is im- 
portant to see that it fits snugly. One end of the rubber tube should be attached to the armlet, 
and the other end to the ciftero of the manometer, the inflator and liberating valve being in the 
middle. The left hand should be used for feeling thie pulse, and with the inflating bulb in the right 
hand, air should be pumped into the apparatus until the pulse at the writt ie felt to stop. The 
pressure, as indicated by the manometer at which this occurs, should be rcNsd off, and then (by a 
very slight turning of the milled head of the valve) allowed to decrease slowly, and the exact pressure 
at which the pulse returns at the wrist should be noted. This will be the maximum systoUe pressure 
in the brachial artery. After each observation the pressure in the apparatus should be released. 
The maximum systolic pressme for an ordtoary healthy adult is between 120 and 130 milli- 
metres of Hg approximately under fifty years of age, and between 130 and 145 millimetres in later 
years. To obtain the so-called diastolic pressure with this instrument, after the pulse at the wrist 
has been stopped, the pressure in the apparatus should be slowly released by a turn of the valve, 
and the pressure at which the maximum pulsation of the surface of the mercury in the msnomotei 
occurs should be noted. In taking repeated observations in the same patient, it is important that 
the same arm should be used each time, and that the patient should always be in the same position 

i.e., cither sitting or lying down. 



Barnard's sphygmomanometer, used with a broad armlet, is also very good. There 
are several portable modifications of the Riva Rocci sphygmomanometer now on 
the market. 

§ 67. Rapid Pnbe. — The rapidity of the heart-beat varies considerably 
within the range of healthy and in many persons the heart may occasionally 
beat 150 a minute for a short time without inconvenience. In infancy 
the normal rate is 130, and this may continue in after-life.^ The pulse 
is normally more rapid during the menstrual period and menopause, in 

^ See footnote, p. 99. 



102 THE PULSE AND ARTERIES [ f 58 

the evenings and after meals. After a severe illness the pulse more easily 
becomes rapid. 

The pathological causes of quick pulse are numerous. Apart from 
cardiac afEections, or Graves' disease, a quick pulse is relatively unim- 
portant in the young. In general terms it is only a serious symptom 
when met with in the latter half of life. It is very desirable in such cases 
to obtain a sphygmographic tracing, for the danger of a quick pulse may 
be fairly measured by the amount of dicrotism present. 

1. In diseases of the valviUar structures of the heart the pulse is quickened, 
more especially in mitral and aortic regurgitation ; and also in the later 
stages of all forms of valvular lesion when cardiac failure conmiences. 
In extreme dilatation, especially with auricular fibrillation, there is a 
condition known as delirium cordis, where irregularity and rapidity of 
action are combined. Foetal rhythm is also met with in dilatation (§ 44). 
An insidious chronic endocarditis, before the occurrence of a murmur, 
may be evidenced by tachycardia as the only sjTnptom for months. 
This is especially the case in mitral stenosis ; Balfour^ mentions a case 
in which the presystolic murmur appeared two years after the heart hurry 
commenced. 

2. In cardiac dilatation (apart from valvular disease) the pulse is 
quickened, especially if accompanied by arterial atheroma or sclerosis. 
In the latter half of life tachycardia is nearly always associated with 
dilatation of the heart, the result of a degenerative change. Thus, one 
of the earliest signs of the failure to compensate for the obstruction caused 
by arterial disease is a persistent tachycardia. Quick pulse, indeed, is 
regarded by some {e.g., Balfour, loc. cit.) as the leading feature of both 
" irritable " and " senile heart." 

3. Pyrexia is recognised as the most common cause of rapid pulse 
when the heart is sound. 

4. Various other toxic conditions increase the heart rate. The heart hurry 
which attends chronic alcoholism is very eerious, as indicating fibroid or fatty 
degeneration of the heart wall, or neuritis of the vagus. Tobacco first slows tho 
heart, but in large doses paralyses the vagus ; hence excessive smoking may induce 
paroxysmal tachycardia. Digitalis in large doses also paralyses the vagus (Bal- 
four). Belladonna increases the rate, fulness, and force of the beat, and increases 
the blood-pressure (Balfour), but in toxic doses it paralyses the vagus and produces 
tachycardia. Tea and coffee may produce temporary heart hurry. 

5. Many affections of the nerves, functional and organic, are attended by heart 
hurry, usually transient, but sometimes persistent. Emotional rapidity of the 
pulse is familiar to everyone. Paroxysmal tachycardia is described elsewhere (f 40). 
Tumours pressing on the vagus may be evidenced by tachycardia, even if the tumour 
be small ; a rapid pulse may, indeed, be the only symptom. 

6. In Graves* disease tachycardia is often the earliest symptom, and in this disease 
there may be throbbing in the whole arterial system, the heart sounds being clear 
and distinct. 

§ 58. Slow Pulse, Infrequent Pulse, or Bradycardia {i.e., slow heart), 
is met with under several conditions. In health a slow pulse is normal 
to certain individuals without any very obvious explanation, and without 

1 " The Semle Heart," 1894. 



f M ] SLOW FUL8E—8T0KE8'ADAM8 DI8EA8B 108 

any other symptoms. Napoleon is said to have rarely had a pulse-rate 
over forty. I have known a gentleman for twenty years, whose age is 
now eighty-two, who has never, to my knowledge, had a pulse-rate over 
fifty when in health : its average is forty. He has always enjoyed very 
good health. In some families it is met with as a hereditary condition. 
It is always well to verify an apparently slow pulse by listening to the 
heart at the same time, for in some cases the infrequency of the pulse 
may be due to some of the heart-beats not reaching the wrist. In disease 
a slow pulse is of importance chiefly in heart and brain disorders. 

1. In heart disorders a slow pulse without irregularity is uncommon. 
It may, however, be met with in connection with the senile heart, where 
it always indicates some degree of dilatation. Sclerosis of the coronary 
arteries, atheroma of the aorta, and fatty or other degeneration of the 
cardiac wall, may also be attended by bradycardia. It is one of the 
cardinal symptoms of Stokes-Adams disease. 

§ 69. StokM-Aiams DiMMe (Heart-Block) is a rare disease, first described by 
B. Adams in 1827, characterised by a permanently slow pulse, with syncopal and 
epileptiform attacks. The patients are usually advanced in years, complain of 
dyspnoea, and have marked bradycardia, the puke-rate ranging from 20 to 40. Any 
mental excitement is liable to bring on an attack. The breathing becomes stertorous, 
the face cyanosed ; there is dilatation of both pupils, rigidity of the body, accom- 
panied by clonic movement« of the limbs ; the pulse beats more and more slowly, and 
finally ceases ; the jaw drops, and for forty to eighty seconds the patient is to all 
appearance dead. No pulse is felt in either wrist, and on auscultation the cardiac 
sounds are inaudible. Then a feeble sound is heard, followed by a stronger, and a 
second later the pulse begins beating (one can feel the artery fill), the cyanosis lessens, 
the pupils contract, and consciousness returns. Many such fits may occur in succes- 
sion, from six to ten in a single night. There is no albuminuria. 

Etiology. — ^This symptom-complex occurs in association with arterio-sclerosis and 
myocardial degeneration in old people ; in young people with syphilis and coronary 
disease. There is a blocking of the normal stimulus and wave of contraction from 
the auricles to the ventricles, due to disease affecting the auriculo-ventricular muscle 
bundle of His. During an attack there is cessation of the ventricular systole, whilst 
the auriclee continue to contract. 

TrtaimenL — Inhalations of strong ammonia may avert an attack. The general 
condition requires attention. Strychnine and bromides are recommended. 

2. If a slow pulse is associated with marked high tension, arterial scleroaia should 
be suspected, even when no sign of arterial disease can be discovered. 

3. Various gastric derangements are frequently associated with a slow pulse, probably 
in a reflex manner. This is, perhaps, the commonest cause of slow pulse in children. 
In adults it may be associated with gastric ulcer and carcinoma. In chronic dyspepsia 
a slowness of the puke is usually associated with some amount of irregularity and 
intermission. 

4. Many nervous disorders may be associated with slow pulse. Thus : 

(i.) If the temperature is raised, the arteries contracted, and the pulse slower 
than normal, and if with this there be some irregularity in rhythm, and perhaps a 
reduplicated second sound, in a child, we probably have to do with an early stage 
of meningitis. 

(IL) Cerebral tumour is another nervous condition associated not infrequently 
with slow pulse. Here, however, it probably only occurs in the late stages, and as 
a pressure symptom. Halberton mentions a case in which a violent blow on the 
head was followed by a permanently slow pulse, with syncopal attacks, succeeded 
by epilepsy. The post-mortem revealed narrowing of the foramen magnum. 

(iii.) Various psychical disorders, such as melancholia, general paralysis, and 
epilepsy, may ako be attended by slow puke. 



104 THE PULSE AND ARTERIES . [ S 60 

(iv.) An abnormally slow pulse has been obsezred in association wiUi spinal injuries, 
especially a£Fecting the medulla and cervical regions. 

5. Drugs, such as digitalis and strophanthus, slow the rate of the heart, and, if 
irregular, steady its rh^iihm. Belladonna and tobacco at first slow the heart. 

6. Slow pulse is also met with in toxic conditions, such as diabetes, jaundice, uraemia, 
and poisoning by carbon monoxide. 

7. In states of prolonged exJiaustion and ansemia, and in convalescence from acute 
illness, bradycardia occurs. 

§ 60. Irregolar Pulse (Airhythinia). — Many forms of arrhythmia have 
long been recognised to occur. Recent work, especially by Dr. James 
Mackenzie and Dr. Lewis, has thrown light on the causes and significance 
of these different forms. The polygraph (§ 35) and electrocardiogram 
records may be required to elucidate certain cases, but these are beyond 
the scope of the average clinician. It is useful to remember that the 
contraction of the heart may start in four positions : (i.) At the mouth of 
the great veins, the normal or sinus rhythm ; (ii.) at the auriculo- ventricular 
bundle, when auricle and ventricle contract simultaneously ; (iii.) on the 
auricular side of the bundle, when the ventricle contracts independently ; 
(iv.) in the auricular tissue. Arrhythmia is a sign of abnormal action 
of one or other function of the cardiac muscle, and may be of trivial or 
of grave import. 

1. Clinically, irregularity of the pulse in the young is usually due to 
sinus irregularity. The length of the cardiac cycle varies with respira- 
tion ; the pulse beats are of equal size, without missed beats. The con- 
dition is more or less transient ; rest and building up of the general health 
are indicated. 

2. The intermittent pulse is not infrequently met with in health after 
meals, or as a constant feature, and it is restored to normal during exercise, 
excitement, or pyrexia. In this condition a pulse beat is missed, occa- 
sionally or frequently, after several regular beats. This form of irregu- 
larity is due to an " extra systole " — i.e., the auricle, or ventricle, or both 
together, start an independent rhythm, and so cause a premature small 
pulse beat, followed by a pause. Sometimes the extra systole is not 
capable of causing a pulse beat at the wrist. If the heart be auscultated 
the physician will hear the characteristic two short sharp sounds indica- 
tive of an extra systole coinciding with the absence of the pulse beat, or 
with the small premature beat, at the wrist. Thus auscultation differ- 
entiates intermittencv from heart block, in which condition no sounds are 
audible over the heart when a pulse beat is absent. The patient may 
experience no symptoms, or may be sensible of cardiac discomfort, palpita- 
tion, or transient giddiness, which alarm him. Intermittency may occur 
in neurotic states, or with dyspepsia, or a distended colon, or after tea, 
coffee, or tobacco, when it is of slight import. It may also occur in con- 
nection with alterations in the cardiac wall — e.g., in elderly people with 
fatty or fibroid heart, when it is due to changes in the auriculo-ventricidar 
bundle ; and after rheimiatism. It occurs also when digitalis has been 
administered long enough. A variety of the intermittent pulse is 



! a ] OAUSES OF IRREGULAR PULSE 106 

described as the pulsus higeminus ; the beats occur in couples, a strong 
beat being followed by a weaker one, after which there is a pause. 

3. In advanced cardiac disease the disorderly pulse of auricular fibrillar 
lion iq.v.) is of grave import. The beats are of varying size and intervals, 
no two are alike, and they are usually very rapid. Distressing dyspncea 
usually accompanies this condition, which occurs chiefly in mitral disease 
and cardio-sclerosis. Rest and large doses of digitalis are indicated. 

4. In the pulsus altemans the rhythm of the radial pulse is regular, but 
there are alternate large and small beats. This condition indicates that 
the contractile function of the heart is failing. It is a very grave sign in 
fibroid hearts, and indicates the necessity of rest. 

5. Irregularity may be due to failure of the conducting power of the 
auriculo- ventricular node. The ventricular systole may drop out, and 
thus the pulse misses a beat. This condition is rare. It may occur in 
influenza and other infectious diseases ; in rheumatic hearts, in cardio- 
sclerosis, and after digitalis. Heart-block is an extreme form of this 
condition. On auscultation the heart sounds are found to be absent at 
the time of the pause in the pulse. The pulse is usually slow, and Stokes- 
Adams syndrome may develop. 

In pfdsus paradoxus thero is completo, or ahnost oompleto, disappearance of the 
pulse daring inspiration. It irdue to cither (1) an increase of the '' negative *' intra- 
tboracio pressure which normally takes place at the end of inspiration, or (2) an 
extreme weakness in the left ventricle, or to both. Maguire has shown that it can be 
produced in even healthy persons at the end of inspiration by so contriving that the 
negative intrathoracic pressure can be suddenly increased. It is met with in intra- 
thoracic tumours, pleural effusion, modiastinitis, and adherent pericardium. 

The jfuUua bisferiens is a rare and peculiar type of pulse occurring in some cases 
of aortic disease (stenosis or regurgitation, and especially the latter). It is apt to be 
confused with the dicrotic pulse, though it indicates neither increase nor diminution 
of tension. A double beat is felt because the ventricle makes two distinct efforts 
during the systole. It is distinguished from dicrotism by becoming more evident 
by pressure, whereas the dicrotic pulse is obliterated by pressure. 

The anacrotic pulse is a somewhat rare condition, resulting from high arterial 
tension. In it the tidal wave is higher than the percussion wave. It is found in 
some cases of aortic stenosis and aneurysm, where the ventricle has to overcome 
abnormal resistance, and the blood cannot rush out in full volume during the systole. 

§ 91. ffigh Blood-Pramire (or high Arterial Tension, as it used to 
be called)^ is, in extreme cases, recognisable by palpating the radial artery ; 
but the digital method is so unreliable that no attempt should be made 
to gauge the blood-pressure except by means of an instnmient. There are 
several of these on the market. The best for the consulting-room are 
probably C. J. Martin's modification of Riva Rocci, or Oliver's alcoholic 
instrument. There are others which are more portable. The sphygmo- 
graphic tracing of high blood-pressure is shown in Fig. 27. 

The normal blood-pressure varies with age and circumstance. It is 
rather lower in women than in men, and lower in children than in women. 
The normal blood-pressure in a healthy adult of about thirty years of 

^ It is a common error to speak of " pulse tension,'' " high-tension pulse/' etc. It 
18 not correct to say that a wave has pressure or tension, but the terms have become 
sanctioned by custom. 



lOfl THE PVL8B AND ASTBBIB3 I J «1 

age may be taken as 120 millimetres Hg. The nonnat blood-piesanie 
rises gradually after that period, so that at sixty years of »%e a. blood- 
pressure of 160 millimetres Hg need not excite alarm. But at any age 
a blood-pressure of 200 millimetres Hg or over is a distinct danger-signal. 

The Symptoms which accompany high arterial tension, and which lead 
us to suspect that condition, are very important, though somewhat 
variable. They consist of (i.) headache, which may be frontal, occipital, 
or vertical, accompanied by vertigo from time to time, and a constant 
feeling of fukesa about the head, (ii.) There may be some lassitude, 
disinclination for exercise, and depression, (iii.) Breathlessnesa on exer- 
tion is common ; very often it is paroxysmal, and the patient thmka he haa 
asthma, (iv.) Wakefulness, or sleeping by dozes, ia not uncommon. 
High tension is rare in children, but these syinptoma occurring in adults, 
especially in those past middle life, arc suspicious, and are confirmed, il 
upon examination, we find the following physical signs : (i.) The pulse 
revealing the above characters ; (ii.) on auscultation an accentuated 
aortic second sound (some- 
times accompanied by a 
reduplicated first sound at 
the apex) ; (iii.) later on, 
if the condition persist or 
frequently return, cardio- 
vascular hypertrophy 
supervenes. 

Hg. 27.— HlOH TENaiON In a cine ot Chronic DHght's Th« CiiuMs o! high arterial 

IMacue, with Albuminuric Retinitis, under the aae tenaioii are nutneroua. Among 

"' ^: «■ ": B''''"*e- High len.101. 1> indict**! the prtrfiraoaiBff catMM heredity 

iBiphlcally by (l) prominent ol the tidal wave "'"*' r""*?" 7 . •' 

(oulew the »rteriei are very atheromatoua) ; (a) smaU- undoubtedly plays a most un- 

iieM of the dicrotic wave, and ita occunence hlgli up portaDtpart. No age U exempt, 

un tho diastolic lino : |3) eradaal (loping ot the but it is found far moie fre- 

aiMtollc line toward, the next m-trokc ^^^^^j^ ^^ ^„j ^^ ^^j^ j^^ 

As regards sex, males are more 

Bubj^l U> tho diueaoe, siiico thoy are mom exjiOBod to the dietetic and other influences 
which raise blood -presBU re. Exciting causoa bring into opeiation one or more of tfaree 
pathological factors— increaxed periphoral resistance, incioased cardiac force, or 
increase in the volume of the blood. Tho exciting causes ai« as follova, arranged 
aa nearly aa possible iu order of importance ; 

1. Anything in tho mode of lite which loads io deficient oxygenation and tlimina- 
lion of nilrogenoua wagU, such as : (L) Excosa of nitrogenous food ; alcoholic drinka 
of any kind, even in moderation ; sedentary habits ; constipation. (2) Toxie eon- 
dilimu of the blood act probably iu the same way. (I) Renal disease is a familiar 
antecedent and accompaniment of high arterial tension, (ii.) Gout. High arterial 
tension so frequently accompanies this condition that it is known sometimes as the 
"gouty pulse." (iii.) The diabetes which occurs in peisoDs past middle life ia attended 
by high tension, but not that more fatal form of diabetes which occurs in younger 
aubjeole. (iv.) Plumbism, which is intimately connected with gout and renal disease. 
(v.) Emphysema, and sometimes other lung conditions (probably by deficient 
oiygeuatiou). (vj.) An semia sometimes, (vii.) Pregnancy. (3) Any condition lead- 
ing to a per«ittetU contraction of the arterioles reaulte in high arterial tensioB. It is 
highly probable that some of the above toxic conditions may act in this way. 
(4) PUOufra, by increasing the volume of tho blood, may rcsalt in increased arterial 
tension. (5) In cardiac hypertrophy there is a great tendency to high blood-p "" 



! 6E ] HIGH BLOOD-PRESSURE 107 



Whenever the heart beats more rapidly and more poweifuUy — as, for instance, during 
excitement or during exertion — there must necessarily be a rise of pressure. This 
is usually transient, but if frequently repeated, as in athletes, it may be a forerunner 
of a persistent high arterial pressure. (6) In certain neuro-vascular diseases there 
is a tendency to dilatation, and in others to spasm, of the peripheral vessels. In the 
latter {e.g,, Raynaud's disease) there is a frequently recurring tendency to high blood- 
pressupe. 

Pathological Effects of High Blood- Pressure and Prognosis, — Temporary 
high arterial pressure is not serious, but when it constantly recurs or con- 
tinues over many months or years, it has grave results. By the physio- 
logical law that increased function results in increased growth, there is 
hypertrophy of the muscular tissues of the whole of the vascular system — 
that is to say, hypertrophy of the heart and of the muscular tissues of the 
arteries (Arterial Hypermyotrophy, § 68). This may be said to constitute 
the first stage. If the increased pressure continue, a degeneration occurs 
in the musctdar tissue of the heart and of the arteries (§ 67). The second 
stage is manifested chiefly by the failure of the heart to compensate for 
the increased peripheral resistance caused by the rigidity of the arteries. 
Certain accidents are liable to occur as the result of high blood-pressure, 
even when this is functional only. Chief amongst these is hsemorrhage. 
A person with high blood-pressure may bleed from anywhere ; rupture of 
the arteries into the internal capsule or other parts of the brain, rupture 
of retinal arteries, hsematemesis, haemoptysis, bleeding from the nose, 
bleeding from the gimis, are all common. When undue pressure on the 
arterial system has been in operation for some time, changes take place in 
the coats of the vessels ; in the larger vessels, such as the aorta, it leads to 
atheroma ; in the smaller vessels, to sclerosis. Arterial disease of both 
kinds is usually very patchy in its distribution. Thus, sclerosis of the 
vessels in the renal area gives rise to granular kidney ; in the hepatic area, 
to cirrhosis of the liver ; and in the vessels of the brain, to what are known 
as senile manifestations. 

The treatment of high blood-pressure in its functional stage is one more 
of general hygiene than of drugs. Salines and mercurial purgatives are 
of the highest value. Vaso-dilator drugs, such as the nitrites, have a very 
transitory efEect (Fig. 28). If the blood-pressure, as measured by the 
manometer, reaches an unduly high figure, venesection should be practised, 
and the patient relieved of at least 20 ounces of blood. Hot baths, Turkish 
baths, electric light baths, high-frequency currents, and, indeed, anything 
which will dilate the cutaneous vessels, should be advised, but walking 
exercise is probably the best. The iodides of potassium and sodium in 
large doses produce good efiects on the blood-pressure. 

§ 62. Low Blood-Ptessiire may be suspected if the pulse, when counted 
with the patient erect, is rapid, and the rate falls 30 or 40 beats when the 
patient is placed in the recumbent posture. As measured by the mano- 
meter, 80 millimetres Hg is regarded as a dangerously low pressure. 
To the examining finger the pulse comes up rapidly, rapidly declines, and 
is very easily obliterated. In very low tension a double wave is felt, the 



lOS 



TEE PULSE AND ABTBJtlSS 



[}U 



second one being small ; this is known as the dicrotic paUe. A sphTgmo- 
graphic tracing bIidwb an increase of the normal depiession (aortic notch) 
before the dicrotic wave, and the dicrotic wave itself is more marked 
than in a healthj pulse. 
When the aortic notch 
falls below the level of 
the base line, the pulse 
is said to be kt/perdicrolic 
(Fig. 28, e). SympUmuoi 
depression, lassitude, 
prostration, and some- 
times dyspepsia and 
sleeplessness, occur in as- 
sociation with low arterial 
tension. Purgatives can- 
not be well borne, and 
the patient may feel 
better when the bowels 
are constipated. Capil- 
lary ptiUation is some- 
times met with in low 
arterial tension, particu- 
larly with aortic legui^- 
tation. By drawing a 
line along the forehead, 
or lightly pressing down 
the tip of the nail, the 
alternate blush and pallor 
due to the capillary pul- 
sation is well brought 
out. In extreme states 
a pulse may even be 
communicated to the 
veins on the dorsum of 
the band. 

Causes. — In health a 
persistent 8tat« of low 
tension is sometimee, 
though rarely, a heredi- 
tary condition. It may 
be foimd also after meals, 
a warm bath or moist 
warmth. 

1. With cardiac mimt- 
lar disease, in all phases 
of failing compensation, 



■inga showing [he e 



MuUn B., 
nephritlB. i 
In tbe Wi 
B, Typical t 



aged forty- H" 



; puenchymatoiu 
_ WlUUm Oalrdner 

n I nflrm a r y, Glasgow, Auguat, 18fl5. 

teiiaiOB. Tracing b showi the leducUos 
ui U1IBUIU luHu IB gtaiiiB lodium nitiite In tour dmca 
duilDB the twenty-lour boun. The remedy was continusi 
and tradngi e and <i on succeBBlve dayi show the giadnal 
redndlonof tenBlonelleeKd, They are nonaal eioepUng 
for Hw esaggeratsd aorOo wave. In the hut traejng e a 
l^ondltlon of STfebdiosotibii 1« ihown, the higb toniloa 
havliu been entirely replaced by tbe oppotlte extreme 

.,,._.... ..__„.j t.. ■.,. .y g (;|j_j|j^ ^^^ ^^ ^^ hoUlB- 



JO] LOW BLOOD-PRESSOSE 109 

there is low tension. The pulse of aortic regurgitation is so characteristic 
that the lesion can be diagnosed by it. It conies suddenly up to the finger, 
and as suddenly collapses. This has received the name of " stot^," 
" slapping," " water-hammer " or " collapsing " pulse, the pulse of unfilled 
arteries, or Corrigan'a pulse, after thejname of the phyaician who first 
described it (Fig. 30). It is best brought out by feeling the radial while 
the patient's hand is held up vertically on a level with the head. In thia 
condition tie radial pulse is 
distinctly postponed — that 
is to say, the pulse at the 
wrist occurs later than the 
apex-beat. Moreover, the 
srtery in aortic iegu^t£- 
tion is lai^, in contradis- 
tinction to aortic stenosis, ^ _ .^ -^ . 

, ,, „' Pig. !«.— Low-TiHSiox.PruB Tk*oi!io. from ■ ««« o! 

where the artery is small. Enuno F«ver, ihowiiw muked DioBoruit. Patl«nt 

The sphygmographic tracing *^^ thirty-«Yen. 

of the " water-hammer " pulse shows a long percussion stroke, scarcely any 
tidal wave, with a sndden down stroke, broken only by a small dicrotic 
wave. In oaaes of a double aortic murmur, this pulse is of great diag- 
nostic significance. If the pulse has a distinctive " water-hammer " 
character, the systolic murmui is due not to aortic stenosis, but simply 
to roughening of the valves or atheroma of the aortic wall. 

2. The pulse is of low tension in all advanced states of cardiac failure 

3. Without o^anic heart disease low blood- pressure is met with in 
neurasthenia, in Addison's disease, tuberculosis, and in all staUs of ei- 



Fl(. 9a.~WATBK-EAlIifKB Plil»,— Tradng (Uken by l)r, Renlnald E, Hnnaon) frnm ■ man, 
and tUr^-fooi, wltb tyilcal aartifl regorgltUlaD, UKompuUed by very grwt caidisc hyp«r- 
tn^Ay Cbovine hMit). WeU-mukad eapUlarr poliatlon >nd lettnol pulutlou vtie prtaenl. 
Trpfol wdlaiaina or watw-tummer pobe. He bad Iwd anslnold lUacks, which neie leLieved 
bf lodiam nlbrite. At tba time tradns was taken pulio wu Si, reapliation 21, and blood- 
pnanue (taken by HIU and Baniard'i Initrnment) KO. 

iatMttoH and debility, such as are caused by over- exertion, physical or 
mental, deficient and bad food, or anxiety — conditions in which vaso- 
motor paresis might occur. In its extreme form it is recognised clinically 
u sui^ical shock or collapse. It is common in adolescents and causes an 
albuminuria (owing to congestion of the kidneys), which has no pathological 
significance (§ 291). 

^1. Low blood- pressure is also met with in all atlhenic varietia of fever, 
especially enteric fever and peritonitis (Fig. 29). 



110 THB PULSE AND ARTERIES [ K 6S,.64, 66 

Treatment depends upon the cause. The food should be nourishing 
and easily digestible. Change of climate is often beneficial. Iron, arsenic, 
quinine, strychnine, and digitalis are all useful. In collapse warmth should 
be applied to the surface and pituitary extract injected hypodermically. 

§ 68. The Patoe in Relation to VtogaoiaB and Treatment of Diieaie. — 
In acute febrile diseases a full bounding pulse is usual, and its absence 
warns us that we are in the presence of an asthenic and more dangerous 
type of case. It is in fevers also that the pulse is our chief guide as to 
whether alcohol should be administered or not. In enteric, for instance, 
if the pulse is weak and the vital powers flagging, stimulants are called 
for, but not otherwise. This was Murchison's rule. In chronic affections 
the pulse is not so valuable an indication of the patient's general condition. 
Perhaps the most important fact to bear in mind is that in the aged, and, 
indeed, all persons past middle life, the pulse should be carefully watched 
from time to time, because a constant high pressure is the main cause of 
arterial degeneration and many of the most lethal diseases to which persons 
in the latter half of life are liable. Constant high blood-pressure affects 
the heart (§ 61). 

The administration of digitalis and other cardiac remedies must be 
regulated by the condition of the pulse. Thus in cardiac valvular disease 
with slow full pulse digitalis should not be given, but only when the pulse 
b of low tension, quick or irregular. The prognosb of auricular fibrillation 
may be gauged by the extent of the response to digitalis (§ 51). If, on 
the other hand, the pulse becomes irregular or too slow during the ad- 
ministration of digitalis, the drug should be at once withdrawn. 

The supervention of acute inflammation within the abdomen — needing, 
perhaps, prompt surgical interference — is indicated by a rapid pulse, 
an3rthing over one hundred is my own guide. The supervention of inter- 
mittency is a still more urgent sign. 

The student should learn by constant and repeated observation what 
important lessons can be learned from the pulse. 

ARTERIAL DISEASE. 

§ 64. Symptomatology. — Among the symptoms to which arterial 
disease may give rise are giddiness or ^' dizziness," feelings of faintness, 
slight syncopal attacks, headache, paroxysmal dyspnoea, gangrene, or 
other conditions referable to the extremities (Chapter XVII.). But 
each of these symptoms, excepting the last named, may be caused by 
disease of some other physiological system. It is only when several of 
them are met with together, and an examination of the heart and arteries 
lends confirmation to the idea, that we are led to conclude that the 
vascular system is at fault. The importance of arterial disease depends 
more upon its effects on the heart, and indirectly on the other organs and 
tissues of the body, than upon the vascular condition per «e. 

§ 65. Pfaysioal Signs of Disease of the Arteries. — The physical signs 
are very few in number, and consist simply of a visible or palpable thick- 



SM] ATHEROMA 111 

ening, dilatation, or tortuosity of the superficial vessels, such as the 
temporals, radials, brachials, and sometimes carotids. There are three 
features to note concerning the accessible arteries : (i.) The size of the 
artery should be observed as we compress or roll it beneath the fingers— 
a feature which sometimes required considerable experience to recognise, 
(ii.) The thickness of its wall; and it must not be forgotten that high 
arterial tension may produce the sensation of a thick wall, and vice versa. 
The thickness of the wall is best ascertained by stopping the pulse with 
the fingers of one hand, and rolling the empty tube beyond the under 
fingers of the other hand, (iii.) By passing the fingers up and down 
the length of the tube, the bead-like thickening due to atheroma may be 
detected. 

The arteries are much more prone to disease than are the veins, which 
is in keeping with the greater liability of disease to attack the left than 
the right side of the heart — at least, during extra-uterine life. The Chronic 
Diseases of the Arteries which admit of clinical recognition are as follows : 

L Atheroma. II. Arterial Sclerosis (synonyms : Arterial Fibrosis, Arterio- 
oapillary Fibrosis, etc.). III. Arterial Hypermyotrophy. IV. Functional Disease 
of the Arteries (9e'3 Diseases of the Extremities, Chapter XVII.). V. Aneuiysmal 
Dilatation. VI. Chronic Endarteritis, due to syphilis and other causes, is only 
recogniaed by its pathological effects (cerebral softening, gangrene, etc., see Diseases 
of the Nervous System : Anatomy). Acute Endarteritis is generally part of Acute 
Endocarditis (§ 39). VII. Embolism, or the blocking of an artery by an embolus, 
is the result usually of cardiac disease, especially infective endocarditis ; or it may 
be secondary to thrombosis. VIII. Thrombosis, or the coagulation of blood in a living 
vessel, is usually the result either of local disease involving the vessel, or of some blood 
change. Both this and Embolism are dealt with elsewhere. See, for example. 
Localised Dropsy, or Phlebitis (Diseases of the Extremities, Chapter XVII.). 

§ 66. Atheroma. — ^Atheroma has unfortunately come to be used in a somewhat 
vague sense, but it is taken hero to mean a localised or patchy thickening of the tunica 
intima, ooctirring for the most part in patients past middle age, unaccompanied, as 
a rale, by any obvious symptoms during life. It starts as a localised hyperplasia in 
the deeper (external) layer of the tunica intima ; and the change may go on to a fatty, 
caseous, and sometimes calcareous, degeneration. When it is advanced, the middle, 
and even the external, coats may be invaded. It is generally more or less wide- 
spread, but the disease nearly always commences and predominates in the larger 
vessels — ».e., in the aorta and its branches. Consequently, if it be detected in the 
radial or temporal, the inference is that its distribution is extensive and that it involves 
the vesseb of the brain also.^ 

Symjitofns are generally altogether wanting.^ However, when the disease involves 



^ Some observers say that, with the exception of the coitonary arteries and the 
vessels of the brain, it does not usually affect the smaller arteries, but I have satisfied 
myself of its existence in the radials and nearly all the arteries of that size in the body 
in advanced oases of atheroma. 

^ This absence of symptoms has sometimes led me to conjecture whether atheroma 
might not be, in a sense, a conservative process, an idea which is further strengthened 
by two other important cireumstances — viz., (I) That the change was most constantly 
found in those situations exposed to the shock of the systole, as, for instance, on the 
upper aspect of the areh of the aorta and in the angle of the bifuroation of arteries. 
(2) It was a constant — and therefore, one might say, a physiological — change in 
ffreater or less degree in aU elderly people dyins in the Infirmary, no matter what might 
be the cause of <&ath. One of the veiy notable cases was that of a woman, aged one 
hundred, who died of pneumonia, and who had not at any time presented any cardio- 
vascular symptoms during life. | 



112 THE PULflE AND ARTERIES t|B7 

the ftoita (Mid it nearlj' «lir»yB oomiuenoes in thkt aitualion), it impairs the sUatioitf 
of that Btniotiiie, and gives rise to an accentuated second aound of the heart in the 
aortio aiea. In the mora advanced oases atheroma maj sometimes be detected ft) a 
nodular oi beaded thickening in the ladial, temporal, and other superficial arteriM, 
which can be fait by moving the Gngen up and down the artery. The p«tient U. 
hovever, unavaro of ita existence, and ma; live to old age, unless he 1m aabjeot to high 
tension or other cardio-vasoular disonier. 

C(mitquence». — HiBtologioally, the change is almost indijtiaguisfaable from the 
■Tphilitjc endarteritia which oocurg in younger persons, and it is only by the >ge of 
the patient and tbe history of syphilis that the latter can be diSenmtiBted. Tbore 
is, however, a third important difference — viz., whereas syphilitic end»r(«ntw 
commonly lesulta in thrombosis, atheroma ntroly does so, unless degenerative changes 
occur. Htemorrhage is apt to occur in those cases, due not to the atheroma, but to 
thinning and dilatetion of the vessel on the proximal or distAl side. Occurring, as it 
does, only in old people, it i« accompanied by, and possibly aids in the production of. 
debility and other eigns of old age ; but it is wonderful bow oxtreuely common wide- 
spread patchy atheroma is even in 
bealthy old people who die of pneu- 
monia or some other interourrent 
maUdy, e.g., the woman aged one 
hundred (see footnote 2, p. 111). 

No Ireatnitnt will remove the 
atheromatous condition, bat ita 
prasenoe is one of the indioatioiu 
for the avoidance of the caiUM of 
high arterial tension. 
Fii.31.— TrNaiLSE)iiLEPci,sE.~w.F.,s«sdfi!ghty- { Q7 Arterial Boleroili.— The t«rm 
al(ht. Bbow* ths Bit^top {of virtual untioit, "arterial soleroais" is here used in 
UioMniiepuHe. "* wi»iomioal Sense, as a generic 

term to mean any widecipread 
thickening and hardening of the arterial coala which leads la toss of elMtioity and 
contractility of the arteries which is dinwJly recojnuabU. It is too often forgotten 
that what may tw called the " parenchyma " of the arterial system — -that is to say, 
its functionally active part— is the middle or rauBouUreoat. Upon the proper func 
tioning of this coat deijends the whole of the regulator mechanism of the arterial 
system, Myexperience»ttbePaddingtonInfirmary,whiob offered a very extensive field 
for researches into the pathology of the vagaular syslom. went to show that, although 
very wide changesmightBiist in the tunica intimaor tunica adventitia without symp- 
toms, very slight changes in the media were nearly always attended by tome kind of 
symptom or effect during life. Histologically, therefore, I differentiate intimal, adven- 
titial, and medial sclerosiB — the last named bemg by far the most important. ' The 
subject of arterial disease is surrounded with conaideiable obscurity, partly because the 
same words are used by different observers in very different senses, and partly on account 
of the difEoulty of making a sufficiently cihaustive examination of the entire arterial 
system in any given cose. A dozen sections of the liver, for instance, will give a fair 
idea of a morbid change in that organ ; but to fonn an accurate conception of the 
structuial changes in the arterial system in any given case, it may be neoesaary to 
carefully examine one or two hundred sections, taken from many different tossbU, 
and to make very accurate maumranenU of these, both naked eye and microeoopio. 

Symjdonu.-^the clinical courae of the disease may be divided into 
two stages : (a) That in which the ventricular hypertrophy is Bufficient 
to compensate for the increased peripheral resistance ; and [b) that in 
which the left ventricle begins tfl fail— that is, fo yield and dilat*. 

(a) In the first stage (1) the patient may be fne fot many years from 
any^symp toms referable to the vascul ar system, so long as tie incaeased 
IBM^^" *^™' SolerosU." (TransaoUons of the Pathological Bociety of >London~ 



iWJ ABTBSIAL 80LEBO8IS 113 

peripheral resiBteace ia adequately and not esceBsively compensated 
for by the ventricular hypertrophy. SometimeB the patient may come 
to m for loBs of vigour or breathleBsneSB ; but more often the thickened 

veaaelo are discovered, so to speak, by accident, when the patient cornea 

nndet our notice for some other malady. On examination, however, we 

may find that the arteries are visibly and palpably thickened at the wrist 

and on the temples, being cord-like, and sometimes elongated and 

tortuouiB. The feel of the vessel 

much resembles that of high 

arterial tension (a condition, by 

the way, whicli may coezist in 

the earlier stages), but by com- 
pressing the pulse above and so 

emptying the vessel, and then 

feeling the artery beyond, the 

thickening of the wall may be 

readily revealed. By sliding 

the fingers up and down, it may 

be distinguished from the bead- ' 

ing of atheroma. (2) As the 

disorder progresses, the patient 

loses his former vigour, mental 

and physical. He is, in a word, 

"old before his time," for it 

has been truly said a man is 

" as old as his arteries." This 

loss of vigour is no doubt due 

to the fact that all the oigans 

and tissues are deprived of that 

regulation of nutrition which 

depends upon the elasticity and 

healthy contractility and re- 
laxation of the muscular tissue 

of the arteries. (3) Breathless- 

nesa, and a tendency to rapidity 

of pulse after slight, or even 

without, exertion are, in my 
experience, the next most con- 
stant features. Somerimes the dyspncea is paroxysmal, and the case 
resembles asthma. The heart is irritable, and this is evidenced clinically 
by breathlessness and a pulse which easily becomes rapid and irregular. 
(6) When the second stage is reached, symptoms arise which, as a 
whole, form a distinct and well-marked clinical picture. They are due 
partly to failure of the arterial functions, but mainly to the failure of 
cardiac compensation. In addition to the preceding, which become 
emphasised, the symptoms are as follows : (1) Vertigo may have occurred 



!1e, 82.— AitebUL SOIBROSIS.— Suction or ■ ladlaL 
aiteiy DusaUlad >bOD( 400 dluoeton, ■talmd 
vrltb uld OKeIn to (how gnnnlu dagensn- 
tloD at moiak flbm in tlu middle coat, wtdcli 
conuueuon and pndom^iatat in Ot inltrnal layeri 
0/ iRi'ddl* coal. Tbbi niatbod ol pnpantlan brbigs 



, _ J Gull and 

Sutton maiDtalimd. Tha >pp«uuices dncilbsd 
by tbem M uUrlo-capUIanr flbrwls ma »l«aya 
be produced by prolonsed httrdanins caapled wKti 

Diufficleat staialDg vKh lofwood. 



114 THi PVLSi AHfD ARTERIES [ f 67 

before the second stage is reached, but the attacks now become more 
frequent. Indeed, about nine-tenths of the cases of senile vertigo met 
with in the infirmary could be traced to this malady. It is not, however, 
a true vertigo, but rather a sensation of " swimming in the head " or 
** dizziness," and the patient feels either as if he were " going to fall " or 
*' going to faint." So frequently did these attacks occur among tiie 
aged and so-called " healthy " old people in the workhouse that they 
used to pay but little attention to their frequent falls due to this cause. 
(2) Actual fainting attacks are met with less frequently, but when present 
they are of more serious import. They vary from a slight interruption 
of the continuity of thought on the one hand to a j)rolonged faint or 
epileptiform seizure on the other. (3) Physical signs pointing to a varying 
degree of h3^rtrophy and dilatation of the heart are revealed on ex- 
amination, together with accentuation of the second sound over the 
aortic cartilage, if high tension be present. (4) Anginoid attacks, or true 
angina pectoris, is another symptom. Quite three-fourths of the cases of 
angina pectoris met with in the infirmary were attended by this condition. 
(5) In extreme states of the disease, especially when accompanied by 
atheroma or endarteritis, there may be gangrene of the extremities, cerebral 
softening, either localised or difhise, and similar changes in other viscera. 
Miliary aneurysms may arise in the periphery of the arteries of the brain, 
and haemorrhage in this situation is one of the most frequent consequences. 
There is always in these cases a tendency to the development of low 
forms of inflammation, especially *^ senile pneumonia." (6) Renal 
fibrosis (chronic Bright's disease) — i.e., granular or gouty kidney — is 
very frequently, but not necessarily, associated with arterial sclerosis. 
Some hold that chronic Bright's disease is essentially a generalised arterio- 
renal disease, and that, although arterial thickening may occur without 
renal disease, the latter is always attended by more or less arterial change. 

In the Etiology (1) heredity is certainly one of the most important 
factors, and families are found in which every member shows a tendency 
to this disease on reaching a certain age. (2) As regards age, the disease 
is, with rare exceptions, only met with in the latter half of life '} and it 
is rather more frequent among men. (3) The pathology of the complaint 
is not yet worked out, but in many cases careful inquiry will reveal one 
or more of the causes of a constant high tension {q.v.). Various toxic 
blood states possibly act in this way, and there is often a history of alcohol, 
lead, or gout. (4) Overwork, and physical strain by leading to an over- 
filling of the arteries, are also possible causes, on the principle that increased 
function causes first increase of structure, and, later, degeneration of the 
muscular coat. 

Diagnosis. — Arterial sclerosis may have to be diagnosed from (1) high 
arterial tension, by stopping the blood current and examining the artery 

^ Syphilitic artenal disease is a patchy endarteritis which occurs in younger subjeota 
usually more or less localised, and therefore does not come within the scope of our 
cpening definition. 



} 68 ] ARTERIAL SCLEROSIS 1 15 

beyondj (2) atheroma, which gives to the vessel an unequal or beaded 
character. (3) Granular kidney, in its slow, insidious onset and vague 
symptoms, closely resembles arterial sclerosis in its clinical history, and 
can only be distinguished from it by the presence of urinary changes. 
The arterial and the renal changes are frequently associated. (4) Other 
causes of progressive debility (Chapter XVI.) may have to be distinguished 
from arterial sclerosis. 

Prognosis. — In the first stage, though nothing can be done to abolish 
the thickening of the arterial walls, much may be done to prevent its 
advance, and if the patient escape pneumonia and other inflammatory 
conditions to which he is liable, he may live many years. The whole 
question of prognosis turns very largely on the state of the heart. If 
the breathlessness is considerable, and the physical signs show marked 
cardiac dilatation, and the pulse is irregular and rapid, the patient is 
not likely to live more than a year or two. If, on the other hand, cardiac 
compensation is good and the patient feels but little distress on movement, 
then the outlook is not unfavourable. 

TreatmefU. — The indications for treatment are (a) to keep down the 
blood-pressure ; {b) to aid the heart ; and (c) to avoid any extra strain 
being thrown upon the heart or vessels. (1) Hygienic measures are of 
great value, and the patient's duration of life will depend upon the kind 
of existence he can afford to live. He should live a very regular life, free 
from any strain on mind or body. The diet should be strictly moderate, 
especially as regards proteids, and should be readily digestible. Unless 
heart failure is very pronounced, alcohol should be avoided. The 
calcium salts in the blood are said to be eliminated by sodium bicarbonate 
(2^ drachms) neutralised with lactic acid, 6 ounces of water are added to 
this, and it is taken in twenty-four hours. At any rate, this relieves many 
of the symptoms of cardiac dilatation. (2) The heart needs our special 
attention, and cardiac tonics and other remedies may be administered 
on general lines (see Cardiac Failure, § 51). The question of Schott baths 
and passive exercises is a most important one, and while some advocate 
them strongly, others say that they are attended with considerable danger 
by increasing the tendency to haemorrhage and the other consequences 
above referred to ; but, in my belief, if the arterial disease is not very 
advanced, the heart undoubtedly derives considerable benefit by this 
treatment. 

§ 98, Arterial Hypermyotrophy is a term which has been employed by the author 
to imply a generalised increase in the muscular tissue of the arteries. In a paper 
read before the British Medical Association at Bournemouth, in 1891,^ based upon 
a collection of cases which were observed in the Paddington Infirmary, it was shown 
that a generalised increase in the muscular tissue of the arteries occurred as a distinct 
clinical and pathological entity, consequent, in all probability, on states of prolonged 
or frequently recurring high tension, by the simple physiological law that increased 

^ Cases of arterial hypermyotiophy and the resulting degenerations in the muscular 
tissue were published in the BriUsh Medical Journal, January 23, 1897, and the Trans- 
actions of the Pathological Society of London, 1904. 



116 ^ THE PULSE AND ARTERIES [ f 

function leads to increaaed structure. In 1895 Drs. Dickinson and Eolleston ^ showed 
that a widespread increase of the muscular tissue of the arteries occurs throughout 
the body in some cases of renal disease. Sir Clifford Allbutt^ has described under 
the name Hyporpiesis (constant high blood-pressure and its attendant symptoms), 
a condition which, from a clinical standpoint (for none of the cases were confirmed 
by autopsy), probably corresponds with the condition which the writer, from an 
anatomo-clinical standpoint, has called ** arterial hypermyo trophy." 

Tho change itself consists of a hypertrophy of the middle or muscular coat of the 
arterial walL It affects principally the medium and small-sized arteries of the body 
— those which normally contain more of this tissue than is found in the laiger vessels. 
Patients may exhibit no sjrmptoms, and rarely die in the early stages of the disease 
or until some granular or other degeneration has taken place in the hypertrophied 
tunica media. The condition, however, is by no means an infrequent one, to judge 
from tho records of the Paddington Infirmaiy, and if it were not such a laborious task 
to examine the arteries of the body, more cases would doubtless be revealed. ^ 

Symptoms, — (1) The arteries have a thickened but elastic feel, although they may 
be of normal size. In a few cases the author has been able to confirm this by means 
of Oliver^B arteriometer. The prolonged first stage is always accompanied sooner or 
later by cardiac hypertrophy. It may exist unknown to the patient for many years, 
and be overlooked by the doctor, or, like arterial sclerosis, discovered accidentally. 
Sooner or later, however, one or more of these symptoms arise, viz., (2) postural 
vertigo from loss of arterial adaptability to posture ; (3) dyspnoea (sometimes of an 
asthmatic or paroxsymal character) ; (4) persistent or recurrent headache ; and 
(5) symptoms of high arterial tension. (6) In the second stage of the disease, when 
granular degeneration and consequent rigidity are present, the symptoms are in- 
distinguishable from those of arterial sclerosis, which, in point of fact, supervenes. 
It is more often found in persons over forty. 

Effects. — Tho results of the thickening in the first stage are (i.) a diminution of 
the lumen of the vessels by reason of the tonic spasm ; (ii.) a more or less permanent 
increase of arterial tension (blood-pressure); {iu.) pari peissu with the arterial thicken- 
ing and high tension there is hypertrophy of the left ventricle. As the result of the 
insufficient or ill-regulated blood-supply, the tissues are insufficiently nourished, 
and tend to degenerate, and are more readily prone to inflammation and disease. 
Tho patient loses his mental and bodily vigour. In the second stage cardiac compensa- 
tion faib. and the middle coat of the arteries degenerates — the consequences of which 
are identical with arterial sclerosis above described. Arterial hypermyotrophy is 
no doubt often associated with granular kidney, probably in about haj^ the oases. 
But from the cases which the author has collected, it is evident that arterial hyper- 
myotrophy may occur quite independently of renal disease of any kind. 

The Prognosis of the condition in its early stage is favourable, if the patient can 
live a careful life, although its existence adds to the gravity of intercurrent diseases. 

The Treatment in the early stage is that of high arterial tension (§ 61) ; in the later 
stages that of arterial sclerosis (§ 67). Symptomatic treatment is always useful. 
For tho breathlessness, nux vomica and digitalis, and aperients, especially I or 2 grains 
of calomel, are at all times useful. For the attacks, especially the vertiginous attacks, 

^ See the Lancet, 1895, vol. ii., p. 137. 

3 The Lane Lectures, Philadelphia Medical Journal, April, 1900, pp. 400-500 ; and 
elsewhere (e.g,, "" The Hunterian Oration,'* c 1885). 

^ It has been said in criticism of these observations that the change consists of a 
swelling of the individual muscular fibres rather than a numerical increase. This is 
difficult to refute, because the opportunity does not often occur of examining the 
arteries before the granular swelling — which is also a consequence of the same cause 
(high tension) — has also occurred. But, in the first place, I would point to the actual 
occurrence of true h3rpertrophy in renal cases, as shown by Rolleston and Dickinson. 
Secondly, I have occasionally been fortunate enough to secure cases — dyine by 
accident, for example — which undoubtedly exhibited a true hypertrophy wiUiont 
degeneration. Thirdly, a very careful examination of several of my oases shows that 
there was an actual increase in the unstriped fibres, in addition to tneir degeneration ; 
and, fourthly. Sir Clifford Allbutt's clinical observations undoubtedly lend confirma- 
tion to the existence of such a pathological condition as arterial hypermyotrophy. 



§»] ARTERIAL HYPERMYOTROPHY 117 

nothing gives bo much relief as nitioglyoerine, and for the severe ones oooasionai 
inhalations of amyl nitrite. This is an undoubted fact, and constitutes one of the 
reasons in support of the theory tiiat these seizures are of entirely circulatory origin. 
It also supports the idea that it is muscular spasm, and not the degenerated arterial 
wall, which produces the vertigo. For the fainting attacks, alcohol is indicated in 
small doses, but I have found that alcohol in anything but very Amall quantities 
aggravates the symptoms and consequences of the disorder. 

f 69. Fnnetional DiseMes of the Arteries. — Of functional diseases or vaso-motor 
derangements we know but little, although several very important maladies are 
attributed to this cause — €.g., Raynaud's disease and migraine. Functional derange- 
ment of the arteries is also manifested by a large number of S3rmptoms; many of which 
are vague and evident only to the patient. On this account they are apt to be 
regarded by medical men as unimportant, and it is true tiiat they are not serious in 
the sense of being letiial ; but to the patient they are often extremely disagreeable, 
irksome, and often terrifying. Of such we may mention alternate flushing and 
palk>r (" flush-storms *'), dead hands, cold hands and feet, chilblains, various other 
erythematous conditions, blue nose, palpitation, tachycardia (f 40), paroxsysms 
of copious urination, acropanesthesia, erythromelalgia, feelings of suffocation, pseudo 
and true angina pectoris, feelings of tingling, itchi^. throbbing, and actual swelling 
of the limbs. A case of the last named is referred to under the heading (Edema 
(§ 425). 

Aneuryiinal Dilatation of the Arteries belongs to surgeiy. excepting aneurysm of 
the thoracic aorta (see f 53). the abdominal aorta (§ 188), and the cerebral arteries 
(CSiapter XIX.). BmboUsm and Thromboeit are referred to under Diseases of the 
Extremities (Chapter XVII.) and the Brain (Chapter XIX. ). 



1*« THE PULSE AND ARTERIES 

function 1^ to increaaed structure. In 18ft5 Dre. Diokmson and 1\< , i 
th»t a widc«prMd mciMae of the muscmJar tissoe of the arteries n. . 
the body in eome caees of lenal disease. Sir Cliffoid AUbutts has d 
the naine Hypoipieos (constant high blood-pressure and it« attenda 
a condition which from a clinical standpomt (for none of the caM- • 
by •utopey). pioUbly eoneeponds with the condign which the u 
anatoimM^lmical standpoint, has ^lled " arterial hypennyotit,phv. 

The change it«oif consists of a hypertrophy of the middle or unisc 
ertonal waU. It afifects principaUy the medium and smaU-sized art. 

--tho» which noimaUy contain more of this tissue than is found iu t 
Pfctiente may exhibit no symptoms, and rarely die in the early Bta^. 
or untU some gmnuUr or other degeneration has taken place in li 
tumca media. The condition, however, is by no means an infrvuu, 
ffom the «conis of the BMidington InfirmaTy. and if it were not .u. 1. 
to examine the artenes of the body, more cases wouW doubtless hv n 

bympamt — (1) The arteries have a thickened but elastic feel a] 
be of noiinal siic. lii a few cases the author has been able to contim. • 
of Ohver 8 artenometer. The prolonged first stage is always accon 
later by caidiac hypertrophy. It may exist unknown to the patio, f^ 
^ be overlooked by the doctor, or. hke arterial adeiosis. discover,. < 
Sooner or Uter, however, one or more of these symptoms ari«e .. 
mfvo frem bss of arterial adaptalrility to posture ; (3) dyspnc^n' 
uthmatic or pa«)«ymal character); (4) persistent or 4eunvnt 
(5) symptoms of high arterial tension. (6) In the second staire of ti. 
gimnular degeneration and consequent rigidity are present the ^ 
dietmguishable from those of arterial sclerosis, which, in p<iint J' 
It is more often found in persons over forty. 

i-^ecto—The results of the thickening in the firH stage are .i , 
the lumen of the vessels by reason of the tonic spasm ; (u!) a mci, 
mcieaw of arterial tonmon (blood-prcssure); {m,) pari passu with o. 
uig ^d high tenaon there is hypertrophy of the left ventricle. A. 
msuffici^t or lU-reguUted blood-supply, fh^ tissues are in^u]' 

The patient loef« his mental and bodily vigour. In Oie *eco«rf staiz. 
tion fails, and the middle coat of the arteries degenerates— the o< 
are identical with arterial sclerosis above described. Arterial 
no doubt often associated with granular kidney, probably in 
But from tile cases which the author has collected, it is evident 
iD>-otrophy may occur quite independently of renal disease of <n^ 
The ProgfUisu of the condition in its eariy stage is favoi,,'. ' ' 
live a careful hfe. although its existence adds to the gravity of 
The Treatment in the early stage is that of high arterial tin^i 
stages that of arterial sclerosis (f 67). Symptomatic trca* 
For the breathlessness. nux vomica and digitalis, and aperin t^ 
of calomel, are at all times useful ^or^ attacks. especiaJ i 
» See the LancH, 18»5, vol. ii, p. 137. 
a The Lane Lectures. PhUadelpkia Medical Journal A , -, 
elsewhere (e.g„ ** The Hunterian Orataon." c 1886) ' 

» It has been said in ori^ism of these obeervatious tli^ 
Bwelling of the individual muscular fibres rather than • 
difficult to refute, because the opportunity does not If" 
arteries before the granular sw6llmfl---whioh is also a < . 

(high tension)— has also occurred. Bol^ a tiM fiist p5 . 
occurrence of true hypertrophy m tmml mmm^ wmaho.l 
ijeoondly. I have oocasioiial^ hmm talmHlt en< ., 



con-. 



t*. 



iJNlOfi 



accident, for example— whM «il49^Mli|RcJMJUbit 
degeneration. Thiiditj. a ^^*>QF JMBI^BK^n 
there was an actual Jniiiwai 
and. fourthly. & O 
tion to the exirtnwt «Ei 




V 





H 




119 

that recurring wheezy cough, 

' tuchitis. I ] 

vomiting occur in whooping- 

^^9 is attended by paroxysmal 

iN HO also is the rupture of an 
jh, with or without expeotora 

' tads and other mediastinal 

uons is very characteristic, and 

' occurs in nervous and hysterical 

five disorders, where there is 

, and with chronic liver disease. 

L in the early morning and on 

^h early phthisis. There may or 

/ innda. When a patient com- 

1 lying down, the uvula should 

••' of congestion will cause con- 

t it will irritate the back of the 

M assumed. A night cough is 

'is in children. 

h^of hysteria is very character- 

>n. 

>ciated with pleurisy or pleuro- 

diagnostic; in the former it is 

)ciated with aneurysm and other 
11 once heard is readily recognised. 
tion in the area of the pneumo- 
^tinal disorders, such as dyspepsia, 
Iren ; (ii.) pericarditis ; (iii.) carious 
})acted wax ; (v.) abdominal disease 
•hragm — e,g., by subphrenic or liver 



•f cough is somewhat important in 

1 may be met with, affections other 

ort dry cough is set up by going into 

•il congestion or irritation. In simple 

1 in paroxysms, especially after talking. 

ii comes on in a warm atmosphere, we 

11 ic irritation of the larynx or trachea 

morning, when a paroxysm is induced 

i-". glairy mucus. The face is congested, 

. vomiting. 

iids upon the cause, but, in general terms, 
lied by bromides, minute doses of opium, 



CHAPTER VI 

THE LUNGS AND PLEURiE 

Owing to the extreme vascularity of the lungs, it is not surprising that 
inflammation of these organs is a frequent complication of acute general 
or blood diseases. Thus, inflammation of the lungs is one of the commonest 
accompaniments of the acute specific fevers and other microbic disorders. 
Again, in the generalised blood infection which arises from a local tuber- 
culous focus, the lungs are, as we should expect, frequently the seat 
of tuberculous lesions, and there are three actUe forms of tuber- 
losis in which the lungs are more or less involved — namely, a 
tuberculous form of Acute Pneumonia (§ 87a), Acute Miliary (generalised) 
Tuberculosis (§ dSla), and Acute Pulmonary Tuberculosis (§ 83). All the 
blood of the body is oxygenated in its passage through the lungs, and the 
lungs are in consequence the great defensive organs of the body. Close, 
heated rooms with tainted air not only prevent the lungs from duly 
performing their defensive function, and hence decrease the power of the 
blood to cope with disease, but they are also the means of conveying 
disease to the lungs themselves. Chronic pulmonary tuberculosis (phthisis), 
one of the scourges of civilisation, is due to the inhalation of air containing 
tubercle bacilli. Both for the protection of the lungs themselves and of 
the entire organism which demands a pure blood-supply, the importance 
of the gospel of fresh air cannot be overrated. 

PART A, STMPTOMATOLOar. 

The Cardinal Symptoms of diseases of the lungs are oongh, lireath- 
lessnesf , expectoration, and sometimes iMun in the chest and h»moptyiifl. 

The more general symptoms are pyrexia, emaciation, and debility. The 
heart, more especially the right side, suffers sooner or later in all serious 
or prolonged pulmonary diseases by interference with the pulmonary 
circulation. 

§ 70. Concerning Cough, if it is attended by expectoration (as in 1 to 
4 below), it points to definite changes either in the lungs or throat. If 
without expectoration (as in 5 to 8 below), it may point to simple con- 
gestion of the throat or larynx, to the presence of pleurby, to the early 
8ta^e of some pulmonary disorder, or to some source of reflex irritation. 
The Causes of Cotigh are as follows : 

118 



§70] OOUQH 119 

1. The commonest form of cough is that recurring wheezy cough, 
attended by expectoration, 8o^t3rpical of bronchitis. i ] 

2. Paboxtsms of coughingTfollowed by vomiting occur in whooping- 
cough and advanced phthisis. Bronchiectasis is attended by paroxysmal 
cough with foetid expectoration at intervals, so also is the rupture of an 
empyema into a bronchus. Paroxysmal cough, with or without expeotora 
tion, occurs with enlarged bronchial glands and other mediastinal 
tumours. 

3. The HAWKING cough of throat affections is very characteristic, and 
is met with in catarrhal pAaiyn^^i^. It also occurs in nervous and hysterical 
subjects. It is also associated with digestive disorders, where there is 
often a collection of mucus in the pharynx, and with chronic liver disease. 

4. The iRRrrABLB cough, most marked in the early morning and on 
going to bed, is especially associated with early phthisis. There may or 
may not be much expectoration. 

5. A NIGHT cough may be due to a long uvula. When a patient com- 
plains that a cough is worse at night or on lying down, the uvula should 
be carefully examined. A slight degree of congestion will cause con- 
siderable elongation of the uvula, so that it will irritate the back of the 
phamyx when the recumbent posture is assumed. A night cough is 
also associated sometimes with threadworms in children. 

6. The long barking or nervous cough^of hysteria is very character- 
istic. It is unattended with expectoration. 

7. The SHORT SUPPRESSED cough associated with pleurisy or pleuro- 
pneumonia is so characteristic as to be diagnostic; in the former it is 
unattended by expectoration. 

8. The GANDER or brasst cough associated with aneurysm and other 
mediastinal tumours is typical, and when once heard is readily recognised. 

9. The REFLEX cough, due to irritation in the area of the pneumo- 
gastric, may be caused by (i.) gastro-intestinal disorders, such as dyspepsia, 
constipation, diarrhoea, or worms in children ; (ii.) pericarditis ; (iii.) carious 
teeth ; and (iv.) ear troubles, such as impacted wax ; (v.) abdominal disease 
in which there is irritation of the diaphragm — e,g,y by subphrenic or liver 
abscess. 

The Diagnosis of these varieties of cough is somewhat important in 
practice, since they arise from, and may be met with, affections other 
than those of the lungs. When a short dry cough is set up by going into 
the cold, it may be due to phar3n[igeal congestion or irritation. In simple 
throat affections the cough comes on in paroxysms, especially after talking. 
On the other hand, if such a cough comes on in a warm atmosphere, we 
should suspect phthisis. In chronic irritation of the larynx or trachea 
the cough is worst in the early morning, when a paroxysm is induced 
by the effort to bring up a little glairy mucus. The face is congested, 
there is difficult inspiration, even vomiting. 

The Treatment of cough depends upon the cause, but, in general terms, 
irritable coughs may be soothed by bromides, minute doses of opium, 



120 THE LUN08 AND PLEURA [ §§ 71, 72 

heroin (yV to } gr.), by a linctufl of squills and tolu, or by various medicated 
lozenges, such as the B.P. morphia and ipecacuanha and krameria lozenges. 
§ 71. Breafhlessness, or dyspnoea, is another symptom of lung alEec- 
tions. The causes of breathlessness are dealt with in more detail in the 
symptomatology of cardiac disorders (§ 20). The types of breathlessness 
special to respiratory disorders are : 

1. Breathlessness attended by sniffino and nasal bubbling is caused 
by nasal or naao-pharyngeal catarrh. The obstruction in the nose or 
mouth usual in such a condition may also cause considerable stertor at 
night-time. 

2. Stbidxtlous respiration, in which the stridor attends both inspira- 
tion and expiration, is caused by obstruction in, or pressure upon, the 
trachea or larynx. It is accompanied in severe cases by drawing in of 
the epigastrium and lower costal cartilages during inspiration (§§ 1226, 127, 
and 128). 

3. Dyspnoea attended by considerable whbbzino or rhonchi in the 
chest is very characteristic of br<m(A%tis, attended usually by emphysema. 

4. The LABOURED respiration which attends other grass diseases of the 
lungs is different from any of the foregoing. Under this heading also 
comes the expiratory dyspnoea of emphysema, which is due to the fixation 
of the chest in a position of inspiration. Undoubtedly the conmionest 
lung condition giving rise to dyspnoea is emphysema, which is revealed 
by a barrel-shaped chest and h3^r-resonance. 

5. A rapid respiration with altered pulse-rbspiration ratio is almost 
diagnostic of lobar pneumonia. In children there is seen in this disease 
a characteristic working of the alse nasi. 

6. Paroxysmal dyspnoea is present in asthmatic attacks, but is more 
often an indication of cardiac disorder (§ 20a). 

§ 72. Pain in the Oheit is usually present with affections of the pleura, but other- 
wise it is not a constant symptom in pulmonary disorders. The various causes of 
pain in the chest are enumerated in § 23. The following are the chief types of pain 
met with in diseases of the lungs : 

(i.) The SHARP, cutting, stitch-like pain of pleurisy, before the effusion separates 
the inflamed surfaces, is greatly aggravated by drawing a long breath. This is un> 
doubtedly the commonest of the pulmonary causes of pain in the chest, and this 
symptom in pneumonia indicates involvement of the pleura. It must be remem- 
bered, however, that in some sub-diaphragmatic diseases — e,g., of the liver, spleen, or 
colon — pain is also felt on deep inspiration. One of the most intense forms of pain 
in the chest is due to diaphragmatic pleurisy. It is referred along the lower costal 
margin, and is accompanied by very shallow respirations, which are chiefly or entirely 
thoracic. Hiccough is occasionally associated. (iL) A sorbnbss behind the upper 
part of the sternum attends the onset of acule bronchitis, (iii.) Sxtdden severe pain, 
followed by considerable pulmonary and general distress, occurs with the onset of 
pneumoUiorax. (iv.) Suddkn pain, attended by hasmoptysis, marks the occurrence 
of embolism of the lung or rupture of an aneurysm into the lung, (v.) Cancer of the 
lung may or may not be accompanied by pain, according to its proximity to the 
pleura or other sensitive structures, (vi.) All mediastinal tumours give rise sooner 
or later to pain in the cheat. 

The presence of expactoration or sputum is an important sign ; its 
physical appearance may lead to the diagnosis of certain lung diseases. 



§78] CAUSES OF HEMOPTYSIS 121 

It must be examined by the physician, and it is therefore described in 
§ 78. It must be remembered that children usually swallow sputum ; 
so also adults with bad habits or unconsciousness. Expectoration from 
the pharynx must not he mistaken for expectoration from the bronchi or 
lungs. The amount of coughing rerfuired to void the sputum may aid 
diagnosis — e.^., in the early stages of bronchitis much coughing brings up 
a little tenacious sputum, in the later stages moderate coughing brings up 
much forthy muco-purulent sputum. 

§ 78. Haemoptysis means the spitting of blood (affia, blood ; irnV), 
to spit), but the term is confined to the expectoration of blood from the 
organs of respiration. 

T\i& fallacies with regard to this symptom are very important, and it 
is sometimes as difficult as it is important to decide whether the blood 
comes frofti the throat or nose, from the stomach, or from the limgs. The 
differentiation is given more fully under Haematemesis (§ 192), but it may 
be mentioned here that blood coming from the lungs is thus characterised : 
(i.) It is preceded and accompanied by a tickling cough (if the blood be 
large in quantity it may excite retching on toucUng the pharynx) ; 
(ii.) the patient usually goes on coughing up a little blood for some time 
afterwards ; (iii.) the blood has a bright red colour, is alkaline, and frothy 
(if very profuse, it may be dark in colour and without froth) ; (iv.) physical 
signs of disease of the lungs are usually, though not always, present — 
they may be absent in the early haemoptysis of phthisis ; (v.) the ante- 
cedent history of the patient may point to pulmonary tuberculosis or to 
cardiac disease, these being undoubtedly the most conmion causes of 
haemoptysis. 

Causes, — For practical purposes the causes of haemoptysis may be • 
divided into two groups : 

(a) Those which produce slight and sometimes protracted or recurrent 
bleeding ; and (b) those which produce a copious bleeding at one time. 

(a) Causes of Slight and Sometimes Protracted Hcemoptysis, — I. Phthisis 
is by far the commonest cause. The haemoptysis of phthisis may occur 
either in the early or in the advanced stage of the disease, and in either 
case it may be small or very large in amount. The presence of this cause 
may be recognised (i.) by the previous and family history of the patient ; 
and (ii.) by evidences of congestion, consolidation or cavitation of the 
lung (§ 77). Nevertheless, the most careful examination may fail to reveal 
any signs, because haemoptysis is frequently the earliest symptom of 
invasion by the tubercle bacillus. 

II. Cardiac Disease, especially mitral stenosis or the late stage of 
mitral regurgitation, is the next most common cause of haemoptysis. 
It may arise in such cases either from congestion, or, more rarely, embolism 
of the lungs. In both cases evidences of cardiac disease are present. 

in. Various Pulmonary Diseases other than phthisis may be attended 
by slight haemoptysis. Thus, in a^mte bronchitis the sputum may contain 
streaks of blood from time to time ; and in pneumonia the sputum is rust- 



122 THE LUNGS AND PLEURJB [ f 7Sa 

coloured about the third or fourth day of the illness. In chronic bron- 
chitis with emphysema the sputum may at times be blood-streaked. The 
haemoptysis due to carcinoma of the lung may be recognised by the irregu- 
larity of the physical signs. Abscess and hydatid may cause bleeding. 

IV. Ulobration of the upper part of the respiratory passages may 
give rise to haemoptysis, small in amount, and apt to be recurrent. A 
careful examination of the throat and larynx generally reveals this cause. 

V. VioARioirs Mekstbitation as a cause of hsBmoptysis is disputed by some. It 
is recognised by ite oocnrrence at the time when menstruation is due, the normal 
menstrual function being absent, and by the absence of signs of disease in the 
lungs. 

VI. GoKSTiTUTiONAL or idiopathic causes. There are certain patients in whom 
slight hsemoptjrsis occurs from time to time, the history and examination revealing 
nothing, and the patient living to a good old age. The haemoptysis in such cases is 
explicable by two hypotheses — ^the presence of undiscoverable tuberculosis, or a 
transient congestion due to some constitutional cause. Thus Sir Aitdrew Clark 
found •hffimoptysis in subjects of the arthritic diathesis. It occurs in subjects of 
arterial and renal disease. 

§ 78a. Pulmonary Embolism complicates mitral disease, septic venous throm- 
bosis, and other conditions in which there is intra-vitam clotting in the vessels. Small 
emboli may give rise to few clinical signs, the chief being pain in the chest, sudden 
dyspncsa and hsBmoptysis. The appropriate treatment is the administration of cardiac 
and general stimulus — e,g., strychnkie, digitalis, ether. 

When large thrombi are dislodged from distant parts and travel to the lung, the 
patient dies at the moment of their impaction in the pulmonary arteries. There are 
no premonitory symptoms ; even the existence of a clot may be unsuspected. Suoh 
clots are not uncommonly found to have originated in the pelvic veins. Cases of 
sudden !death following operations when the patient appeared to be in excellent con- 
dition are usually due to this variety of thrombosis. For these cases there lb no 
treatment except a watchful care lest patients are allowed to get up too soon after 
operations. 

(b) Causes of Hcemoptysis in which there is a Considerable Quantity of 
Blood at One Time — ^I. Phthisis. — Copious bleeding (which may be con- 
tinuous, perhaps for hours or for a day or two), without ending fatally, 
is almost invariably due to pulmonary tuberculosis. The chief features 
by which it is recognised are given above. 

II. Rupture of an Aneurysm into the trachea or bronchus is a by no 
means rare accident in the history of that malady. It is the one cause 
of haemoptysis which is usually followed by immediate death, though 
in some cases there may be a considerable leakage going on for a day or 
two before the final issue (§ 53). 

III. Ulceration of the larynx, throat, trachea, though usually causing 
small and recurrent haBmorrhages, occasionally leads to a large amount 
of hsBmorrhage. 

IV. Purpura, hsemophilia, scurvy, leucocythaemia, and some other 
Blood CoNDmoNS may be attended by bleeding from the lungs. These 
causes are for the most part rare, but when present are readily recognised. 
It may also occur with the eruptive fevers. 

Differentiation. — In order to arrive at a diagnosis of the cause of 
haemoptysis in any given case, we must first of all examine the chest 
(lungs and heart) very thoroughly; secondly, use the laryngoscope to 



§ 74 ] PULMONARY EMBOUSM 123 

investigate the larynx and naso-pharyngeal passages; and, thirdly, we 
most inqniie into the patient's history. 

* The Prognosis depends, of course, upon the cause. Hsemoptysis is 
nearly always a serious symptom, and when profuse is followed by con- 
siderable debility. In this way it may hasten the end of an advanced 
case of phthisis. But the h8Bmopt3rsi3 of early phthisis, though indicating 
definite involvement of the lung tissue, is not so serious, and with 
proper precautions the patient may completely recover and live to 
old age. 

Treatment, — (a) For projuae hcBmorrhage immediate treatment is 
necessary. The patient must be kept at absolute rest in bed. Ice is 
usually applied to the chest, but it should not be kept on in one place 
longer than twenty minutes at a time. The nourishment allowed must 
be cold. A hypodermic injection of morphine (gr. ^), or full doses of 
opium with acid, sulph. dil., or turpentine internally (T1\^xxz. in mucilage 
four-hourly, and gradually reduced), are the most efficacious remedial 
drugs for early administration. Ac. sulph. dil. (T\x.) with alum (gr. v.) 
may then be given every twenty minutes. A large dose of ergotin succeeds 
in some cases. Whitla recommends turpentine vapour in the room. 
Other drugs recommended are amyl nitrite, which dilates the arteries and 
so relieves the veins and capillaries, gallic acid, hazeline,^or atropin or 
digitalis hypodermically. Full doses of ipecacuanha or other emetics 
have also been reconmiended. 

(6) When hsBmoptysis occurs in small ^pMntity, calcium chloride (g. xx. 
every four hours) renders the blood more coagulable, and is specially useful. 
The hssmorrhage of congestion due to cardiac disease should not be checked, 
unless it becomes excessive, as it relieves the pulmonary congestion. 
When hssmoptysis occurs in elderly arthritics, give a sedative cough 
mixture, saline purgatives, iodides, and cod-liver oil. 



PART B. PHT8I0AL EXAMINATION. 

The physical examination of the lungs is carried out by means of 
Inspection and Mensuration, Palpation, Percussion, and Auscultation. 

§ 74. biqieotion and HensoratioiL— The inspection of the chest must 
be carried out in a good light, and the patient must be instructed to 
stand or sit erect, or, if in bed, to lie flat and evenly, and to breathe deeply. 
After noting the movements from the front, examine the back, then look 
from behind over the clavicles in order to make out the slighter distor- 
tions or inequalities of the chest. By inspection and mensuration we note 
(1) the rate and character of the breathing ; (2) the shape and size of the 
chest ; (3) the chest capacity. The chief landmarks of the chest are 
mentioned in § 31, and the regions into which, for descriptive purposes, 
it is divided anteriorly, are given in Fig. 33. Posteriorly the chest is 
divided into the suprascapular, scapular, and infrascapular. The 
scapular region is divided, by the scapular spine, into the infra- and supra- 



12* TBB LVSaS AND PLEVBS { % 74 

BpinouB regions. The names sufficientlj indicate the positions of the 
various regions. 

1. Bate and Charade of the Breaiking. — The rate Taries normally from 
1*1 to 20 per minute, or onp-fonrth the rale of the pulse ; and any diange 
in this proportion, or pulse- respiration ratio, should be observed. Notice 
whether the breathing is rapid, slow, shallov, or irr^fular. The respira- 
tion should be counted without the patient's knowledge ; thus while 
counting the breathing, it is a good plan to feel the radial artery as if you 
were examining the pulse. Both sides should move equally. Flattening 
or immobility of any part of the chest points to disuse of that part of the 
lung — e.g., from consolidation. Flattening or protrusion of the inter- 



ns, »:),— Anleilflr Thotacln Ragionii. 

spaces indicates fluid. Drawing in of the interspaces on both sides during 
inspiration is indicative of some interference with the free entry of air into 
the lungs (inspiratory dyspnoea), as in diphtheria or other cause of obstruc- 
tion of the larynx or trachea. Ckeyne-Stokeg breathing is a peculiar 
rhythmical irregularity of breathing (see § 20b). When movement of the 
chest causes pain, as in pleurisy, or when the muscles of the chest wall are 
paralysed, there is abdominal breathing. 

2. The Shape and Size of the Gheet.—k cross-section of the heaUhy adult 
chest gives almost the form of an ellipse, the longer diameter being from 
side to side. In the child it is more circular in shape. The chest should 
appear symmetrical, although la reality the right side is slightly larger 



174] 



INSPECTION AND MENSURATION 



125 



than the left. There should be no marked hollowing anywhere ; the 
clavicle should form only a moderate prominence between the supra- and 
infra-clavicular regions. The circumference of the chest varies with the 
height of the individual, but it should average for a man 5 feet 6 inches 
about 34 to 35 inches. With deep inspiration it should expand about 
1^ to 2 inches. The measurement at the level of the nipples in the male 
is a rough measure of the individual chest capacity (see above). The 
relative shape and capacity of the two sides is measured by a cyrtometer 
(see also p. 126). The principal abnormalities in shape are the emphyse- 
matous, phthisical, and rachitic chests. 

The commonest form of abnormality in the shape of the adult chest is 
the emphysemaUms, or, as it is called, the barrel-shaped chest. Briefly 
expressed, this alteration consists of the fixation of the chest in a position 
of permanent inspiration, and expiration cannot be completely performed. 
The sternum becomes curved, the low^r 
part being unduly drawn in; and a 
horizontal section shows the chest to 
be unduly circular (Fig. 34). When 
the hands are placed flat upon the 
chest on each side, they readily ap- 
preciate the fact that in advanced 
cases there is elevation, but no lateral 
expansion of the thorax, during in- 
spiration. The upper ribs are crowded 
together, whilst the lower ribs are 
farther apart than normal, and the 
epigastric angle is very wide. Owing 
to the permanent elevation of the 

clavicles and upper part of the chest, and the unusual degree of develop- 
ment of the accessory muscles of inspiration, the neck looks abnormally 
short in an emphysematous subject. 

The 'phthisical chest is too long vertically, and, in section, too rounded. 
On inspection from the front it appears flat, but this flatness is more 
apparent than real, owing to the slipping forward of the scapulae towards 
the front of the rounded chest. In the phthisical chest the antero-posterior 
is larger than the transverse diameter, as in childhood. 

The rachitic chest is common in children. Owing to the weakness of 
the bones, the chest acquires a characteristic shape (Fig. 35). A vertical 
groove occurs at the weakest part of the wall of the chest — i.e., down each 
side of the sternum, just outside the " rickety rosary " or beaded junction 
of ribs and cartilages (§ 447). Harrison's sulcus is often present at the 
same time ; it is a horizontal groove at the level of the xiphoid cartilage, 
running from the middle line in front obliquely outwards and slightly 
downwards as far as the mid-axilla, along the costal arch. 

The pigeon-breast is found in those who have had some obstruction to 
respiration in early youth, such as that due to adenoids or whooping-cough. 




Fig. 84. — CH18T OF EMPHTSaXA. The 

dotted line represents the normal outline. 



126 



THE LUNQ8 AND PLEURA 



[§76 




llg. 86.— Raobitic Chest. The 
dotted line represents the 
normal outline. 



The sternum is prominent, the ribs meeting it at a more or less acute angle. 

The cross-section of the chest is therefore almost triangular (Fig. 36). 
Among the irregular or asymmetrical abnormalities in the shape of the 

chest which the student should look for are hcUomng, prominence, or 

contraction, 

(a) Localised Hdlomng or "flattening" of the infraclavicular region 

may indicate phthisis, or any disease rendering the underlying part of lung 

useless for respiration. 
(P) Undue Prominence on one side of the ribs anteriorly may be due to : 

(i.) Scoliosis — i.e., lateral curvature of the spine, the convexity of the chest 

being in the opposite direction, (ii.) Intrathoracic tumour, fluid, abscess, 

or air (pneumothorax) in the chest, (iii.) If 
the cardiac region be prominent, it may be 
the result of cardiac disease in early youth, 
before the ribs were fully developed, and 
possibly an adherent pericardium, (iv.) An 
enlarg^ liver or spleen or abdominal tumour 
or abscess may also cause a bulging of the 
lower ribs on the right and left sides re- 
spectively, (v.) Subcutaneous emphysema or 
oedema, a localised deposit of fat or other 
tumour. 

(y) Contraction of an erUire side of the 
chest which may be due to : (i.) collapse of a 
lung (§ 100) ; (ii.) previous empyema (§ 86) ; 
(iii.) chronic interstitial pneumonia and fibroid 
phthisis (§§ 97 and 94a). 

The Cyrtometer is an instrument consLsting of two 
flexible pewter or pure tin bands joined by a hinge 
and graduated in inches. It is used to measure the 
relative size and shape of the two sides. Plaoe the 
hinge exactly opposite the spinous prooesses posteriorly, 
and bend the pewter limbs round to the front following 
the contour of the chest precisely. The instrument is 
then placed on paper, and the outline thus obtained 
may be marked by running a pencil round the band. 
AVhon possible, the Rontf en rays should be employed to aid the diagnosis of early 

tubercle, tumours, and fluid effusions, and for the detection of the position and extent 

of movement of the diaphragm. 

§ 75. Palpation is the next step in the routine examination of the lungs. 
The amount of movement with respiration is estimated better by palpa- 
tion than by inspection. This test is important in the diagnosis of consoli- 
dation at one apex, and in the detection of fluid, tumour, or other cause 
of deficient activity of one lung or part of a lung. By palpation Vocal 
Fremitus (V. F.), or the vibration of the voice, can be felt. It is scarcely 
appreciable in women or children with high-pitched voices, but is marked 
in the adult man. The V. F. is normally greater at the right than at the 
left apex. This test is of the greatest value in differentiating solid and 




36.— PiQKON Chest. The 
dotted line representB the 
uormal outUne. 



i n ] PALFATWN^PEHOVaaWN 127 

fluid. Thus the V. F. is increased where there is consoUdation of the lung, 
as in pneumonia or phthisis, whereas it^is diminished or absent when the 
lung b separated from the chest wall by fluid, thickened^pleura, tumour, 
or air, or when air is not entering the larger bronchi, as in cases of obstruc- 
tion of a bronchus. Not only is the V. F. a valuable differential sign, but 
its degree of diminution b a useful measure of the amount of fluid present 
in cases of pleuritic effusion. In bronchitis the rhonchi can be felt — 
rh<mchial Jremitas ; and in pleurisy and pericarditis yHc^ton may be dis- 
tinctly felt by the hand. Tenderness due to broken rib, pointing empy- 
ema, subcutaneous emphysema, and external tumours are made out by 
palpation. 

§ 78. PeroiUHdon is, after palpation, the next step in the examination of 
the chest. There are two kinds of percussion, immediate and mediate. 
In the latter a piece of ivory or wood is placed on the chest, and is struck 
by a small hammer, or with the finger. The immediate is the more usual 
form of percussion. To elicit the normal resonance of the lungs percussion 
should be stronger than when applied to make out the cardiac dulness. 
Begin at the apex and percuss altemate sides at exactly corresponding 
points in order to compare the healthy and unhealthy sides, and thus 
work gradually downwards. Place the first or second finger firmly and 
fiat against the chest, in a horizontal position — i.e., parallel to the suspected 
line of dulness. (Only in suspected mediastinal tumour should it be placed 
vertically.) Then strike upon it with the tips of all the fingers of the 
right hand. The blow should come from the wrist, not the elbow ; and 
the " staccato " movement should be imitated. Some use one (the 
middle), two, or three of the fingers of the percussing hand, but this makes 
Uie stroke too light, unless, as sometimes happens, it is desirable to demon- 
strate the delicate shades of pitch, intensity, and quality of the soimd.^ 

When examining the back of the chest (Fig. 37), the patient should be 
instructed to cross his arms and bend a little forward so that the scapulee 
are drawn out of the way. The normal resonance of the lung extends 
posteriorly to the upper border of the eleventh rib on the right side, and 
the lower border of the eleventh rib on the left side. On deep inspiration 
the resonance extends an inch lower, and during deep expiration an inch 
higher. Owing to the thickness of the scapular muscles the note over 
the scapulse may be quite dull in muscular people. To examine the sides of 
the chest the patient should be told to put his hands on the top of his head. 

The normal pulmonary note can only be learned by practice and ex- 
perience, and the student should frequently practise first an normal chests, so 
as to accustom himself to the normal resonance ; and afterwards on 
abnormal chests. 

^ The pitch or tone of the note is its position on the scale, and the more solid the 
Btructnie, the higher the note ; the more hollow, the lower and more drum-like or 
tympanitic. The intensity of a note depends on the solidity of the wall of a cavity 
as compared with its size. The timbre or quality of a note is a characteristic which 
depends on the nature and structure of the vibrating body, just as a wire string and a 
gut string, though producing the same^oto, possess a different timbre" or quality. 



THE LVSOS AND PLEVRJE 



The normal pertusaiou note is resonant. It is dvU or flat when the lung 
tissue is too solid, as in pDeumooia ; or when the chest contains fluid, as 



iduriniupin- 
eitenditoUw 
Jirib. 



Fig. ■iT.—T:B% LUNCS IM) OTBint ViGcUiA FBUM THK ItACR.— The rlglit JuDB Jiu tlireo lubes, tlir 
Jclt LuDR tMO only, and Uib lutiClOLi ut ILie Brest lluuree an tboKii in tbe flgiuc. Ibi liDes 
on the SsDie are only i[ipiojlinste guiiiei. Whi'n accursc-y ia desired, Ibe exact poilUou 
of tbe Inng fiuuiea l> obtained by ansculto-iieraiealon. > rough guide to (he upper border 
o( the lover lobea la found in tbe poaiCton of tbe vertebral borden of tbe Acapule wben the 
paUeut cToaeea hla anna In front of him, and places each band on the oppoalle abonldei. Tbe 
great Ahdic, nbJeh Mparitea Die midiljc and lower lobea, on tbe rlgbt aide, and tbe upper uid 
loser loba on tbe left aide, !> Indicated on LoUi gidei by drawlntt a line from tbe tecond donal 
vertebra to tbe Junction of the liilb coalal cartilage with (be sternum. The fiuuie leparttlng 
tba middle and upper lobca on tbe right aide la found by drawing a line from the Junction 
(rf tbe fourth costal cartilage with the atemom to meet tbe line of tbe great Baanre In thg mid- 
axUla. 

in pleuritic effusion, or with a thickened pleura or turaour. The percussion 
note is h^fer-resoHat^, or tympanitic, whenever the lung tissue is unduly 



5 77 ] A U8GULTATI0N 129 

open — i.e., too full of air, as in emphysema, when there is a cavity near the 
surface, or when there is air in the'pleura (pneumothorax). Cracked-pot 
aound is a modification due to a large cavity (Phthisis, § 94). It is normal 
in children, in whom it is due to the great elasticity of the ribs. When 
one part of the lung is over-distended with air, as it is in the part which 
is above a pleuritic effusion (which compresses the lower part of the lung), 
or above a pneumonic consolidation, the note is unduly resonant. This 
kind of resonance is called Skodaic resonance; and it may be almost 
tympanitic (drum-like) in character. It is due to the relaxation of the 
healthy lung tissue, and the increased amount of air which it contains. 

Gairdner's Idne.^ — It is useful to remember that a line diawn from the left anterior 
azillaiy fold to the nmbilions is normally resonant thrtmghout its entire length. Abnor- 
mally it may be impinged upon anteriorly by oonfiolidation in the upper part of the 
loft lung, cardiac enlargement, or by enlargement of the liver ; and posteriorly by con- 
solidation or fluid at the base of the lung, splenic enlargement, or other abdominal 
tumours. 

Increawd Beiistance is another quality which can be observed in the process of per- 
cussion as above described. This property of resistance can perhaps be better elicited 
by placing a finger of the right hand over an intercostal space and pressing lightly. It 
is greatest over fluid, and thus affords an important sign in pleural effusion, but is 
present also in consolidation, though in a less degree. It is a sign which, at first, is 
difficult to elucidate, but comes to be relied upon, in addition to peroussion, by some, 
especially by those whose appreciation of differences in note is imperfect. 

§ 77. Auscultation. — In using the single stethoscope, place the small 
end flat against the chest, and whUe it is held in this position by the finger 
and thumb, adjust the ear to the other end. The tendency of beginners 
is to adjust the stethoscope to the ear, but this should be carefully avoided, 
else the chest end gets tilted, and the chest sounds are imperfectly conducted. 
The ear may be placed directly against the chest, with an intervening towel, 
but it does not localise the sounds so well. In auscultation there are 
four things to be observed : (a) The character of the respiratory murmur 
(R.M.) ; (b) the relative length of inspiration and expiration ; (c) the 
presence of adventitious sounds within or outside the lungs ; and {d) the 
voice-sounds or vocal resonance (V.R.). 

(a) The normal character op the breath sounds — i.e., the vesicular 
or " respiratory murmur " (R.M.), caused by the air entering and leaving 
the air vesicles, should be listened to in healthy chests as often as possible. 
It has a soft whiffing character ; expiration can hardly be heard, but if 
heard, there is normally no pause between it and inspiration. The R.M. 
is normally very loud in children, and when a loud R.M. is met with in 
adtdts, it is called " puerile breathing." The breath sounds are in most 
persons harsher over the right apex. The breath sounds are inoreased— 
i.e., the breathing is " tubular " or " bronchial "^ when the limg is solid, 
as by tubercle, pneumonia, or collapse, or when a new growth lies between 

^ It was Sir William Gairdner who emphasised the value of this line in physical 
diagnosis, but I am not certain if he was the first to do so. 

* The terms " bronchial " and " tubular *' are generally taught as synonymous, but 
some schools (e.g., the Edinbureh) teach [that there are three kinds of bronchial 
breathing — ^high-pitched, or tubular ; medium-pitched, or true bronchial breathing ; 
aad;,low-pitohed, or cavernous breathing. 

9 



130 THE LUNGS AND PLEURAE [ § 77 

the larger bronchial tubes and the surface. In this condition the sound 
produced in the larger bronchi is conveyed direct from them to the ear 
owing to the increased conductivity of the solid lung substance. Bronchial 
breathing can be heard normally by listening over the upper segment of 
the sternum, or near the fourth dorsal vertebra at the back. It has three 
features — inspiration and expiration are of equal length and character, 
have an interval between them, and are both rough. Cavernous respira- 
tion is exaggerated tubular breathing, and is heard when the sound pro- 
duced in a dilated bronchus or cavity is conveyed in like manner to the 
surface. Cavernous respiration is normally heard over the trachea. 
Amphoric breathing is a sound like air entering a bell-jar, and is heard 
over pneumothorax or a very large cavity. The breath sounds (R.M.) 
are diminished or absent when a layer of fluid, tumour, or a thickened 
pleura intervenes between the lung and the chest wall, or when the air does 
not enter the lung tissue owing to obstruction in a bronchial tube. 

(b) The RELATIVE LENGTH OP INSPIRATION AND EXPIRATION is approxi- 
mately as 10 to 12, but heard through the stethoscope, the inspiratory is 
three times as long as the expiratory sound, which follows it without a 
pause. Expiration is prolonged in any disease which involves a loss of 
elasticity of the lung tissue, such as emphysema, or tubercle in an early 
stage. 

(c) The presence or absence of adventitious sounds has next to be 
noted, (i.) Pleuritic friction is produced by the two inflamed and rough- 
ened surfaces of the pleura rubbing together, (ii.) Within the lung various 
moist and dry sounds may be added to the respiratory murmur. Thus the 
presence of excessive mucus or other fluid in the large bronchial tubes 
gives rise to "large or bubbling rdles^^ as the air bubbles through the 
fluid. When the small tubes or air cells are similarly affected, " small 
mucous r&les " or " crepitations " are heard which resemble the rustling 
of tissue-paper or hairs rubbed together near the ear. They are audible 
in cases of early pneumonia and oedema of the lungs. If the lining mem- 
brane of the large bronchial tubes be thickened and dry, or with only a 
small quantity of moisture present, " sonorous rhonchi " are produced, like 
the snoring of a person asleep. If the smaller tubes are thickened " sibilant 
or whistling rhonchi " are heard (see Fig. 40). Rhonchi are often hard to 
distinguish from friction sounds, but it may be remembered that, whereas 
friction sounds heard during inspiration and expiration are separated by 
a short but distinct interval of silence, rhonchi are not so separated, but 
fade one into the other. Crepitations sometimes resemble friction sounds, 
but are distinguished by being audible only during inspiration. 

(d) The voice SOUNDS, or vocal resonance (V.R.). (i.) When the patient 
speaks, the vocal resonance is increased {bronchophony) over a cavity, op 
if the conductivity of the lung substance is rendered greater by consolida- 
tion, such as that produced by tubercle or pneumonia. If this be so great 
that even whispered words are conducted, it is known as whispering pec- 
toriloquy. Some authors confine this term to the very exaggerated whis- 



§77a] . AUaOULTATlON^FALLACIES 131 

pering sounds which are heard over large smooth- walled cavities, (ii.) The 
vocal resonance is diminished when a layer of fluid or air intervenes 
between the lung and the chest wall {e.g,, in pleuritic efEusion and pneumo- 
thorax), or when there is a thickened pleura. Nevertheless, in a slight 
pleuritic effusion and at the upper level of a moderate efEusion the higher 
tones of the voice sounds are sometimes conducted, especially at the angle 
of the scapula, and resemble the bleating of a goat (hence called JEgophony), 
Clinicalk/, all the diseases of the lungs may be conveniently divided into 
those with dnlness on percmudony those in which the percussion note is 
normal^ and those in which it is hsrper-resonant Those with dnlness 
may be subdivided into two groups — those in which the dulness is due to 
CONSOLIDATION, and those in which it is due to fluid. The clinical features 
by which solidification of the lung is distinguished from fluid in the chest 
are so important that they are given in a tabular form. 

Table V.— Physical Signs op 

Consolidation of Long. Plenral Effiuion. 

'Movement impaired. . . Movement impaired. 

InsPEcnoN. . . - May be flattening over the part May be bulging (of intercostal 

(if infraclavicular region). spaces). 

Palpation. . . V.F. inobeased. . . V.F. diminished or absent. 

Percussion. . . Resonance impaired. . . Absolutely dull over fluid. 

j BRBAXmNO TUBULAR. . . R.M. ABSENT Or WEAK. 

I y.R. INCREASED. .. V.R. DIMINISHED. 

(The most important features are in small capitals.) 



Auscultation. 



AoBcalto-Peronssion, when employed by experienced observers, enables them to 
define the boundaries of the heart, or of a mediastinal tumour, with greater accuracy. 
It is useful to determine the lobe in which disease is situated. In this method the 
stethoscope (preferably, a binaural) is placed over the middle of a lobe, while one coin 
is tapped on another, first over another lobe, and then over the same lobe as that to 
which the stethoscope is applied. The listening ear recognises the difference of the 
impact in the two cases. The coins are then placed over the supposed margins of the 
lobes, and by the slighter or stronger impact conveyed to the ear the division between 
the lobes can be readily defined. In pneumothorax the pathognomonic ** bell-sound " 
is obtained by this method. 

§ 77a. Fallacies in Diagnosis of Diseases of the Chest. — This list includes the most 
important fallacies, but it is impossible to make it exhaustive. 

1. When the chest wall is very thin the sounds heard on auscultation are propor- 
tionately loud. The percussion note is also louder, and it is consequently easy to fall 
into the error of supposing that emphysema is present. In children the breath 
Bounds are always more distinct than in adults, and are, moreover, more readily con- 
ducted, so that adventitious sounds having their origin on one side may even be heard 
quite plainly on the other. 

2. A chest wall with excess of subcutaneous fat or oedema will give rise to error 
if it be not borne in mind that the sounds on auscultation and percussion are alike 
deadened and indistinct. The sounds heard over the scapular region are always 
less distinct than those heard elsewhere. When a patient does not breathe deeply, 
owing to debility or pain on movement of the chest, or when the chest wall is very fat, 
the breath sounds may be almost inaudible. 

3. The presence of much hair on the chest gives rise to sounds like fine crepitations 
as it is rubbed by the stethoscope. 

4. The fault of applying the stethoscope to the ear instead of the ear to the stetho- 
scope often leads to the chest piece being only in partial apposition to the chesty an 



132 THE LUNQ8 AND PLEURM [ § 78 

error which causes misleading sounds to reach the ear. The friction between the 
rubbers of the stethoscope may originate sounds which are misinterpreted. 

5. It is well to remember that dulness on percussion does not necessarily mean 
that there is fluid or consolidation present. It may also be caused by thickened 
pleura and by the presence of tumours. The latter may be outside the chest, but 
pushing up into the thorax — €,g., hepatic or splenic enlaigement, subdiaphragmatic 
abscess. 

6. Tumours of the chest wall will sometimes lead to the impression that there is 
some difference in the size of the two sides of the thorax, and tJiis difference may be 
referred to some morbid condition of the chest contents. The swelling caused by 
subcutaneous emphysema or bloodclot, both of which may follow an accident, gives 
rise to a faint crepitation which may be easily mistaken for the signs of injury to the 
lung beneath. 

7. When one lung has been long out of action, as in fibroid phthisis, the other 
undergoes compensatory enlargement and encroaches on the affected side of the 
chest. The hypertrophied lung gives rise to sounds identical with those of emphysema. 

8. The breath sounds are better heard and the percussion note is higher at the 
right than at the left apex, owing to the presence of the eparterial bronchus on the 
right side. 

9. Atrophy of the muscular tissues about one shoulder leads to an apparent flatten- 
ing on that side very like that seen in phthisis. 

10. Peritoneal friction, due to inflammation below the diaphragm, may be mistaken 
for pleuritic friction, as it is frequently audible at the base of the lungs, and as far up 
as the seventh interspace. 

11. Distension of the abdominal organs, as in meteorism, may extend high up into 
the chest and simulate hyper-resonance of the lungs. This is especially probable 
when the lungs have been drawn up with adhesions or fibroid contraction. A hernia 
of the diaphragm with protrusion of the stomach, or the opening of an abdominal 
abscess into the chest, may cause amphoric echoes and bell sounds, as in pneumothorax. 

12. Dextro-cardia is very rare, but it is necessary to bo on one's guard lest it be 
rashly supposed that the heart is displaced by effusion or by some tumour. ( 

13. Finally it is well to remember that the presence of lung signs usually found in 
association with acute disease must always bo interpreted with duo regard to tho 
constitutional condition and co-existing signs of disease in other organs. 

§ 78. Examination of the Sputum. — Much may be learned from an examination of 
the sputum. First, as regards its Appearance. In simple pleurisy, though the 
cough is distressing, expectoration is absent (t.e.*, the cough is ** dry "). If the disease 
be confined to a moderate catarrhal process of the l^ronohial tubes {e.g., bronchitis), 
the sputum is white, clear, and frothy (" mucous expectoration "). If the process 
be more severe and suppurative, or if the lung tissue bo breaking down, then pus is 
present, and the sputum is yellowish (muco-purulent). Thin watery sputum is ex- 
pectorated in large quantity in oedema of the lungs. In phthisis, when the lung is 
breaking down, the sputum is often voided in thick purulent masses like coins, hence 
called nummvlar. In cases of pulmonary abscesses, tuberculous cavities, and of 
empyema bursting into the lung, large quantities of almost pure jma are expectorated 
from time to time. Extremely foetid expectoration is voided in gangrene of the lungs 
and in bronchiectasis. The latter is distinguished by having large quantities of putrid 
ftputum, brought up by paroxysms of violent cough at one time ; while in the intervals 
the cough and expectoration are those of bronchitis. The bronchiectatic sputum, on 
standing, sepanntes into three layers — ^the upper clear and frothy ; the middle granular, 
with mucus ; the lower purulent, with thick ** Traube's plugs " (p. 133). The foul 
odour is due to valerianic and butyric acids. In pneumonia the sputum is very 
characteristic, being (i.) almost airless and extremely viscid, so that the vessel con- 
taining it may be inverted without spilling it, and (iL) tinged with blood, thus having 
a ** rusty " colour. In severe cases, and in new growth of the lung, the sputum becomes 
thinner, frothy, and dark red, the " prune-juice " sputum. Casts of the bronchial 
tubes, which can be seen by the naked eye (Fig. 46, p. 156), are expectorated in plastic 
bronchitis, and occasionally in croupous pneumonia, and shreds of membrane in 
diphtheria. Hydatid cysts, resembling empty gooseberry-skins, are expectorated 



ITS] 



EXAMINATION OF THE SPUTUM 



in tlut rare oondition hTdatid diaease of the langs, or when hydatid of the liver nip- 
tniBB into them. In town dwelleis, uid tboae with doaty oooupAtions, the sputum 
is dark, or even blsck. from tiie presenae of osrbonsoeouH and other particles. " An- 
chovy sauce " coloured spntum ie oharacteriatic of absceas of the liver which has burst 
irtto the lung (| 244). 

MiCBOSCOPic EXAHIHATIOK OF THH SpnTUM.^Varioufl hociaia lfi.g., tuberoie, 
pneBinococcuB, inBuenza. pyogenic ooooi, anthrax, glanden, plagoe, the fungi of 
actinomycosis and ospergilloBiB) may be found in the spntum. The method of detecting 
these ia described in Chapter XX. 

In all destructive diseases of the lung fngmeata of pulmonary tissue are present 
— Le., epithelial cells and connective tissue. The moat characteiistic is eUutie titmt. 
Elastic Gbres are best revealed by taking a small portion of the sputum and boiling 
it with liquor potasan, which breaks up and randeia clear all tiie other olemente. but 
leaves the elastic libiFs unattaoked. Ilieae sink to the bottom of the t«st-tnbe, and 
may be withdrawn by a pipette (pieoautions, see Urinary DepoaitB) for eiamination 
under the misoroeoope. They appear as wavy, highly 
cefractite fibres, of uniform thickness, with square-out 
ends, and are typically arranged aa if surrounding au 
air cell (Pig. 3S). Elastic tiaaue ia found. in the mouth 
after meaU. so the mouth and teeth shonld, M a 
precantion, be cleansed before the observation is made ; 
bat circularly arranged elastic Gbres are quite distinctive 
of breaking-down lung tissue. The Traubo " plugs " of 
a bronohiectatic sputum (} 103) are little pellets, which 
oontain pua and epithelial oalls, with needle-shaped 
fatly-acid ciystala. Sometimes elastic fibres are also 
present in small amount. They are believed to he 
pathognomonic of bronobiectasia. 

CuTtchmajm'a spiraU are found in the sputum of 
asthmatio patients. They form pellets or paieg, the 
siie of sago grains, which can be uncoiled to form 
a thread about an inch long. Microscopically, they are 
seen to consist of fine mucous fibrils wound spirally 
round a central core of mucus. They are probobly 
allied to small bronchial casts (Finlajson). Charcot- 
Lofdat crystals (Fig. 39) are colourless, pointed, octa- 
hedral ciystals, formerly suppoaed to be pathognomonic 
of asthma, but now known to occur in the sputum of 
plastic bronchitis also. They are composed oE phos- 
phate of spermin. Pcehl considera spermin to be a de- p\g_ 39, chsrDot-Lerdaa 

composition product of nucleo-albumin which normally Cryatali. 

circulates in the blood. Many diseases (especially nervous) 

are asaociated with an excess of phosphate in the system, which, combined with 
spermin, may form Charcot-Leyden oiystala. They have also been found in the 
blood ot Uoktsmia. HmmiUindm ciystala are brown or yolbw needles or platea, 
fonnd in cases of old hemorrhage from any cause. OHcittterin, leitcin, and tyroiin 
crystals are found occasionally in oases where the sputum has been purulent for a 
long time- Various paratitea [actinomycee, blastomycos, strep (othrix, eohinococous, 
Di«toma palmonale, etc.) are sometimes found in the sputum. Saroinie and Oldiura 
albicans come usually from the alimontary tract. 




Fig. 38.— Elartio Fibroi. 



§ 79. ClaniflcattoiL — For practical purposeB diseaees ot the lunga and 
pleune, like those of the heart, may be divided into Acute and Chromic, 
and each of these may be subdivided into tliose without dulness, those 
with duhiess, and those with hypei-n 



134 



THE LUNGS AND PLEUEjE 



[§80 



o 

n 



00 
CO 



Acute. 

I. Acute Bronchitis. 
II. Dry Pleurisy. 

III. Acute Phthisis. 

IV. Whooping-cough. 
V. Acute Pulmonary 

(Edema. 



Chronic. 



^ 



I 



I 



00 
00 



A 



I. Pleurisy with effusionl § 
(and Empyema). J | - 

o 



{ 



II. Pneumonia- 



(a) Lobar. 

(b) Lobular. 



o 



S 



I 

AS 






I. Chronic Bronchitis (and 
Plastic Bronchitis). 



I. Chronic Phthisis^ (and 

Fibroid Phthisis). 
II. Hydrothorax. 
III. Pulmonary Congestion 
(or (Edema). 

IV. Interstitial Pneumonia. 
V. Thickened Pleura. 
VI. Cancer and other neoplasms. 
VII. Collapse of the lung. 
VIII. Syphilitic disease. 



o 

CO 

AS 



I. Pneumothorax. 



I. Emphysema. 



Paroxsrsmal. 

I. Asthma. 
II. Acute Pulmonary (Edema (sometimes). 

§ 80. The Routine Procedure here resembles in principle that of diseases 
of the heart. First, What is the patienCs leading symptom ? If suffering 
from lung disease, his cardinal symptom will be one of those mentioned 
in section A. Breathlessness and cough are the chief cardinal symptoms. 

Secondly, follow this up with a few questions to ascertain the history of 
his illness, and especially whether the disease be acute or chronic. Other 
important points are whether the patient has been exposed to a " chill," 
and whether there is any ** limg disease " in the family. Do not use the 
word " consumption " ; it may frighten your patient unnecessarily. 

Thirdly, proceed to the Physical Examination of the Lungs. The 
routine method is as follows : 

1. Ascertain whether there is any increased rate or other modification 
in the breathing or alteration in the shape of the chest (by inspection, and, 
if necessary, by measurement). 

2. Ascertain if there be any dulness or hyper-resonance (by percussion), 

3. Listen to the breath and voice sounds, directing special attention to 
any part suspected of disease (by auscultation), 

4. Test the voice soimds by palpation, 

5. The sputum should be inspected, and, if necessary, examined micro- 
scopically. 

^ There is no dulness in quite the early stages of some cases. 



§80] 



ROUTINE PROCEDURE 



135 



The chest should always be stripped, and it is more convenient to 
examine the patient in a sitting posture, if he be not too ill. 



If the illness developed gradually, and is of some standing, and un- 
attended by marked constitutional disturbance, then turn to Chrome 
Pnlmonary Disorders (§ 91, p. 153). 

If the illness came on recently and suddenly, accompanied by fever, 
quickened respiration, coated tongue, and with marked malaise, then the 
case is one of the Acute Pulmonary Diseases, below. 

There is one disease of the lungs, Asthma, which comes on in sudden 
acute attacks from time to time ; it is chronic, with acute exacerbations 
(§ 90, p. 151). 



Acute Diseases. — We now proceed to percuss the chest. In all acute 
diseases special attention should be directed to the lower and back part 
of the chest just below the scapulae. Careful percussion of this region 
wiU give us important aid in diagnosis. 

Table VI. — Diagnosis op Acute Diseases op the Lungs 

AND Pleura. 



I. Acute Bronchitis 



If. DryPlenrlBy 



III. Acute Pulmonary 

TuberculOBis 

IV. Pleurisy ^^th 

effusion 

V. Croupous Pneu- 
monia 



Percussion Note. 



Normal 



Normal 



Normal, or scattered 
areas of dulness. 

Doll 



DuU 



Auscultation. 



B.M. and V.R. normal ; Loud moist relies 
and dry rhonchi. 

Breath and voice sounds normal ; Pleuritic 
friction. 

Scattered fine moist rAles may be the only 
auscultatory signs. 

R.M., V.R., and V.F. diminished ; Pleuritic 
friction at early and late stage. 

V.R. and V.F. increased ; Bronchial breath- 
ing ; Fine or coarse (redux) crepitations. 



The acute diseases without alteration in the percussion note, i.e., withaut 
dulness, excluding Whooping- cough, which is an infective disorder, and 
has no physical signs in the lungs peculiar to it, and Asthma, which is of 
a paroxysmal character — are : I. Acute Bronchitis ; II. Dry Pleurisy ; 
III. one form of Acute Pulmonary Tuberculosis ;1 and IV. Acute 
Pulmonary (Edema. 

I. The fcUient complains of a cough, with frothy expectoration, and his 
temperature is slightly elevated ; there is no alteration in the percussion note^ 
but an auscultating the chest, loud rhonchi are heard. The disease is Acute 
Bronchitis. 



^ In the early phase of this malady there is no alteration of the percussion note, but 
as the disease progresses a patohy dulness appears* if the patient Uve long enough. 



136 THE LUNGS AND PLEURjE [ § 81 

§ 81. Aoata BronohitiSy or inflammation of the bronchial tabes, is cer« 
tainly the most common acute disease of the lungs in this climate. 

Symptoms, — The disease commences gradually in the course of one or 
two days, with a feeling of tightness of the chest, of soreness behind the 
sternum, shortness of breath, frequent cough, and slight rise of tempera- 
ture, 100° to 101° F. The inflammatory process lasts from ten days to three 
weeks, and gradually subsides. The sputum is viscid and scanty during 
the first few days, and then becomes thinner, muco-purulent, and more 
easily coughed up. 

Physical Signs. — The percussion note is unaltered unless, as so fre- 
quently happens, emphysema be present also, in which case the chest is 
unduly resonant. On auscultation the vesicular murmur is obscured over 
the whole chest on both sides by loud rhonchi and moist rales (see Fig. 40) 
which are variable and altered by coughing. On palpation rhonchial 
fremitus can frequently be felt. 

Causes. — Bronchitis is generally attributed to : (i.) A chill ; that is to 
say, sudden exposure to cold, with a determination of blood to the interior, 
(ii.) Sometimes, however, it is caused by spreading from laryngitis, 
(iii.) It is a frequent complication of many of the specific fevers, especially 
measles, whooping-cough, and typhoid. It is so frequently present with 
the first and last as to constitute an aid to the diagnosis of those diseases, 
(iv.) Certain occupations which expose people to irritating vapours and 
small particles of dust predispose to acute bronchitis. Thus the cotton- 
mill hands and chemical manufacturers frequently suffer from bronchitis. 
It is also common amongst cabmen, mariners, and others who are exposed 
to all weathers, (v.) It is a common accompaniment of many other 
pulmonary diseases, though it may be a subordinate feature ; and (vi.) it 
is commonest in childhood and old age. 

The Diagnosis is not difficult in most cases, but acute tuberculosis is at 
first very apt to be regarded as acute bronchitis. Thevdiagnosis is aided 
by the greater elevation, and the intermitting character of the pyrexia in 
the former, and by the presence of the tubercle bacillus in the sputum. 
The " capillary bronchitis " of children is really a broncho-pneumonia {q.v.) ; 
the constitutional symptoms and dyspnoea are much more marked, there 
may or may not be some dulness, and the difEerentiation from simple 
acute bronchitis is not always easy. 

The Prognosis is favourable in adolescence and adult life, and it always 
clears up in one to three or four weeks, though it has a special liability to 
retujn, and ultimately to become chronic. It is dangerous in infancy and 
old age, where the resisting powers are feeble. It is one of the commonest 
causes of death in the latter. If an attack of acute bronchitis does not 
begin to clear up in two or three weeks, pulmonary tuberculosis should be 
suspected, especially if the patient be young. 

Treatment. — The indications are : (i.) During the first stage, to promote 
the secretion ; (ii.) when the secretion is free, to stimulate the bronchial 
mucous membrane ; (iii.) during convalescence, to improve the general 



! a ] AOOTB BB0N0HITI3 137 

condition so aa to enable the patient to throw off his liability to bronchitic 
attacks. At the onset give an aperient and a diaphoretic mixture, with 
perhaps a few grains of Dover's powder to soothe the pain. Poulticing 
is useful, and emetics are given to children. To promote the flow of 
secretion warm alkaline drinks and expectorants such as ipecacuanha and 
antimony, together with liq. ammon. acet., are especially useful. When the 



secretion is free — that is, after three or four days — stop the antimony, 
and administer expectorants, such as ammonium carbonate, syrup of tolu, 
senega, and squills (Formula 57). If the patient is of a gouty oi rheu- 
matic diathesis, oi the sputum is very tenacious, add potassium iodide to 
the expectorant mixtures. The patient must be confined to bed, and will 
derive great benefit from the inhalation of steam. In childhood this is 
best done by a bed canopy and a steam kettle beside it ; in adults, a kettle 



138 THE LUNOS AND PLEURA [ §§ 81a, 82 

with a long spout on the fire will suffice. Linseed-meal poultices, a tur- 
pentine stupe to the chest, or a covering of cotton wool give great lellef 
to the distressing tightness of the chest (see also FormulsB 30 and 68). 
During the stage of recovery tonics and cod-liver oil are called for. 

§ 81a. Acute Suffocative Catarrh is a disease affecting the whole or a very large 
portion of the mucous membrane of the bronchi. It is very uncommon in adults, but 
more common in children. It starts acutely, with urgent dyspnoea and cyanosis, 
without expectoration, and is usually either fatal or has subsided in twenty-four to 
forty-eight hours. Relief is accompanied by a cough, and the expectoration of copious 
secretion. The temperature is but slightly raised. It is said to be due to a turgescenco 
of the mucous membrane, analogous to urticaria. 

II. The patient complains of sharp pain in the chest on inspiration ; he 
has a short dry cough, and his temperature is moderately elevated ; on ausculta- 
tion, FRICTION is heard. The disease is Dry Pleurisy. 

§ 82. Dry Pleurisy is inflammation of the pleura without effusion. In 
this disease there is a fibrinous exudation on the visceral and parietal 
layers of the pleura, and a tendency to the formation of adhesions, and 
to the effusion of fluid. 

Symptoms, — The disease in some cases comes on quite suddenly with a 
stitch-like pain in the chest. The constitutional disturbance is never very 
great, and the patient rarely takes to his bed. The temperature may rise 
to 100° or 101° F., rarely higher. The most obvious symptom in this 
disease is pain in the chest, affecting one side only in most cases, and 
characterised by being greatly increased on deep inspiration. The pain 
is caused by the contact of the inflamed pleural surfaces, and is usually, 
though not necessarily, located over the diseased part. 

Physical Signs, — Percussion reveals nothing. On auscultation, the 
respiratory murmur may be found to be normal or shortened, as the 
patient endeavours to restrain the movements of the chest on account of 
the pain so caused. From the very outset a pleuritic rub is heard over 
one side, often most marked at the angle of the scapula (compare § 77). 
Sometimes the inflammation undergoes resolution or adhesion, sometimes 
it goes on to effusion. As effusion takes place, the pain and pleuritic 
friction disappear, to reappear again when this subsides. 

Causes, — (i.) Sometimes it is a primary malady, attributed to chill, 
especially in persons of a gouty or rheumatic diathesis, (ii.) It may occur 
as a complication of some acute infective disease, such as measles or scarla- 
tina, (iii.) Inflammation may extend from disease of the underlying 
lung, such as pneumonia, tuberculosis, cancer, and embolism, or from 
adjacent organs, such as the liver or spleen, (iv.) Undoubtedly a large 
number of apparently simple pleurisies are tuberculous in origin (some go 
so far as to say 82 per cent.) ; and this fact should always be remembered. 

The Diagnosis from muscular rheumatism (pleurodynia) is made by the 
tenderness and absence of friction sound in the latter. In intercostal 
neuralgia there are tender points along the course of the nerve, and the 
pain is not aggravated by deep inspiration. Pleuritic friction is distin- 



§ 8S ] ACUTE PULMONARY TUBERCULOSIS 139 

goished from the rhonchi heard in bromAUis by there being in nearly every 
case of pleurisy a distinct interval between the inspiratory and the ex- 
piratory rub. 

Prognosis, — It is not a serious malady, and readily yields to treatment ; 
but sometimes eSusion occurs (Pleuritic Efhision, § 85). When this 
efiusion becomes purulent (Empyema, § 86) the prognosis is grave. Thick- 
ening of the pleura may result, especially in tuberculous cases. 

Treatment. — CJonsiderable relief is derived by simply strapping the 
alFected side of the chest, so as to limit the costal movements of respiration: 
This may be combined with some local application ; that which gives 
greatest relief is imdoubtedly a linseed-meal poultice. As the disease 
becomes chronic, counter-irritants are called for, more especially iodine, 
which may be painted on daily until the skin becomes sore. If it does not 
disappear in the course of a few weeks, we must suspect some other cause 
for the mischief, such as those mentioned under pleurisy with effusion. 
Diuretics, diaphoretics, iron, and other tonics are useful. 

III. The patient exhibits the signs of subacute bronchitis ; but he has 
SEVERE MALAISE and a HECTIC TEMPERATURE, and the sputum may contain 
TUBERCLE BACILLI. The disease is Acute Pulmonary Tuberculosis. 

§ 8S. Acnte Pulmonary Taberonlosis (acute phthisis, galloping consumption) is a 
catarrhal process affecting the entire lung tissue, due to the invasion of the tubercle 
bacillus. It is often part of a tuberculous process infecting the whole body, and. is 
therefore sometimes described as the pulmonary form of acute general tuberculosis 
(see Chapter XV., where a chart is given showing the typical course of the temperature 
in both diseases). 

Symptoms, — ^The malady is of most insidious onset, with progressive weakness and 
emaciation. Some weeks before any physical signs are evident the thermometer 
shows the typical intermittent pyrexia so characteristic of tubercle — an evening 
elevation of 101 ** to 103*^ F., and a morning normal temperature. In rare cases the 
inverse type is present, when the temperature is higher in the morning than in the 
evening. Night-sweats and cough are present, with muco-purulent expectoration. 
Dyspncea, and sometimes cyanosis, develop out of proportion to the physical signs ; 
the latter symptom may be extreme, and of itself is a very characteristic feature. 
Great weakness ensues, and in the third or fourth week the patient may develop the 
symptoms of the typhoid state. 

The Physical Signs referable to the lungs are indefinite, or resemble at first those 
of bronchitis. At first there is no alteration in the percussion note, but by-and-by 
careful percussion discovers scattered patches of dulness. Auscultation at first may 
give little help, but in the course of a week or so it reveals rhonchi and fine r.Uos over 
certain areas, which do not shift from place to place, as in bronchitis. Later on the 
rales are coarse and bubbling, and areas of tubular breathing may bo found. 

The Diagnosis in the first stage from bronchitis and bronoho-pneumonia is extremely 
difficult. We have to rely upon the disproportionate emaciation and cyanosis, the 
character of the temperature, and the patchy distribution of the physical signs in 
tuberculosis. In other cases the malady is almost indistinguishable from enteric fever 
except for the marked predominance of the pulmonary signs and the absence of the 
roseola, and the Widal test is negative. In all stages the detection of the tubercle 
bacillus in the sputum is a valuable aid to' diagnosis, though its absence does not 
exclude acute pulmonary tuberculosis. The various tuberculin tests may be tried in 
doubtlol cases (§ 94). 

Causes. — ^The disease may occur at any ago, but is commonest in young adults, and 
in those with a family history of consumption. In some instances acute general 



140 THE LUNGS AND PLEURjE [§§ 84, 

tuberouloais originates from a primary focus, such as a tuberculous joint, which had 
been considered cured. Sometimes the disease follows measles or whooping-cough in 
children. 

Prognosis. — ^The disease is almost uniformly fatal in about two to twelve weeks- 
Treatment is almost entirely symptomatic. 

IV. The pcUienty a child, his paroxysms of coughing which frequendt/ 
terminate in vomiting ; there is very slight feverishness, but the only signs 
in the lungs are those of a little bronchial catarrh. The disease is Whooping- 
cough. 

Whooping-coiigh (Pertussis) is an acute infectious disease, and it is 
described among the microbic disorders (§ 368). 

V. The patient is suddenly seized with acute dyspnoea and copious frothy sptUutJi 
flows from the mouth and nose. The disease is Acute Pulmonary CEdebia. 

§ 84. Acute Pnlmonary (Edema. Symptoms. — ^The sudden onset of acute 
dyspnoea, with copious, often blood-stained (rose-coloured) sputum, are most char- 
acteristic. The diagnostic point about the sputum is that it contains albumen. 
The face is pale, the expression is one of intense anxiety ; there may be a cold 
sweat. The pulse is feeble, and there may be pain or a feeling of oppression in the 
chest. The disease is conjectured to depend on weakness of the left ventricle, 
allowing the accumulation of fluid in the lungs. It may arise in the course of 
heart disease, more especially aortic disease, arterio-sclerosis, pregnancy, epilepsy, 
angio-neurotic oedema, acute infections, or Bright's disease. The physical signs 
consist of rales and crepitations which are heard all over the chest. 

Treatment. — Sometimes the disease is so rapidly fatal that no treatment is of avail. 
The best emergency treatment is blood-letting to 20 ounces. In fulminating cases 
this should be undertaken without delay. Atropine and belladonna have an almost 
specific action ; yk^ gr. of the former should be given hypodermically at the earliest 
possible opportunity, the recurrence of attacks cannot be prevented except in those 
cases where the patient is able to foretell their coming. In these a dose of atropine 
in time will ward off or very much mitigate the attack. The only prophylactic treat- 
ment is directed to the presumed cause of the attacks — i.e., to the underlying disease. 
The disease may never recur, but in some patients may persist at variable intervals 
for years. ^ 

We now turn to the Acute Diseases with Dulness on Percussion — 
I. Pleurisy with Effusion (Serous or Purulent) ; II. Pneumonia and 
IIJ. Broncho-pneumonia. 

I. The patierU has a dry cough, vnth moderate fever and other constitu- 
tional symptoms. On examining the chest, the respiratory murmur, vocal 
resonance, and vocal fremitus are found to be diminished or absent. The 
disease is Pleurisy with Effusion. 

§ 86. Acute Pleurisy with Effusion. — When describing acute Dry 
Pleurisy (§ 82) it was pointed out that the disease may undergo resolution 
or result in adhesions. It may also go on to eftusion — Pleurisy with 
EfEusion. 

Symptoms. — There is usually a history of a more or less acute onset 
with pain in the side (§ 82), but as the disease progresses, and the surfaces 
of the pleura are separated by fluid, pain becomes less and less marked. 

^ Leonard Williams, the Lancet, December 7, 1907, and discussion in subsequent 
numbers. 



!»} ACOTE PLEURISY WITH EFFV810S 141 

The patieDt suffers from general malaise, and finds it diflicult to lie on the 
wnitd side, because the action of the healthy lung is thereby impeded. 
A degree of breatUessness may be present, but even with a large amount 
of fluid this is not invariably a prominent featuro. 

Pkyticfd Sigru (see Fig. 41).— Percussion reveala absolute dulneas over 
the fluid. Above the level of the fluid, if the lung be otherwise healthy, 
there is a hyper-iesonant note (Skodaic resonance). When the effusion 
is large it canses displacement of organs, which may be very considerable 
(sM Fig. 42). The level of the fluid does not usually shift with the position 
of the patient, as it does when there ia non- inflammatory (dropsical) fluid 
in the cheat. On auscul- 
tation over the fluid, the 
breath sounds are absent ; 
the vocal resonance is 
greatly impaired or lost.^ 
At the upper margin of the 

fluid posteriorly — perhaps 

jost about the angle of the 

scapula — only the highest 

pitched tones of the voice 

are transmitted, and they 

produce, therefore, a sound 

like the bleating of a goat 

(^ophony). On palpation, 

the vocal fremitus is found 

to be diminished or absent t 

over the fluid, and there '' 

may be bulging of the 

intercostal spaces. The 

amount of fluid present J 

raBybeeetimatedby(i.)the 

d^ree of diminution of 

the vocal resonance and _ 

... J ... , ^, Fig. 41.— Dlagnm to 

fremitus, and (u.) the L^t"*""^ i>»>uo<i> m 

amount of displacement of 

oigans. The diagnosis of pleurisy in its earlier stages is referred to under 

Dry Pleurisy. The differentiation of the physical signs of fluid in the chest, 

as compared with those of consolidation of the luug, is so important that 

it is given in a tabular form in § 77. It is sometimes difficult to make out 

the left margin of the cardiac area when there is effusion in the left pleura. 

Dr. 8. H. Habershon has suggested a very valuable aid in such cases. 

Place a vibrating tuning-fork, such as aural surgeons use, in mid-axilla 

over the seventh rib. Listen with the stethoscope over the centre of the 

cardiac area, and gradually move it towards the tuning-fork, and in other 



142 



THE LUNQS AND PLBVSX 



[sa 



B boy >gecl twelve, adml 
the care of Sir WIIUsd 
in the Wsttetn Innnnsr] 
April io. 1805. 



directions. As the stethoscope crosses the boundaiy of the heart, there 
is a distinct difference in the note heard through the stethoscope, and in 
this way the cardiac boundaiy may be 
determined. 

Course and Prognosis. — In about a fort- 
night from the dat« of onset the fluid 
usually shows signs of diminution in 
quantity, the vocal fremitus and re- 
sonance return, and the breath sounda 
, become moie audible. This is the usual 

course, but several untoward results may 
ensue : (i.) The effusion may remain for 
an indefinite time, and re-collect after 
tapping, (ii.) Adhesions may take place 
between the two layers, and considerable 
thickening of the pleura result, (iii.) The 
fluid — especially in children after scarla- 
tina — may become purulent (Empyema, 
^a^°^Z see below). 

f'o^B^dn'" Treatment.— To get rid of the effusion 
', aioagow, pui^atives, diuretics, and diaphoretics 
(potassium citrate and bitartrate, potas- 
sium nitrate, liquor ammonife acetatis, 
etc., Formula 55) are often efficacious. 
Counter-irritants may be useful. Iron and 
other tonics arc useful. Autoserotherapy 
has had success abroad in pleural and peri- 
toneal effusions. One to ten c.c. of the 
serous fluid are aspirated ; the needle is 
withdrawn as far as the subcutaneous 
tissue, where its contents are injected. 
If these measuies fail after a few weeks' 
trial, paracentesis should be performed 
(Figs, 42 and 4-3). Under certain con- 
ditions it is inadvisable to delay para- 
centesis : (i.) A laige effusion {e.g., with 
duluess extending upwards as far as the 
third rib ; (ii.) cardiac embarrassment, 
laiiy Pot. d't. Br', x. Pot. as evidenced by cyanosis, palpitation. 

Patient alia Lad dianimea at tiiia barrassment, flhown by urpent dyspnoea 
and paroxysmal attacks of coughing ; 
(iv.) effusion in the other pleura, or oedema of the other lung. It should 
be remembered, in recurrent effusion, that tubercle may be the cause. 

Paraeenten) ThoracU. — The inxtramont used is an adaptation of the familiar trocar 
and cannula. We aro here dealing with a, cavity whowi contents are under a minus 
prmsuro, so it ii nacossaiy bo have a pump or exhausted bottle cotnmuuiaating with 



Fla. «S.— Showi altered atste of du 
UDder lue ol dlnretia <A]irll 
Un. hydrarg. was applied, am 



f 86 ] EMPYEMA 143 

the trocar. The site of puncture — usually the seventh interspace in the posterior 
axillary line — should be cleansed with acetone or other strong antiseptic. The needle 
of the aspirator should be boiled. The bottle or chamber of the syringe is next 
exhausted of air. If the point of the instrument be not very sharp, it is desirable to 
make a nick with a scalpel in the skin, previously pulled downwards over the rib below. 
Then the instrument is thrust into the intercostal space boldly at the acme of an 
inspiration. Communication is then established with the bottle or syringe, the flow 
being regulated by the tap or piston, so that the outflow may not be too rapid. Much 
coughing by the patient indicates that the point is touching the lung. A quantity 
varying between 5 and 50 ounces may be withdrawn, but the operation must be 
stopped if coughing or respiratory distress is caused. Seal the opening with collodion. 
At the present day siphonage is preferred to the aspirator by some. If the fluid 
contain blood, it may denote a slight wound of the liing or carcinoma, or occasionally 
tubercle. If it be purulent, the surgical measures for empyema are applicable, and it 
is wise to be prepared for this eventuality. In cases of serous effusion. Sir James Barr* 
recommends that the fluid should be withdrawn by siphonage, and replaced by about 
half to three-quarters of its bulk of sterilised air. When all the liquid is withdrawn, he 
injects 4 c.c. of adrenalin (1 in 1,000), diluted with 10 c.o. of sterile normal saline. 

la. The physical signs are those of pleurisy with elusion, hU it does not 
dear up in due course, and the patient has sweatings, shiverinos, and 
ntREOULAR ELEVATIONS of temperature. The disease is probably Empyema. 

§ 86. Empyema is a collection of purulent or sero-purulent fluid within. 
the pleura. It most often follows a serous effusion, but it may be purulent 
from the beginning. 

The Symptoms and Physical Signs are similar to those of serous effusion 
(q.v., supra), with certain others in addition — viz. : (1) It may be foimd 
that the fluid does not dear up as & serous effusion should do, and thus the 
presence of pus may be suspected. (2) Whenever pus forms, either in the 
pleura or elsewhere, it is marked by the occurrence of sweatings, shiverings, 
and an intermittent pyrexia. (3) (Edema of the integument, the pointing 
of an abscess in an intercostal space, over the clavicle, or even in the groin, 
or copious discharge of pus by the mouth, are in rare instances the first 
distinct evidence of a localised empyema. (4) The history generally 
throws considerable light on the case by revealing one of the cat^es of em- 
pyema — namely : 

(i.) Pneumonia, especially in children, may be followed by empyema ^ ; 
(ii.) septic conditions of the pericardium, mediastinum, or respiratory 
tract — sepsis in any part of the body may cause a simple effusion to 
become purulent ; (iii.) tuberculosis in any form in the thorax ; (iv.) the 
acute specific fevers ; (v.) abscess of the lung — e.g., in bronchiectasis — 
abscess of the liver or spine bursting towards the pleura, or peri-hepatic 
abscess resulting from appendicitis, leaking gastric or duodenal ulcer; 
(vi.) careless paracentesis, or any wound from without, permitting the 
introduction of organisms. 

(5) In doubtful cases a leucocyte count should always be made, since 
in the absence of acute lobar pneumonia more than 20,000 leucocytes per 
cubic millimetre would strongly favour a diagnosis of empyema. (6) The 

^ See Bradshaw Lecture, Brit. Med. Journ., November 9, 1907. 
2 In children there* is often rapid onset of pus without constitutional signs, as in 
Pyopericarditis (§ 38a). 



144 THE LUN08 AND PLEURJE [ § 86 

agpiration of a few drops of the fluid with a hjrpodermic needle will often 
settle the diagnosis, though there are two fallacies in this method : first, 
in rare cases the fluid may be too thick to come through the needle ; or, 
again, the pus may be encysted between the lobes of the lung. In any 
case, an examination of the point of the needle may assist the diagnosis. 

Prognosis. — Empyema is always serious, and may run a somewhat pro- 
longed course of some months. Cases of pure pneumococcal empyema are 
much more favourable than those due to streptococci or staphylococci, 
either alone or with the tubercle bacillus. Its course can be considerably 
modified by prompt and adequate surgical treatment. Early operation, 
adequate drainage, and strict aseptic precautions, both at the operation 
and at the subsequent dressings, are the points in treatment which most 
favourably influence prognosis. If left to itself, the results vary : some- 
times there is compression and destruction of the lung ; sometimes there 
is a falling-in of the side of the chest ; sometimes, as above mentioned, the 
pus opens into the lung or burrows in various directions ; sometimes it 
opens through the chest wall ; or it may become partially absorbed, and 
result in a caseous mass. 

Treatment, — When we are sure that the fluid is purulent the empyema 
should be opened and drained without delay. Every aseptic precaution 
should be taken. To drain an empyema it is usually necessary to remove 
1 to 1| inches of rib, which is best taken from the seventh or eighth rib 
in the posterior axillary line. When the patient is anaesthetised, insert a 
needle in order to locate the pus. This should determine the site of the 
operation, a point being selected in as dependent a position as possible. 
The skin is pulled down with the finger, and an incision is made 3 inches 
long on and parallel to the rib. The periosteum is scraped oS with a 
raspatory, and the piece of rib removed with strong bone forceps. The 
parietal pleura is then incised. The intercostal artery situated just 
beneath the lower border of the rib should be avoided ; if cut, it must be 
ligatured. The finger should be introduced into the cavity as soon as it 
is opened and before the pus has drained away. By this means any 
adhesions may be gently broken down and the large fibrinous flakes of 
pneumococcal empyemata be removed. Drainage should be effected by 
means of a large tube, which can usually be shortened to 1 inch or so after 
about forty-eight hours. At subsequent dressings the same strict asepsis 
should be maintained, because secondary infection makes the prognosis 
much worse. In the case of very large empyemata, causing great embar- 
rassment, it is sometimes advisable to remove some of the pus by aspiration 
as a preliminary measure, but this should be followed by operation after 
about twelve hours. 

II. The fotient has been taken ill suddenly ; the temperature is high^ 
the dyspncea considerahUy and the expectoratum soon becomes rusty ; there are 
signs 07 ooNsouDATiON ot the bose of one lung. The disease is Acute 
Lobar Pneumonu. 



S 87 ] PNEUMONIA US 

§ 87. PaeDmonia — i.c., inflammatioii of tlio pulmonary tissue prd^r, 
or parenchymatous inflammation — occurs in two forms. The firgt ami 
more acut« is, from its area of distribution, termed " Lobar Pneumonia,'* 
or, from the nature of the inflatntnatlon, " Croupoua Pneumonia." The 
second is termed " Lobular Pneumonia," because it affects the lobules of the 
lungs (also called Broncho -pneumonia. Catarrhal Pneumonia ; see below). 

Aoste Lobar Pneoinoiua commences suddenly, with well-marked con- 
stitutional syraptoma, such as headache, backache, rigor, and, in children, 
vomiting. The temperature during the rigor rises to 103° or 104° F., and 
it remains at this point for about a week (Fig. 44). The aspect of a pneu- 
monia patient is very characteristic (§ 7)-~the face is flushed, and herpes 
often appears on one side of 
the mouth. There is pain in 
the affected side, short cough, 
shallow, rapid breathing, and 
on the third or fourth day 
tenacious rusty-coloured 
aputum. The pulse -respira- 
tion ratio is 2 to 1, instead 
of the normal 4 to 1. The 
urine is scanty, high-coloured, 
with diminution of the 
chlorides. The patient shows 
more and more distress, and 
in a short time there may be 
delirium, with signs pointing 
to failure of the heart. 
About the sevetUh or eighth 
day the fever, in favourable 
cases, terminates by crisis, 
falling to normal in the course 
of a few houre. This ia accom- •■■'» "■-■*«i^^* ^=^ >l'"'J"^°'"t- '^*""'S *="^*=^ 

crlua on tins aevaatb day, Ueorge H.. ssed 
panied by marked genera! Uiirty-Uve, wm taken iU very inddenly when Lii 

improvement; the pulse- ude. 

respiration ratio returns to 

normal, and a critical sweating or diarrhcea may occur. Crisis often 
occurs on the odd days — i.e., fifth, seventh, ninth, or eleventh of the 
disease. Pseudo-crises occasionally occur, but these are distinguished 
from true crises by the fact that the pulse and respiration do not 
return to normal. In rare cases the temperature falls by lysis. The whole 
illness lasts about two or three weeks. If it lasts longer, tuberculotia 
shotdd be autpeded (§ 87 a). 

The Physical Signs are limited to one lobe or one lung, usually the right 
lower lobe. It is only in rare cases that both lungs are aSected. Pereus- 
aioQ may, for the first day or two, reveal no dulneas, but, as a rule, there 
is elicited early in the disease slight impairment of the percussion note, 

10 



146 THE LUN08 AND PLEURM { § SIT 

which soon becomes dull. On auscultation, the breath sounds are weak, 
and fine rustling crepitations are heard, which have been compared to the 
rustling of hair or tissue-paper against the ears. As the inflammatory 
exudation increases, the lung tissue becomes solid, and over the dull area 
we get all the signs of consolidation (p. 131). When the fever abates, coarse 
moist rales (redux crepitations) are heard, and the percussion resonance 
and normal breath sounds gradually return. 

Etiology, — Pneumonia occurs at all ages and in both sexes, but is com- 
monest in adult males. It is a microbic disease, the specific cause being a 
diplococcus, the pneumococcus of Fraenkel. Debilitating influences, such 
as exposure, are said to predispose to the disease ; but it is surprising how 
often strong, apparently healthy men are attacked, and these not infre- 
quently succumb. A blow on the chest may determine an attack. Like 
other local inflammatory diseases, it may arise as a complication of a con • 
stitutional malady ; the acute specific fevers in particular rendering a person 
vulnerable to the pneumococcus. When pneumonia runs an atypical 
course we should always bear in mind the possibility of the lung afEection 
being only a complication of a constitutional disease such as typhoid fever. 

Diagnosis, — Pneumonia is diagnosed from acute pleurisy with effusion 
by means of the data given in the table of diagnosis between consolidation 
of the lungs and fluid in the pleura (§ 77). Broncho pneumonia runs a 
different course, and the signs are scattered over both lungs (see table 
below). The sudden onset of acute pneumonia resembles that of scarlet 
fever, erysipelaSy and smaV^pox, but the absence of rusty sputum and altered 
pulse-respiration ratio distinguishes them. There is a pneumonic form of 
acute pulinonary tuberculosis which has to be borne in mind (§ 87a) ; also 
various aberrant forms of pneumonia (§ 876). Pneumonia jnay at its onset 
simulate abdominal inflammation^ pain being referred to the abdomen, and 
lung signs being absent (§§ 164 and 169). 

Table VII. — Differentiation between 

Lobar or Croupous Lobular or Broncho- 

Pneumonia. PNEUMONIA. 

Onset . . . . Suddon, with rigors . . Gradual, and procodod by 

bronchitis. 
Course of Tempera- 
ture . . . . Continuous . . . . Remittent. 
Defervescence . . By crisis seventh day . . By lysis in three to four weeks. 
Percussion . . Dulness in one lung, usually Scattered patches of dulnese 

the base. in both lungs. 

Auscultation .. (i.) Fine crepitations .. (i.) Fine crepitations and con- 

(ii.) Consolidation signs in a solidation signs over dull 

day or two. areas, though obscured by 

rhonchi and bronchi tic rales. 
Sputum . . Rusty . . . . Frothy and muco-purulent. 

Respiration . . Pulse-respiration ratio 2:1. No marked difforonoe of pulse- 
respiration ratio. 

Prognosis, — The case mortality varies from 20 to 40 per cent, in hospital 

cases. The usual mode of termination is by heart failure. Much depends 

on the position and extent of the lesion, which is graver when both lungs 



§ 87 ] PNEUMONIA 147 

are involved or when the disease attacks the apex. The reason for Uiis 
is that apical pneumonia usually occurs in a lung already damaged by 
tubercle. It must, however, be remembered that small areas of consolida- 
tion may be associated with very great toxaemia. A lethal termination 
may be anticipated with marked cyanosis, a typhoid condition, scattered 
rales over both bases (indicating oedema), with lowered temperature. 
The absence of the usual increase in the leucocytes is of the gravest import. 
Pneumonia is graver at the extremes of life, in alcoholics and in debilitated 
persons; but robust men in the prime of life often succumb, although 
the prognosis is generally stated to be good in healthy adults. As regards 
complications, meningitis is generally fatal, and endocarditis extremely 
grave. But of all conditions influencing the prognosis of lobar pneumonia 
chronic alcoholism is, in my belief, the worst. 

Tteatment. — There is at present no specific remedy for pneumonia, so 
that treatment is mainly expectant. Our chief endeavour should be to 
maintain the patient's strength, and to achieve this, rest in bed, good 
nursing, and visits by the doctor at least twice a day are essential. Patients 
treated near an open window have less dyspnoea and cyanosis, and sleep 
better than those treated in a vitiated atmosphere. They should be kept 
thoroughly warm by blankets and hot bottles. The diet must be fluid, 
2 to 3 pints of milk, into which may be stirred three or four eggs, being 
given in the twenty-four hours. Sleef is of such paramount importance 
that no patient should be allowed to spend a restless night. The cause for 
the restlessness should be sought for and treated. Frequently pain is the 
disturbing factor. This may be relieved by the local application of ice,^ 
fomentation, or poultices, or a leech. Another cause of sleeplessness is 
engorgement of the right heart. In every case of pneumonia careful watch 
should be kept over the right heart. If the patient is blue and restless, 
the cardiac dulness increased considerably to the right, the liver enlarged, 
and the veins of the neck full, we should immediately relieve the right 
heart, either by venesection (about 5 ounces) or by applying six leeches to 
the skin over the liver. This extreme condition may be averted by the 
timely use of two or three leeches. Pyrexia over 103° may be the reason 
for sleeplessness, and may be reduced by tepid sponging, a measure which 
next to the relief of pain and engorgement of the right heart is the most 
satisfactory means of procuring sleep. For the sleeplessness, hypnotics, 
such as paraldehyde, trional, or veronal may be given, but never chloral 
or sulphonal. Opium may be used in the early stages of the disease, and 
is often of the greatest value, its sedative effect more than counterbalancing 
its action as a cardiac depressant. 

General and Cardiac Stimulants. — Strychnine should be injected hypo- 
dermically, beginning with 3 minims of liquor strychninae every eight 

^ Dr. Lees oUims that the ioe-ba^ has a direct inhibitory action on the pneumonic 
process in the area of lung over which it is applied. Two ice-bags should be placed, 
one in front and one behmd, directlv on the skin. The legs must at the same time 
be kept warm by hot water bottles ( * The Treatment of Some Acute Visceral inflam- 
mations, and other Papers," 1904). 



148 THE LUNGS AND PLEURJS [ §{ 87o. 876. 88 

hours on the fourth day, gradually increasing the dose according to cir- 
cumstances, until the crisis is over. Digitalis is of less use, but may be 
given if there are signs of cardiac muscular weakness. Ammonium car- 
bonate affords an additional and rapidly-acting stimulant. Concerning 
alcohol, there is much difference of opinion. It is particularly indicated 
in alcoholic patients, for whom it should be used freely, and especially 
in conditions of collapse near the crisis, when it may tide the patient over 
so that he is out of danger before the subsequent depressing effect of the 
drug becomes manifest. Atropine is helpful, but tends to increase the 
delirium. Oxygen inhalations should be tried for the respiratory distress. 
Concentrated oxygen is an irritant, and should therefore be diluted with air. 
Vaccine treatment is being tried. A dose of 50 million pneumococci, 
followed by one of 100 million in twenty-four hours, does good if given 
at the beginning of the disease.^ 

§ 87a. A Pneomonic Form of Acute Pulmonary Tuberculosis, or pneumonic phthisis, 
is sometimes met with. The symptoms resemble those of pneiunonia, and may start 
suddenly with a rapid rise of temperature and pain in the side. The temperature 
may continue high for a week or so. The physical signs also resemble those of pneu- 
monia. It differs from this dieoaso, however, in the presence of tubcrolo bacilli in the 
sputum, and the temperature, instead of falling abruptly by crisis about the seventh 
day. graduaUy becomes intermittent, and the course of the disease becomes indefinitely 
prolonged for weeks. This is followed by physical signs of breaking down, purulent 
expectoration, night sweats, and generally death in five to twelve weeks from ex- 
haustion, haemoptysis, or complications, such as pneumothorax (§ 94). 

§ 876. Aberrant Acute Pneumonias (Deuteropathic Pneumonia). — We have seen 
that in pleurisy, acute lobar pneumonia, and in other inflammatory diseases of the 
lungs, the course of the malady is fairly definite, and the physical signs in the lungs 
aie characteristic. But it is important to remember that these same conditions may 
occur secondary to, or as part of, some general disorder. Under these circumstances 
some of the symptoms or physical signs may be wanting or irregular, and it may not 
fce possible to arrive at a diagnosis, except by passing in review the whole history of 
the case, and by making a thoruugh cmd systematic examination of all the other 
organs. Instances of this eccentric group of pneumonias ai'e met with in acute 
glanders, plague, anthrax, syphilis of the lung, actinomycosis, and psittacosis. 

The practical outcome of the m considerations is that when a case of pneumonia, or 
other apparently local inflammatoiy condition, is atypical in its physical signs or its 
clinical history, we probably have to do with a manifestation of one of the conditions 
just mentioned, or some general disease, such as enteric fever, scarlatina, pyasmia, or 
other general infective disorder. 

III. The iUness has come on somewhat gradually ; there is cough, wUh 
frothy expectoration ; the physical signs of consolidation are scattered 
and accompanied by signs of bronchitis. The disease is frobahly Broncho- 
pneumonia. 

§ 88. Acute Lobular Pneumonia, or Broncho-pneiunonia (catarrhal 
pneumonia), is also an acute parenchymatous inflammation of the lungs, 
but it runs a very different course to that of acute lobar pneumonia. The 
inflammatory process occurs in small patches, scattered unequally through- 
out both lungs, and it is accompanied by bronchitis : hence its name. 

The Constitutional Symptoms come on more gradually in this disease. 
I'he temperature is remittent, about 100*^ F. in the mornings and 101° to 

i Nathan Raw, The Lancet, March 9, 1912. 



§ 88 1 AOUTE LOBULAR PNEUMONIA 149 

103^ F. in the evenings, accompanied by cough, dyspnoea, and frothy 

sputum. The pulse is rapid, but the pulse-respiration ratio is not altered 

to anything like the extent of that in lobar pneumonia, ^nd the face is 

generally pale instead of flushed. The fever is maintained by the fresh 

implication of neighbouring lobules for about three t-o six weeks or longer. 

Physical Signs, — When the patches of consolidation are small, there 

may be no dulness on percussion, but only tubular breathing ; but when 

they are of moderate size, signs of consolidation (§ 77) can be made out. 

The chief auscultatory signs in children consist of i/ntensdy loud, *' conso- 

nating,*' r^es and rhonchi. 

SUology. — ^Bronoho-pneumoiiia oooara at all ages, bat is eapeciatty frequent in 
90ung children. The cases fall into two groups, primary and secondary. Primary 
broncho-pneamonia, due to the pneomoooocus, arises in much the same way as lobar 
pneumonia. Secondary forms arise : (i.) Complicating acute infections, such a^ 
measles, whooping-cough, diphtheria, small-pox, influenza, tjrphoid and scarlet fevera ; 
(iL) complicating chronic debilitating conditions, such as chronic Bright's disease, 
chronic cardiac disease, or bed-lying, as from fracture of tho femur in old people ; 
(iii.) aspiration or deglutition pneumonia, such as occurs after operations on the 
tongue, mouth, or nose, in quinsy, cancer of the oesophagus communicating with tho 
air-passages, bronchiectasis, and following hsemoptjrsis or the passage of food down 
an insensitive trachea, as in post-diphtheritic paralysis. A common but more chronic 
variety is of tuberculous origin. 

Diagnosis. — Chronic phthisis is limited to the apex at first, and runs 
a characteristically chronic course. The pulmonary signs of measles, 
whooping-ooughy and bronchitis resemble broncho-pneumonia in its early 
stages, and it may not be easy to diagnose these several diseases until the 
rash of the one or the whoop of the other appears. The constitutional 
symptoms in acute bronchitis are much less severe. The diagnosis from 
acute miliary tvbetculosis may be very difficult, as sputum is usually not 
obtainable, but if it can be examined, the tubercle bacillus will be found. 
The diagnosis from lobar pneumonia is given in tabular form above (p. 146). 

Prognosis, — The case mortality in children under fiy^ varies from 30 to 
50 per cent. (Osier) ; the younger the child the more fatal is the disease. 
The strength of the patient and the duration of the disease are leading 
factors in the prognosis. If he is debilitated, especially if the environ 
ment is unfavourable, he soon becomes a prey to the tubercle bacillus, 
and the case rapidly runs on to phthisis (q,v.). Similarly, the longer the 
case lasts the more likely is it to have a fatal termination, and in adults 
this is very often the case. Broncho-pneumonia is nearly always 
secondary,, and the third leading factor in the prognosis is the nature of 
the antecedent disease. When a child weakened by a prolonged fever is 
attacked, the prognosis is very grave, but after whooping-cough and 
measles it is much more favourable. Nevertheless, children often recover 
in apparently hopeless cases. The aspiration and deglutition pneumonias 
are usually fatal. 

Treatment resembles that of lobar pneumonia, but stimulants are indi- 
cated from the outset of the disease ; two drops of brandy for every month 
of an infant's age may be given every second hour. Children should be 



THE LVNOS AND FLEURX 



[!« 



placed in a steam-tant, and email frequent doses of tr. belladomue ad- 
miniBteied. For adults the pain and incessant cough may require opium, 
beat given as Dover's powder, and poultices applied to the back give 
considerable temporary relief. The cheat afterwards maj' be covered 
with a cnttoQ-wool jacket. If the symptoms become more distreasing 
and the cough and dyspnn'a inrreasc, stimulating pxpectoranltt should bo 
ordered ; and if the c^ugh continue difficult an emetic may be given. 
For the reduction of the hyperpi-rexia, cold sponging may be adopted, 
especially if ceiebral symptoms are present. 

We now turn to the acnte diflean with hypcr-naonanoe on peronaiion 
— vi^., Pneumothorax. We must bear in niind that an acute diseane 
may supervene upon a 
chronic condition accom- 
panied by hyper- resonance 
—e.g., when acute bron- 
chitis supervenes on emphy- 
sema (see Table IX., § 102). 



The patient it in marked 
DISTRESS, tchick has come on 
SUDDENLY ; there is hyper- 
resonance and absence of 
breath sounds. The disease 
is Pneumothorax. 



TyroptnlUc per- 
cDUlaa : sbwDot 
of brenth tad 



Fig. 46.— Dlisnm ot HmsoniBCHOiBOKAX. 



S 89. Pnanmotlionx is a term 
used to denote the preaanoe of ai r 
in Che pleural oavity, the air 
having gained admiuion by per- 
foration of the ploura, ^ther from 
within or from without. Theairii 
after a time acoompanied by pug, 
and the condition ia tboD known 
aa pyopnoamo thorn ; if accom- 
panied by aeroua effusion, as 
hjdiopoeumothonx (Fig. 46). 

The Symplonu of the onset of 
tho condition differ aoooiding 
to the condition of the lung — 
).«., whether it is fairly healtJtj or is widely diseoMd. (a) When pneumothorax 
occurs in the less aSeoted of the two lungs — the other side being extensively diseased 
— (he symptoms am very urgent, and consist of severe pain in the side, attended by 
great dyspntBa, shallow, quick breathing, cyanosis, and some degree of collapee, with 
sweating, lividity, and a weak pulfo. Tho patient usually lies on tho healthy side. 
(b) Id other cases, whoro pDeumotbomx comes on in a lung which ia already much 
disestod, the onset may bo hardly noticed. 

The Phi/aical Signa oonsiet of : (J.) A bulging on the afFected side ; (ii.) diminisbad 
vocal tnmituB; (iiL) hyper-rosonanco on peroussion (unless then is very great dls- 
tension, when the note may be dull) ; (iv.) on ansoultatbn the rospiratory murmur 
may either be inaudible or amphoric ; the vocal resonance is ustuJly diminished, but 
pectoriloquy and bronchophony Bie sometimes present The bdl soujid may be 
elicited on tapping the chest with two coins in one position, and listening with a 
stethoscope in another. When fluid i« also pieMDt, and this is uaual, metAlUo tinkling 



SM] PNEUMOTnORAX^ASTHMA 151 

is heard. Tho Succcuasion SpUuih, when it oan be elioitod without damage to the 
patient, is tho meet charactoristic sign of hydropneumothoraz — a fact which was well 
known to Hippocrates.^ It may be obtained by placing one*s ear against the chest, 
and shaking the patient's body to and fro. 

Etiology. — (i. ) Undoubtedly tho commonest cause (75 per cent. ) is advanced phthisis, 
when a cavity bursts into tho pleura, (ii.) Tho converse process may take place in 
ompyema, when the pus bursts into the lung, (iii.) A fractured rib may lead to per- 
foration of the pleura, (iv.) Lo.<» common causes are gangrene of the lung, abscess 
connected with the spine or liver, or an ulcer of the stomach or cesophagus. bursting 
into tho pleural c^ivity. (v.) It rarely happens in healthy people, although cases have 
been recorded. * 

Proffjtosis, — ^The occurrence of pneumothorax is always very grave. It is difficult 
to estimate its case mortality, because death may be sometimes produced by tho 
condition of the lung apart from the accident, but about half die within the first 
week, and some in a few hours, from shock or suffocation, when tho lung on which the 
patient has been mainly dependent gives way. Only about 10 per cent, of all cases 
taken together ultimately recover. The immediate risk depends upon the uigency of 
tho dyspnosa and cyanosis, tho state of the other lung, the patient's general health, 
and the cause of tho accident. As regards the cattse, the pneumothorax that results 
from late phthisis or gangrene of the lung is very fatal ; but that which occasionally 
complicates whooping-cough, pneumonia, early phthisis, and injury, often results 
in recoveiy. Certain it is that the longer the patient lives after the onset of tho 
pneumothorax, the better is the prognosis for ultimate recovery (p. 164). Doath 
usually occurs from shock and suffocation, as mentioned above, or from asthenia, 
due to the prolonged discharge and lung disease. 

Treatment. — A h3rpodermio of morphia is desirable for the pain, and stimulants 
for the collapse. The question of paracentesis for the removal of air is important. 
It has been done with advantage when groat distension is present, as indicated by 
marked displacement of organs, extreme pain and discomfort, but the relief is usually 
only temporary. When pus is present, the treatment should be that of emp3rema. 
If clear fluid is present, it may be aspirated. In other cases it is inadvisable to 
aspirato or operate, especially in phthisical cases, which should be left to the 
vis medicairix naturas. 

There is one disease of the lungs which belongs neither to the acute nor to 
the chronic category, but is paroxysmal, occurring in attacks of sudden 
onset, usually withoxjt elevation of temperature — Asthma. 

§ 90. Asthma is characterised by paroxysmal attacks of very severe dyspnooa, 
the inspiratory effort being short, the expiratory prolonged. It is accompanied 
by much lividity and distress. Chronic bronchitis is liable to complicate asthma, 
but it is important hero to draw attention to the frequent error which is made by 
regarding exacerbations of chronic bronchitis as paroxysms of asthma. 

Symptoms and Clinical History, — ^The leading characteristic of this disease is its 
paroxysmal nature. A person who is subject to asthma may be perfectly well at 
one minute, and half an hour later may be seized with the most violent dyspnoea. 
It often commences in tho early mom ng, the patient awakening with a fooling of 
tightness of the chest ; he gasps for breath, and clings to surrounding objects in order 
to bring into play the extraonlinary muscles of respiration. Each attack lasts from 
a few minutes to a few days, and then, without apparent reason, the patient rapidly 
recovers his normal and healthy condition. 

There are many curious and unexplained features in connection with this malady, 
one of the most interesting being the tendency to skin eruptions (especially urticaria 
and the various forms of erythema), and another the fact that these eruptions may 
alternate with the attacks of dyspnoea. Varioiis other neuroses, and even attacks 
of insanity, may alternate in the same way. The paroxysms of asthma are occasionally 
preceded or ushered in by violent attacks of sneezing, by itching, or by tho passing 

^ " De Morbis," lib. ii., cap. xvi. 

' Transactions of the Medical Society, 1897, vol, xx., p. 120, 



162 THE LUN08 AND PLEURM { § 90 

of large quantities of limpid urine. Sometimes an attack i« terminated in this 

Phymcid Signs. — On inspection the cheat is seeii to lie maintained in a ]V)8ition of 
inspiration, nndnrRoinR )»ut little expansion wiMi the short inspirations. The per- 
cussion note may be unaltcrv-il, but, after many attacks, emphysema supervenes, 
with consequent hyper-resonanoe. On auscultation the short inspiratory effort is 
feeble and scarcely audible ; expiration prolonged. Loud rhonchi replaee the normal 
vesicular murmur and often coarse r.iles, owing to the accompanying bronchitis. 

Etiology, — Some regard the asthmatic attack as a series of spasmodic attempts 
on the part of the diaphragm, intercostal muscles, and extraordinary muscles of 
inspiration, to overcome some obstruction to the entry of air. But the central fact, 
which alone explains all the symptoms, is a narrowing of the bronchial tubes. This 
is probably due to spasm of the involuntary bronchial muscles, which is attended 
by hyporsemia of the submucosa and swelling of the mucous membrane. Some hold 
that the latter is the primary condition, and that the disease is therefore an 
angioneurosis. 

Among the predisposing causes we find : (i.) A neurotic family history. Careful 
inquiry may reveal asthma or other neuroses, especially those so-called functional 
diseases of the nervous system connected with the involuntary muscular system, 
such as attacks of flushing and shivering, faints, and the like, (ii.) Asthma may 
occur at any age, but nearly always makes its first appearance soon after 
the ago of puberty, (iii.) Any previous lung disease, especially chronic bronchitis, 
may predispose to asthma. Malaria, gout, and other constitutional conditions, are 
often associated with it. (iv.) Conditions of the nasal passages, such as ulceration, 
hypertrophic rhinitis or polypi. 

Among the exciting causes of an attack may be mentioned : (i.) Certain atmo- 
spheric conditions which are ill-understood, and often appear to be most contra* 
dictory. Thus I know one patient who is free from asthma • n London, but develops 
an attack immediately she seeks a high altitude. Another always develops an 
attack when she enters London. Some find the sea relieves them, others that a seaside 
place determines their attacks, (ii.) Reflex causes, such as derangement of the 
alimentary canal, and dietetic indiscretions {e.g., the eating of cheese or fish), will 
often determine an attack ; and so also will (iii.) dust and irritating particles. 

Diagnosis. — ^The diagnosis usually presents no difficulty. The paroxysmal occur- 
rence of the disease is quite characterist c. Paroxysms of dyspnoea coming on at night 
are apt to occur in the course of Bright*s disease and cardiac disease, and have been 
loosely called asthma. 

Prognosis. — ^The disease of itself does not shorten life, but tends to produce emphy- 
sema, bronchitis, and their attendant evils. Children may grow out of the disease ; 
adults never lose it completely. The severity and frequency of the attacks are our 
only gruides to prognosis. 

Treatment. — (a) During the Attach. — Various remedies have been tried. Mentioned 
in the order in which I have found them most useful there are : tr. lobelia, belladonna, 
hyoscyamus, opium in small doses, and pyridin, a remedy introduced and strongly 
advocated by Germain See. An injection of 5 minims adrenalin (1 in 1,000) may 
abort an attack. Spraying the nose with the solution is often efficacious. Atropin 
and cocaine sprays also relieve. The diet during the attack should be the lightest 
possible ; milk alone is best. Various inhalations are sometimes useful, either for 
the prevention or relief of an attack — e.g., the vapour from a teaspoonful of turpentine 
and chloroform in equal parts, or the fumes of paper prepared with a strong solution 
of nitrate of potash, or the inhalation of amyl nitrite. If a mixture containing equal 
parts of the leaves of stramonium, lobelia, black tea, and potassium nitrate, be burnt 
in a tin plate, and the fumes be inhaled, much relief is usually afforded. Various 
other preparations, in the form of cigarettes of stramonium, potassium nitrate, and 
belladonna, are used. 

(h) Between the Attacks. — The effect of locality on the disease can only be ascer- 
tained by experience, and, as above mentioned, it is impossible to foretell what effect 

* These facts point possibly to an infection of the general vaso-motor system similar 
to that in the pulmonary system which produces the spasmodic dyspnoea. 



§•1] 



CLASSIFICATION 



153 



a particular climata will have. As a rule, though with many exceptions, town air 
and fogs are detrimental. To prevent an attack, special attention should be directed 
to the diet, light nourishing food should be advised, and the avoidance of solid 
meal<« after two o'clock in the day. Iodide of potassium, administered for a long 
period of time, certainly tends to ward otf attacks in some patients, and potassium 
bromide at bedtime may act similarly. Ai^senic also is very aseful. The nose should 
bo examined for polypi, etc., and these, as possible causes of irritation, must be 
removed. 



CHRONIC DISEASES OF THE LUNGS AND PLEURA. 

§ 91. GlassifioaiioiL — Chronic disorders of the lungs and pleurse msy 
follow an acute attack of the conditions described in the previous sections, 
as when chronic bronchitis and emphysema succeed attacks of acute bron- 
chitis. But many of the chronic diseases of the lungs, such as pulmonary 
tuberculosis, start insidiously, and attention may not be directed to the 
lungs for a considerable time. 

The chronic diseases, like the acute, may be classified for clinical pur- 
poses, according to the results of percussion. It is convenient in actual 
practice, although unscientific, from the point of view of classification, to 
make a subsidiary group in which the sputum is highly offensive or has 
some other characteristic feature. 



(a) Chronic Disease in which the Percussion Note is unaltered : 

I. Chronic bronchitis 

(b) Chronic Diseases attended by Dolness on Percussion : 

The commoner disorders presenting dulness in regular and 

areas either at base or apex are — 

I. Chronic phthisis 

TI. Hydrothorax . . 

TIL Pulmonary congestion (or cedema of the lungs) 

The rarer diseases, having irregular and senlterei ai^as of dulness aro — 
IV. Interstitial pneumonia 
V. Thickened pleura 
VI. Cancer and other neoplasms 
VII. Collapse of the lung tissue 
VIII. Syphilitic disease of the lung 
(IX. Mediastinal tumours) . . 

(c) Chronic Diseases attended by Hyper-resonance : 

I. Emphysema . . 

II. Pneumothorax^ and various other conditions in 
which the hyper-resonance is not the leading or 
constant feature 

(d) Diseases recognised by the Character of the Sputa : 

I. Bronchiectasis 
II. Gangrene of the lung 

III. Abscess of thi lung 

IV. Aetinomyoosis and other diseases due to fungi 



§ 93 

defined 

§ 94 
§ 95 
§ 91] 

§ 97 
§ 98 
§ 99 
§ 100 
§ 101 
§ 54 

§ 102 



§ 89 



§ 103 

§ 104 

§ 105 

§ 105a 



^ Pneumothorax sometimes comes on acutely, but it is more often part of a chronic 
diflemw. 



154 THE LUNQS AND PLEUR.E §§ 92, 98 

§ 92. Method of Procedure. — ^The routine examination is conducted 
as in acute disorders {§ 80) — viz., after ascertaining the leading symptom, 
and the history of the ilhiess, we proceed to Inspection, Palpation, Per- 
cussion, and Auscultation. In percussion, remember to keep the hand 
flat and firmly pressed against the chest, while it is struck by one or more 
fingers of the other hand, used as a hammer, and with a staccato stroke. 
Remember also that the note is normally dull over the mammae in most 
women, over the scapulae in muscular men, and that it is slightly lower- 
pitched at the right than the left apex. The chest must, of course, be 
stripped. 



Groxtf a. — The patient's symptoms point to chronic disease of the longs, 
and on examining the chest there is no alteration in the percussion note. 

I. The patient has a chronic cough ; there is no elevation of temperature, 
and on auscultation rhonchi and rales are heard over the chest. The 
disease is Chronic BRONCHms. 

§ 98. Chronic Bronchitis is a chronic inflammation of the bronchial tubes. 
It may be chronic from the beginning, or it may supervene on repeated 
attacks of the acute disorder. 

Symptoms, — A patient with chronic bronchitis and — its usual sequel 
— dilated right heart presents a tjrpical appearance. Stout in build, with 
short, thick neck, of florid complexion, short of breath, wheezy respiration, 
and pulsating jugular veins, he presents an aspect which can be recognised 
at once. The clinical history extends over many years, with alternate 
diminution and aggravation of the symptoms. The cough is usually 
present during the winter, and improves as the weather gets warmer. 
The constant coughing and straining to bring up the secretion results 
sooner or later in generalised emphysema. In later stages the cough 
continues all the year round, and finally an attack of capillary bronchitis, 
oedema of the lung, or some intercurrent malady, throws a little extra 
strain upon the overburdened right heart, and death ensues. There are, 
as a rule, no febrile or constitutional sjnnptoms. 

The Physical Signs vary with the amount of secretion present, the 
amoimt of the complicating emphysema (§ 102), and bronchiectasis (§ 103). 
In cases of long duration the chest is barrel-shaped (emphysematous, 
§ 74). Rhonchial fremitus may be felt on palpation. On percussion there 
is never any dulness, and the note is hyper-resonant in proportion to the 
emphysema present. On auscultation sibilant and sonorous rhonchi and 
bubbling rales can be heard ; and crepitations at the base, due to oedema, 
may be present. 

There are four recognised varieties of this disease : (i.) Bronchitis with 
winter cough, attended by slight or abundant expectoration, mucous or 
muco-purulent, sometimes fibrinous, sometimes containing streaks of 
blood, (ii.) Dry Bronchitis is attended by a frequent cough and soreness 
of the chest, but little or no secretion ; it is of a very obstinate character, 
and occurs mostly in elderly people of a gouty diathesis, (iii.) Bron- 



§ 9S ] CHRONIC BRONCHITIS 155 

(^iorrhosa is recognised by the expectoration, which is of a thin, clear, or 
thick and ropy nature, very abundant and devoid of air. (iv.) FcBtid 
Bronchitis may occur in the later stages, and marks the onset of bron- 
chiectasis. The sputum is very foetid from time to time (see Bronchiec- 
tasis, § 103). 

Tlie Diagnosis of chronic bronchitis is not usually difficult. It may be 
readily diagnosed from chronic phthisis by the appearance of the patient, 
by the absence of hectic fever and emaciation, and by the absence of the 
tubercle bacillus from the sputum. 

Etiology. — Chronic bronchitis may occur at any age, but is more common 
in elderly people. Sometimes, as before stated, it follows repeated attacks 
of acute bronchitis, but it may be chronic from the beginning. It often 
affects plethoric subjects, especially those of a gouty habit, and it is one 
of the recognised complications of Bright's disease. It is a frequent 
sequel to cardiac valvtdar disease, more especially disease of the mitral 
orifice. It may complicate other diseases of the lungs, especially phthisis, 
and may be a sequel of the acute specific fevers, especially measles and 
enteric fever. 

Prognosis, — Patients with chronic bronchitis seldom entirely recover, 
though they may live for a great many years ; and if the heart is fairly 
healthy and care be taken to avoid exposure, life is not very materially 
shortened. The coexistence of gout, Bright's disease, and cardio- vascular 
degeneration make the prognosis somewhat less favourable. The con- 
dition of the lungs is not so much a guide to prognosis as the condition of 
the heart. This, indeed, is the point around which the progress centres, 
and the untoward symptoms which render the prognosis grave are thus 
referable to the heart — ^viz., considerable dilatation of the right heart 
with evidences of cardiac failure, such as dropsy, rapid, irregular pulse, 
great breathlessness, and cyanosis (see § 50). 

Treatment. — The extreme frequency of the disorder renders the treat- 
ment a matter of considerable importance. In severe cases the'^patient 
must be confined to one room at a imiform temperature of 62° F. day and 
night. When the mucous membrane is dry and irritable, a steam kettle 
gives great relief ; it must be kept constantly going, not used intermit- 
tently. In slight cases, however, the patient can go about, but chill and 
exposure should be avoided. The important question of when a patient 
may go out must depend largely on the weather — cold and moisture, 
especially when in combination, are especially injurious. 

The indications as to treatment are : (i.) To stimulate the relaxed 
mucous membrane with such remedies as am. carb., senega, squills, etc. 
(ii.) When the cough is dry, soothing remedies, such as bromides, codeia, 
and tr. camph. co. should be given, or remedies directed to promote the 
secretion, such as ipecac., ammon. chlor., potass, iod., and alkalies (the 
last two especially in rheimiatic or gouty cases), may be employed, (iii.) 
Wien the sputmn is very abundant, we should endeavour to diminish 
secretion by such remedies as the balsams (tolu and peru), tar prepara- 



166 THE LUNOa AND PLEVRM { § »Sn 

ttons (cieoaote, guaiacol, petroleum), tuipeutine, camplior, senega, etc., 
given either intemall}' or in the fonn of inhalationB. For the latter, tar, 
cj^osote, and tcrpbene may be used. Counter- irritants to the chest— 
e.g.. turpentiue, camphor, or eiicalyptuB, are very popular n-ith some, 
(iv.) When t.hero is much apasm of the tubes, lobelia, iodide, and other 
remedies for asthma are to be tried, (v.) Cardiac tonics and stimulantA 
are called for sooner or later where dyspncea and other cardiac symptoms 
are present, (vi.) In cases with a gouty taint Ems water each morning, 
and small doses of iodide may be added to the other treatment, and the 
emuDcliiries may be aided by sipping hot water morning and evening, 
and at intervals during the day. 

S 9Sa. Ftiitlo BnmchitU is inflammation of tho bronchi, with the formation of 
libTo-pUatio OBBts. which arc ospoctonted. 

Symptom». — The symptoma consist of (i.) violent attacks of coughing, with ex- 
piratory dyspnoea, followed by (ii.) the expectoration of a fibrinous cost of a bronohus 
[vidt Fig. 46). (iii.) Tho patient geoenkUy suffers from 
chtonio bronohitis, and a liltlo hiemoptysia may follow 
the expulsion of a oast, (iv.) Somctimos there am no 
constitutional symptomB, but slight pyrexia, and in 
some cases oven rigors may bo present. Such symp- 
toms auporvsning in a case of chronic bronchitiB load 
us to siupoot tho condition. 

Fhytieal Sign^ may bo absent. If present, thoy 
aro those of an obstnictad bronchus — an absent or 
diminished respiratory murmur, acoompanied possibly 
by impaired percussion noto. WhistUng Aonobi or 
" flapping " Boundfl may be heard. 

CaKtet. — The disease is twice as common in men 
as in women. It may oceur at any age in subjects of 
chronic bronobitis. 

Prognogig. — The condition is more serious than 

bronchitis. Two varieties have been described : 

(1) Ad acute form, lasting for some weeks ; and (2) a 

Fis. <fl. — Brokchi*!, Cast. chronic form, occurring at intervals, for years, in tho 

course of chronic bronchitis. Each attack may last 

for some weeks, and the casta bo coughed up daily. The condition occasionally leads 

up to a fatal iasae from dyspncea, as when a large cast cannot bo brought up. 

The TreatmtiU differs but little from that of bronohitis. The removal of the 
membrane may be promotod by the inhalation of Ume-watoc. atomised by means 
of a spray, which in used with a view to dissolve the mucin in the oast. Various oils 
(<.;., creosote oil, 1 in 40) have been injected as solvents, bnt the results have not 
been very promising. 

Group B. — We now turn to those chronic diseases of the lungs 
which are accompanied by dnlnen on pereosrion. (a) The more common 
diseases, in which the dulness occurs in regular and fairly defined arras 
at base or apex, are : I. Chronic Pulmonary Tubehcui,o8is ; II. Hyiiro- 
THORAX ; and III. Pulmonary Congestion or (Edrma. 

I. The ■patient comjitaina of gradual emaciation and perhaps cough; on 
examination of the chetl signs op consolidation may be found, most 
marked at the apex of the lung ; there is intbbmittbnt PTBBXiA, and the 
sputum may coTOain the tubercle bacillus. The disease is Chronic Pul- 
monary TuBBRGULOSia {Phthtsis). 



S 94 1 CHRONIC PULMONARY TUBERCULOSIS 157 

§ 94. Ohrcmio Pnlmonary Taberoalosis (Phthisis) may be defiued as a 
wasting disorder due to tuberculosis of the lungs. The word phthisis is 
objectionable because it only indicates one of the symptoms — viz., the 
wasting (<^^tV(D, to waste). In view of the fact that this disease is the chief 
cause of death in Great Britain (483,321 in 1910), the importance of the 
subject cannot be overestimated. The number of deaths in 1910 in London 
alone was 5,555, or 1* 14 per 1,000 living. The disease was formerly regarded 
as due to roimd, nodular growths, " tubercles," scattered throughout the 
limgs, which are made up of a large number of small round cells, epithelioid 
cells, and giant cells. Owing to the discoveries of Koch we now know 
that these little nodules are only the inflammatory manifestations con- 
sequent on the irritation of a bacillus (the tubercle bacillus), and that 
the disease is primarily due to the ravages in the economy of this bacillus 
and its toxic products, and secondarily, to the supervention of other infective 
processes, and especially those due to pyogenic organisms invading the lungs. 

It is customary to describe the anatomy in three stages. It is now 
generally believed that tuberculosis of the limgs begins as a tuberculous 
endo-bronchitis, due to the settling of the mircobe in one of the smaller 
bronchial ramifications. It has been shown by Birch-Hirschfield, who 
took metallic castings of the bronchial tubes, that the reason the microbe 
settles at the apex is because in this situation there is, as it were, a ** dead 
end," in which air is not so readily changed as in other situations. As 
a consequence, any dusty particles containing the bacillus which are 
inhaled and reach this situation, settle down, and there set up an irrita- 
tion, resulting in a small localised ulceration of the mucous membrane. 
This corresponds with the generally accepted teaching that pulmonary 
tuberculosis is chiefly caused by the inhalation of tubercle bacilli. The 
congestion which takes place around the primary foci constitutes (a) the 
first stage. (6) In the second stage there is considerable cell proliferation 
filling up the air cells and resulting in the formation of nodules consisting 
of granulomatous material in the neighbourhood of the primary mischief. 
This is the stage of consolidation, (c) The third stage is one of breaking 
down. Owing to the indolent character and low vitality of the new cell 
formation, it caseates and softens, becomes the seat of pyogenic organisms, 
and destruction of the air cells and formation of smaller or larger cavities 
results. Thus we have three stages : (a) Congestion ; (b) consolidation ; 
and (c) breaking down, with the formation of cavities (Fig. 47). 

Symptoms, — The disease is essentially a chronic one, and its onset is 
very insidious. It is always more amenable to treatment in the early 
stage, and since the introduction of modem methods of treatment an 
early recognition of the disease has come to be of paramount importance. 

(a) Prodromal Stage, — Phthisis has six modes of onset, which, in order 
of frequency, are as follows : (i.) Progressive weakness, attended perhaps 
by cough; (ii.) haemoptysis^; (iii.) dyspepsia; (iv.) laryngeal tubercu- 

^ Elarly haemoptysis of a very profuse kind may occur before any physical signs arc 
discoverable. 



158 THE LUNOS AND PLBVRM (IM 

loais ; (v.) dry pleurisy ; {vi.) acute paeumonia (g 87o), bronchitis, or 
broncho- pneiunonia. Among the earlier general aymptomt which should 
niake ua suspect the invasion of tubercle are unexplained debility, attended 
by languor and antemia on the one hand ; or loss of weight, with unex- 
plained dyspepsia, or slight elevations of temperature in the evening on 
the other. The temperature is an indicatioii of the very greatest im- 
portance, for no ACTIVE Ivberculoua process can take place in any port 0/ 
the body without the occurrence of some pyrexia, however slight. The type 
of this pyrexia is equally distinctive, for it is of an inlermiUent character, 
being normal in the morning, and raised in the afternoon or at night ; in 
rare instances this is reversed. If we have any suspicion of tubercle, the 
temperature should be taken every two hours, so that we may not miss 
any slight access of temperature during the day. AJlbutt has pointed 
out that a premenstrual elevation of temperature sometimes occurs. In 
the early stage the patient may 
not be aware of the feverishness, 
III. L'oviutioa. though generally he feels a chilli- 

ness in the evening, and as the 
11. ConMiidutioD. disease progresses, night sweats 

form one of its moat characteristic 
I. Cangratlon. features. 

The later symptoms of the 
disease are largely due to the 
action of organisms other than 
the tubercle bacillus. The clinical 
manifestations of these " mixed 
infections" are not always 
obvious, but many hold that 
' PuLuoNARv whenever the temperature rises 

Ml rOGETHKB ^-^^^^ jqq.^o ^^ jqjo p jj j^ j^^ 

to a superadded infection of this 
kind. It adds considerably to the gravity of a caae, and its prevention, 
by freah air, cleanliness, and a hygienic mode of life is important. 

The Physical St^tu accompanying the prodromal stage are necessarily 
somewhat vague and difficult to detect. The patient's chest should be 
thoroughly stripped, and he should be taken to a room where perfect 
quiet prevails ; and if with the above symptoms we find weak or harsh 
breathing and prolonged respiration at one apex— especially if this is 
accompanied by an occasional single sibilant rale— we may be fairly 
certain that the disease is developing. Persistent inspiratory " sticky " 
clicks at one apes are very suggestive, if not pathognomonic of early 
phthisis. It is important to auscultate while the patient coughs, for 
rales not previously audible may thus become evident. The signs just 
named can often be heard best at the apex, behind, by placing the patient's 
hand on his opposite shoulder and listening to that part of tiie lung, just 
external to the bronchi, which will thus be Mncoivrerf by the scapula. Fine 



194] OHBONIC PULMONARY TUBERCULOSIS 159 

crepitations may be heard in that situation weeks before any signs can be 
discovered at the apex in front. In front the earliest signs may be heard 
just beneath the clavicle. Sometimes, later on, we are led to detect 
phthisis by an imdue loudness of the heart sounds at the apex of one lung. 
Absence of dulness, like the absence of bacilli, is not evidence of the 
absence of tubercle. The sputum should be repeatedly examined for 
tubercle bacilli. If primary disease of the upper air passages be excluded, 
the presence of tubercle bacilli in the sputum is diagnostic of pulmonary 
tuberculosis. The early morning sputum should be examined, as it is the 
most likely to contain the bacilli. However, the absence of bacilli, even 
after a series of examinations, does not indicate the absence of phthisis. 

Other tests for the presence of tuberculosis are : 

i.) In Morel' a test an ointment impregnated with tuberculin is rubbed into the 
skin ; in tuberculous oases a papulo-pustular rash appears and lasts several days. 

(it) In Yon Pirquet's cutaneous reaction the arm is lightly scarified, and a drop of 
Koch*8 concentrated old tuberculin is rubbed on the scarified area. In a positive 
reaction a red papule appears, occasionally after a few hours, usually within twenty- 
four hours, but it may bo delayed oven longer. This test is valuable in children ; 
in adolte 70 per cent, of apparently healthy persons react. 

(iiL) In CalmeUe's ophthalmic reaction a drop of 1 per cent, of Koch's old tuberculin 
is placed on the conjunctiva. This tost is not devoid of risk to the eye. If positive, 
it indicates the presence of tubercle which may or may not bo active ; if negative, it 
does not necessarily indicate that active tuberculosis is absent. 

(iv.) In the subcutaneous tuberculin test Koch's old tuberculin is inoculated under 
the skin in increasing doses — \ milligramme, 1 milligramme, 5 milligrammes, and 
10 milligrammes. A positive reaction is shown by (1) a local reaction at the site of 
inoculation, which is of no importance ; (2) subjective malaise and fovcr, and (3) re- 
action at the site of the tuberculosis. Thus in pulmonary tuberculosis crepitations 
and increased expectoration would occur. This test should never bo employed 
when patients have fever or other obvious organic disease. 

Dr. Inman ^ points out that none of these tests are of assistance in deciding whether 
tuberculosis is active or dormant, and they arc valuable only as one of many factors 
which have to be considered before advising lengthy courses of treatment. 

(v.) A positive opsonic index test, however, points to the pro;jonco of active tubercu- 
losis ; but a negative test does not disprove the existence of tuberculosis. The normal 
opaonio index range is between 0*8 and 1*2. An abnormally high, or an abnormally 
low, or a widely vaiying index, indicates the prosence of active tuberculosis. 

(6) The 8t(ige of consolidation and (c) the stage of softening and cavita- 
tion may be dealt with together. The symptoms, physical signs, and 
the corresponding limg changes are given in the form of a table for the 
purposes of convenience. The physical signs usually begin at the apex, 
and are generally best heard at the back, sometimes at the apex of the 
lower lobe. From this position they extend downwards, and thus it is 
possible in the same patient to recognise in advanced cases the signs of 
the third stage, or cavitation, at the apex ; below these, signs of consolida- 
tion ; and below these, signs of congestion (as in Fig. 47). Such a con- 
dition indicates considerable activity. Many accessory signs may be 
mentioned : enlarged heart area due to retracted lung, hsemic heart 
murmurs due to anaemia, clubbed Engers in chronic cases of long duration, 
etc. Extensive tuberculous disease may sometimes exist with but little 

^ Inman, the Lancet, December 17, 1910. 



im 



THE LUN08 AND PLEURJE 



[§M 



constitutional disturbance, and on the other hand, considerable disturb- 
ance of health may be present, without any abnormal physical signs — 
depending, partly, on the distance of the lesion from the surface of the 
lung. 

Table VITT. — Three Stages of PHTHI^^Is. 



Anatomy, 
(Ste Fig. 47, p. 158.) 



Physical Signs. 



Symptoms. 



(a) CoKGKSTi024of lung j At apex of the lung — 



tissue, consequent 
on invasion by 
tubercle bacilli. 



(b) Consolidation — 
due to the hyper- 
plasia, cell infil- 
tration, and the 
fusing together of 
the tuberculous 
foci. 



(c) Breaking down 
and Excavation, 



(i.) Feeble R.M., with oc- 
casional fine crepita- 
tion heard at end of 
inspiration ; or 
(ii.) Unduly harsh breath- 
ing with a pro- 
longed expiration. 

Over diseased part, usu- 
ally at apex, are : 
(i.) Impaired movement ; 
(ii.) Flattening ; 
(iii.) Increased vocal fremi- 
tus ; 
(iv.) Bull percussion note ; 
(v.) Bronchial or tubular 

breathing ; 
(vi.) Bronchophony (in- 
creased V.R.). 

Signs as in (6). plus — 

1. Moist clicking rales ; 
and later on — 

2. Signs of presence of 

cavity : 
(i.) Cavernous 

breathing, 
(ii.) Post-tussic suc- 
tion ; 
(iii.) Pectoriloquy ; 
(iv.) Rdles with me- 
tallic tinkle. 



(i.) Increasing languor on 
exertion ; 

(ii.) Slight morning cough ; 

(iii.) Slight rise of tempera- 
ture ; 

(iv.) In some cases htemop- 
tysis. 



(i.) Weakness and emacia- 
tion increase ; 

(ii.) Temperature markedly 
higher in the even- 
ing ; 

(iii.) Night sweats ; 

(iv.) Anaemia. 



All the above 83rmptoms 

aggravated : 
(i) Cough distressing, with 
quantities of num- 
mular expectora- 
tion; haemoptysis 
may bo profuse ; 

(ii.) Temperature high, and 
with wide range ; 

(iii.) Sometimes diarrhuea, 
etc. 



The presence or absence of a cavity is in the majority of cases impossible to 
diagnose with certainty. The percussion note is usually dull, but varies with cir- 
cumstances. Thus the note is resonant when (i.) the cavity is largo, or lies very 
superficially ; and (ii.) there is not a great amount of consolidated lung tissue between 
the cavity and the chest wall. When the cavity is large and superficial, and the 
communicating bronchiis remains patent, a characteristic note, almost tympanitic » 
is obtained on percussion whilst the patient keeps his mouth open. This is known 
as the ** cracked-pot " sound (bruit de pot fele). Many attribute most importance 
to the sign known as ** post-tussic suction.*' To elicit this sign, the stethosoope is 
applied over the suspected cavity, the patient is told to cough, and immediately 
after the cough a characteristic swishing sound is heard, duo to the sucking of air into 
the cavity. This may be accompanied by copious rales. 



{94] CHRONIC PULMONARY TUBERCULOSIS 101 

The Diagnosis of the disease is not difficult except in the early stages, 
and in the absence of bacilli in the sputum, (i.) Various other causes of 
hsemoptysis may have to be differentiated (see § 7t)) ; (ii.) various other 
causes of anaemia may have to be eliminated (Chapter XVI.) ; (iii.) when 
the condition begins with dyspepsia, it is very liable to be overlooked 
unless the physician is aware of this mode of commencement ; (iv.) other 
causes of cough (§ 70) ; and (v.) various laryngeal affections may have 
to be excluded (§ 119). (vi.) When it supervenes on bronchitis or broncho- 
pneumonia, our only clue consists in a delayed convalescence, together 
with the persistence of rales ; and the fine clicking rales of phthisis are 
quite distinctive to the experienced ear. In the later stages of the disease 
the differentiation from the other cases of percussion dulness is not difficult 
(table, § 91). 

Etiology, — In phthisis, as in other microbic disorders, there are, on the 
one hand, predisposing causes which relate to the patient (i.e., the soil 
on which the bacillus grows) and his powers of resistance ; and on the 
other hand, exciting causes which relate to the microbe itself. If the 
" soil " is not suitable — i.e., if the person is not predisposed by heredity 
or other cause, the bacillus will rarely grow. For these reasons its in- 
fectivity has been overlooked all these years. (1) Heredity is a potent 
cause, the individual being bom with a predisposition to the disease. 
This factor, however, does not, as we shall see, occupy the prominent 
position which it was formerly believed to occupy. In a large proportion 
of cases no evidence of heredity is obtainable. (2) Both sexes are pretty 
equally affected, and the favourite age at which the disease usually super- 
venes is between twenty and thirty. The patient may be attacked at 
any time of life, although it is very rare under two years. (3) Any con- 
dition of malnutrition may produce a predisposition to the bacillus invasion, 
whether it arise from deficient food, from hyper-lactation, from exhausting 
diseases such as diabetes, or the acute specific fevers, after which an 
attack of phthisis is by no means infrequent. It is a curious circumstance 
that pregnant women are not prone to the disorder, and a phthisical 
subject becoming pregnant will often improve until after her confinement, 
when an exacerbation of the disease will occur, which has usually a fatal 
result. (4) Unhealthy surroundings play a most important part in the 
production of phthisis, and indoor occupations such as those of lace- 
makers and city clerks are specially unfavourable. A damp soil un- 
doubtedly favours the production of the disease — even the dampness 
from faulty construction of a dwelling will do so. A moist, hot atmo- 
sphere, such as exists in certain factories, favours the spread of the disease. 
A dust-laden atmosphere, such as that of stonemasons, knife-grinders, 
tin and copper miners, fustian-cutters, is a potent cause of phthisis. (5) 
The recent report (1911) of the Royal Commission on Tuberculosis con- 
firms the view that tuberculosis in mankind is due to two types of tubercle 
bacillus, one of human and one of bovine origin. Pulmonary tuberculosis 
is usually due to infection by the human bacillus, which is conveyed by 

11 



162 THE LUNGS AND PLEURM [ § 94 

air tainted with dried sputum containing living bacilli — hence the im- 
portance of destruction of the sputum. In children, on the other hand, 
the bacillus is usually of bovine origin, and it is found chiefly in the 
abdomen (peritoneum or glands), joints, cervical glands, and in the lungs 
when acute miliary tuberculosis carries the bacillus from an infected focus 
to the blood-stream. The bovine bacillus apparently enters the body 
via the alimentary canal, and therefore it may be concluded that the 
disease is due to the ingestion of infected milk or other products of tuber- 
culous animals. It is, however, an undoubted fact that mankind is 
naturally resistant to the tubercle bacillus. Birch-Hirschfield undertook 
a laborious investigation of 4,000 post-mortems, and he foimd that in 
40 per cent, of these persons, dying from all manner of diseases, the lungs 
showed evidences of tubercle which had imdergone spontaneous recovery. 
In view of these facts, and that most of the predisposing causes above 
mentioned are preventable, there is no reason why phthisis should not 
one day become as rare in England as leprosy is to-day. 

Prognosis, — 1. Usual course and duration. Phthisis is essentially a 
chronic but progressive disorder, and until recently nearly all cases apply- 
ing for treatment terminated fatally. The death-rate from phthisis in 
1838 was 38 per 1,000; in 1892, 14 per 1,000 living; and in 1910 
13-4 per 1,000 living. Rapid cases may terminate in death in the course 
of three to six months. When the disease is indolent, and the patient 
resistant to the microbe, it may drag on for years. There are four 
chief modes of death, which in order of frequency are — (1) asthenia, 
(2) hemoptysis, (3) asphyxia from pneumothorax, (4) the occurrence of 
other complications. 

2. The prognosis in reference to Causation, depends on : (i.) Heredity. 
Unquestionably it takes a more favourable course and the process tends 
to be less active in cases where there is no family history of tuberculosis, 
(ii.) The age of the patient influences the course considerably, for it is 
much more rapid in the young than in people over thirty, (iii.) The 
hygienic surroimdings of a patient, as we shall see under treatment, 
make considerable difierence to the course of the disease. Where the 
patient is well-to-do and can be removed from those conditions which 
have promoted the disease, he has a good chance nowadays of recovery ; 
but among the poor, who are forced to continue among their squalid 
surroundings and at their work, a fatal issue almost necessarily results, 
(iv.) Previous alcoholic excess diminishes the chance of recovery. 

3. Untoward Symptoms. — (i.) Undoubtedly the most important feature 
is the temperature. Not only is an active tuberculosis evidenced by 
pyrexia, but the degree of fever, and still more the extent of the variations, 
are a fairly precise measure of the activity of the tuberculous process, 
(ii.) The condition of the lung is of course important. The presence of 
rales, as denoting softening and advancing disease, is unfavourable ; and 
their disappearance favourable, but the extent of lung involved is as 
important a factor in prognosis. Thus, a man in the third stage, with 



S 94 ] CHRONIC PULMONARY TUBERCULOSIS 163 

a cavity at the apex in one lung, and little disease elsewhere, has a better 
chance of recovery than one with slight tuberculous foci scattered through 
the lung. If both lungs show disease in the third stage, recovery is rare, 
though health has been restored in some cases after prolonged treatment, 
(iii.) The general symptoms also aid us in recognising the rate of progress. 
When the weight is increasing, the temperature declining, and food is 
taken well, the chances of recovery are good, (iv.) Early haemoptysis 
does not affect the prognosis in any way, but occurring later in any 
quantity is apt to weaken the patient considerably. 

4. Complications. — The presence of complications is undoubtedly bad. 
The commonest complications are : (1) Pleurisy, which is very frequent, 
but is often of a conservative nature, for adhesions may sometimes pre- 
vent pneumothorax ; (2) tubercle may occur in other parts — the peri- 
toneum, meninges, and especially in the intestine, giving rise to ulcera- 
tion and an exhausting diarrhoea ^ ; (3) the larynx may be affected either 
previously or subsequently, and imdoubtedly it adversely influences the 
prognosis ; (4) lardaceous disease of the liver, spleen, and other organs 
used to be frequently seen ; (5) pneumothorax and pyopneumothorax may 
ensue from the bursting of a cavity into the pleura — fatal asphyxia may 
result (§ 89) ; (6) thrombosis of various veins is a less common complica- 
tion; (7) peripheral neuritis is now a recognised occurrence, sometimes 
very early in the disease ; (8) vomiting. 

It is a good rule never to commit yourself to an opinion on any case 
of phthisis without first noting the effects of treatment. 

Treatment of Phthisis. — The subject of treatment will be dealt with 
under four headings : (a) remedial ; (b) symptomatic treatment ; (c) treat- 
ment by tuberculin; (d) the open-air treatment; and (e) preventive 
measures. The indications of all treatment are to reduce the inflammation, 
to destroy the virus, to build up the strength, and to palliate the symptoms. 

(a) The Remedial Treatment formerly in vogue was mainly directed to 
building up the strength by means of cod-liver oil, maltine, hypophos- 
phites, and other tonics. Cod-liver oil is of great value in treating afebrile 
cases. Guaiacol, 20 grains (gradually increased), creosote, eucalyptus 
and other antiseptics may be given at any time. Thiocol (gr. v.) thrice 
daily has all the advantages, without the drawbacks, of creosote. By 
some these are also administered as an injection into the lung. Perhaps 
the best of this kind of treatment is the use of a spray four times a day, 
lasting fifteen minutes, of formalin.^ Inhalation of antiseptics may be 
administered by Yeo's respirator. Counter-irritants were largely used 
to reduce the inflammation, the favourites being iodine or croton oil 
applied over the apex of the lung. These measures were supplemented 
in wealthier patients by sea-voyages, high, dry moimtain air, and residence 

^ BiarrhoBa may also occur as part of the hectic fever without any ulceration of the 
bowels. 

^ Dr. Lardner Green recommends the following formula (Formalin =40 per cent, of 
Formic Aldehyde) : Formalin, 5i« ; Glycerine, 3iv. ; Aq. Dest, 5v. Use as spray four 
times a day, fifteen minutes at each inhalation {Lancet, August 19, 1899, p. 521). 



HA THE LVNQS AND PLEVBM \ § 94 

abroad during the winter, combined with a liberal dietary and generaj 
hygienic mode of life.^ These various methods are still useful, but at 
the present time we have other powerful means of combating this lethal 
disease. It has been noted in some cases that the supervention of 
pneumothorax, if not very quickly fatal, often leads to a considerable 
improvement, and therefore the induction of artificial pneumothorax 2 
has been tried as a therapeutic measure. From 250 to 500 c.c. or more 
of nitrogen are introduced into the pleural cavity through a syringe. 
The lung collapses and is thus put at rest until the nitrogen is absorbed. 
It may be necessary to repeat the injection more than once. The method 
is only suitable where one lung is almost free from disease. In some 
cases the results have been extremely favourable and the operation in 
experienced hands is not dangerous. 

(h) Symptomatic Treatment. — It will be seen that in the third stage 
there is not much hope of recovery, but even in the worst cases we can 
ameliorate the symptoms, and so ease the passage to the grave. (1) For 
the cough, tinct. camph. co. and other expectorants are not of much use. 
The best cough mixture is one containing liquor morphine, or, better 
still, codeia in small doses with dilute sulphuric acid. Wcum alkaline drinks 
promote expectoration. (2) Night sweats, which are often very profuse 
and exhausting, may be combated by atropine, zinc oxide, picrotoxin, 
and strychnine, especially the first named. Night sweats are said to be 
seldom troublesome if there be free exposure to fresh air. (3) The diar- 
rhoea is also very exhausting, and must be combated with catechu, opium, 
intestinal disinfectants, and mineral acids. (4) Pleuritic pains may be 
eased by stupes, or painting with tincture of iodine. (5) The concurrent 
dyspepsia must be combated in the usual way, but the vomiting is often 
a very troublesome symptom, and there are three kinds of vomiting which 
admit of three different methods of treatment, (a) If preceded by nausea, 
it points to disorder of the stomach, and should be treated by bismuth, 
etc., on the usual lines, (b) If the vomiting be preceded and caused by 
coughing, it is a good plan to give hot drinks just before a meal, in order 
to encourage the expectoration and get the paroxysms of coughing over 
before the meal is commenced, (c) If neither of these causes can be 
traced, the vomiting is probably due to irritation of the vagus, and may 
sometimes be relieved by opium. Sometimes vomiting is controlled by 
the will. (6) The treatment of haemoptysis, pneumothorax, and laryngeal 
ulceration are dealt with elsewhere. 

(c) Treatmsnt by Tubercvlin depends upon the principle of immunisa- 
tion (§ 386). Koch followed his discovery of the tubercle bacillus by 

^ Simple respiratory exercises, such as the following, designed to expand the chest, 
form a useful adjunct : (i.) With the back against the wall, fully extend the arms to tho 
level of the shoulders slowly for eight times, (ii.) Continue the same movements until 
the arms meet above the head, (iii.) Start with the hands above and in front of tho 
lioad, and bring them slowly down until the backs of tho hands meet behind the body, 
at the level of the buttocks, the arms being rigid all tho while. These should be done 
twice daily, gradually increased to five to six times daily. 

* Colebrook, the liwcei, 1911. 



§94] CHRONIC PULMONARY TUBERCULOSIS 105 

soon afterwards issuing to the world the toxin produced by the bacillus. 
This he called tuberculin, and it is now called oil tuberculin. It was 
administered hypodermically and produced considerable " reaction " — 
i.e., constitutional disturbance — in the patient. It was largely used, but 
the results were not satisfactory. There are now several tuberculins on 
the market. The initial hypodermic dose (sttVif ^g-) ^ gradually increased 
imtil the patient can tolerate larger doses without any rise of temperature 
or excessive local reaction. If either local or general reaction occurs, 
the dose is diminished and the interval between the doses is increased. 
Some hold that tuberculin should not be administered except by those 
who are conversant with the methods of control by measurement of the 
opsonic index. Others report good results from large doses. Dr. Nathan 
Raw^ finds that small doses of bovine tuberculin give good results in 
pulmonary tuberculosis. 

(d) The " open-air,^^ hygienic, or sanatorium treatment of phthisis, as 
it is now called, is not altogether a new method, for fresh air has always 
been advocated as advantageous to these patients. Systematic open-air 
treatment was first established at Nordrach. There are now numerous 
sanatoria both at home and abroad. Much discussion has taken place 
as to whether the treatment cannot be carried out without a sanatorium. 
Among the well-to-do, perhaps, a sanatorium is not indispensable, but in 
the middle and lower classes the necessary discipline cannot be otherwise 
carried out. That residence in a sanatorium is not absolutely necessary 
is evidenced by cases which have been under my care, even in an advanced 
stage of phthisis, who were unable to go away. One of them spent all 
the daytime in Kensington Gardens, in all weathers, and when indoors 
the windows were always open. This patient recovered in six months.^ 

Briefly, the advantages gained by this method of treatment consist of. 
(i.) Increased medical supervision from day to day and hour to hour by 
the medical officer of the sanatorium ; (ii.) the continuous exposure of 
the patient to fresh, pure air, night and day, the windows never being shut 
and sometimes wholly removed ; (iii.) systematic exercise in suitable cases ; 
(iv.) the ingestion of a large amount of suitable food ; (v.) a suitable 
amount of rest during the fever stage, and a freedom from excitement ; 
(vi.) the avoidance of mixed infections by hygienic mode of life. Cleanli- 
ness and fresh air tend to obviate pyogenic processes and infections. 
All possibility of the introduction of influenza and other infective dis- 
orders should be avoided by the proper regulation of visitors to patients. 
I believe that some day these latter will be subjected to the most rigorous 
scrutiny and inquiry before being allowed to come in contact with the 
consumptive patients in a sanatorium. The mixed or superadded in- 
fections do more harm than the tubercle bacillus. This is probably the 
reason why tuberculous patients do so badly in the wards of a general 
hospital. The treatment varies at the different sanatoria. In some, 

1 The 2>znce^ April 8, 1911. 

^ See also a case reported in the Lancet, January 20, 1900. 



166 THE LUNGS AND PLEURM [ § 94 

graduated labour is the chief feature ; in some the high altitude ; in others 
tuberculin injections form important factors in the treatment. Patients 
who return to ordinary life, return with a working knowledge of the 
hygienic rules appropriate for consumptive subjects. 

The possible disadvantages ujged are : (i.) The fear of hyper-medication 
that may go on in sanatoria ; and (ii.) certain unsuitable cases (see below) 
may be deleteriously affected. 

In carrying out sanatorium treatment, seven rules should be observed : 

(1) Much depends on the suitability of the case, and the earlier the stage 
the better. There are three conditions in which the sanatorium, or open- 
air treatment, is imdesirable : (i.) When the process is too active, as 
evidenced by a high and wide range of temperature^ ; (ii.) when the lungs 
are too far destroyed; and (iii.) when the case is attended by active 
bronchial catarrh. 

(2) The food must be abundant, and the cuisine appetising and attrac- 
tive .2 But here an important caution comes in, else the patient puts on 
fat without influencing the disease. The food must be in proportion to 
the exercise, and the patient's weight should never much exceed his 
previously normal weight. The proteid food should be increased relatively 
to the farinaceous, otherwise the patient becomes plethoric and breathless. 

(3) Evidences of benefit should be carefully looked for. They are three 
in number : (i.) A lowering of the temperature and a lessening of its range ; 
(ii.) an increase in the appetite ; (iii.) increase of weight combined with the 
two previous features. 

(4) In deciding the important question of rest or exercise, the great 
value of accurate temperature records is again seen. The system of 
graduated labour introduced at Frimley Sanatorium by Dr. Paterson^ is 
being followed by many with excellent results. There are six grades of 
labour, varying from walking exercise, carrying heavy implements, to 
the full work of a navvy. The patient is not allowed to begin work until 
the temperature is stable at not over 99° F. in males, and 99' 6° F. in 
females. If it rises after slight exercise, the patient rests until it is normal. 
Progressively heavier work can be performed without any rise of tempera- 
ture. The normal and mental effects are invigorating and enable the 
patient to resume ordinary occupation after leaving the sanatorium with 
a healthier standpoint than after a long rest with idleness. 

(5) Amusement is necessary, but it requires to be carefully regulated. 



^ Some do not regard this as a contra-indication to open-air treatment ; but in such 
cases the length of the journey has to be considered, and the undesirability of mixing 
such patients with others. 

^ Thirteen pints of milk, or its equivalent, is in most institutions adopted as a fair 
standard of diet ; that is, 9 ounces of proteid, TJ ounces of fat, 10 J ounces of carbohy- 
drate : total, 27J ounces water-free food. With ** Parkes* Hygiene " percentage com- 
position tables, varying diets can easily be made up containing the above proportion 
of food elements. 

^ "Auto-inoculation in Pulmonary Tuberculosis," by Marcus Paterson, 1911. 
The continual auto-inoculation induced by exercise sets in motion the protective 
mechanism of the blood. 



S94] CHRONIC PULMONARY TUBERCULOSIS 167 

The patient should not talk too much, and any excitement or heated 
discussion is bad. The whole day, and, ifjoossible, the night also, should be 
spent out of doors, no matter what the weather may he, and outdoor 
amusement cultivated. A very useful contrivance is a small revolving 
summerhouse, the front of which is open, and can be turned away from 
the wind. 

(6) The duration of the treatment must be sufficient, and should be 
continued for some time after all symptoms have disappeared. If the 
case is only in the first stage, cure may be accomplished in six months. 

(7) The hygiene and the locality of the building are important matters, 
but the reader must refer to special works for this. The beneficial effect 
of mountain air has been proved beyond dispute. It is particularly in- 
dicated in cases of consolidation without cavitation, but later stages also 
can be benefited. Deeper, longer, and more complete respirations are 
taken at high altitudes, and the air is purer than elsewhere. 

(e) Preventive Treatment. — Since the microbic origin of tuberculosis was 
admitted, the question of how far it is a contagious disease has been 
keenly debated. The results of the labours of the Royal Commission are 
mentioned above (p. 161), and from these conclusions it is obvious that 
preventive measures come imder the headings of (1) prevention of the 
communication of the disease from man to man ; (2) prevention of its 
extension from animals to man; and (3) education of the public. (1) 
Prevention of infection from man to man is ensured by destruction of 
the microbe, and by strengthening the resisting powers of those heredi- 
tarily predisposed to the disease. For the destruction of the microbe 
the rooms in which phthisical people have lived must be thoroughly 
disinfected ; and the sputum must be destroyed before it dries. The 
patient must spit only into some portable receptacle containing a dis- 
infectant such as lysol, or into paper sputum cups which can be burned. 
Tuberculous patients should not share the sleeping rooms of healthy 
individuals. (2) The method of prevention of infection from animals is 
a matter for the consideration of the State. Bovine tubercle is conveyed 
by the ingestion of the flesh or products of diseased cattle. In order to 
protect the community from this danger it is necessary to have adequate 
inspection and full powers of dealing with infected meat and milk. (3) 
There are many ways of educating the public on the hygiene of the home 
in tuberculous families. Tuberculosis exhibitions, lectures, etc., merit 
the support of every medical man. The most practical scheme at present, 
however, is the multiplication of tuberculin dispensaries. Sanatoria, 
hospitals, and dispensaries ought to work in association. At the dis- 
pensaries the early cases of tuberculosis are detected and drafted off to 
sanatoria ; the homes of the invalids are visited and the inmates are 
instructed as to the correct hygienic measures to adopt in order to pre- 
vent contamination of those uninfected persons who have been in contact 
with the disease. Treatment is also given at the dispensaries, but their 
greatest sphere of usefulness lies in their educative influence. 



168 THE LUNGS AND PLEUBJB [ H 94a. 95 

f 94a. Fibroid Phthisis is one of the least oommon of the yarieties of pulmonaiy 
tuberculosis. It may be defined as a tuberoulo-fibroid disease of the lungs, occurring 
for the most part in elderly subjects, running a protracted course, and terminating 
in contraction of the lung. This disease is very apt to be confused with chronic 
interstitial pneumonia or cirrhosis of the lung (§ 97).^ 

Symptoma. — The dineaEe is essentially one of insidious onset and long duration. 
The patient complains of a chronic cough for many years. Later on this may become 
paroxysmal, and especially troublesome in the morning. Progressive shortness of 
breath, clubbed fingers, slowly increasing weakness and emaciation, with little or no 
fever, constitute the other symptoms. 

The Physical Signs begin and are almost always most marked at the apex. Both 
lungs are usually affected (which contrasts with interstitial pneumonia), but the signs 
of disease are afterwards more advanced on one side. There is impairment of the 
chest movement, and later on contraction of one side of the chest. The area of 
prsecordial dulness is increased when the left lung is involved ; and the heart and other 
viscera may be displaced. The signs of consolidation, with gradual softening, may 
also be present. Hemoptysis sometimes occurs, and the tubercle bacillus may be 
discovered on careful and repeated examination of the sputum. 

The Diagnosis from other forms of phthisis is made by the extremely protracted 
course of this disease and the age of the patient. Chronic interstitial pneumonia 
resembles it very closely, both in its physical signs and symptoms, and the diagnosis 
of interstitial pneumonia can only be inferred (i.) from the absence of the tubercle 
bacillus after oft- repeated examinations, and (ii.) from the more usual localisation 
in one lung. 

Etiology. — Fibroid phthisis is more frequently met with at and after middle life. 
It may follow chronic bronchitis, broncho-pneumonia, or repeated attacks of pleurisy. 
In true Fibroid Phthisis the tubercle bacillus is primarily deposited in a healthy lung 
under the same circumstances as in chronic pulmonary tuberculosis, and then causes 
an indolent fibroid reaction. On the other hand, chronic interstitial pneumonia 
may become the seat of tuberculous invasion, and in that case the causes of chronic 
interstitial pneumonia are the causes of fibroid phthisis (see Interstitial Pneumonia, 
S 97). 

Prognosis. — Its couree is very indefinite and protracted. Sometimes acute tuber- 
culosis supervenes. The chief complications are bronchiectasis, compensatory 
emphysema of the lungs, lardaceous disease of other oi^ns, and cardiac failure. In 
general terms the prognosis depends upon the same conditions as those of pulmonary 
tuberculosis and the Treatment is the same. 

II. The jxUient complains of breathlessness ; on examining the chesty dul- 
ness is found at one or both bases, and signs of fluid are detected there. 
The disease is Hydrothorax. 

§ 95. Hydrothorax is a chronic collection of serous fluid in the pleural cavity, 
differing from the effusion of pleurisy in being non-inflammatory. 

Symptoms. — The general symptoms may be but little marked if the fluid is small 
in quantity. The onset is usually gradual. Dyspnoea is generally present, especially 
on exercise, but its degree depends upon the amount of fluid. As hydrothorax is 
always a secondary condition, the symptoms may be masked by the presence of dropsy 
elsewhere ; and it is remarkable how often hydrc thorax is overlooked on this account. 
In rare cases the fluid collects with great rapidity. 

The Physical Signs are those of fluid in the chtst {vide § 77). The level of the 
fluid in hydrothorax, imless excessive in quantity, moves when the patient alters 
his position, thus differing from the inflammatory fluid of acute pleurisy. This 
is an important diagnostic feature which can always be elicited, except when the fluid 
is confined by adhesions. 

Diagnosis. — The disease has to be diagnosed from other disorders giving rise to 
dulness on percussion (p. 153). As regards pleurisy, in addition to the mobility of 

^ Reference to chronic interstitial pneumonia (§ 97) will show to what condition the 
term ** fibroid phthisis " should be confined 



S 96 ] HYDROTHORAX— (EDEMA OF THE LUNG 169 

tho fluid, hydrothorax is distinguished by the absence of pyrexia at the onset, by the 
abeence of pain, and by the fact that the fluid occurs usually on both sides. 

Etiology. — (i.) Hydrothorax may form part of tho general dropsy of Bright*s disease, 
in which circumstances both pleurae are involved. Here tho hydrothorax is of no 
very great importance per se, but the onset of dyspnooa in Bright's disease should 
always direct our attention to tho plourae. (ii) Similarly, it may form part of cardiac 
dropsy, in which circumstances one pleura is often solely or chiefly affected, (iii. ) New 
growths in the chost are generally attended by hydrothorax. This is especially so 
in tho case of carcinoma, which should always be suspected in the aged. In this 
case the fluid is blood-stained, and may be found to contain cancer cells. In tubercle 
there is rarely much fluid in the pleura, adhesions being more common, (i v. ) Aneurysm 
or other intrathoracic tumours pressing on the veins of the thorax may give rise to 
hydrothorax on one or both sides. 

Prognosis. — The disease is essentially chronic, the duration depending very much 
upon the causa In general terms the prognosis of the condition is unfavourable. 
Ihe patient should be carefully watched for tho occurrence of shivering, sweating, 
or intermitting pyrexia, as indicative of empyema. The sudden onset of signs of 
fluid in the chest, accompanied by shock or collapse, in a case which has previously 
presented tho symptoms of aneurysm, points to the occurrence of hsemorrhage into 
the pleural cavity (hsemothorax). 

Treaimeni. — ^The treatment is comparatively simple. Tho administration of brisk 
hydragogue purgatives will generally reduce the amount of fluid ; if this fails, or if 
the fluid return, or in any case where dyspnoea is extreme, paracentesis (§ 85) should 
bo resorted to. The operation of tapping may bo repeated indoflnitely. Diuretics 
or cardiac stimulants are useful. For the rest, the treatment must be diroctod to 
tho primary condition (see also § 85). 

III. The patient complains of breatMessne^s ; on examining the chest, dulness, usually 
slight, is found at one or both bases, and on auscultation, fine crepitations are heard. 
The disease is Pulmonary Congestion or (Edema. 

§ 96. CBdema of the Long (Pulmonary Congestion). — CEdema of the lung is a 
serous exudation into and around the air vesicles. It is synonymous with the term 
"hypostatic congestion,' or, as it is sometimes called, "hypostatic pneumonia" 
It determines the end of many serious disorders. 

Symptoms. — (i.) It is never a primary condition, and therefore our attention is 
first directed to the symptoms of its cause. The advent of hypostatic congestion 
is always insidious, and it is only by careful watching that it can bo detected, 
(ii.) A considerable amount of dyspnoea is present, which may amount to orthopnoea. 
(iii.) There is a frothy mucous expectoration, not infrequently tinged with blood. 

The Physical Signs are somewhat indefinite, but they are found, as is implied by 
the term " hypostatic," chiefly at the bases of both lungs. The percussion note is 
somewhat impaired, and the air entry at the bases is diminished, and is attended 
by abundant moist crepitations. 

Ditignosis. — ^Tho condition is diagnosed from true pneumonia by the gradual onset, 
the indefinite signs, and the absence, for tho most part, of pyrexia and other con- 
stitutional symptoms. Any rise of temperature that may be present is duo to the 
primary or causal condition. 

Etiology. — (i.) The disease is most frequently mot with in elderly peoplo. (ii.) Pul- 
monary oedema complicates various blood disorders and fevers, especially typhus 
and typhoid fevers. The latter, indeed, is so frequently complicated in this way 
that hypostatic congestion is an aid to tho diagnosis in tho second and third weeks 
of tho disease. In Bright's disease and anaemia, oedema of tho lungs occurs as part 
of a generalised dropsy, (iii.) Cardiac and other diseases, loading to mechanical 
dropsy, produce oedema of the lungs, (iv.) Tumours pressing on the veins within the 
mediastinum may result in pulmonary oedema. 

Prognosis. — ^The prognosis is always grave, because pulmonary oedema indicates 
either considerable impediment to tho circulation in the lung?, or a serious toxic 
condition of the blood. It frequently terminates life in circulatory disorders, and 
in specific fevers of the asthenic type. In pneumonia it heralds a fatal issue. The 
extent of the oedema is indicated very fairly by the degree o' dyspnoea. 



no THE LUNGS AND PLEURA [ f 97 

TrtatmenL — ^The indications are to rolieve the cause, if possible, and to stimulate 
the heart. Ammonium carbonate and other stimulating expectorants aid the heart 
and promote expectoration. The liberal administration of alcohol and other 
diffusible stimulants is called for. In the aged, among whom even slight disorders 
are apt to be attended by pulmonary oddema, it is well to keep the paiient propped up 
in a somi-recumbent posture. For the same reason it is advisable, in cases of fracture 
and other surgical maladies in the aged, to get them up as soon as possible, even at 
the risk of doing harm to their surgical ailment, so as to obviate the occurronce of 
hypostatic congestion of the lungs. 

Group B. — We now turn to the rarer chronic diseases attended by dnlness 
on "percussion, in which the dulness occurs in irregular and scattered areas : 
IV. Interstitial Pneumonia ; V. Thickened Pleura ; VI. Cancer 
AND Other Tumours ; VII. Collapse ; VIII. Syphilitic Disease ; and 
IX. Mediastinal Tumours. 

f 97. Chronic Intentitial Pnenmonia — apart from that form due to the malign 
effects of certain trades — is a rare disease. It may be defined as a chronic inter- 
stitial fibrosis of the lung, localised or diffuse, according to the variety, running a 
protracted course, and resulting in contraction of the pulmonary tissue. 

An increase of the fibrous tissue of the lung may take place under the following 
conditions, all being chronic processes : 

(i.) An indolent tuberculous process may assume a fibroid character. Fibrosis 
is one of the ordinary terminations of a tuberculous focus ; but when the progress 
is very slow and protracted, with excessive formation of fibrous tissue, it constitutes 
true fibroid phthisis, 

(ii.) The constant inhalation of dust in certain trades {e.g., fustian cutters, jute 
workers, wool-sorters, stone, knife, and other grinders and polishers, iron and coal 
miners, etc.) gives rise to a chronic hroncho-prteumonia, followed by a peribronchial 
fibrosis, which later on involves considerable areas of lung tissue. 

(iii.) Repeated attacks of pleurisy may be attended by a subpleural fibrosis 
(thickened pleura), and dense bands of fibrous tissue may extend into the lung (Sir 
Andrew Clark). 

(iv.) Acute broncho-pneumonia, becoming chronic, may, although very rarely, result 
in an interstitial fibrosis. This form very often terminates by becoming tuberculous. 

(v.) An acvie lobar pneumonia, similarly, may assume a chronic course, and may 
result in an interstitial fibrosis (Addison). TMs form has not the same tendency 
to become tuberculous. 

(vi) Syphilitic disease of the lung is rare, except as a congenital manifestation in 
infancy, in which circumstances the change consists of a fibroid induration of the 
lung (Kingston Fowler). 

All these may become the seat of tuberculous disease, but only the first, which 
is a tuberctdo-fibroid process, should bo called " fibroid phthisis.'* The other varieties 
constitute cirrhosis of the lung, and if they are invaded by the tubercle bacillus, they 
form a fibro-tuberculous process, which in its later stages may be indistinguishable 
from fibroid phthisis. 

The general Symptoms consist of progressive weakness and dyspncea. There is 
no fever unless there is ulceration of the bronchi or septicaemia — a common occur- 
ronce in late stages of the disease. 

The Physical Signs may be found either at the base or the apex, though usually 
the former. Except in the variety due to the inhalation of irritating particles, only 
one lung is involved, thus differing from fibroid phthisis, in which both lungs are usually 
affected. There is deficient mobility of the diseased side, which later on undergoes 
contraction, so that there may be considerable difference in the measurement of the 
two sides of the chest. There is dulness on percussion. On auscultation, bubbling 
rales may be hoard, but sometimes the only symptom is weak bronchial breathing 
or a weak respiratory murmur. The expectoration sometimes contains blood, but 
never the tubercle bacillus. 



SI 98, 09] MALIGNANT DISEASE OF THE LUNG 171 

The Diagnoaia of interstitial pnoumonia from fibroid phthisis is sometimes very 
difficult, as may bo soea in the description of the yarious piooesses just named. It 
is also liable to be mistaken for empyema. 

The Etiology of the condition is given above. It is met with chiefly in male subjects 
undor the age of fifty — especially between fifteen and thirty. Alcoholism predisposes. 
The commonest form of chronic interstitial pneumonia is that met with in persons 
engaged in trades attended by the inhalation of irritating particles. Sometimes it 
is a sequel to other pulmonary disorders. 

Prognosis. — ^The prognosis is serious, because nothing will remove the fibrous 
tissue. As regards the duration of life, the prognosis is good if the patient is not 
losing weight and the disease is not too extonsive. The complicaiions are bronchiectasb, 
a very frequent sequel, dilated right heart, and emphysema occurring in other parts 
of the lung. When ulceration of the bronchi has taken place, lardace3us disease 
and septicemia may ensue. 

TreatmenL — Counter-irritation and respiratory exercises are given on the lines 
advised in Chronic Phthisis (§ 94). Formula 61 is usefuL 

§ 98. Thickened Plenra is a condition which sometimes succeeds dry pleurisy, 
especially recurrent dry pleurisy. It is important to be able to recognise it, lest 
it should be mistaken for some more serious condition, though it is somewhat difficult 
to diagnose. It is more often localised to one part, and that most commonly at the 
apex associated with chronic phthisis. The symptoms are : (i.) A localised enfeeble- 
ment of the respiratory murmur; (ii.) dulness on percussion; and (iii.) diminution 
in the vocal resonance and fremitus. 

The diagnosis is arrived at (L) by the history of the case — e.g., there has been an 
attack of pleurisy or pneumonia in the past — and (ii.) by the absence of signs of active 
disease when the patient is kept for some time under observation. The condition is 
often discovered only by chance, when the patient seeks advice for other ailments. 
Treatment is of no avail ; and, if only moderate in degree, the disease is not of much 
consequence. Counter-irritation may be applied. 

§ 99. Malignant Disease of the Lung. — Cancer of the lung is rarely a primary 
condition, but is most frequently secondary to cancer of the breast or abdominal 
organs. The most common form of malignant disease, sarcoma of the mediastinum, 
is described in § 54. A primary malignant growth tends to involve one lung ; secondary 
growths tend to bo disseminated in both lungs. The evidences of the former are 
usually more distinct than those of the latter. 

Symptoms. — ^The lung trouble may be preceded by signs of malignant disease 
elsewhere. The first evidence of involvement of the lung is breathlessness, 
followed by cough and by expectoration, which may from time to time be tinged 
with blood (" prune- juice sputum.") Pain is often present, and indicates generally 
that the pleura is invaded, in which case there is usually a certain amount of pleuritic 
(blood-stained) effusion. 

The Physical Signs are often very indefinite. Clinically, there are two forms — 
(a) The nodvlar form is usually attended by serous effusion (see Hydrothorax, § 95). 
Effusion into the pleura coming on slowly, or returning persistently, in an elderly 
person not the subject of phthisis is of itself suspicious, and the diagnosis is con- 
firmed when, on aspiration, the fluid is found to be blood-stained. Sometimes in the 
midst of what appears to be a hydrothorax we detect the signs of consolidation. This 
probably indicates that the neoplasm has come to the surface in one locality. 

(6) With the infiltrated form we find signs of consolidation, accompanied later on 
by the moist sounds due to the breaking down of the growth. Here again nearly 
every variety of physical sign may be met with in different parts of the lung, and if 
the main bronchus be obstructed, there is entire absence of the breath sounds. 

Diagnosis. — ^The condition has to be diagnosed from different forms of pneumonia, 
from pleurisy with effusion, and from hydrothorax. The type of cell found in the 
effusion after paracentesis is diagnostic in many cases. The age of the patient, the 
course of the affection, the absence (usually) of muoh pyrexia, the presence of enlarged 
glands and cachexia, should enable us to come to a conclusion. 



172 THE LUNGS AND PLEVRM [ §§ 99a, 100 

Prognosis, — Tho quostion is one of duration, and this can only be gauged by daily 
obsoryation of tho caeo, and by noting the rate at which the growth appears to be 
spreading. Death usually occurs in about six months. 

Tho Treatment resolves itself into the relief of pain and the amelioration of other 
symptoms which may be present. 

§ 99a. Hydatid Csrsi is a more frequent disease of the pleura or of the lung in 
Australia than in this country. No symptoms may be experienced by tho patients 
for a long time. If superficially situated, it causes bulging of the chest waU. The 
physical signs resemble those of pleural effusion, but tho dulness has a more rounded 
outline. When a cyst occurs at the apex of a lung, it is usually mistaken for tubercle. 

The diagnosis may be impossible from examination of tho chest, until the X rays 
are employed. Eosinophilia is always present, and aids tho diagnosis. The char- 
acteristic booklets may be expectorated, and hydatids may be present in other 
organs. The serum of the patient gives a specific precipitin reaction. 

Prognosis. — The cyst may rupture into tho pleura or into tho lung, and cause 
haemoptysis or abscess. Serious constitutional symptoms may arise from the onset 
of suppuration. Or it may open into a bronchus, thus leading to spontaneous recovery. 

The treatment is mainly surgical. 

§ 100. Atelectaiis, or Collapt e of the Long, is a condition in which the lung tissue 
is in an unexpanded state. The term ** atelectasis '' is usually applied to lung tissue 
which has never properly expanded, a congenital condition, duo to imperfect develop- 
ment. The term " collapse of tho lung " is applied to lung tissue which has previously 
expanded, but in which the air vesicles have subsequently collapsed. 

Atelectafis is a congenital condition, of which symptoms occur in tho new-bom 
child, and consist of cyanosis, with shallow, rapid respiration. The lower part of the 
chest is drawn in by each respiration. On auscultation, the respiratory murmur 
is found to be very faint. 

The Symptoms of coUapse of the lung follow and complicate those of tho disease 
which has led to tho condition ; for instance, the patient may not recover so rapidly 
as he ought, or tho breathing is more embarrassed than can be accounted for by 
the concurrent disease in the chest. Tho physical signs vary considerably with tho 
degree of collapse. Thus : 

(a) In comflete collapse of a part of the lung, as, for instance, in collapse due to 
compression or complete obstruction of a bronchus high up, there is impairment of 
tho percussion note, with a diminution or absence of tho breath sounds, and of the 
vocal resonance and fremitus. 

(6) Where the collapeo is only partial in degree — e.g., where the bronchi remain 
patent, as occurs sometimes when the lung is compressed by pleuritic or pericardial 
effusion — there are signs resembling those of consolidation (§ 77), except that the 
percussion dulness is not so marked, and the breath sounds, though bronchial in 
character, are somewhat feeble. 

(c) ^Vhere the collapse is slight and limited, the chief sign is an enfeebled respiratory 
murmur. In addition, during deep inspiration are heard fine rustling crepitations, 
due to the expansion of the collapsed vesicles. 

The Diagnosis is made usually by the existence of a causal condition. W^hen 
this is detected, attention may then be directed to the physical signs of the lungs. 
It will be observed that the signs of partial collapse resemble the signs of consolida- 
tion, and those due to slight collapse resemble early pneumonia. 

Etiology. — The causes are of throe kinds : (a) Causes which produce obstruction, 
such as (i.) a tumour at the root of the lung (e.^., aneurysm) ; (ii.) obstruction in 
the throat {e.g., adenoids) ; (iii.) stricture of a bronchus {e.g., gumma); (iv.) secretion 
obstructing the bronchi, though this is only sufficient to cause obstruction n children 
Buffering, for example, from whooping-cough, or broncho-pneumonia ; (v.) foreign 
todies oh struct ng the larynx or bronchus. 

(6) Compression of tho lung may be produced by pleural or pericardial effusion, 
an enlarged heart, or tumours of the mediastinum, or of the abdomen. The condition 
is often the result of spinal curvature. It may occur after abdominal operations and 



§1 101, 102 ] SYPHILIS OF THE LUNG-^EMPHYSEMA 173 

ansesthosia, and givo rise to difficulty in diagnosis, unloss the possibility of its occurrence 
is borne in mind. 

(c) Paralysis of the intercostal muscles or diaphragm, as in diphtheria or other 
cause of neuritis. 

In adults collapse is most often met with as the result of pleural effusion or tumours 
in the chest ; in children, of bronchitis or broncho-pneumonia. 

Prognosis. — ^The course of the disease depends very much upon the caus3. Recovery 
as a rule soon takes place after compression by effusions, obstruction or stricture of 
the bronchi, and throat affections. 

The TnalmerU is unsatisfactory. It should be directed to the removal of the 
causo, and especially to the promotion of recovery of any concurrent pulmonary 
disorder. That form which yields best to treatment is mot with in children with 
bronchitis and broncho-pneumonia. In adults it might be well to try the efficacy 
of respiratory exercises.^ 

§ 101. Syphilis of the Long. — In infants this disease may take one of two forms : 
(a) The pneumonic condition of lung, which is found in infants, usually stUl-bom, is 
universally regarded as an interstitial pneumonia of syphilitic origin. (6) Qummata 
are occasionally mot with in the lungs of infants who are the subjects of hereditary 
syphilis ; still more rarely they are met with in adults. Dyspnoea is usually the only 
symptom. The signs are those of consolidation, and collapse. In adults syphilis 
of the lungs may take other forms — e.^., broncho-pneumonia, bronchiectasis, etc. — 
and may lead to extensive infiltration and breaking down, or to fibrosis. 

Group C. — Chronic Diseases attended by Hyper-rejonanoa on per- 
cussion : I. In quite nine out of ten cases of hyper-resonance it exists on 
both sides, and is due to Emphysema. There are five other conditions 
which give rise to it — namely : II. Pneumothorax (§ 89) ; III. Skodaic 
Resonance (§ 75) ; IV. A very large cavity in the lung (Phthisis, § 94) ; 
V. A Tumour between the chest wall, and a large bronchus (§ 99) ; VI. 
Dissemination of Solid Material through the lung in certain excep- 
tional circumstances {e,g,, pneumonia, sarcoma, etc.). The diagnosis of 
these various conditions is given in the form of a table (p. 174). All except 
Ebiphysema are described elsewhere. 

I. The jxUient has complained of breathlessness for some years. There is 
hyper-resonanoe on both sides of the chest. The disease is Emphysebia. 

§ 102. Emphsrsema is a chronic non-febrile disease of the lungs in which 
the air vesicles become hyper-distended, the walls separating each vesicle 
become atrophied, inelastic, and ruptured, and as a result the aerating 
surface is greatly diminished, and the lungs deficient in their elastic 
recoil. 

Symptoms, — (1) The onset of the disease is imperceptible, and generally 
supervenes gradually after repeated attacks of bronchitis, the patient 
becoming more and more breathless after each attack. (2) This breath- 
lessness is practically the only symptom, and it differs from all other 
kinds of breathlessness in this, that the chest remains permanently in the 
inspiratory position — in other words, owing to the inelastic state of the 
lungs and the shape of the chest, the patient finds it more difficult to 
expire than to inspire. A certain degree of cyanosis is generally present. 
(3) Symptoms of bronchitis are nearly always present, 

^ " Respiratory Exercises in Treatment of Disease, notably of the Heart, Lungs, 
Nervous and Digestive Systems," by Dr. Harry Campbell. London, 1899. 



174 



THE LUN08 AND PLEURJS 



[§102 



Table IX.— Causes of Hyper-resonance. 



Cause. 



I. Emphysema. 



II. Pnenmotliorax. 
mostly Hydro- 
pneumothorax. 
An acute condi- 
tion. 

in. 8ko<laic Reso- 
nance — i-e., the 
high-pitched 
note above a 
large pleuritie 
efftuion^ when 
the lung is other- 
wise healthy. 

IV. A very large 
cavity, or ex- 
tensive bronchi- 
ectasis (rare). 

V. A Tomoor (or 
pneumonic^con- 
solidation) be- 
tween the chest 
wall and a lar^e 
bronchus (rare;. 

VI. Infiltration of 
solid and even 
fluid material 
through the lung. 
e.g.f early stage 
of pneumonia, 
miliary tubercle, 
etc. (rare). i 



Hyper-resonance. 



Bilateral and uni- 
versal. 



Hyper- resonance 
always unilateral, 
though it may extend 
beyond middle line. 



Unilateral: level 
may shift with posi- 
tion of patient. 



Auscultation. 



R.M. distinct and 
expn. much pro- 
longed ; signs of bron- 
diitis, if present. 

Absence of R.M. 
and V.F. over af- 
fected area ; some- 
times amphoric 
breathing. Bell 
sound. 

Loud R.M. ; V.F. 
felt over affected 
area. 



Other Diagnostic 
Features. 



Barrel-shaped 
I chest, cardiac dulness 
obscured, and organs 
I displaced. 

Organs displaced ; 
history of emphysema 
or tuberculous cavity. 



History of pleurisy; 
signs of fluid lower 
part of chest. 



Unilateral, and of 
limited extent (may 
be cracked-pot sound). 

Unilateral, and of 
limited extent; dul- 
ness elsewhere. 



Hyper -'resonance 
not marked (may be 
bUateral). ~ 



AmphoriC| Expectoration of 
breathing, whispering i pus and long history 
pectoriloquy. * of phthisis or bron- 

: cliitis. 



Tubular breathing 
md bronchophony. 



Symptoms of intra- 
thoracic tumour. 



Signs of consoUda- 
, tion in some parts. 



Hy];>er-re8onance 
generally transient. 



The Physical Signs, expressed briefli/y are a barrel-shaped chest, hyper- 
resonance, and prolonged expiration. The shape of the chest is special 
to emphysema (see Fig. 34). The chest assumes permanently the shape 
of a healthy chest in a position of deep inspiration. The antero-posterior 
diameter is considerably increased (see § 74). The h3?3)er-resonance is 
always bilateral, and it obscures the dulness of the neighbourmg organs 
— namely, the heart, the liver, and the spleen. These organs are also 
displaced downwards. The apex-beat may not be palpable, but epigastric 
pulsation is usually felt. On auscultation, the respiratory murmur is 
modified ; the inspiratory sound, which is full, is followed by a pause, and 
then by a prolonged expiratory sound. There are no adventitious sounds 
proper to emphysema, but, as just mentioned, bronchitis {q-v.) nearly 
always accompanies it. The heart sounds, especially at the base, may 
not be heard, or only with difficulty. Well-established emphysema inter- 
feres considerably with the pulmonary circulation, on account of the 
ruptured alveoli, and consequently the right side of the heart in course of 
time becomes dilated. 



§ 102 ] EMPHYSEMA 175 

Variety. — In old people there is sometimes hyper-resonance with 
weak breath sounds, but no enlarged barrel chest; this is called 
Atnyphic Emphysema, and is due to the giving way of degenerate air 
vesicles. 

The Diagnosis is extremely easy, because the bilateral hyper-resonance, 
the prolonged expiration, and the barrel-shaped chest are quite charac- 
teristic (vide Table of Diagnosis). 

Etiology, — (i.) Emphysema occurs usually in elderly subjects. Both 
sexes are affected, but it is much commoner in males owing to the preva- 
lence of bronchitis and asthma in them, (ii.) Heredity is said to play 
no part in the disease, but imdoubtedly a hereditary tendency can fre- 
quently be traced, (iii.) Certain occupations render people prone to 
emphysema — i.e., those which throw strain upon the lungs, as in the case of 
glass-blowers, wind-instrument blowers, etc. (iv.) The disease is frequently 
associated with senile degeneration, chronic Bright's disease, and cardio- 
vascular changes, (v.) Bronchitis is the most frequent of the exciting 
causes, owing to the prolonged coughing and straining to get up phlegm, 
and owing also to the blocking of certain tubes with thickened secretion, 
which prevents the access of air to some alveoli, and unduly distends 
others, (vi.) Asthma is also a potent exciting cause, owing to the con- 
stant strain on the elastic tissue of the lungs. 

Prognosis. — Patients may live with emphysema to a good old age, and 
provided it is only moderate in degree it does not necessarily shorten life, 
though it predisposes to, and adds to, the seriousness of other pulmonary 
disorders. The gravity of any particular case is best measured by the 
extent of cardiac involvement (q.v.). 

Treatment. — The indications are : (i.) To relieve the accompanying 
bronchitis (see § 93) ; (ii.) to improve the cardiac condition ; and (iii.) to 
restore as far as may be the elasticity of the hmgs. The diet is of con- 
siderable importance in advanced emphysema, for any distension of the 
stomach greatly adds to the respiratory distress. It is a good rule never 
to let patients take a solid meal later than two o'clock in the day ; other- 
wise their nights become considerably disturbed by the breathlessness. 
Cardiac tonics, especially strychnine, and, in my experience, tinctura cacti 
grandiflori, are useful. Quinine and cod-liver oil often do good, although 
I cannot explain how the latter acts. 

To lostoie the elasticity of the thorax is important, but difficult to accomplish ; 
of late years a special form of respiratory exercise has been put forward as fulfilling 
this condition, and to relieve the difficulty of expiration. With this end in view, 
Gorrhardt^ has recommended the employment of mechanical expiration by com- 
pression of the thorax methodically, every day for five or ten minutes, by another 
person, who places his two hands flat upon either side of the patient's chest. A 
similar result has been attained by Bossbach*s Althomstiihl (breathing-chair). In 
view of the fact that in many oases the maintenance of the inspiratory position is 
due to calcification of the costal cartilages, division of the latter has been attempted 
successfully by some sui^geons. 

^ Strumpel's " Pathologic und Therapie." 



IV r. THE LUNOS AND PLEURA [ §§ 108, 104 

Group D. — There are three chronic pulmonary conditions in which the 
percussion note varies considerably in different cases, but the ffensive 
character of the sputum reveals their presence — ^viz. : I. Bronchieotasis ; 
II. Gangrene ; and III. Abscess of the Lung. In Abscess the sputum 
is not so invariably offensive. IV. Actinomycosis and other diseases due 
to fungi affecting the lung can usually be diagnosed only by examination 
of the sputum. 

§ 108. Bronchiectasis. — Bronchiectasis is a cylindrical or saccular dilatation of the 
bronchial tubes. The condition is met with most frequently as a complication of 
chronic bronchitis or chronic pneumonia. 

Symptoms. — ^The patient complains chiefly of persistent cough. At intervals of 
several days violent increase of coughing occurs ; it is started, perhaps, by some 
change of posture, and is followed by the expectoration of a large quantity of extremely 
foetid sputum. In the intervals the sputum is scanty, but the breath is offensive. 
The foetid sputum contains pellets or " Traube plugs," and sets characteristically in 
throe layers (see § 78). 

The Physical Signs, if present, are mostly those of a cavity, attended by general 
signs of chronic bronchitis in both lungs ; occasionally only one is affected. The 
patient is often cyanosed, and has clubbed fingers. 

Diagnosis. — ^The extremely foetid odour of the sputum — occurring as it docs at 
intervals of perhaps several days or weeks, during which the sputum is not foetid — distin- 
guishes bronchiectasis from all other diseases. In gangrene of the limg the sputum 
may be foetid, although in a loss degree, but it lacks the intermittent character. 
The position of the bronchiectasis is generally marked by dulness in the lower lobe 
of one lung, which may bo made to disappear by making the patient lie face down- 
wards for some time, with his head low, till he coughs up a large amount of sputum. 
The causes of the two affections also aid the diagnosis. Abscess of the lung is attended 
by a very profuse purulent expectoration, but it is not so foetid. 

Etiology. — (i.) In patients past middle life by far the most usual cause is prolonged 
chronic bronchitis, and in children whooping-cough. The dilated bronchial tube 
results from the continual strain of coughing on the weakened walls, (ii.) Various 
forms of chronic pneumonia and chronic phthisis are believed to be attended by 
bronchiectasis, but in such cases it is probably a cavity in the lung tissue, and not 
true bronchiectasis, that we meet with, (iii.) A foreign body plugging a bronchus 
is an occe^onal cause, (iv.) In very raro cases it is a congenital defect. 

Prognosis. — The condition is a very serious one, and for the most part incurable. 
The patient may live from one to ten years. The prognosis is much worse in bilateral 
cases, or in cases associated with extensive disease of the lungs or pleura. 

The Complications which may occur are fatal haemorrhage, gangrene of the lung, 
lobular pneumonia, and pysemia. 

Treatment. — ^The indications are to relieve the disgusting foetor and to cure the 
primary disease. The first is accomplished by liberal antiseptic inhalations of tur- 
pentine, coal-tar, or creosote.^ The most valuable form of treatment is the oroosote 
vapour bath. Patients are placed in an air-tight room, in which creosote is volatilised, 
the time of exposure being gradually increased from five to twenty minutes. Terebenc 
and creosote may be given in capsules (4 minims) three times a day. Some inject 
menthol or guaiacol into the trachea in the proportion of 5 and 2 grains in 1 drachm 
of olive oil twice a day. When the cavity is low down and near the surface, suigical 
measures for its drainage have been adopted. 

§ 104. Gangrene of the Lung. — Owing to the extreme vascularity of the pulmonary 
tissues, gangrene of the lung is a rare condition, but it occasionally occurs over a 
limited area. It is usually a secondary condition, but it sometimes occurs in a lung 
previously healthy. 

Symptoms. — (1) The onset may bo acute, and marked by prostration and an irregular, 
intermittent pyrexia of a pya>mic typo, with a very rapid pulse. (2) If, as is usual, 

1 Brit. Med. Journ., June 22, 1895. 



§! 104, 105 ] ABSCESS OF THE LUNG 177 

the gangrenous part opens into the bronchi, a profuse foatid expectoration soon 
follows. The sputum contains fragments of lung tissue, and generally blood also. 
The breath is extremely foetid. (3) Pain in the side is usual, though it depends upon 
the involvement of the pleura. There is persistent cough, which aggravates the pain. 
(4) The Physical Signs are those of consolidation, sometimes those of a cavity. 

Diagnosis, — ^The only condition which is liable to be mistaken for it, by reason 
of its foetid expectoration, is bronchiectasis, which is distinguished by having 
(i.) " Traube plugs '' in the sputum, and (ii.) a gradual onset and longer course. 

Etiology. — It is predisposed to by intemperance, old age, diabetes, and marasmus. 
Exciting causes are : (i.) Particles of food entering the limg, as in the insane, or patients 
with laryngeal paralysis, or persons in a drunken coma. In children a foreign body 
swallowed may produce it, though rarely, (ii.) Septic matter passing from the throat 
or mouth, (iii.) Severe asthenic t3rpes of pneumonia are occasionally so complicated, 
(iv.) It may complicate bronchiectasis, (v.) Septic emboli, (vi.) Aneurysm pressing 
on the root of the lung. (vU.) The extension of an abscess near the lung. 

Prognosis. — ^The disease is almost invariably fatal, either immediately from collapse, 
sometimes from fatal haemorrhage, or, later, from prostration. A few cases have 
recovered where the patch was of small extent. In cases which have been recorded 
as lasting for months or years it is veiy doubtful whether the lesion was true gan- 
grene ; bronchiectasis is more probable. Occasionally the condition leads to pyo- 
pneumothorax. 

Treatment. — Keep up the strength of the patient by means of abundant nutritive 
stimulants, iron and quinine. For the rest, the treatment is the same as in bronchi- 
ectasis. Surgery has succeeded in some cases. 

§ 106. Abscess of the Long is a serious and, happily, rare condition, but as it is 
nearly always secondary to some grave or fatal disorder, it does not add very materially 
to the gravity of the situation. 

It is usually manifested by the expectoration of a large quantity of purulent pus, 
which may or may not be foetid, and is never so foetid as in bronchiectasis or gan- 
grene. The constitutional disturbance to which it gives rise is usually masked by 
that of the primary malady. Thf Physical Signs are those of localised consolidation, 
but these also are generally masked by those of the primary lesion. When the abscess 
bursts, the signs are those of a cavity. 

It may occur in the course of (i.) advanced pulmonary tuberculosis ; (ii.) pneumonia ; 
(ui.). pyaemia ; (iv.) cancer, suppurating hydatid, or other tumours of the lung, such 
as a gumma breaking down — a somewhat rare condition ; (v.) it occasionally follows 
the introduction of septic foreign bodies or wounds in the throat. 

Prognosis. — ^The prognosis is very grave, but depends upon the cause. Occurring 
in the course of pyaemia, it indicates the progress towards a fatal termination. It is 
less grave in pneumonia occurring in otherwise healthy persons. 

Treatment. — ^Medical treatment is not of much use. Surgical interference is not 
good in malignant and pysemic conditions, but in other conditions, if fairly superficial, 
the abscess may be drained. 

§ 105a. Actinomycosis may affect the pleura or the lung, imitating the signs of 
empyema, pneumonia (§ 876), phthisis, or bronchiectasis. In the absence of cutaneous 
or other lesions it is rarely diagnosed except by an examination of the sputum, when 
the little yellow pellets containing the ray fungus are visible. The blood serum gives 
a specific agglutinin reaction. The disease is usually fatal. 

Aspergillosis. The fungus aspeigillus fumigatus may cause signs resembling tuber- 
culosis. The disease affects pigeon-feeders, who chew the seeds containing the fungus. 
It may undergo spontaneous resolution. 

Blastomyces may affect the lungs. Cutaneous and other lesions are usually present 
in addition. 



12 



CHAPTER VII 

THE UPPER RESPIRATORY PASSAGES AND THE THYROID 

GLAND 

The throat may be the seat of the same morbid processes as affect other 
mucous structures, such as catarrh, ulceration, or new growths. It is, 
moreover, in this position that several very important general or con- 
stitutional maladies, such as diphtheria, scarlatina, and syphilis, have 
important local manifestations. These facts have long been known, but 
it has come to be recognised only quite recently that the throat, and 
especially the tonsils — organs whose functions are still imperfectly known 
— may constitute the portal of entry of certain microbic conditions. It 
has also been suggested that the virus of influenza, rheumatism, malignant 
endocarditis, and other septic conditions, thus gain admission into the 
general systemic circulation. 

This chapter will deal with the symptoms referable to the iihar3nix 
(§ 106), the larynx (§ 119), the nasal cavities (§ 129), and the thyroid 
gland (§ 135). 

THE THROAT. 

§ 106. Symptomatology. — " The throat " may be said to consist of the 
fauces, tonsils, palate, pharynx, and larynx, and we are here concerned 
with the investigation of these structures. The symptoms indicating 
disease of these parts are principally two — namely. Sore Throat and 
Hoarseness. The examination of the mouth and tongue is described 
imder Disorders of Digestive Tract (Chapter VIII.). 

(a) Sore Throat is indicative mainly of disease of the pharynx, tonsils, 
and structures around. If the patient complains of " sore throat," turn 
to § 108. 

(b) Hoarseness and Other Alterations of the Voice are indicative 
of some affection of the larynx (§ 119). If Nasal Intonation or Nasal 
Discharge be present, turn to § 129. 

There- are also several minor symptoms which arise in conjunction with 
these, such as a dryness accompanied by tickling sensations, or an exces- 
sive secretion, which leads to " hawking " and " coughing." Thus it 
happens that we may be consulted for what the patient believes to be 

178 



SIWJ CLINICAL INVESTIGATION 179 

polmonary disease, wKeit in reality the lungs are perfectly Iiealtliy. 
Dyspacsa and dysphagia may also be produced by local conditions of 
the throat and laryni. " Globus," or paroxysmal sensations as of a ball 
in, or constriction of, the throat is a symptom of hysteria. 

g 107. CUnical Investigation. — The anatomy and relations of the throat 
are indicated in Fig. 48 ; the various parts may be investigated by 
(a) direct, and (6) indirect {i.e., laryngoscopic) examination. 

(o) For the Dieect Exauination of the fauces and neighbouring 
structures all that ia necessary is a good light and a spatula or spoon to 



Fig. 48. — NiBAI IND BnccjL CAViriES, ihoirlng tbe method ol LARTNaoscawo EXASmATiOn. — 
The threo turWnato bonei are Been, the interior and of the Inferior turblaata boDa having been 
lemoved to ibaw the inner opening o[ the lachrymal duct. The opening of the Emtaohlan 
tube la Inst bsblnd the poatcrloc end of the Inlenoi turbinate bone. The exact pojltlon of 
laryngofcoplo mirror In examination of larynit Is «hown — naniely, over the root of the uvula. 

depress the tongue. If direct daylight is not available — as for instance, 
when the patient is in bed — a laryngoscopic mirror can be used {vide 
tn/ra), or a wax vesta, with or without a bright spoon behind it to act 
as a reflector. The patient should be instructed not to strain, and to 
" breathe tptiedy in and oui." The posterior wall may be seen by directmg 
the patient to say " Ha — ah," in which procedure the soft palate is raised. 
Note should be made of the colour of the mucous membrane, the presence 
of exudation or ulceration, of granulations oi adenoid vegetations in the 
pharynx, of any mucous patches such as occur in syphilis, or any bulging 



180 THE UPPER RESPIRATORY PASSAGES [ $f 108, 109 

of the pharyngeal walls. The size and length of the uvula should always 
be observed, for a long uvula may be the sole cause of chronic cough and 
numerous otherwise unexplained symptoms. When a patient complains 
of cough coming on, or getting worse, at night or when he lies down, 
elongated uvula should be suspected. It does not follow that such a 
uvula may appear too long at the time of inspection. Temporary con- 
gestion from various causes — e,g,y much talking — produces undue elonga- 
tion and nocturnal cough. Painting with tannin may reduce it, but the 
proper treatment is amputation, and it is wonderful what immediate relief 
is obtained. 

(6) The Indirect or Laryngoscopic Examination of the throat is 
given in § 119. 

§ 108. Classiflcation, Diagnosis, Prognosis, and Treatment. — Sore Throat 

is a symptom common to nearly all diseases of the throat. Mentioned in 
order of frequency, the diseases which give rise to sore throat are as follows 
(laryngeal affections being eocdudedfor the f resent ; see § 119) : 

Commoner Causes. Rarer Causes, 

I. Catarrhal pharyngitis, including two VI. Retro-phaiyngeal abscess or tumour, 

acute and three chronic varieties. VII. Phlegmonous sore throat and acute 

II. Tonsillitis. oedema. 

III. Scarlet fever. VIII. Cancer, and other new growths. 

IV. Diphtheria. IX. Tuberculosis. 

V. Syphilis. X. Other acute specific fevers. 

§ 109. I. Acute Catarrhal Pharyngitis is an inflammation of the mucous 
membrane of pharynx and soft palate, and to a certain extent of the 
tonsils also. It may be so mild as to cause only slight discomfort in 
swallowing, dryness of the throat, tickling and hawking, and in such 
mild cases there is only a moderate congestion of the parts. But in 
severer cases there are constitutional symptoms of some severity, and 
locally there may be oedema and ulceration. The temperature in such 
cases varies from 100° to 104° F. The disease rarely lasts more than a 
few days, ending generally in resolution, although sometimes it passes into 
a chronic condition. 

Hospital Sore Throat is a severe variety of the preceding, attended by 
considerable ulceration upon the fauces, tonsils, and even pharynx. 
There is the greatest difficulty in swallowing, speaking, and sometimes 
in breathing. The submaxillary and cervical glands are enlarged, and 
there is often considerable pyrexia and constitutional disturbance, the 
prostration being out of all proportion to the local inflammation. 

(a) Chronic Catarrhal Pharyngitis presents the same symptoms as the 
acute variety, in a milder degree, and extending over a longer period of 
time. It is often known as Relaxed or Relapsing Sore Throat, on account 
of the chronic congestion of the parts and the consequent predisposition 
to the repeated occurrence of subacute attacks. It forms one variety of 
clergyman's or school-teacher's sore throat. 



§109] CHRONIC PHARYNGITIS 181 

(6) Granular (Follicular) Pharyngitis is a chronic condition, the local 
symptoms of which resemble the foregoing, with the addition of visible 
granulations on the pharyngeal walls due to the enlargement of the 
follicles 1 ; hence it is sometimes called follicular pharyngitis. This is a 
common condition, and a person who is the subject of it, although ap- 
parently in good health, is liable to suffer from repeated attacks of sore 
throat whenever the weather is damp or his health a little below par. 
There is excessive mucous secretion, which collects in the throat, especially 
in the morning, and leads to chronic cough and hawking. When the 
disease has lasted some time, the throat becomes dry from atrophy of the 
follicles (Pharyngitis sicca). 

(c) Granular (Adenoid) Pharyngitis is another form of chronic pharyn- 
gitis, due to the presence of adenoid hyperplasia and vegetations in the 
pharynx and naso-pharynx. They are sometimes confined to the naso- 
pharynx, and by an ordinary inspection of the fauces little mischief, 
excepting congestion, can be discovered. The lymphoid granulations may 
involve a large part of the naso-pharynx, occurring as a large grooved 
cushion or pedunculated growth, which, on examination, can be seen and 
felt behind the soft palate. This condition is said always to start in 
childhood. The child breathes with the mouth open, and thus acquires a 
characteristic vacancy of expression. The intellect is often below the 
average. The voice has a dull or nasal twang, and there are snoring and 
disturbed sleep. The nares are narrowed, and the palate may be high 
from the negative pressure in the nose, the diminished air tension in the 
nose not counterbalancing the normal air tension on the buccal aspect of 
the hard palate. Pigeon-breast may follow. The condition is a pregnant 
cause of middle-ear catarrh and subsequent deafness. Adenoids in the 
naso-pharynx are usually accompanied by chronic enlargements of the 
tonsils. The disease often runs in families. 

The Causes of pharyngeal catarrh vary somewhat in the different forms, 
although the several causes are largely interchangeable. (1) There is no 
doubt that in certain persons exposure to cold and damp is immediately 
followed by an attack of pharjmgitis, but how far this acts as an exciting 
cause, or whether, as in the possible case also of tonsillitis, the condition 
is set up by a microbe which thrives xmder certain atmospheric conditions, 
is not yet determined. (2) Unhygienic surroundings, such as bad drains, 
the atmosphere of a hospital, and the like, may certainly give rise to a 
very severe ulcerating pharyngitis (e.g., hospital sore throat) ; and here, 
again, the cause may be a microbe. The same condition may arise in 
private houses in which the drainage is out of order. (3) Bad health in 
the individual affords undoubtedly a predisposition to the disease, and 
especially to granular pharyngitis, so much so that the throat in some 

^ The word " folliclo" is applied, not only to tho lacunar glands or crypts in tho 
tonsil, but also to the localised collections of adenoid tissue found in the posterior wail 
of tho pharynx. These latter, when enlarged, form the " granulations '* of the granula r 
pharyn2L 



182 THE VPPER RESPIRATORY PASSAGES [§109 

persons constitutes a veritable barometer of the state of their health. 
(4) The gouty and rheumatic diatheses offer a predisposition to pharyn- 
gitis (compare No. 6 below). (5) Various local conditions, such as nasal 
obstruction or insufficiency, leading to mouth-breathing ; and thus chronic 
rhinitis and adenoid vegetations are potent causes of recurring "sore 
throats." Excessive use or wrong methods of production of the voice 
(clergyman's and school-teacher's sore throat), excessive smoking, the 
constant use of alcohol, spiced or hot foods, or working in a dust-laden 
atmosphere, often play an important part. The bristle of a tooth-brush 
or a fish-bone impacted in the pharynx is a not infrequent though un- 
suspected cause. (6) I have often met with chronic pharyngitis in people 
who live too well. The excessive secretion and the perpetual hawking 
which results have in several instances directed the attention of the 
patient and of his medical adviser to the throat, larynx, or lungs ; but 
the cure of these cases cannot be accomplished until dietetic and other 
measures are directed to the relief of the portal congestion. (7) Pharyn- 
gitis, especially in its chronic forms, is often associated with anaemia, and 
iron is one of the most valuable remedies we have. 

Prognosis, — Pharyngitis is one of the most frequent and troublesome of 
the minor ailments which we are called upon to treat. The milder varieties 
of the acute pharyngitis last only a few days, but the severer forms, such 
as hospital sore throat, may last many weeks, and be followed by 
considerable debility. All the chronic forms have a great tendency to 
relapse. 

Treatment. — The indications are to relieve the local inflammation, to 
improve the general condition, and to prevent relapse. For the acute 
forms, most of the remedies mentioned under Tonsillitis are available. 
In all subacute and chronic forms, smoking, alcohol, and other causes of 
local irritation must be avoided. Excessive secretion may be removed by 
a gargle of bicarbonate of soda. For the " relaxed throat " a garglecon- 
sisting of a wine-glassful of water, to which a pinch of salt has been added, 
is useful ; so, also, are gargles of alum, potassium chlorate, and ammonium 
chloride (Formulse 15 to 19). Probably carbolic acid, painted on as 
glycerine (B.P.), or employed as a spray, gargle, or lozenge, is the best 
application. A good spray is that of menthol (10 grains to the ounce of 
paroleine). Later, astringent paints should be used — e.g., nitrate of silver 
(20 grains to the ounce) or equal parts of tincture of iodine and the 
glycerine of alum. 

The most efficient treatment for the granular forms of pharyngitis, 
where gargles are of little use, is painting with silver nitrate (40 or 80 grains 
to the oimce), tannin (1 drachm to 1 ounce), or with liquor ferri per- 
chloridi, or iodine in glycerine. Trichloracetic acid is recommended 
highly. In cases of dry pharyngitis the ammonium chloride inhaler or 
lozenges are very useful. The actual cautery may be used to the indi- 
vidual granulations. All these measures, however, give only temporary 
relief to the aderwid variety, when scraping away the vegetations is neces- 



§ no ] TONSILLITIS 183 

sary. For a permanent and radical cure these must be thoroughly 
removed under general anaesthesia. Nasal obstruction, if present, must 
also be relieved. The general health in certain forms, especially the 
granular varieties, is often of more importance than the local condition, 
and many a relapsing and granular pharyngitis can be cured by Blaud's 
pills. Any rheumatic or gouty diathesis should receive attention, and 
dyspepsia or constipation, especially if associated with portal congestion, 
should be appropriately treated. 

§ 110. IL Tonsillitis, or inflammation of the tonsil, is met with clinically 
in acute and chronic forms. Peritonsillitis is sometimes described as a 
variety ; it is an inflammation of the connective tissue in the vicinity of 
the tonsil ; it accompanies catarrhal pharyngitis, and is sometimes due 
to decayed teeth. 

The three forms of Acute Tonsillitis are as follows : 

(a) Acute Parenchymatous Tonsillitis (Quinsy, Acute Suppurative Ton- 
sillitis). The symptoms are pain, swelling and redness of the tonsils, 
coming on more or less suddenly with constitutional disturbance, the 
temperature varying from 101° to 104° F. Cases without pyrexia are 
occasionally seen. One tonsil is usually more affected than the other, 
and there is pain, stiffness, and tenderness behind the angle of the jaw. 
The disease usually subsides in the course of a week; if it lasts longer 
than this, suppuration has almost certainly occurred on one or other side. 
This is evidenced by the increased enlargement, by the swelling spreading 
along the soft palate, backwards, and downwards into the pharynx. The 
abscess usually bursts in the course of one or two weeks into the pharynx, 
but it occasionally points in other directions. 

(6) Acute Follicular Tonsillitis is of a more superflcial character. It is 
attended by the same symptoms as the foregoing, with the exception that 
abscess rarely occurs ; and the surfaces of the tonsils present numerous 
yellow points of thick purulent secretion, and perhaps ulceration. There 
are usually less fever and pain. 

The Diagnosis of both these forms of tonsillitis from scarlet fever and 
diphtheria is sometimes a matter of considerable difficulty, but one of 
great importance. It is given in the form of a table (p. 186). 

Etiology, — The function of the tonsils is still a matter of some imcer- 
tainty, and therefore it is not surprising that the etiology of tonsillitis is 
largely speculative. (1) Hereditary predisposition seems to play its part, 
for tonsillitis often occurs in subjects having a gouty or rheumatic tendency. 
(2) Unhygienic conditions, and especially bad drainage, have been credited 
with causing the disease. (3) The tonsils become acutely inflamed in all 
cases of scarlet fever, in diphtheria, and in so large a proportion of cases 
of rheumatic fever that they are regarded as the portal of entrance of the 
virus of that disease. (4) Cold and damp weather are certainly conditions 
under which tonsillitis frequently arises. (5) Traumatism, such as drink- 
ing out of a boiling kettle. Fish-bones and bristles of a tooth-brush 
sometimes give rise to one-sided tonsillitis. 



184 THE UPPER RESPIRATORY PASSAGES [fUO 

(c) A rare fonn of acute tonsillitis is known as Vincent*! Angina. Care must be taken 
not to mistake for diphtheria a form of sore throat first described by Vincent. It is 
characterised by one or more patches of exudation, often presenting a necrotic appear- 
ance, on the tonsib or adjacent anterior pillar, and sometimes encroaching on the 
palate. The pellicle is not easily detachable, and leaves a shallow ulcerated surface, 
the healing of which may be somewhat tedious. It is attended by some pyrexia and 
a variable amount of constitutional disturbance. Whether or not ** Vincent's Angina " 
should be regarded as a specific infective process is not clearly proven. Examination 
of a swab from the affected surface will reveal the presence of a large fusiform bacillus, 
which stains readily with the ordinary aniline dyes, but which will not grow on 
ordinary culture media, and a delicate mobile spirillum. Both these organisms, 
however, may be found occasionally in cases of ordinary ulcerative stomatitis, in 
carious teeth, and in some cases of septic scarlet fever. There is reason to regard the 
affection as infective, and in an *' exudation throat *' in which no diphtheria bacilli 
can be detected the possibility of Vincent's Angina should be remembered. 

Chronic Tonsillitis occurs in two forms. That form chiefly seen in 
adults after repeated attacks of acute tonsillitis is due to a fibroid degenera- 
tion, and is known as relapsing tonsillitis or chronic fibroid tonsillitis. 
The other and commoner form is that seen in children, which consists of a 
parenchymatous hyperplasia. The condition is almost always associated 
with adenoids in the naso-pharynx, and consequently there are snoring 
and mouth-breathing. 

Course and Prognosis, — Acute tonsillitis is a frequent, and sometimes 
very troublesome, but never fatal, disease. Sometimes the patient con- 
tinues at work, but at others he is totally incapacitated. Chronic ton- 
sillitis is important, because it renders the patient liable to repeated 
attacks of acute tonsillitis and coryza. It is a common source of recurrent 
pharyngitis, leading to otitis media and deafness. Enlarged tonsils met 
with in children occasionally disappear during adolescence ; but in some 
way, only imperfectly explained, the mental and physical development of 
children who have chronic enlargement of the tonsils is sometimes im- 
peded. It is, however, doubtful whether the development of the child is 
hindered unless there be concurrent adenoids, which interfere with the 
respiratory or oxidative processes of the body. 

Treatment, — The indications are (a) to reduce the local congestion ; 
(6) to reduce the pyrexia ; and (c) in chronic tonsillitis to prevent relapse. 

(a) Powdered sodium bicarbonate applied directly to the tonsils has 
been credited with aborting the disease. A cocaine spray (4 per cent.) 
relieves the pain. Cold or hot compresses externally, steam inhalations 
warm gargles of potassium chlorate, sodium bicarbonate, salol, and weak 
alum or carbolic acid (1 in 100) or formalin (2 per cent.) relieve the con- 
gestion (Formulae 15 to 19). In subacute cases the tonsil may be painted 
with pot. iod., gr. xv. ; iodine, gr. xii. ; ol. menth. pip., \\u, ; glycerine, §i. 

(6) To reduce the pyrexia a brisk saline purge should be given at the 
outset. Tincture of aconite (1 minim doses) may be given every half -hour 
during the first few hours ; then sodium salicylate, as in rheumatism, salol, 
or liquor ferri perchloridi. If quinsy does not clear up in a week, one 
may be almost sure an abscess has formed, and should be incised. This 
is best done with a curved bistoury, round which plaster is twisted to 



!§ 111-118 1 VARIETIES OF SORE THROAT 185 

within half an inch of the point, which should be directed inivards and 
backtoards to avoid the internal carotid. Make a small incision ; then 
insert a dressing forceps and stretch the opening. 

(c) In chronic tonsillitis the most useful remedies are iron, quinine, cod- 
liver oil, and other tonics. Salicylic acid, guaiacum, and colchicum are 
U3ed in the relapsing form. The chronic enlargement may be diminished 
by painting the throat with glycerine of tannic acid (a most nauseous 
preparation) or other astringents {vide supra). But in most of these cases 
the question of tonsillotomy arises sooner or later. Parents sometimes 
raise objections on the score that it may " impair the voice " or " injure 
the health," but there is no reason to believe that this is ever the case. 

§ 111. nL In Scarlet Fever the tonsil is generally the chief scjit of 
inflammation in the throat. Both scarlet fever and acute tonsillitis 
start more or less suddenly, with constitutional symptoms, and thus the 
diagnosis is often one of considerable difficulty. There are four distin- 
guishing features of scarlet fever — viz. : (i.) The diffuse scarlet colour 
of the soft palate and pharynx, with complete immunity of the larynx ; 
(ii.) sudden onset of the illness with high fever ; (iii.) on the second day 
the rash ; and (iv.) about the third day the " strawberry " tongue (see 
Table X., p. 186, and § 353). 

§ 112. IV. The sore throat of Diphtheria may be recognised at once if 
there be an ashy-grey patch of exudation upon the soft palate. When 
this is absent it is chiefly with follicular tonsillitis that difficulties arise. 
In diphtheria the large size and the colour of the patches (which are grey 
with surrounding red areolae), the difficulty of removing them, and the 
raw bleeding surfeice left, enable us to come to a conclusion. The onset 
is more insidious, the pyrexia less marked, but the prostration is greater 
in diphtheria. A muco-purulent or hsemorrhagic discharge from the nose 
is very characteristic of diphtheria. The occurrence of albuminuria is 
given by some as distinctive of diphtheria, but it is very frequently 
observed in acute tonsillitis also. When other diagnostic features are 
absent, the presence of one large patch on a tonsil, instead of several small 
patches, is in favour of diphtheria. 

§ 113. V. Syphilitic Sore Throat is very characteristic. This and the 
other secondary manifestations of syphilis come on about three to six 
weeks after the appearance of the chancre. (1) The tonsils may be in- 
flamed, but the inflammation is more generalised, and the mucous mem- 
brane presents greyish- white semi- translucent irregular patches (" snail - 
tracks"), on the fauces, tonsils, palate, and other parts of the buccal 
mucous membrane. Superficial ulceration may also be present, especially 
on the tonsils, with red punched-out edges and yellow-grey secretion. 
(2) Bilateral symmetry is a very characteristic feature of all these lesions. 

Tertiary syphilitic ulcers may produce sore throat, their favourite 
position being the soft and hard palate, the tongue, and the fauces. They 
are usually preceded by gummatous swellings. (1) The ulcers are deep, 
with ragged floor, sharply cut edges, and covered with thick yellow-grey 



186 



THE UPPER RESPIRATORY PASSAGES 



[§114 



secretion. (2) They are progressive, and in course of time will destroy the 
hard palate or any other parts they invade. (3) They leave characteristic 
stellate cicatrices, which are indisputable evidence of the disorder. 



Table X. 



Tonsillitis. 



Scarlet Fever, 



Diphtheria, 



Swelling and redness 
chiefly confined to one or 
both tonsils. In the fol- 
licular form, tonsils covered 
with sticky mucus, with 
numerous small, separate 
yellow spots of secretion 
on one or both, which are 
easily removable. Noth- 
ing on soft palate. 



(a) Local Signs. 

Diffuse bright redness of 
throat and palate gener- 
ally. The tonsils swollen, 
and may bo covered with 
mucus, and sometimes with 
multiple yellow points. 
Nothing on soft palato in 
ordinary cases. 



(i.) Onset moderately 
sudden, with moderate 
fever. 

[(ii.) Temperature may 
be very high, but local 
symptoms are usually 
more troublesome than 
general symptoms. 



(6) General Syaiptoms. 

(i.) Onset very sudden, 
with high fever. 

(ii.) Temperature very 
high. Local symptoms 
a subordinate feature. 

(iii.) Rash on second 
day. 

(iv.) Strawberry 
tongue about third day. 



Ashy-grey patch or 
patches on tonsils, uvula, 
atid soft palate (latter situ- 
ation is pathognomonic) ; 
patches larger than the fol- 
licular secretion in ton- 
sillitis. Patches consist of 
membrane surrounded by 
rod areolae ; difficult to 
remove, leaving raw sur- 
face. Klebs-Lbffler ba- 
cillus found in membrane. 
Sometimes a muoo-puru- 
lent, acrid nasal discharge, 
0>mparative absence of 
pain. 



(i.) Onset insidious. 
Early and marked enlarge- 
ment of cervical glands. 

(ii.) Temperature not 
80 high at first, and may 
remain low during whole 
course. 

(iii.) Paralytic soquelsB 
sometimes. 



The less frequent causes of Sore Throat are — Retro-pharyngeal Abscess, 
Phlegmonous Sore Throat, Neoplastic Ulcerations, ard Acute 
Specific Fevers. 

§ 114. VI. Retro-phanmgeal Abscess, or inflammation of the lymphoid 
and areolar tissue between the pharynx and the spine, may come on in- 
sidiously, or it may be comparatively sudden. It is known by (1) the 
rigidity of the head, with difficulty of swallowing and alteration of the 
voice ; (2) evidence of swelling in the posterior pharyngeal wall on inspec- 
tion and palpation, by which it is diagnosed from other causes of dyspnoea 
in children. 

Etiology, — Those cases with an acute onset are generally either part of a 
septic inflammation after fevers, or occur in rachitic children under four. 



§§ 115-118 ] PHLEGMONOUS SORE THROAT 187 

Retro-phaiyngeal swelling coming on slowly is generally due to pus bur- 
rowing from some adjacent structure, especially from caries of the ver- 
tebrae. 

Prognosis and Treatment, — The acute condition is always grave, and 
requires prompt surgical interference, generally free incision ; meanwhile, 
steam inhalations and warm fomentations relieve the symptoms. 

S 115. Vn. Phlbomonous Sorb Throat — i.e.. Acute Septic Inflammation of the 
Pharynx and Laiynx — or Angina Ludovici (when the inflammation is chiefly 
external, in the nock).^ — ^This very severe disease may start inside the throat, with 
Sjrmptoms of sudden pain, accompanied by considerable swelling, leading to severe 
dyspnosa, stridor, aphonia, and complete dysphagia in a few hours. There is much 
o&dema around the fauces, followed by a brawny infiltration of the skin of the neck, 
spreading from under the jaw to the tongue and larynx. Sometimes the infiltration 
starts exiemaUy, and rapidly invades the internal structures. There is groat con- 
stitutional disturbance, and a temperature of 102° to 105° F., but unless pus forms, 
rigors and delirium are generally absent. Pus formation is further indicated by 
widely and irregularly intermittent pyrexia. Mild cases begin with a stiffness and 
pain in the tissues around the jaw, and if recovery -s to take place, the symptoms 
go no farther. But in many oases, and especially in alcoholic and debilitated subjects, 
the disease rapidly progresses, and death takes place in twelve to forty-eight hours 
from heart failure, coma, or asphyxia from oedema of the larynx. Suppurative forms 
are very fatal. Among the recognised complications are pneumonia, pericarditis, 
pleurisy, and meningitis. There is a more chronic form in which induration is in 
excess of pus formation ; this may continue indefinitely until the pus is found and 
drained. 

Etiology, — ^The condition, happily, is rare, and the causes consequently obscure. 
(1) It sometimes arises in association with scarlet fever, erysipelas, and small-pox (in 
former times being a common cause of death in this disease), or other acute specific 
fevers. (2) Dental suppuration or an alveolar abscess often forms the souree from 
which rapid infiltration starts. (3) It may arise in people apparently in good health, 
and has then been attributed to the entrance of a specific microbe by the tonsils, or 
through the socket of an extracted tooth. 

TrecUmenL — ^The indications are to control the inflammation, and to keep up the 
strength of the heart. Quinine (4 or 6 grains) should be given every four hours. 
Iron and digitalis are recommended. Remove carious teeth or stumps. Free and 
early incisions should bo made into the oedematous tissues, and the practitioner 
should be at hand to perform tracheotomy if the dyspnoea be increasing. Stimulants 
must be liberally administered. 

AcuTB (Edema of the throat may be part of the above disease when the oedema 
is secondary to septic infection ; or it may be part of a general dropsy or angio-neurotio 
oedema. It is dangerous, as it may spread to the larynx and cause death by suffoca- 
tion (§ 121a). 

§ 116. VnL Carcinoma frequently, and Sarcoma occasionally, affect the pharynx, 
either primarily or secondarily. Their diagnostic features are the same as those 
mentioned under The Tongue (§ 148). 

S 117. IX. Tuberculous Ulcers of the pharynx are rare as primary lesions. 
(I) They resemble syphilitic ulcers, but there is pallor of the mucous membrane, and 
a characteristic ** worm-eaten *' appearance of the pharyngeal wall. (2) Their course 
is not nearly so rapidly progressive. (3) It may be possible to obtain the tubercle 
bacillus from the scrapings ; and (4) there are usually other manifestations of tubercle, 
especially in the lungs. For treatment, see Tuberculosis of the Larynx (§ 123). 

§ 118. X. Acute Specitio Fevers other than those mentioned above, such as 
typhoid, give rise to inflammation and ulceration of the throat. In variola, for 

^ The disease has been variously described by the following names : Acute Inflam- 
matory (Edema, Erysipelas of the Throat, Phlegmonous Cellulitis, Acute Infectious 
Phlegmon (a term applied by Senator when the inflammation was confined to the wall 
of the pharynx). 



188 THE UPPER RESPIRATORY PASSAGES §119 

example, the pustules often form upon the palate, fauces, and buccal mucous mem- 
brane, leaving superficial circular ulcers. An examination of the throat is often 
useful as an aid to the diagnosis between measles, scarlet fever, and small-pox. The 
first named always affects the larynx, rarely the pharynx ; scarlet fever always affects 
the pharynx, and veiy rarely the larynx ; whereas small-pox affects them hoth about 
equally. Patches of Lichen planus may be found on the palate when the disciaso 
exists on the skin, and the eruption of varicella may be found in that situation. Other 
patches may be due to thrush or T^erpes, 



The Larynx* 

§ 119. Symptoms and Clinical Investigation. — It will be remembered 
that the two cardinal symptoms of diseases of the throat (used in its 
widest sense) were (a) Sore Throat, and (b) Alterations of the Voice. 
Both of these may be present in disorders of the larynx, but it is the 
latter especially which indicates derangements of the organ of voice. 
Diseases of the larynx are also sometimes indicated by Cough, Hawking, 
Dysphagia, Dyspnoea, and actual Pain in the organ. But in some cases 
all of these may be absent ; there may, indeed, be pronounced disease 
of the larynx (e.^., paralysis or papilloma) without any subjective symp- 
toms.^ 

The Clinical Investigation of the larynx (laryngoscopy) is a pro- 
cedure of considerable technical nicety, and requires some practice. The 
necessary appliances are a good steady light, a reflecting mirror mounted 
on a band or a spectacle frame for the operator's forehead, and a small 
circular throat-mirror mounted on a handle at an angle of 135°. The 
light should be placed on a level with, and a little behind, the patient's 
left ear. The operator takes his seat directly opposite ; and it is advisable 
that his seat should be a little higher than that of the patient. Having 
directed the patient to open his mouth and " breathe quietly in and out," 
the first step is to adjust the reflecting mirror in order to thoroughly 
illuminate the back of the pharynx. The focal length of the head-mirror 
is generally 10 to 20 inches, and this should represent the distance of the 
mirror from the patient's pharynx. Having wanned the throat-mirror 
over the lamp to prevent the moisture of the breath from settling upon it, 
the next step is to pull with the left hand the patient's tongue gently out 
of the mouth with the aid of the comer of a towel or a piece of linen rag. 
Take the comer of the towel in the right hand, lay it on the patient's 
tongue, then grasp the tongue and towel firmly between the left thumb 
and finger. Take care not to hurt the under surface of the tongue against 
the teeth of the lower jaw. Then test the warmth of the throat-mirror 
against your cheek or the back of your hand, and, having pushed the 
patient's head a little backwards by pressing your right thumb against 
the upper teeth, introduce the mirror with the right hand, taking care to 

^ Not long ago I met with the case of a well-known operatic singer who had a small 
papilloma just beneath one vocal cord. Her voice was in perfect order, and she could 
reach the highest notes with ease. The only defect was a hardly perceptible weakness 
in the middle register. 



5 IBO ] LARYIfOOaCOPY 189 

avoid touching the top of the tongue in so doing. Push the mirror oblique!? 
upwards against the soft palate just over its junction with the uvula 
(Fig. 48, § 107). A good view of the vocal cords should be obtained 
by slightly lowering or raising the handle. In children and persona with 
very sensitive throats it is sometimes advisable to aniesthetise the pharynx 
before laryngoscopy, either by a spray of, or painting with, a 4 or 5 per 
cent, solution of cocaine, or by the admiuistration of a few doses of bromide 
during the preceding twenty-four hours. 

In normal conditions the epighttii, which is in reality anterior, appears 
at the wpfer fart of the mirror. The vocal cords, which are of a peirly 
white colour, are close together at their upper or epiglottic ends ; and at 
their lower (really posterior) ends are widely divergent during quiet 
respiration. At their lower ends they appear to terminate in two promi- 
nent knobs seen at the lower edge of the mirror, which mark the position 
of the arytenoid cartilagei 

(Figs. 49 and 49a). The ._._ , 

ary-cpiglottic fdd» stretch on 
each side from the aryte- 
noids to the aides of the 
epiglottis. In these folds, 
iust external to the aryte- 

' ., L -J u Fig. *B.— QiiiBtIn«p__ __. — . ..._ 

noid on each side, may be tion. Uon. 

seen a small prominence, 

the cartilage of Wrisberg. To the outer side of the cords lie the ven- 
tricular bands or false cords of mucoua membrane. With a little 
practice, and under favourable circumstances, the bifurcation of the 
trachea may be seen. 

Direct Larynooscopy is now practised. By means of Kiliian and 
Briining's bronchoscope or the modifications of it, the interior of the 
bronchi may be directly examined. When a foreign body has entered the 
air-passages, the patient should immediately be X-rayed, then examined 
by one who is expert in the use of this instrument. 

In LiBYNuoscopif there am four MAiTEas to bo invoatigatod : 
(a) Tho prosonco of congestion or ■pailor of tho vocal cords and the parts around. 
CongeatioQ of the vocal cords is an evidoiico of Larvnoitis, Bometimos of ulcontion 

(6) Tho preaanco of any lUceralion. Ulcoratioo occurring ii 
ago is very often duo oithor to Svpnius or Tdbercle; in a 
life it [3 not infroquontly ualiokant. 

(c) Tho preaencD of a nodule or tmiu growth. A nodule or now growth provos moit 
frequently to be a Papilloua. 

(d) Whothor thoro is any paraltjais or spasm of tho vocal cords, which is ovidonood 
by the Biie, shape, and mobilily of tho aperture. 

Wu Hhall doal with tho disoidora of tho laryni in this ordor. 

§ 180. Clasfdflcation. — As just mentioned, there may be no subjective 
symptoms even with pronounced disease of the larynx, and therefore it 
will be well to adopt as a basis of cJasaification the physical signs discovered 
by laryngoscopy. However, when symptoms are present there is always 



190 THE UPPER RESPIRATORY PASSAGES [§121 

some ALTERATION OP THE VOICE (cxcept, perhaps, bilateral abductor 
paralysis, in which there may be dyspnoea and stridor without alteration 
of the voice). The principal diseases giving rise to such alterations (i.e., 
the causes of alterations of the voice) may be grouped as follows : 

I. Laryngitis — 

(a) AciUe Laryngitis, including also — 

CEdcma Glottidis, and 

Foroign Bodios in tho Larynx or Trachea. 

(b) Chronic Laryngitis, including also — 

Perichondritis, and 
Congenital Laryngeal Stridor. 

II. Ulcerations of the Larjmx — 

(a) Tuberculous Ulceration, 
(6) Syphilitic Ulceration, 
(c) Malignant Ulceration. 

III. Nodules and New Growth — 

(a) Benign, 
(6) Malignant. 

IV. Paralysis of the Vocal Cords — 

Bilateral Abductor Paralysis. 

Unilateral Abductor Paralysis, 

Total (Ab- and Adductor) Bilateral Paralysis, 

Total (Ab- and Adductor) Unilateral Paralysis. 

V. Spasm of the Vocal Cords — 

Laryngismus Stridulus (§ 128). 

VI. Diseases of the Pharynx (§ 108) ; VII. Diseases of the Nose (§ 129) ; 
VIII. Some severe Pulmonary affections; and IX. Certain 
Neuroses also cause alterations in the voice. 

1. The 'patient complains of huskiness or loss of voice, a comparatively 
dry cough, soreness on simUoicing, and there are local signs of congestion 
of the vocal cords. The disease is Laryngitis, of which two varieties ard 
met with. Acute and Chronic. 

§ 121. Acute Lanmgitis comes on somewhat rapidly, and usually runs 
it i course in a week. As a rule it is not a serious affection, but in children 
it may be alarming. In children a slight laryngitis coming on suddenly 
is a frequent cause of what mothers describe as " croup." Owing to the 
dryness of the cords, the child wakes up suddenly at night with loud 
inspiratory stridor followed by an attack of coughing. This symptom is 
technically known as laryngitis stridulosa, and is not to be confused with 
laryngismus stridulus (see § 128). Simple laryngitis is differentiated 
from membranous croup (laryngeal diphtheria) by the perfect general 
health of the child in the former. 

Etiology. — The chief cause of acute laryngitis is exposure to cold — 
especially when combined with overuse and wrong production of the voice 
(e.g., actors, music-hall artistes, etc.). It is frequently a part of the 
" common cold." Diphtheria or measles may start in the larynx. Persons 



§§121-128] LARYNOITIS-^aSDEMA OLOTTIDIS 191 

who suffer from chronic laryngitis {q-v.) or nasal obstruction are predisposed 
to attacks. A foreign body in the larynx or trachea is a cause of irritation 
which may produce sjmaptoms resembling laryngitis. 

Prognosis. — The affection is troublesome and apt to recur. When 
occurring during the course of the specific fevers, the prognosis is less 
favourable, because (Edema Glottidis may supervene. 

Treatment, — All use of the voice must be forbidden. The patient must be 
kept in a warm, moist atmosphere, and should use warm inhalations (such as 
tr. benzoin co. 3i. to the pint of boiling water, and see also Formula 110). 
Warm compresses or fomentations should be applied externally, and 
warm mucilaginous and alkaline drinks should be freely taken. The 
most efficacious medicine is one containing small doses of vinum anti- 
monialis and potassium iodide. According to some, a strong solution of 
silver nitrate (20 grains to 3i.) applied locally at the outset may cut short 
the disease. For laryngitis stridulosa, apply hot sponges to the throat, 
and give vin. ipecac, in teaspoonful doses, with warm water, every ten 
minutes or so until emesis ensues. Adrenalin (iTLii.) may relieve rapidly. 

§ 121a. (Edema Olottidif, or oedematous lar3rngitis, consists of an oedematous 
swelling affecting the epiglottis and submucous tissue of the laiynx, but the vocal 
cords are not involved. The onset is usually sudden, and attended by considerable 
dyspnoea, dysphagia, and inspiratoiy stridor. The diagnosis is usually simple, on 
account of the swelling which can be seen and felt on palpation at the back of the 
tongue. If this be absent, some difficulty may be experienced, but the sudden onset 
of laryngeal dyspnoea should bring the disease to our minds. It may arise either as 
a primary or as a secondary affection. As a primary disease it may come on as part 
of an acute septic inflammation of the throat, or it may be part of an oedematous 
angio-neurosis of urticarial origin (see Acute CEdema of the Tongue). It may occur 
as a secondary condition in association with (1) one of the various causes of acute or 
chronic laiyngitis ; (2) a general anasarca ; (3) injury of the glottis by boiling or caustic 
liquids, etc. Its rapid onset is the chief source of danger, but if the patient does not 
shortly succumb to asphyxia, recovery generally takes place in a few days. 

The Treatment consists in the administration of emetics, and ice internally and 
externally. In severe cases, if a 20 per cent, cocaine spray fail, scarification of the 
epiglottis must be resorted to ; and if this be imsuocessful, tracheotomy must be 
performed without delay. 

§ 1216. The Swallowing of a Foreign Body, and its passage into the larynx or trachea, 
has always to be borne in mind in children suffering apparently from acute laryngitis. 
for the history is often wanting. Paroxysms of dyspnoea or of coughing in a child 
without obvious cause should make us suspect it. Unless it has passed into the 
bronchus (usually the right), a foreign body may be seen by laryngoscopic examina- 
tion. On the other hand, when a foreign body passes into the bronchus, it may cause 
so little cough or disturbance at the time that the patient may imagine he has swal- 
lowed it, or he may be unmindful of the incident. Some obscure cases of unilateral 
bronchiectasis are probably due to such causes. When the presence of a foreign body 
is suspected, a skiagram should be taken, and with the aid of direct bronchoscopy the 
object may be removed even from the bronchus. 

§ 122. Chronic Lanmgitis is a troublesome affection on account of the 
perpetual hoarseness and liability to acute laryngitis. Its causes are 
(1) repeated acute attacks; (2) excessive speaking, singing, teaching, and 
overuse of the voice (actors, clergymen, school-teachers, etc.) ; it also 
afEects masons, fustian-cutters, and others exposed to dusty atmospheres ; 
(3) nasal obstruction and mouth-breathing ; (4) tubercle, syphilis, and 



192 THE UPPER RESPIRATORY PASSAGES [§1280-128 

new growths, the evidences of which should always be sought in cases of 
intractable laryngitis. These usually go on to ulceration, under which 
they will be described. (5) Spread of inflammation from adjacent parts. 
Many cases of chronic laryngitis depend upon a granular condition of the 
pharynx. (6) Rheumatic and gouty diatheses predispose. 

Treatment. — The indications are to avoid the cause and to relieve the 
local congestion. The removal of the cause is most important, and often 
most difficult to accomplish, for a large number of the patients are singers, 
teachers, and others whose living depends upon the daily excessive use of 
the voice. The avoidance of tobacco and alcohol will aid, and residence 
in a dry climate will often accomplish a speedy cure. Much may be done 
to prevent or relieve the condition by proper voice-production and respira- 
tion. This affection is extremely common among our board-school 
teachers, owing chiefly to faulty voice-production, and they ought to be 
specially trained to obviate this defect. Locally, painting with strong 
astringent remedies, such as zinc chloride (30 grains to the ounce) or silver 
nitrate (20 to 60 grains to the ounce), are useful. These strong applica- 
tions should not be made more than twice a week ; weaker solutions can 
be applied more frequently. The patient himself may use sprays of alum 
(5 grains) or zinc sulphate (2 grains to the ounce) for five minutes twice 
daily, or inhalations of turpentine, creosote, iodine, menthol, etc., for 
fifteen minutes three times a day. 

§ 122a. PerichondritiB is an inflammation of the perichondrium of the laryngeal 
cartilages. Opinions differ as to its frequency. If considerable, it may lead to 
necrosis of the cartilages and abscess of the larynx. The differential features, besides 
loss of voice or hoarseness, are dull aching pain and acute tenderness. This may be 
accompanied by swelling in the neck. As regards its Etiology, apart from traumatism, 
it is rarely a primary malady. It more often occurs secondary to syphilitic oi 
tuberculous laryngitis. Syphilis is its commonest cause. It also follows enteric 
fever. 

Prognosis and Treatment. — It is a serious affection, for even in the mild forms the 
voice is rarely restored. Groat stenosis of the larynx may result. If there be much 
swelling, the dyspnoea is very marked, and the patient may die from pneumonia or 
gangrene of the lungs, or, in the suppurating forms, from pysomia. Abscess and 
fistula may follow. 

§ 1226. Congenital Laryngeal Stridor is a term applied to more or less continuous 
inspiratory dyspnoea, accompanied by a croaking sound, occurring in infants. It 
may be constant up to the age of two, or occur only at intorvab during that 
period of life. It is believed to be caused by a folding of the epiglottis, possibly duo 
to some malformation. It is usually attended by a certain amount of lar3mgitis and 
hoarseness, and passes off without need for operative interference. 

II. Ulcerations of the larynx are met with chiefly in tubercle and syphilis, and in 
persons past middle life malignant disease may be a cause. The simple erosions present 
in catarrhal laryngitis hardly amount to ulceration. Ulceration is also found in the later 
stages of Lupus and Leprosy, usually when cutaneous lesions are present. 

§ 128. Chronic Tnbercnloiis LaryngitiB should always be suspected when delicate 
patients complain of constant hoarseness. This form of laryngitis is recognised by 
(1) the general pallor of the mucous membrane, accompanied by a thickening or 
swelling most marked over the arytenoids or the aryteno-epiglottic folds ; (2) the 
occurrence of irregular, slowly growing ulcers, usually bilateral ; and (3) the history 
or presence of pulmonary tuberculosis. 



K 124^ 126 ] BEN ION NE W QRO WTHS 193 

The Prognosis is always grave, and until rooently reooveiy when the larynx was 
involved in tubeioulosis was piaotioally unknown. The course of the affection 
depends more upon the condition of the lungs ({ 94) than that of the larynx. 

The Treatment at first is largely constitutional — e,g,, creosote in doses of 1 to 5 
minims is recommended. Locally, menthol, one part to five of olive oil, used as paint, 
or an insufflation of menthol (8 grains) with iodoform and boraoic acid (of each 
1 drachm), is valuable. When ulceration has occurred, after being swabbed with 
cocaine and curetted, the parts should be thoroughly brushed with lactic acid, 10 to 
60 per cent. This is a very favourite application. For the pain, which may be 
severe enough to cause dysphagia, morphia (J grain), with starch (^ grain), may be 
blown into the lar3mx ; or it may be sprayed with 10 per cent, cocaine. Dundas 
Grant injects alcohol into the superior laryngeal nerve with excellent results. 
Absolute rest from speech, a warm, dry climate, and sanatorium treatment, are 
indicated (§ 94). 

f 124. Ohronio Syphilitio Laryngitif. — ^The laryngitis accompanying secondary 
syphilis may resemble simple catarrh, with the addition of whitish patches (§ 113). 
But that which occurs in the later stages nearly always takes the form of ulceration. 
The intensity of hyperemia, the irritability, and the profuseness of the purulent 
discharge are features of syphilitic ulceration. It is distinguished from a tuberculous 
ulceration by (1) the bright red coloration of the mucous membrane ; (2) the 
presence of a deep, rapidly grotoing ulcer, with bright yellow surface, regular edges, 
often undermined, sometimes unilateraL If the ulcers invade the upper surface of 
the epiglottis, this is said to be pathognomonic of syphilis. (3) The presence of a 
syphilitic history. 

Prognosia and Treatment, — ^This form of laryngitis is twice as rapid as, and far 
more destructive than, the preceding, and is liable to involve the cartilages (vide 
Perichondritis). Even when arrested considerable stenosis may result. The usual 
constitutional treatment must be carried out, full doses (60 to 100 grains) of potas- 
sium iodide being given. Local applications of iodoform, or a spray of perchloride 
of mercury (1 in 1,000), are employed. 

(c) Malignant Disease and (in other countries) Leprosy give rise to ulceration of 
the larynx (see below). 

III. Nodules and New Orowths. — Flat loccdised thickenings of the mucous 
membrane are spoken of as toarts, nodes, or nodules. When they are peduncu- 
lated they are spoken of as polypi. In either case they begin most frequently 
CM a unilateral thickening on or near one of the vocal cords. In the early 
stage they are extremely difficult to distinguish from syphilis or tuberde, and 
sometimes tins can be accomplished only by the history. With one invportarU 
exception [singer's node) nodules are unilatebal, and this feature of 
cLsymmetry distinguishes them from the thickening which may result 
from chronic laryngitis. The practical poirU of prime importance is the 
distinction of benign from malignarU growths, often a task of considerable 
difficulty. 

S 125. Benign Kew Orowths begin most frequently as warts, nodules, or thickenings, 
the surface of which is smooth, although congested. They may give rise to no sjrmp- 
toms for a considerable time, unless they happen to be on the free edge of the cord. 
Periiaps the commonest of these growths is what is known as a singer's node. This 
lesion very often affects the under surface of the vocal cord, and hence may be over- 
looked for a long time. It is distinguished from other nodules by its frequent involve- 
ment of both sides symmetrically. A projection on one cord at the junction of the 
anterior toith the middle third is probably a Singer's Wart ; one situated at the junc- 
tion of the posterior with the middle third is probably pachydermia laryngis. In the 
latter case there is a nipple on one cord which fits into a crater on the other. Paohy- 
dennia Laryngis is a localised chronic laryngitis (§ 122), usually most marked over 

18 



104 



THE UPPER RESPlBATOMt PA88A0E8 



[ $$ 126, 129 



tho vocal processes. Benign nodules, as a class, are differentiated from malignant 
by the absence of pain and the paucity of symptoms of any kind. A pedunculated 
benign growth (polypus) of the laiynz has the same clinical features, but is accom- 
panied by very characteristic attacks of paroxysmal dyspnoea. Leprosy may affect 
tho larynx. Benign growths often cause but little inconvenience. They aro 
generally removable, without ulterior damage, by snaros or cutting forceps. 

§ 126. Malignant Growths of the larynx occur chiefly in men. They may be divided 
into two groups, extrinsic and intrinsic. The extri!%8ie variety start as thickenings of 
the mucous membrane, which may resemble benign growths, or may be greyish- 
white, or have a ragged suif ace. It rapidly passes on to ulceration, with hsemorriiage 
and pain ; secondary enlargement of the glands follows. Death ensues unless the 
larynx is extirpated early. Intrinsic cancer, on the other hand, is of slow growth and 
low malignancy. It usually starts in the vocal cord, and causes a persistent huskiness. 
Every case of persistent hoarseness occurring in men over middle age should be sent 
to a laryngologist tor examination, llie operation of lar3mgo-fi8suro affords 80 per 
cent, of cures in these cases if seen early. (See St. Clair Thompson, Med, Press, 
February 21, 1912 ; and the Lancet, February 24, 1912.) 

IV. Paralysis of the Tocal Cords can he detected only by carefully inspecting both the 
POSITION and the mobility of the cords during (i.) rest, (ii.) phonation and (iii.) deep 
inspiration. 

§ 127. Paralysis of the Tooal Oords. — ^The chief actions of the larynx aro (i.) Abduc- 
tion (glottis-opening), which is performed by the posterior crico-arytenoids, and 
(ii.) Adduction (glottis-closing), which is performed by the lateral crico-arytenoids 
and the arytenoideus muscle. The cords aro renderod tense by the orico-thyroids 
(external tensors), and are relaxed and shortened by the thyro-arytenoids (internal 
tensors — i.e., the muscle which lies in the vocal cord). The larynx is supplied by 
two nerves, the superior laryngeal and the recurrent laryngeal branches of liie vagus. 
The former supplies the crico-thyroid or tensor muscle and the mucous membrane 
of the larynx, while the recurrent laryngeal supplies all the other muscles. In pro- 
gressive lesions of the recurrent nerve the abductors are paralysed first, and later 
on the adductors. 



Table XI. 



Nam$ of MuteU. 



Crieo-thyroid 
or external tentor. 

Thvro-arytenoid 
propritu^ internal tensor 
in cord ittelf. 

Posterior erieo-arytenoid. 



Lateral crieo-arytenoid. 



AryUnoideus, 



Action, 



Nerve Supply, 



Superior 
laryngeaL 

Recurrent 
laryngeal. 



Recurrent 
laryngeal. 

Recurrent 
laryngeal. 

Superior laryngeal 

and recurrent 

laryngeal. 



Phonation. 



Respiration, 



Tense and elon- 
gate the vocal cords. 

Adjusts edges of 
the cords. 



Close the glottis 

(posterior third 

chiefly). 



Abduct — <.«., open 
glottis. 

Adduct — i,e,, close 
glottis. 



The Signs of Laryngeal Paralysis, — It is very rarely that a smgle muscle is paralysed ; 
the paralysis nearly always affects a physiological group of muscles — i.e., the glottis- 
open ers (abductor paral y sis) or glottis-closers (adductor paralysis) on one or both sides. 

* Lateral thyro-arytenoid is the lateral part of this muscle. 



il871 



PABALYSia OF THB VOCAL C0BD3 



196 



FBralysiti la o!Um ocoonipaniod by more or Iobb oatnirh. which modiSos the appear- 
ance Bomovliat, bat the evidences of laiyngeal paralysis depend upon the position 
and mobility of the cords during phonation and mapiration. The symptoms are 
given in Tabic XII. 

Normally, during rest the cords am midway botwcon open and cloiiod (Fig. 60) ; 
during phonation thoj aro approiimatod bo that practically no space is loft between 
tJiem (Fig. 62) ; during deep inspiration they an widely oponod (Fig. 49a). 



^^ 



Fig. SI.— CADAVKEUO FUSITIUFI 



high ii( 



When tho cords are normal during phonation, but do not movo out on inspiration, 
there is bilateral paralysis of the glottis -opener? — bilateral abd-uclor paralgtu (Fig. 63). 
If both cords movo during phonation, but one of tham fails to move out fully during 
inspiration, thont is anitalei-al abductor paralyaia (Fig. 54). 

When tho cords neither move to the middle lino with attomptod phonation, nor 
movo as far outwards as normal during deep inspirations, but lemain midway between 
the two in the cadaveric position (Fig. 61), thore is loUU bilaleral paralyiia of adduatoia 
and abductors (Fig. 56). 

If diiring phonation and inspiration one coid remains immobile, there is tolat 
unilateral paralyat». 

Table XII. — Laryngeal Paralyses. 
(From Gowers, sligbtly modified.) 



Luion. 




Sign,. 


' Bilateral abdocter 
1 (opener) 
1 paralysis. 


VolCT little fhansed : cough 

long, and alt*Qd«d with loud 
.trider. 


Both cords near together; not 
aepaiatcd during Iniptratlon, bnt 
even drawn nearer together. 


paralytit. 


nflectlon of voice or cougli. 


One cord near the middle line not 
moving during inspiration, the othei 


1 Total bilateral 


No voice ; no cough ■. stridor 


poslUonl. 


psralfBla. 


Voice low-pitched and hoarse ; 
no cough: itildor abaent or 


and motioulBM, the other moving 
freely, and even beyond tho ndddle 


Bilateral adductor 
1 poriS^..' 


No voice ; normal cough ; no 
Btridot or dyspniea. 


Cords normal in position, and 

but not brought (ojether on an at- 
tempt at phonatioD. 



196 THE VPPBR RB8FIRAT0RY PA88AaB8 [(187 

If thuiu isaphonia, andon l&iyngoscopio oxamination tincordedo not meet propeiiy 
duimg attemptod phonation, ^though thoy move outw&tdB with inapiration, theio 
is bSaUnd oddtKtor paralj/M (Figs. 56 and 57).' 

The Eliology of laiyngeal paTaljses diffore coDsidorablf in the varioiu forms. Tbo; 



may a 



oonditioDS, bat each u so charactoriBtic thai 



a bo readily identified. Thus hygtericid parah/iU is always double, and voiy 

nearly always duo to adductor paralysis. Abductor paraJysia is generally — and if 
Dnilat«nl is always — organic in origin. If the left vocal conl oaimot be abductod, 
it is almost cortainly due lo pressure on the loft reoumat Uiyngeal, and this in oiuo 
casoB out of ton is due to anevfytm of Oie aorla. 
{a) BiLATBRAL Abductob Pabalysis (Fig. 63) may be duo to — 

([.) The earlier stages of praeure upon both recurrent laryngeal nervos, aa by 

mcdiastijial tumour, or poricardia] effusion (^ 54). 
{ii.) Peripheral neuriUs from toxins (such as diphtheria, alooholism, inflaenxa), 

certain drugs (t-g-. lead, arsonic), or simple catarrh. 

(iii.) Central Causa, as in leeions affecting the medulla or base of the brain, 

bulbar priatysis, cerebral tumours or syphilis, hsmorrfaage into the 

bulb, tabos docsalis. disseminated sclerosis, meningeal conditions, etc. 

(6) Unilatroai. Abddctob Paralysis (Fig. 54) is due to the same oauses acting 

on one side only. Thus, if on the left side, it is duo in nine cases out of ten to aneurjwn 

of the aorta, although no other signs of that condldon 

may be present. Malignant tumourof the (esophagus 

may also afloot the left recurrent laryngeaL Thickened 

right pleura may be the cause of a paralysed right 

locurront laiyngeol. Pressure upon the vagus in the 

nock, as by an enlarged thyroid, or cervical glands. 

may affect one or both sjdos. 

(g) Totai. (Ab- and Addvctob) Bilatbbal Faba- 

FlB. 6S.~BILATBBAL PABAITBIS "f"? '^'8- f ' ^, ??*"<»">" "'™^°' "^° .""Si"- 

Of TBB QioTTiH-oPBNKM *>"' '* ™»y (raioly) be due to catorrii or hysteria. It 
(BiLATEBAL Abdcqiob mav aiiss from any of the causes mentioned under 
PABAiYBis). — TbB patient Bilateml Abductor Pamlysis, but is most frequently 
y^^'S ^h^S^n h.V"^ of "tUrai origin. It occurs lator in the disease than 
cordi <lo noi man mawardi abductor paralysis, the abductor fibres m the nerve 
diaiBt iap inipiiatim (u being the first to be affected. 

'"■raTiiSiTa ****' a. '■*' T:'^'^ (Ab- and Adductoe) Umutkbal Paba- 
tli8 above liK^^^ne* LYSIS is due to the same causes as mentioned under 
prodnwd by acute larrngesl unilateral abductor paralysis — i.e., usually preBsuie 
oatairh, but the cordj would upon the recurrent laiyngoaL This oonditbn, how- 
be pink iostel el white. ^^ ^^^ ^t ^ Uter stoge in the oa«., unilateral 
abductor paralysis being a feature of the earlier stage- 
Total paralysis is soaoUmos calked " recurrent paralysis," because it is due to 
paralysis of the recurrent laryngeal. 

(c) BiLATEBAL Addcctob Pabalysis (Figs. 66 and 67) is always fututional (vii., 
univnnected with gross letiotu) : (1) hystfliical ; (2) simple catarrii, or overuse of the 
voice ; (3) general weakness, as in amemia. But the first of those is by far the most 



Prognwis. — Laryngeal paralysis is generally only a minor element in the ease- 
When ooouiring alone, however, the prognosis in adductor paralyos is good, because 
it is always of functional origin. Paralysis arising from syphilis is remediable if 
truated early. In all forms, however, the prognosis depends upon whether the cause 

Treatmtnl. — Hysterical paralysis should be treated on linos laid down olsowhero- 
Strong faradisation or static electricity to the laryni is indicated, the patient being 
instnictod to call out loudly. In oiganie paralyses the prognosis depends upon the 

' Further particulara of the actions of the various muscles may be found in a study 
of laryngeal paralyses since the introduction of the laryngoscope, by Sir Fclis Semon 
Brain, 1882. vol iv.. p. 471). 



§1«8] 



NERVOUS GROUP 



197 



oause. Potassium iodide should reoeiye a fair triaL Stryohnine and eleotrioity are 
usefuL In organic oases, if dyspnooa be severe, tracheotomy must be performed. 

Illttstbations of Labykgeal Paralysis. — It should be rememberod, in studying 
these illustrations, that to test the motor power of the vocal cords it is necessary to 
make the patient nrspraE deeply to opbk the cords, then to phonatb, so as to close 
the cords, for a given position of the oords conveys no information unless it is first 
known which of these acts the patient is performing. 

In laryngeal paralysis it is very important to decide whether a functional or organic 
cause is in operation, and the following hints should be remembered : 

1. Glottis-closer (adductor) paralysis is generally functional; glottis-Opener 

(abductor) paralysis generally Organic. 

2. Bilateral paralysis is generally functional; One-sided paralysis is generally 

Organic. 

3. Left Abductor (glottis-opener) paralysis suggests Aneurysm. 





\ 



a 

QQ 



Fig. 64. — ^Lbfp Abduotob, or glottts- 
opener, paralysis. — Dubinq in- 
SPIBATIOIT the left cord remalni 
fixed. Instead of moving oatwarda 
like the right cord does. This 
occurs in early paralysis of the 
recurrent lanmgeal nerve of ob- 
GANio OBIQIN — e.(f., aneorysm. 



Fig. 65. — ^TOTAL BiLATBBAL paialysis. 

— DT7BING INSPnUTION and DX7BIN0 

PBONATION both cordt are immo- 
bile, and remain in what is prac- 
tically the cadaveric position. 
Nearly always of obqanio origin, 
and frequently central. 



£ 





V 



Fig. 56. Fig. 67. 

Figs. 66 and 67. — Pabtial Bilatbbal Adduotob, or glottis-closer, paralysis. — It 
is the condition commonly met with in hysterical or fxtnctional aphonia. 
DUBINO PHONATION the cords close anteriorly and posteriorly, bat leave an 
elliptical space between them. The glottis is closed by two muscles — ^the crico- 
thyroid in front, and the arytenoideus b^nd. If the obico-tbyboid is mainly 
affected, the condition depicted in Fig. 66 is seen, and it is met with in functional 
aphonia and exhaustion. The abytbnoidevs closes the posterior angle, and 
wtien this is paralysed the posterior angle remains open (Fig. 57). Both of these | 
forms are met with in acute and chronic laryngitis, and are generally independent of | 
any actual nerve lesion, excepting perhaps p^pheral neuritis and some rare cases 
due to a local lesion affecting the recurrent laryngeal nerve of both sides. / 



EZ 






V. Spasm of the Laryngeal Muscles and consequent Inspiratory 
Dyspncba, is not a very common occurrence, except in the form of Laryn- 
gismus Stridfdus, a disease almost confined to childhood. It may arise when 
a foreign body fosses into the larynx, and may ooiasionally occur in aduUs 
who are thz subjects of acute laryngitis. Inspiratory dyspnoea may also arise 
in Bilateral Abductor Paralysis, 

§ 128. Larynsfisaps Stridulus or Nervous Croup^ is a form of paroxysmal 
inspiratory dyspncBa. It consists of a sudden spasmodic closure of the 

^ Synonyms : Spasmus glottidis, spasmodic croup, child-crowing, spasm of the 
larynx. 



198 THE UPPER RESPIRATORY PASSAGES [§188 

glottis, followed by a long noisy inspiration whicli produces a crowing 
sound, and is due to spasm of the adductors. It is a nervous affection, 
and appears to be due to some irritation of the vagus or of its recurrent 
laryngeal branch. The whole attack lasts from a few seconds to a minute 
or two. The child may become cyanosedor the spasms may spread to 
other muscles and give rise to general convulsions. Occasionally it ter- 
minates fatally. The attacks come on either during sleep, or in the 
waking state. They are very apt to recur, and the severity of the attacks 
may increase at each recurrence. On the other hand, if the attacks are 
slight, they may gradually disappear as the child grows older. In the 
intervals the child is free from cough or hoarseness, and the larynx appears 
healthy. 

The Etiology is obscure. It is practically confined to children of from 
four months to two years old, and nine-tenths of these are rachitic — that 
is to say, children in whom infantile convulsions and tetany are also apt 
to arise. It is twice as common in boys. It is more frequent in the 
spring time, and it is often hereditary. In older subjects laryngeal spasm 
and inspiratory dyspnoea occur sometimes in tabes dorsalis, when it forms 
the laryngeal crisis of that disease. Its rarer causes are epilepsy, hysteria, 
tetany, chorea, reflex irritation of the vagus or its recurrent laryngeal 
branch from mediastinal growths, a growth or foreign body in the larynx, 
or too long a uvula. 

The Diagnosis is not difficult, though it is well to bear in mind the 
possibility of a foreign body in the throat, larynx, or trachea. There are, 
however, three pathological conditions to which the term "croup" is 
loosely applied and which are also characterised by a paroxysmal 

INSPIRATORY DY8PN(EA. 

1. Laryngismus stridulus is the non-inflammatory nervous affection 
described above. This is recognised by the absence of cough, hoarseness 
and other symptoms referable to the larynx in the intervals between the 
attacks. There is often a history of similar attacks. 

2. Catarrhal Laryngitis (laryngitis stridulosa, false croup) is often 
associated with attacks of dyspnoea, coming on usually at night in 
children under ten who are suffering from cough and hoarseness during 
the day. It may last for an hour or so. This is due to the collection of 
thick secretion, or to the sticking together of the edges of the glottis from 
slight laryngeal catarrh (§ 121). 

3. Membranous Croup, or laryngeal diphtheria. — This is true diph- 
theria, and is attended by the constitutional and other symptoms of that 
disease (Chapter XV.). However, some {e.g., Whitla and others) maintain 
that a non-diphtheritic membranous croup may occur. A severe injury 
le,g,y drinking out of a boiling kettle) may certainly result in a membranous 
or " diphtheritic " inflammation of the mucous membrane. 

Treatment of Laryngismus Stridulus. — (a) For the Attacks, — In severe cases 
cold water may be dashed in the face, or the patient plimged into a hot 
bath, or alternately hot and cold, or cold water douches applied. In- 



§129] PHYSICAL EXAMINATION OF THE NOSE 199 

halation of chloroform or ether relieves it promptly. Artificial respiration 
is often of great service, and it may restore, even after apparent death. In 
the rare cases in which the spasm is prolonged and continuous, tracheotomy 
may be necessary. Mild cases require no treatment except rest and 
warmth. 

{h) For the Intervals, — The patient should be kept very quiet, and irrita- 
tion of the surface or the application of any stimuli conducive to an attack 
should be avoided. Reflex causes of irritation should be sought in the 
gums (e.^., teething), in alimentary canal (e,g,, worms or gastric disorder), 
in the lungs and elsewhere (vide causes). The general treatment of rickets 
should be adopted, and it is worth bearing in mind that children taken 
into the country very often cease to have these attacks. Sponging with 
cold water twice or three times a day is of value ; and as to medicine, 
bromides and chloral in small doses allay the irritability of the nervous 
system, on which the condition mainly depends. Faradisation of the 
pneumogastric is sometimes useful. 

VI. and YII. DiseaMB of the Pharynx (ante) and of the Nose (post) 
are generally attended by a certain amount of hoarseness and alteration of the 
voice. The latter give to the voice a peculiar nasal twang, which is very 
characteristic. 

The Nasal Cavities. 

§ 129. Symptoms and Physical Examination. — ^Diseases of the nose will 
be considered under three cardinal symptoms : Inodorous discharge from 
the nose (Rhinorrhoea) ; foul discharge from the nose (Ozsena) ; mouth- 
breathing and snoring (Obstruction of one or both Nostrils). Bleeding 
from the nose also occurs in some nasal disorders, but it is no^ a cardinal 
symptom. It is perhaps more generally associated with some constitu- 
tional or general derangement. Sneezing, ticUing in the nose and sniping 
may also be present ; and the quality of the voice may be altered, particu- 
larly in nasal obstruction. The sense of smM is always disturbed to some 
extent in nasal disorders. In some instances, headache, vertigo, and 
other nervous derangements are met with in association with disorders of 
the nose, especially when the free transit of air through the nasal passages 
is interfered with, and the atmospheric pressure within the tympanum 
disturbed.^ Various constitutional symptoms may result from septic 
conditions of the nose or the adjacent sinuses, and not infrequently a 
patient suffers from listlessness and general debility for a long time before 
our attention is directed to the true source of his troubles. 

CBnioal Investigation. — ^Rhinoscopy or examination of the nose may be 
effected through the anterior nares (anterior rhinoscopy), and the posterior 
nares (posterior rhinoscopy) ; and by digital examination posteriorly. 

^ A notable instance in my own experience was that of a lady of thirty-five who 
suffered from the most troublesome tinnitus aurium and occasional giddiness, which 
was not relieved until the middle turbinate bone was removed by Dr. Soanes Spioer 
(see the Author's ** Clinioal Lectures on Neurasthenia/* fourth edition). 




200 THB UPPER RESPIRATORY PASSAGES [ § 129 

Antebior Rhinoscopy. — ^First examine the anterior nares for any 
obvious disorder, such as fissures, ulcers, scars from ulcers, any narrowing 
of the nares, or a deviation of the septum ; secondly, introduce a speculum 
(Fig. 58), using either a direct light or one reflected from a mirror on the 
forehead, as in lar3aigoscopy. In this way an examination of the inferior 
turbinate bone can be made, to see if it be hypertrophied. The inferior 

or middle meatus can be thus examined for polypi or 
alteration in the mucous membrane. If, as frequently 
happens, the anterior part of the inferior turbinate is 
hypertr<^hied, and hides the view, this may be reduced by 
swabbing out with a cotton-wool pledget soaked in a 10 per 
cent, solution of cocaine. 
^^spEOTOot?.^ Posterior Rhinoscopy is effected by precisely the same 

procedure as in laryngoscopy (§ 119), using the smallest of 
the mirrors, and turning it upwards. It is convenient to have a special 
mirror for this purpose mounted on a curved handle, the stem being 
hinged at its extremity, so that it can be raised to any desired angle. It 
is important to avoid touching either the dorsum of the tongue or the 
posterior wall of the pharjmx. The patient should be instructed to breathe 
gently all the while through the nose. By moving the mirror slightly in 
different directions we are able to examine the posterior nares and 
turbinated bones, the inner end of the Eustachian tube for any swelling, 
and Luschka's tonsil {cf. Fig. 48). The pharyngeal or Luschka's tonsil is 
a mass of lymphoid tissue on the pharyngeal roof and posterior wall above 
and between the Eustachian tubes ; when in a condition of hyperplasia it 
forms the cushion-like growth of post-nasal adenoids (§ 109). 

A great deal of information may be derived by passing the finger behind 
the soft palate, but for this purpose it is generally necessary to spray the 
pharynx with cocaine (10 per cent.). 

Our first inquiries concerning any given case of suspected disease of 
the nose should be relative to the leading symptom, especially whether 
there be any nasal discharge, and whether it is inodorous or foul smelling. 
We cannot depend upon the patient's statement on this point, because 
very often the same disease which causes a foul discharge may blunt the 
sense of smell. Secondly, we must investigate the history, and whether 
any of the other sjonptoms above mentioned were present. Thirdly, we 
must proceed to the physical examination by testing whether the 
patient can breathe freely through each nostril separately ; by examining 
the anterior, and, if necessary, the posterior nares. 

Classification. — ^Diseases of the nose, like those of the throat, are best 
classified by the physical signs met with on examination — ^viz., nasal 
discharge, nasal obstmciion, epistazis— and their causes. 

(a) Acute Inodobous Discharges (Acute Rhinorrhcea) — the causes 
of which are — 

I. Acute Rhinitis; II. Syphilis (snuffles); III. Diphtheria, and other fevers; 
IV. Coryza ; V. Hay Fever ; VI. Glanders. 



§180] ACUTE IN0D0B0U8 DI8CHARQE FROM NOSE 201 

(6) Chronic Inodorous Discharges (Chronic Rhinorrhoea) — ^the 
causes of which are — 

I. Ghronio Simple Bhinitis ; II. Chronio Hypertrophic Bhinitis ; III. Cerebro- 
spinal Bhinorrhoea ; IV. Ulcerations of the Nose, Polypi, and occasionally 
OEktarrh of the Sinuses. 

(c) Chronic Offensive Discharges (Oz«Bna), which have for causes — 

I. Ulcerations and Bone Disease — Syphilis, Tubercle, and Lupus ; II. Atrophic 
Bhinitis ; III. Empyema of Antrum and other Sinuses ; IV. New growths 
and x)ol3rpi breaking down, and impacted foreign body. 

(d) Nasal Obstruction (Snoring and mouth-breathing) — the causes of 
which are — 

L Pharyngeal Adenoids ; II. Polypi ; III. Deviated Septum ; IV. Hypertrophy 
of Turbinate ; and V. Foreign body and neoplasms in adjacent parts. 

(e) Epistaxis, the causes of which may be Local or General. 

§ 190. Acute (or recent) InodorouB Discharge from the Nose (Rhinor- 
rhoea). — Discharge is afreqiient symptom when disease of the nose is present, 
and we should endeavour to ascertain if this he odourless or offensive, although 
these are, of course, only r dative terms, athd the two groups cannot be sharply 
defined. Among the causes of Acute Inodorous Discharge, cor^enital 
Syphilis should he suspected in infancy ; Diphtheria in childhood ; Coryza 
in aduUs, 

I. Acute Rhinitis may be set up by irritation of any kind, as the vapour 
or dust of some trade, or by any injury. For instance, a profuse discharge 
from one nostril in a child should always make us suspicious of his having 
inserted a pea, marble, or other foreign hody, although the history may be 
wanting. But its commonest cause is a " cold " (see Acute Coryza below). 

II. ^* The Snuffles." — ^In infants a few weeks old, congenital syphilis is 
almost invariable attended by a profuse nasal catarrh, and is known 
familiarly as the " Snuffles." The other features of nasal syphilis will be 
referred to under Ulcerations. 

in. Diphtheria and other fevers. A profuse nasal discharge excoriating 
the upper lip, with slight elevation of temperature, and prostration, coming 
on suddenly in a child or young person previously healthy, is so character- 
istic of diphtheria that the disease may almost be diagnosed from these 
features alone. 

rV. In Acute Coryza, " catarrh,** or " cold in the head/' there is profuse 
muco-purulent discharge attended by sneezing, running from the eyes 
and febrile symptoms with frontal headache, extending over a few days. 
It is usually attributed to some exposure to cold (" a chill ") ; but it fre- 
quently prevails in an epidemic form, and is then of microbic origin. It is 
predisposed to by cold and damp weather, by adenoids, and the other 
causes of chronic rhinitis. It is not a serious disorder, but its repeated 
occurrence may lead to middle-ear catarrh, or to bronchitis by extension. 

Treatment of " CatarrhJ*^ — In severe cases it is advisable for the patient 
to keep in bed. At the outset a full dose of Dover's powder given at night, 



202 THE UPPER RE8P1BAT0BY PASSAGES [§1S1 

or a mixture of tr. aconiti TTl^i., liquor ammonisB acetatis, with other salines, 
every two hours, may cut short the disease. Locally, sprays of cocaine 
(2 to 4 per cent., applied with caution, occasionally), or equal parts of 
boracic acid and borax dissolved in water, or camphor and menthol (gr. 8 
to 5i. of paroleine), may abort the disease. Ferrier's snuff ^ is also useful. 
Inhalations of camphor, menthol, or vinegar taken at night are reputed 
to be efficacious. Vaccines are efficacious in some cases. 

V. Hay Fever, or, as it is sometimes called. Hay Asthma, is a severe catarrh of the 
nasal mucous membrane and conjunctivse. coming on fairly regularly in the summer 
or autumn of each year, presumably connected with the inhalation of the pollen of 
flowers. It is accompanied by the symptoms of severe coryza, just described, which 
come on somewhat suddenly in a person predisposed, who has been outdoors (usually 
in the hay-making season), and are attended by a certain amount of constitutional 
disturbance. There appear to be two clinical varieties of this disease — (L) where the 
symptoms are chiefly constitutional ; and (ii.) where the symptoms are chiefly local. 
In the latter there is generally hypertrophy of the inferior turbinate, which constitutes 
an important predisposing factor. 

The Etiology of this disease is somewhat obscure, but it evidently is connected in 
some way with pollen, especially that of grasses. There are some people, usually 
those with a marked neurotic taint, who cannot go within a couple of miles of a hay- 
field in the summer without developing the disease. It is diagnosed from simple 
coiyza chiefly by its seasonal occurrence. It resembles asthma in some respects, 
especially in its periodicity, but differs in that the nasal, instead of the bronchial, 
mucous membrane is involved. The malady is not a fatal one, but causes serious 
discomfort and inconvenience. Sometimes people get rid of it as they get older, 
but in others it continues throughout life. 

Treatment, — ^The first indication is the avoidance of the cause. This may be accom- 
plished by a sea- voyage, residence at the seaside at a high altitude, or by living indoors 
in the city, taking care that no plants or flowers enter the house. But there is no rule 
in this respect ; for some do better at a high altitude, others at a low one ; some get 
better at the seaside, others in a town. Quinine, arsenic, iron, or belladonna, may 
be taken before the attack is expected. Antipyrin (15 grains) has been credited with 
cutting short an attack. If the disease extends to the bronchi, asthma papers and 
cigarettes should be employed. Locally, means should be taken to prevent the pollen 
reaching the mucous membrane. For this purpose Brunton recommends smearing 
the nostrils with zinc oxide ointment, which not only allays the irritation, but, by 
remaining longer unmelted, is more efficacious than other ointments. Antiseptic sprays 
destroy the pollen. Of these quinine, J grain to the ounce, dissolved in normal saline 
solution, as being less irritating than water, gives good results. Sir Andrew Clark 
recommended swabbing out with hyd. perchlor., gr. i. ; quin. hydrochlor., gr. iL ; 
glyc. ac. carbol., ^i. To relieve the discomfort, cocaine tabloids (J grain), inserted 
in the nose, sprays of cocaine (4 per cent.), or menthol (20 per cent.) are used. The 
mucous membrane, if thickened, must be treated as in hypertrophic rhinitis. Pollan- 
tin has been greatly recommended. 

VI. Glandeii. — ^The copious discharge of viscid semi-purulent matter from the nos- 
trils is one of the earliest symptoms of Farcy, or Chronic Glanders (§ 362). 

Vn. Kyiafis is chiefly met with in tropical countries. It is due to the presence of 
maggots. The eggs from which they hatch are laid by a fly on the nasal mucous 
membrane, usually while the patient is asleep. Inhalation or local application of 
pure chloroform is the usual remedy, but insufflations of calomel are also successful. 

§ 18L In Chronic Nasal Discharges it is stUl more diffljuU to draw the 
line between odorous and inodorous discharges, since many of the conditionSy 
though odourless at the outset, become offensive later on, and it will generally 
be necessary to pass in review all the conditions mentioned in this section 

^ Bismuth Subnitrate, 5vi. ; Morph. Hydrochlor., gr. ii. ; Pulv. Acao., 3u« 



§ lai ] GHRONIO NASAL DISCHARGES 203 

and § 132 below. The following are the chief causes of inodorous 

DISOHABGE : 

I. Chronic Rhinitis is a chronic inflammatory condition of the mucous 
membrane of the nose, attended by increased secretion, and usually by 
thickening. It occurs in three forms : (a) Simple ; (6) Hypertrophic 
(infra) ; (c) Atrophic (§ 132). The first two give rise to an inodorous, 
but the ATROPHIC to an odorous discharge. 

Chronic Simple Rhinitis consists of a chronic congested, and some- 
times, later on, a hypertrophied state of the mucous lining of the nose, 
attended by a continuous mucous or muco-purulent discharge. There 
is generally a certain amount of nasal obstruction, giving rise to altered 
voice and snoring. 

Etiology, — (i.) It is predisposed to by cardiac and pulmonary disease, 
alcoholism, and the strumous diathesis. It may be determined by (ii.) re- 
current attacks of neglected coryza over a long period of time ; (iii.) the 
injury caused by an unsuspected foreign body, in which case the con- 
dition is generally confined to one. side ; or (iv.) the constant irritation of 
dust and noxious vapours — e.gr., in masons, fustian-cutters, (v.) It is often 
associated with adenoids, enlarged tonsils, and other causes of obstruction 
to the nasal respiration. 

Prognosis. — The disease is chronic, and requires prolonged treatment. 
The chief fear is that middle-ear catarrh may result from the extension 
of the inflammation up the Eustachian tube. Even apart from this, it 
is very important to treat these cases in strumous children, because the 
condition interferes with the respiratory functions of the body. 

Treatment, — ^In the early stages alkaline washes — bicarbonate of sodium, 
gr. XV., and borax, gr. v., or carbolic acid, gr. iii. to 5i. — sniffed up or given 
by the nasal douche. This is followed later on by a spray of menthol and 
eucalyptol (gr. xxx. to Ji. of aquol or paroleine), or an ointment of cocaine 
and thjrmol (gr. x. to $i. of white vaseline), or by the use of the ammonium 
chloride inhaler. Constitutional treatment is necessary, by means of 
tonics, cod-liver oil, and malt. Alcohol should be avoided, and a high 
and dry climate should be sought. In the later stages, the only satisfac- 
tory method of treatment is applying chromic acid (gr. v. or x. to 5i-)» 
or, still better, the galvano-cautery. 

II. Chronic Hypertrophic Rhinitis is a special form distinguished from 

the preceding by the fact that there is considerable hyperplasia of the 

nasal mucous membrane, especially over the inferior turbinate bone at 

its anterior and posterior ends. It presents the same symptoms as the 

preceding, but in a greater degree. Even in slight cases it is apt to be 

accompanied by headache and mental depression. It is frequently asso- 

cated with adenoids. The Prognosis is on the whole less favourable. 

The Treatm,ent is much the same, but more active measures are indicated, 

and especially treatment by the thermo-cautery. 

in. Oerebro-spinal Bhinorrhoda is a oontinual dripping of a watery, dear fluid 
(cerebro-spinal fluid) from the nose, due to the formation after injury or disease of 
a communioation between the nasal cavity and the sub-arachnoid space. The fluid 



204 THE UPPER RESPIRATORY PASSAGES [§182 

passes through the cribriform plate of the ethmoid. Its nature is at once recognised 
by the fact that it reduces Fehling^s solution. Little can be done for the condition ; 
inteiference is apt to be followed by meningitis. The flow sometimes ceases spon- 
taneously. Some cases have been successfully treated by applying to the nasal mucosa 
irritants which cause swelling and occlusion of the lumen of the sinus. 

IV. Ulcerations of the Koie, Polypi, Dtfease of the Sinmef, occasionally produce 
inodorous discharges, but the discharge is more often offensive (see below). Chbonic 
Frontal Sinus Empyema is, however, attended by (i.) a purulent, non-fatid nasal 
discharge, (ii.) frontal or supra-orbital headache or feelings of discomfort, and (iii.) more 
or less well-marked nasal obstruction, caused by inflammatory enlargement of the 
middle turbinated body, or by pol3rpi. Headache only occurs from retention, and not 
when drainage is free. There may be tenderness on pressure over the affected side. 

V. Post-nasal Oatarrh is a condition in which the catarrhal processes are confined 
to the naso-pharynx. Its importance is derived from the fact that it is not easily 
recognised unless looked for. The constant swallowing and absorption of septic 
matter from the post-nasal focus may give rise to serious constitutional results, and 
by direct extension the ear or sinuses may be affected. Treatment is on the same 
lines as that for the commoner forms of nasal oatarrh. 

§ 182. Ozeena or a Chronio Offensive Discharge /rom the nose may occur 
in the later stages of many of the conditions mentioned in the preceding 
section. But the chief causes of foul discharge from the nose are as follows ; 
the commonest and fouUest occurring in atrophic rhinitis in the young ; 
SYPHiLiTio DISEASE in middle life ; and cancer in the aged. 

Foreign bodies (which have already been referred to) athd Polypi, both of 
which may cause one-sided ozcena, wQl be described under Nasal Obstruction 
( § 133) which is their leading symptom. It wiU be necessary to give some 
detailed account o/^— Ulcerations and Bone disease ; Atrophic Rhinitis ; 
and Empyema of the Sinuses. 

I.' Ulcerations and Bone Disease attacking the nose are mostly of syphil- 
itic, occasionally of tuberculous, origin. Neoplasms in the later stages 
ulcerate, but in the earlier stages give rise to Rhinitis or Nasal Obstruction 
(§ 133). 

(a) Syphilitic Rhinitis. — In the early stages of sjrphilitic infection we 
may get an acute catarrh with superficial ulceration, which is the condition 
found in children with congenital syphilis, known as " snuffles." In the 
later stages gummata form in various situations, which rapidly involve 
the bone and other parts; the discharge then becomes very foul. The 
ulcers have the same character as those affecting the throat (g.v.). 

(6) Tubercnloiis Ulceration more often involves that part of the nose near the 
orifice, but otherwise the ulcers much resemble the preceding. They are difFerentiated 
from them by their very much slower progress, as well as by their site. The bones are 
rarely attacked, and consequently the discharge may be more or less inodorous ; 
and there is rarely the falling in of the bridge of the nose, which so frequently occurs 
in tertiary syphilis. The ulceration of Lupus differs but little from the true tuber- 
culous ulceration, except that lupus vulgaris usually involves also the skin of the alse 
nasi, wTience ii has probably spread. 

Atrophic rhinitis is distinguished from these ulcerations by the pallor 
and thinning of the mucous membrane, the absence of visible ulcers, and 
the absence of a history of evidences of syphilis or tubercle respectively. 

The Prognosis of nasal ulceration is fairly good if the patient come 
imder treatment early, but if not it leads to considerable destruction of 



§ 182 ] OZMNA 205 

tissue. Tuberculous ulceration may slowly lead to the destruction of the 
oUb of the nose, but syphilis results in the most extensive destruction of 
the hones both of the septum and the palate ; the bridge of the nose falls 
in, and the.anterior nares may be represented by a single gaping orifice. 
It is this extensive and rapid destruction which is so pathognomonic of 
nasal syphilis. 

The Treatment should be much more prompt and vigorous in ulceration 
of the nose than in chronic rhinitis and similar affections, because of the 
destruction which ensues. Carbolic and astringent sprays are useful 
palliatives, but surgical measures are called for if the bone is involved. 
All dead bone must be removed. Tuberculous ulcers be scraped. Large 
doses of potassium iodide lead to rapid healing of syphilitic ulcerations. 

IL Atrophic Bhinitif > also known as idiopathic or true ozsoa, is characterised by 
(i.) a thick, foul discharge, which is sometimes profuse, sometimes scanty ; (ii.) the 
nasal cavities are often large, and the bridge of the nose broad and sometimes depressed. 
The mucous membrane is thin, pale, and covered with crusts, hard, adherent, and de- 
composing. Sometimes it is unilateral — e.^., in cases of deviated septum. A certain 
amount of chronic pharyngitis is usually present, (iii.) The breath has a foul odour, 
which is not detected by the patient, as the sense of smell is blunted. It is Diagnosed 
from the other causes of ozsBna by the absence of ulceration, the presence of atrophied 
mucous membranes, and wide cavities. 

Etiology, — (L) It is commoner in the young and in women. It usually starts before 
sixteen years of age. (ii.) Unilateral atrophic rhinitis is mostly due to some local 
cause, such as deviated septum or sinus disease, the narrower side being healthy, 
(iii.) The exciting causes of bilateral atrophic rhinitis are obscure : it has been said 
to follow chronic rhinitis in strumous children ; (iv.) in some cases it is a sequence of 
hypertrophic rhinitis. 

Prognosis, — Prolonged treatment is necessary for its cure, and even this is not very 
hopeful if the disease be advanced. The disorder is generally most marked at about 
twenty years of age ; it becomes less troublesome at middle age, and, as it gradually dis- 
appears with advancing years, we may presume that it tends slowly to spontaneous cure. 

TreaknenL — Alkaline and antiseptic douches and sprays are indicated, as in § 131. 
To stimulate the mucous membrane, nasal tampons of cotton wool, soaked in glycerine, 
are used. These aro useful in unilateral rhinitis, as they insure respiration through 
the narrower cavity. The nose may be swabbed out with silver nitrate (10 grains to 
the ounce), or with trichloracetic acid (5 to 20 parts in 1,000), which removes the smell. 
Constitutional treatment is also advisable. Vaccines may assist. 

in. Ohronio Empyema of the Antrum and other sinuses is a term applied to a 
chronic suppurative inflammation of the lining membrane, though the term '* em- 
pyema " should be reserved for cases in which there ib retention. The most constant 
and cardinal symptom is a purulent or sero-purulent discharge from one nostril, which 
is generally offensive or sickly. It may arise as an extension of nasal catarrh, or 
various suppurative nasal conditions (syphilis), tubercle, bone disease, etc. 

Empyema of the Antrum may be due to irritation from a tooth. Many of the patients 
have had deoistyed teeth in the upper jaw. It is recognised by the discharge being 
intermittent, returning usually about the same time each day, and flowing freely when 
the head lies on the opposite side, or is lowered between the knees. The discharge 
may be seen coming from beneath the middle turbinate. If a bright light is held in 
the mouth, the cheek of the affected side remains darker than the other (trans-illumina- 
tion). 

Discharge from the frontal or anterior ethmoidal sinuses flows best when the patient 
is upright. It comes from under the middle turbinate, and there is often pain in the 
brow and orbit (see also p. 204). 

Discharge from the posterior ethmoidal and sphenoidal sinuses flows over the middle 
turbinate and down into the pharynx. There may be exophthalmos, ptosis, stra> 
bismus, etc., with disease in this locality. 



206 THE UPPER RESPIRATORY PASSAGES [§188 

Various constitutional symptoms are recognised as being associated with sinus 
disease, due probably to the toxaemia which results from septic absorption. Lassi- 
tude, headache, occasional elevations of temperature, and numerous nervous and 
va80*motor symptoms are amongst the commonest. They generally present a periodic 
or paroxysmal character. Trifacial neuralgia may also result from sinus disease. If 
overlooked or neglected, empyema may excite middle-ear catarrh (with tinnitus, 
deafness, etc.), recurrent nasal catarrh, and nasal polypi. 

Prognosis and Treatment. — Sinus empyoma is chronic and intractable, but very 
rarely fatal. The treatment is based on surgical principles, but the chief indications 
are free drainage and stimulation of the chronic inflammation until it takes on a more 
healthy action of repair. 

IV. Neoplasms and Polypi (§ 133), and Impacted Foreign Body (§ 130, 1.), are referred 
to elsewhere. 

§ 133. Nasal Obstruction, Snoring, and Mouth-breathing. — 'S'asal obstruc- 
tion may be ^partial or complete, and it may exist on one or both sides. It is 
met with in a greater or less degree in nearly all of the various nasal conditions 
previously discussed, and it is a marked feature in Hypertrophic Rhinitis 
(p. 203). Its commonest cause in children is Pharyngeal Adenoids 
(§ 109). It is also a cardinal symptom in Nasal Polypi, Devution or 
Spur op the Septum, Alar Collapse, Foreign Bodies, Neoplasms, 
ar^ Abscesses. 

Effects, — Apart from the inconvenience of snoring, nasal obstruction 
renders the individual prone to pharyngitis, stomatitis, bronchial catarrh, 
and other consequences due to the entry of cold air into the lungs without 
being properly warmed by its passage through the nose. Among the 
other consequences are a nasal quality of the voice, distortion of the chest 
(when arising early in life), and impeded respiratory functions of the body 
generally. These disorders consequently assume an importance quite 
out of proportion to the degree of local mischief. 

I. Pharyngeal Adenoids are of very frequent occurrence. They con- 
stitute one of the forms of granular pharyngitis, and the disease has been 
referred to under that condition (§ 109). It is the most frequent cause 
of mouth-breathing and snoring in children. It is often overlooked by 
parents, a circumstance greatly to be regretted for three reasons. In the 
first place, it is one of the most potent causes of chronic otitis media and 
deafness in after-life ; secondly, it impairs the respiratory functions of the 
body, as just mentioned ; and thirdly, the open mouth and vacant aspect, 
which are so characteristic, produce an appearance of backward intelli- 
gence which in point of fact often results. 

II. Polsrpi, or pedunculated tumours, are the most frequent new growths 
in the nose. Polypi are of three kinds : (a) Gelatinous ; (6) Fibrous ; 
and (c) Malignant. 

(a) Gelatinous or Mucous Polypi are the most common form of 
polypi. They usually consist of myxomatous tissue, believed by some to 
be associated with inflammatory disease of the subjacent bone. They are 
often multiple, and most often grow from the muco-periosteum of the 
upper and middle turbinated bones. Their detection is not difficult, for 
in addition to the feeling of " stuffiness " and the watery discharge (which 



{ ia4 ] NASAL OBSTRUCTION— EP18TAXI8 207 

may be intermittent), they are easily seen through the nasal speculum as 
pale grey glistening bodies. They are apt to recur after removal, but are 
not malignant in other respects. 

(b) Fibrous Polypi grow from the roof of the naso-pharynx. By their 
growth they displace the parts around and are apt to give rise to ** frog 
face." The discharge is often foul, and may be heemorrhagic. They 
sometimes become malignant (fibro-sarcoma). They may occur at any age. 

(c) Malignant Polypi may be either fibro-sarcomatous or carcino- 
matous. They are known by their rapid growth, and the resulting de- 
formity of the face, " frog-face," and by the offensive and haemorrhagic 
discharge. Sarcomatous growths are chiefly met with in the young ; 
carcinomatous in the aged. 

Prognosis and Treatment, — The benign poljrpi are not dangerous to life, 
but are liable to recur. Malignant growths give rise to a condition of 
considerable gravity. Occasionally fibrous tumours atrophy. Gelatinous 
polypi, arising as they do from the anterior part of the cavity, can generally 
be removed by means of a nasal snare or forceps ; but the other varieties, 
springing usually from the posterior parts and infiltrating the tissues 
around, may require an operation of some magnitude. 

m. DefUted Septam and Hasal Spar. — The nasal septum is rarely quite in the 
median line, but the displacement is often considerable. Sometimes it results from 
injuiy. Various consequences may ensue, such as hypertrophied turbinate on ono 
side, atrophic rhinitis on the other. When an angle is formed in the septum nasi, it 
is spoken of as a '* spur," and this is most readily dealt with by the surgeon. 

IV. Hypertrophied Tnrbinate is met with usually either as part of, or a consequence 
of, chronic hypertrophic rhinitis. It may occur on one or both sides, and in either 
case, in narrow nostrils, produces partial obstruction, snoring, and mouth- breathing. 
It is removable by turbinectomy ; sometimes the thermo-cautery is employed (see 
Hypertrophic Rhinitis, p. 203). 

V. Foreign Bodies within the noae, Heoplaf mi, and Absceieei in adjacent parts may 
also produce unilateral nasal obstruction. 

§ 184. EidstaziB (bleeding from the nose) may bo a symptom of nasal 
disorders, but if in any appreciable quantity it is usually an evidence of 
some general disorder. Not infrequently both general and local causes 
are in operation, and the nasal cavities should alvoays he carefully examined. 
The bloodvesseb give way in this situation (sometimes as a kind of safety 
valve) merely because they are thin- walled, numerous, and near the sur- 
face. So much is this the case that the diminished atmospheric pressure 
to which mountaineers are subjected is sufficient to produce nose bleeding 
when they reach great heights. The Causes may be divided into two 
groups — ^Local and Constitutional. 

(a) Local Causes, in which the haemorrhage consists usually of little 
more than streaks, may arise from any marked congestion of the mucous 
membranes, such as that which accompanies adenoids, acute rhinitis, 
worms in the nose ;^ or as a consequence of mechanical violence, applied 

^ Dr. Manasseh relates the case of a child with epistaxis in whom a leech was found 
in the nose. This had gained entrance by the child drinking at springs in a district 
where leeches abounded in the water. — Lancet, September 16, 1899, p. 785. 



208 THE UPPER RESPIRATORY PASSAGES [ § 184 

either directly to the nose or to the base of the skiill. Any serious destruc- 
tive disorder — such as new growths, especially malignant, syphilitic, 
tuberculous, or other ulcerations (which if small are very apt to be over- 
looked) — ^may be attended by a certain amount of recurrent bleeding. In 
these circumstances the haemorrhage is usually an intermittent and sub- 
ordinate feature. The diagnosis rests on the characters already given. 
When small in quantity the blood often passes backwards into the throat 
and is swallowed, or it may be expectorated or coughed up, and be mis* 
taken for hsematemesis or haemoptysis. 

(b) With CoNSTrruTiONAL Causes the bleeding is usually, although 
not always, of larger quantity, and it may, indeed, be so profuse as to 
endanger life. The blood in this group comes from a spot near the anterior 
part of the septum. Among the predisposing causes none is more frequent 
than an idiopathic tendency which exists in certain individuals to bleed 
upon slight provocation, a tendency which runs in families. Without 
amounting to haemophilia, certain persons undoubtedly present some 
inherent quality which renders them more liable to bleed from their 
mucous surfaces, with or without a wound. It may exist in only one 
member of a family, but more often in several brothers and sisters. I 
have often noticed that such a predisposition may exhibit the pheno- 
menon of atavism and skip a generation. Epistaxis is more frequent in 
children, especially in boys. It is also met with in the aged, but only 
when vascular disease and some of the other conditions about to be men- 
tioned exist. The constitutional cases may be grouped under (a) Altera- 
tions in the Cardio-vasoular System, and (b) Altered Blood States. 

(a) Epistaxis occurring for the first time in an apparently healthy 
person over forty years of age should always give rise to the suspicion of 
chronic Bright's disease. It affords us, moreover, an indication for the 
treatment of this malady, of which advantage may sometimes be taken, 
for it relieves the vascular tension which would otherwise seek relief in 
some less favourable situation. For instance, I have observed several 
patients who, after repeated admissions to hospital for epistaxis, have 
finally come in to die of cerebral hsemorrhage. Epistaxis is a frequent con- 
sequence of cardiac valvular disease, emphysema, chronic bronchitis, and, 
cirrhosis of the liver. It may also be an evidence of lardaceous or other 
disease of the vessels. Finally, epistaxis is one of the forms of vicarious 
menstruation, and, like the bleeding which may take place in hysteria and 
other conditions where the vaso-motor system is disordered, we must regard 
this as an extreme effect of disease of the sympathetic nervous system. 

(b) Concerning Altered Blood States, it may occur with purpura, haemo- 
philia, scurvy, leukaemia, anaemia (simple, and especially pernicious), and 
the specific fevers, especially typhoid, rheumatism, and the haemorrhagic 
forms of the exanthemata. It is in children a not infrequent prodromal 
manifestation of whooping-cough and similar microbic disorders. 

Prognosis, — Slight epista2ds in children is of no consequence, but occur- 
ring for the first time in persons at or past middle life should receive our 



§ 184 ] EPISTAXIS 209 

serious attention, and its cause should be carefully investigated. Inquiry 
should always be made as to whether it has occurred previously in the 
life of the individual, because, as above mentioned, certain persons have 
this tendency, and in these the symptom may not be of much importance. 

Treatment, — The indications are — first, to check the haemorrhage if 
profuse ; and secondly, to ascertain the cause. 

The epistaxis which accompanies Bright's disease, and the congestion 
of cardiac and pulmonary disease should not be checked unless the amount 
be profuse. In such cases the epistaxis is usually preceded by headache, 
and is accompanied by high arterial tension. It may be one of Nature's 
methods for the relief of congestion, as evidenced by the fact that the 
headache and the high arterial tension are relieved by the haemorrhage. 
In all cases of epistaxis, the first thing to do is to examine the arterial 
tension. So long as this remains high or moderate no harm can accrue 
from the epistaxis. 

(a) The treatment of the attack resolves itself into checking the hsemor- 
rhage. The patient should be kept perfectly quiet, with the head erect, 
and chin forward, the head being cool, the feet warm, with hot bottles if 
necessary. The arms may be raised above the head and ice applied to the 
lower cervical spine. A homely substitute for the latter has long been 
in vogue in the form of the front-door key. Some recommend pressure 
to the anterior part of the septum by the thumb and forefinger externally. 
The cautery applied to the bleeding spot is also efficacious. Other useful 
measures consist of the application of hydrogen peroxide or adrenalin to 
the site of the haemorrhage, if this can be discovered, or the use of styptic 
sprays or hamamelis, catechu, vinegar, lemon-juice, etc. Finally, if all 
these fail, the posterior nares must be plugged. If haemorrhage continues 
for several days, internal treatment must be given — calcium chloride and 
terebene. Serum, especially horse serum, may be injected subcutane- 
ously. 

(6) Between the attacks a very thorough investigation of the nasal and 
post-nasal cavities must be made. Minute lesions, quite sufficient to cause 
epistaxis, are very easily overlooked. The treatment of recurrent epistaxis 
is not always an easy matter, for the cause is often obscure, and we are 
often driven to regard the case as belonging to the idiopathic group above 
referred to. In a good many cases iron is efficacious in warding ofi the 
attacks ; and calcium chloride by increasing the coagulability of the blood. 



THE THYKOID GLAND. 

This gland is anatomically connected with the upper respiratory pas- 
sages, but is physiologically quite separate. It supplies an essence to the 
economy which is necessary to the well-being of the individual, and it is 
in close relationship with the other ductless glands, the supra-renal, the 

pituitary, the pancreas, the ovary and others. In health it enlarges at 

14 



210 THE THYROID QLAND [§186 

puberty, during menstruation, sexual excitement, pregnancy, lactation, 
and in the presence of most acute specific fevers, notably rheumatic fever. 
Symptomatology. — There are two opposit<3 clinical conditions which 
may arise from disorder of the thyroid gland. In one there is a diminished 
thyroid action, a condition of Athyroidiamy the symptoms of which (leth- 
argy, lowered vitality, and impaired growth and development) are similar 
in kind but less in degree to those of Myxoedema and Cretinism. The 
other condition is one of increased (or perverted) thyroid action or Thyroid- 
ism, the symptoms of which resemble Graves' disease ; and these, with 
the exception of the proptosis, can be produced by the internal administra- 
tion of thyroid gland or extract in large doses. It is important to remem- 
ber that the size of the gland is not in any degree a guide to which of these 
two sets of symptoms are to be expected in a given case, for enlargement 
of the gland is consistent with atrophy of the glandular elements and 
diminution of function ; while what appears to be a small gland may be 
functionally very active. 

§ 135. Physical Examination and Classification. — ^There are but two 
physical signs referable to the thyroid gland — viz., enlargement or diminu- 
tion of volume. When the alteration of volume is only slight it is difficult, 
if not impossible, to estimate it with accuracy, because it is partially 
covered by muscles, and is intimately connected with the trachea and 
other deeper structures. The patient should be instructed to let his head 
fall forwards and to swallow whilst we endeavour to palpate the gland. 
The thyroid rises during deglutition as no other neck tumour or organ 
does. Some idea may be obtained of the progress of a case by measuring 
the neck from time to time, always exactly at the same level. 

Classiflcation. — In general, enlargement is attended by a condition of 
thyroidism {e.g.. Graves' disease), and a diminution by a condition of 
athyroidism (e.^., myxoedema) ; and there are two well-marked types of 
disease which are usually associated with enlargement, and two with 
diminution in volume of the thyroid gland. 

(a) The two diseases (besides cancer and other neoplasms) in which 
enlargement of the thyroid is — at some stage of the malady — the essential 
or pathognomonic feature^ are — 

I. Graves' Disease — or Exophthalmic Goitre — is the term applied to 
that form of enlargement of the thyroid which is attended by proptosis, 
and by numerous cardio-vascular and nervous symptoms, with marked 
disturbance of the general health. These general sjmptoms collectively 
constitute thyroidism. They are often present long before there is any 
visible enlargement of the gland. 

II. Simple Goitre or ** Bronchocele " is the term applied to a simple 
increase in size of the thyroid gland, either congenital or coming on in 

^ In Acromegaly (Chapter XVII.) the thyroid is sometimes slightly enlarged or 
diminished in size, but it has generally been regarded as a subordinate Mature in this 
rare and strange disease. In some cases of Cretinism (which is included in group h) 
the thyroid gland is considerably enlarged, but deficient thyroid action constitutes the 
chief factor of the disease. 



186 ] OR A VE8* DISEASE 21 1 

childhood or early adult life, generally attended by slight though definite 
diminution of function. 

(6) There are also two diseases in which atrophy of the thyroid — or at 
any rate a diminution of its function (and usually of its size) — is the essen- 
tial feature of the malady : 

I. Cretinism is the term applied to the condition of stunted growth 
(both in mind and body) of the individual, due to congenital atrophy or 
absence of the gland function, although the gland itself may be either 
enlarged or diminished in size. It is a condition of congenital athy- 
ROiDiSM. The disease is endemic in certain districts. 

II. Mtxcedema is the term applied to the group of symptoms (lethargy, 
low vitality, etc.) which, coining on in adult life, especially towards middle 
age, accompany atrophy of the thyroid gland. This is a condition of 
acquired athyroidism. 

It therefore follows that : 

1. Increased or disordered thyroid secretion gives rise to profound disturbance of 
the general health, and neuro- vascular irritation (Graves' disease). 

2. An innocent enlargement of the thyroid, unaccompanied by increased or dis- 
ordered thyroid secretion, has no effect on the economy (as in most cases of broncho* 
oele). 

3. Simple absence or diminution of the thyroid secretion results (a) when it is 
congenital or comes on in early life, in deficient development, mental and physical 
{i.e,, cretinism) ; and (6) when it supervenes in adult life, in lethargy and deficient 
vitality (myxcedema). 

Diseases usuaUy attended by thyroid enlargement — viz,, Graves' 
Disease and Bronchocele. 

§ 136. Graves' Disease (Synon. : Exophthalmic Goitre, Basedow's dis- 
ease) has been defined on the preceding page. Usually the onset is very 
insidious. There are five groups of sjmptoms, and the varieties of the 
disease depend on which of these predominate. 

Symptoms. — (1) Cardio-vasctdar disturbances are among the earliest and 
most important symptoms. They are never absent, and may exist for 
months before any other evidence appears : (i.) Palpitation, (ii.) The 
increased frequency and tumultuous action of the heart is accompanied 
by a rapid and sometimes feeble pidse, up to 150 or more on the slightest 
exertion or emotion. The rate may sometimes be reduced by absolute 
rest by 40 or 50. (iii.) Paroxysmal dyspnoea and a distressing sense of 
suffocation, produced and relieved by the same means as the preceding, 
(iv.) Evidences of cardiac disease, such as the murmur of dilatation (said 
to be present in two-thirds of the cases, § 44), are frequently present. The 
commonest murmur is a systolic, heard loudest over the second left 
costal cartilage, and sometimes propagated up the vessels of the neck, 
(v.) Sometimes slight dropsy and occasionally albuminuria are observed. 

(2) Nervous disturbances are always present. They are very variable : 
thus (i.) there may be nervousness, irritability, insomnia, depression 
alternating with excitement, hysterical attacks, melancholy, or mania, 
(ii.) Hyperaesthesia, perverted sensations, neuralgic headache, vertigo, 
tinnitus aurium, and hallucinations of sight or hearing, (iii.) Other fairly 



212 THE THYROID OLAND [§1S6 

common symptoms are fine and rapid vibratile tremors of the hands 
(always), or of the lips (seldom), (iv.) Vaso-motor disturbances of many 
different kinds, intolerance of heat, sudden perspirations and cutaneous 
disturbances such as pigmentation and loss of hair. Diarrhoea is a very 
common symptom. 

(3) Thyroid Enlargement is always present at some stage of the disease, 
though it is rarely the first symptom noticed by the patient, probably 
because there are no means of detecting slight enlargements. Therefore 
in the early stages we have to rely upon the other symptoms. The en- 
largement varies considerably in different cases, and is by no means 
proportionate to the other symptoms, because the symptoms depend 
more upon the histological element of the gland which is involved than 
the degree of enlargement (p. 210). Mechanical effects of thyroid enlarge- 
ment may be present (see Bronchocele), and occasionally alteration in 
the voice from this cause is the first symptom noticed by the patient. 

(4) Exophthalmos (proptosis or protrusion of the eyeballs) is present in 

a varying degree, though sometimes not imtil late in the disease (Fig. 2, 

§ 10). It is best detected by seating the patient in a chair, standing 

behind him, and looking down his forehead. As a rule no changes can 

be detected in the fundi. Later on ulceration of the cornea occasionally 

takes place, either from neuro-trophic causes or from deficient protection. 

Four signs of Graves* disease referable to the eyes bear the names of different 
physicians. Von Oraefe's sign is a condition in which the upper ejrolid does not 
follow the eyeball when this makes a downward movement. Moebiua^s sign is an 
insufficiency of convergence of the two eyes when looking at a near point. Stellwag^s 
sign is an absence or deficiency of blinking as an involuntary act. Abadie^s sign in 
tlSs disorder is an involuntary twitching or spasm of the levator palpebrsB superioris. 
All except the first are present only in advanced cases, and are not therefore of very 
great value in the diagnosis. 

(5) The general health of the patient is always disturbed. Anaemia is 
pronounced, and is usually in proportion to the severity of the other 
symptoms. Progressive weakness is always present. The varieties of the 
disease depend on which of these five groups of symptoms predominates. 

Etiology. — (i.) Upwards of 95 per cent, of cases are females, (ii.) A 
large number are young adults between the ages of fifteen and thirty, 
(iii.) Locality has no known influence, (iv.) Heredity has not been traced 
so far as the disease is concerned, but the family often show neuroses in 
the shape of epilepsy, chorea, hysteria, insanity, etc. (v.) Fright, anxiety, 
love affairs, and mental overwork are potent factors in determining the 
disease. 

Diagnosis. — The five cardinal symptoms are : (i.) thyroid enlargement, 
(ii.) proptosis, (iii.) rapid cardiac action, (iv.) fine tremors of the hands, 
and (v.) mental and emotional instability. 

Prognosis. — The duration of the disease varies from some six months to 
many years. It may certainly shorten life, but many very severe cases 
have recovered under modem methods of treatment. The mortality has 
been variously stated as from 10 to 50 per cent. ; probably more modern 



§187] GRAVES' DISEASE—BRONGHOCELE 213 

statistics would give only from 5 to 10 per cent. If the duration be pro- 
longed, the disease will certainly leave its mark upon the cardio-vascular 
system. The prognosis is always anxious in the direction of mental 
instability. Those who recover not infrequently develop myxoedema. 

Treatment, — The early recognition of the disease is very important, for 
a great deal can be done in the early stages. Rest in bed is the prime 
essential. Freedom from fuss and worry is very important. The patients 
are always difficile, but those about them should avoid thwarting or 
arguing with them. Of drugs, belladonna is the most successful. Bro- 
mide of quinine often succeeds admirably. Digitalis and heart tonics 
should be avoided ; iron and arsenic are useful ; iodides are contra- 
indicated. The most successful therapy is by means of extracts of some 
of the other internal secretory glands. Thymus gland has been used with 
success ; so have supra-renal, pituitary, and ovarian extracts. Leonard 
Williams has had excellent results with the intramuscular injection of 
bile salts {Practitioner, November, 1911). Extirpation of the thyroid or 
division of the isthmus has been successfully adopted as a remedial measure, 
and is indicated when the gland is greatly enlarged, causing dyspncea, or 
when medical treatment has failed after a fair trial. Excision of part of the 
diseased gland, under local anaesthesia, preceded in some cases by ligation 
of the thvroid bloodvessels, has also been successful in a number of cases. 
(Dunhill and Kocher, the Lancet, Feb. 17 and March 2, 1912.) 

Galvanism (doscendlng) is often useful, and small doses of X lays have given good 
results in some cases. Parathyroid gland has been administered, but without con- 
vincing results. The discovery that the thjnroid is a protective gland, which neutralises 
circulating toxins, has led to the trial of various sera. Thus Moebius has injected a 
serum prepared from the blood of thyroidectomised sheep, and Murray a serum from 
rabbits, fed on increasing doses of thyroid extract. Rodctgen, the desiccated milk of 
dethyroidised goats, has given good results, but all these recent methods require much 
longer trial to estimate their value. 

§ 187. Bronohocele (Simple Croitre) is another form of enlargement of the thyroid 
gland. It may affect the whole organ, or only one of its lobes, or the isthmus. Ana- 
tomicaUy, the enlargement may be due chiefly to parenchymatous increase or to cystic 
enlargement. The enlargement may be so great that the organ amounts almost to 
the size of an infant's head. 

The Symptoms which attend the disease are those due to the mechanical pressure of 
the tumour, and it is by the absence of the cardio-vascular, nervous, and other 
symptoms that this condition is distinguished from Graves' disease. The chief 
pressure symptoms are referable to the larynx and trachea. The voice is modified 
early in the disease, and vertigo, due to pressure on the vessels, may be present. The 
general health may be good, but the patient is usually somewhat anaemic, otherwise 
the symptoms are those of athyroidism rather than of thyroidism. It may be Diag- 
nosed from other tumours in the neck by the fact that it invariably rises with the 
larynx during deglutition. The enlargement generally increases steadily, but it is 
only rarely that there is any danger from tracheal obstruction and asphyxia. 

The Etiology of the condition is not well known. More often females arc affected, 
and it sometimes starts during pregnancy, or a catamcnial period, but it is most prone 
to start during adolescence. The disease is endemic in certain districts, and these 
for the most part are valleys which have a calcium or a magnesium and limestone 
subsoil, together with a large amount of sulphate and carbonate of lime in the drinking 
water. That it is not entirely due to the last-named condition is shown by the fact 
that in districts where this permanent hardness of water exists bronchocele does not 



214 THEjrUYROlD QLAND [ § 188 

occur. Captain McCarrison^ believes that the endemic goitre of Chitral and 
Gilgit is due to amoeboid organisms. Dogs, horses, and mules suffer also from the 
condition. 

Treatment. — ^The patient should, of course, leave the district ; or, if this is impossible, 
the water used for drinking purposes should be boiled. In McCarrison's cases cures were 
obtained by vaccines prepared from the stools, and by intestinal antiseptics, especially 
thymol and lactic acid bacilli. In this country it is found that small doses of thyroid 
extract (gr. J to J), together with the local application of Ung. Pot. lod. to the tumour, 
will generally effect a cure. Arsenic is also useful. Surgical interference may be 
necessary. 

Disease in which the thyroid is usually diminished in size — mz,, 
I. Cretinism, II. Myxcedema. The latter is described elsewhere, since the 
leading symptom is General Debility {Chapter XV L). 

§ 188. Cretinism is a condition of dwarfism and deformity attended by mental 
imbecility, due to an absence or perversion of the thyroid secretion, and is endemic 
in certain districts. In advanced and typical cases the face is characteristically 
broad and flat, the tongue protrudes from the mouth, the eyes are wide apart, and 
the head is brachycophalic {i.e., broad transversely). The skin and hair are dry and 
coarse, and the mental condition is extremely backward. In severe cases the body 
may be so dwarfed that a person of twenty is the size of a child of five. The limbs 
are shortened, the neck stunted ; pads of fat are present above the clavicles ; the hands 
are short and square (spade-like), the abdomen prominent, and an umbilical hernia 
is often present. The thyroid may be enlarged, small, or absent (see Figs. 6 and 7, 
J 19). Kushton Parker* distinugishes three varieties, both etiologically and patho- 
logically. In one, the thyroid is embryologically not developed, or only partially 
developed, the cause being presumably akin to that which brings about other embryo- 
logical deficiencies, such as acardia, acephalia, etc. In a second, the thyroid under- 
goes the same changes as in endemic goitre, and doubtless from the same cause, any 
differences being due to loss of thyroid function. In a third, the thyroid, after per- 
forming its functions healthily for a time, atrophies, doubtless from causes akin to 
those of adult myxcedema. 

Etiology. — Cretinism is endemic in certain districts — e.g., the valleys of Switzerland. 
Cases occur also in certain parts of England, especially in the valleys of the Lake 
District and Derbyshire. Sporadic cases are found in healthy families. The causes 
are unknown. Some attribute it to consanguinity of the parents, to alcoholism, 
tubercle, sjrphilis, or to maternal worry during pregnancy. It is associated with 
deficient thyroidal function, and hence may be regarded as congenital myxcedema. In 
slight cases of cretinism the diagnosis from other forms of mental deficiency may be 
difficult. The condition of the skin and hair are valuable diagnostic features. 

Prognosis. — ^The patient may grow up capable of doing light manual work, or may 
remain an idiot. Under treatment begun early, the child may recover completely, 
but in other cases, although the body is greatly improved, the mind does not improve 
in proportion. 

Treatment. — ^Thyroid extract, beginning with ^-grain doses (6 grains of raw gland), 
causes a rapid and remarkable change. The skin becomes soft, the general conforma- 
tion normal, and, if the treatment has not been too long delayed, the mind assumes 
its natural vigour. The patient must continue to take the thyroid all his lifo, or else 
he will relapse. A case showing the remarkable efficacy of this treatment is figured 
in §19. 

Complete myxcBdema is dessribed in detail elsewhere (§419). It should 
be remembered that there are degrees of thyroid insufficiency which, 
though falling short of typical cretinism or fully developed myxcedema, 
are nevertheless sufficient to account for many of the minor troubles for 

^ Proceedings Royal Society of Medicine, December, 1908, and January, 1912; and 
see the Lancet, 1911, p. 1346, vol. ii. and vol. i., 1912. 
^ ** Acquired Cretinism, or Juvenile Myxcedema," Brit. Med. Journ., May 29, 1897. 



§ 188 ] CRETINISM 215 

which patients seek advice. In childhood such deficiency shoidd be sus- 
pected if adenoids or nocturnal enuresis are present. In adults, especially 
in women about the menopause, increase of weight, falling hair, intolerance 
of cold, muscidar fatigue, a slow pulse, a dry skin with a tendency to 
chronic eruptions, are all suspicious features. In younger women prema- 
ture greyness, and in men premature baldness, are also suggestive. Rare- 
faction amounting to complete absence of the outer two-thirds of the eye- 
brow is a fairly constant sign. The treatment is by thyroid extract in 
very small doses (i^ to J grain three times daily). Large doses often 
aggravate the condition.^ 



^ Dr. Leonard Williams, "Adenoids, Nocturnal Enuresis, and the Thyroid Gland 
(Bale and Sons); also "Thyroid Insufficiency," Clinical Journal, 1909. 



t* 



CHAPTER VIII 

THE MOUTH, TONGUE, AND GULLET 

The Month. 

(Lips, Breath, Saliva, Teeth, and Gums.) 

We often regret that we cannot investigate the internal organs more 
thoroughly, but how seldom do we avail ourselves of the instructive 
information afforded by a thorough examination of the mouth ? Many 
of the indications of syphilis, hereditary or acquired, may be so revealed ; 
several other constitutional conditions produce symptoms in this locality, 
such as anaemia and lead-poisoning ; and a good idea of the general con- 
dition of the patient can be obtained from a careful inspection of the 
tongue. Many of the disorders special to the mouth are comprised among 
the "causes" of stomatitis. For the diagnosis of these disorders it is 
necessary to make a thorough examination of the Lips, the Breath, the 
Saliva, the Teeth, and the Gums. We will consider the symptoms 
referable to these structures in that order. 

§ 139. The Lips. — Dryness of the lips is often one of the most conspicuous 
evidences of indigestion, and it is a very useful one, because this disorder 
has so few physical signs to assist us. The lips are pale in anaemia, they 
are cyanosed in advanced bronchitis with dilated right heart, and in many 
other conditions (see Cyanosis, § 26). This cyanosis is especially marked 
in congenital heart disease. The hard chancre of syphilis may occur on 
the lip, § 404. In elderly men epithelioma may occur on the lip. Fissures 
around the lips are an almost infallible sign of S3rphilis, especially when 
surrounded by a reddened infiltration. This infiltration helps us to dis- 
tinguish a syphilitic fissure from the " cracked lip " which is the only 
condition liable to be mistaken for syphilis. Cracked Up occurs mostly 
in nervous children who lick and bite their lips and are exposed to cold 
winds. It can generally be remedied by the application of some simple 
ointment, such as zinc ointment or cold cream, whereas the syphilitic 
fissures do not yield to this treatment. By pressing the comer of the 
mouth inwards and forwards when the patient opens it, we may often 
detect a mucous patch surrounding a syphilitic fissure inside the mouth. 
The scars left by syphilitic fissures are also a useful indication of a previous 
attack, or still more frequently of the patient having had congenital 

216 



S§ 140-142 ] THS BREATH—THE SALIVA— THE PALATE 217 

manifestations. They are white and stellate. (See § 11 for other 
conditions.) 

§ 140. llie Breath should be normally quite free from any kind of 
odour. Offensiveness of the breath may arise from four sources : (1) A 
want of cleanliness in the mouth, particles of decomposing food, and the 
presence of decayed teeth, may give rise to a very offensive odour of the 
breath. (2) Dyspepsia, constipation, and other conditions of the alimentary 
canal, and the derangement of digestion in fevers, may also produce a bad 
smell of the breath. (3) Some diseases of the nose ; thus it always accom- 
panies ozsena. (4) A large cavity in the lungs, especially if bronchiectatic, 
and gangrene of the lungs produce a putrid odour (§§ 103 to 105). The 
odour of bronchiectasis is characterised by being intermittent ; it comes on 
suddenly, lasts a day or two, and disappears gradually. Certain general 
conditions are attended by a more or less characteristic odour of the breath. 
Thus, in diabetes it is sweet ; in acute alcoholism it is alcoholic or ethereal. 
In urcemia it is said to be urinous. Certain drugs give rise to a very charac- 
teristic odour in the breath — e,g., turpentine (a resinous odour), chloral 
(odour of chloroform), bismuth (odour of garlic), and opium (odour of the 
drug). Alcohol, ether, chloroform, and many other volatile substances 
are partly excreted by the breath. 

§ 141. The Saliva may be increased (i.) in mouth inflammations ; (ii.) in 
chronic gastritis, in which there is such a profuse flow of saliva during the 
night that it gives rise to the impression that the patient, in the morning, 
is vomiting clear alkaline fluid (water- brash or pyrosis) ; (iii.) in pregnancy, 
and in mania, hydrophobia, and some other diseases ; (iv.) after the adminis- 
tration of mercury, pilocarpine, bitters, and, according to some, alkalies and 
acids. The saliva may appear to be increased in cases of bulbar paralysis 
or mental deficiency. The saliva is decreased (i.) in certain febrile states, 
(ii.) in diabetes, (iii.) severe diarrhoea, (iv.) chronic Bright's disease, and 
(v.) during the administration of atropine or daturin. A condition known 
as " dry mouth " (xerostomia) has been described by same authors,^ in 
which there is a constant deficiency of saliva. The cause of this is obscure. 

§ 142. The Palate may be " cleft " from childhood, otherwise a hole in 
this situation is practically always an evidence of past syphilis. The soft 
palate shares in the diseases of the fauces (§ 108). It is a favourite position 
for the membrane of diphtheria, which in this situation forms an important 
means of differentiating the disease from follicular tonsillitis, the exuda- 
tion of which never affects the palate. The hard palate is sometimes in- 
volved in the diseases of the floor of the nose. A swelling may appear 
here in abscess of the antrum, or in abscess dependent on disease of the 
lateral incisor tooth. The latter is the commonest cause of swelling in 
this situation, according to Tomes (loc, cit.). 

Thirst accompanies all febrile conditions and inflammatory conditions 
of the gastric mucous membrane. It is met with also in diabetes, after 
diarrhoea and vomiting, and after a diet excessively salted. 

1 Clin. Soc. Trans., 1885. 



218 THE MOUTH, TONGUE, AND GULLET [ §§ 148, 148a 

§ 143. The Teeth are subject to a certain amount of variation, even in 
health. The average dates of the eruption of the temporary and permanent 
teeth are as follows : 



Temporary or " Milk " Teeth. Permanent Teeth. 

About 6th to 8th month, lower central About 6th year, first molars, 
incisors. 

About 8th to 10th month, upper in- 
cisors. 

About 12th to 14th month, first molars. 

About 18th to 20th month, canines. 

About 2 to 2^ years, posterior molars. 



7th ,, central incisors. 

8th ,, lateral incisors. 

9th „ anterior bicuspid. 
10th ,, posterior bicuspid. 
11th to 12th year, canines. 
12th to 13th „ second molars. 
17th to 26th „ third molars. 



One quarter of the mouth may be represented diagrammatically thus : 
Teeth .. I. I. C. M. M. | Teeth .. I. I. C. B. B. M. M. M. 

Month of 1 o n lo ^rt «^ I Year of 



... 6 9 18 12 24 ' -^"-JoU 7 8 11 9 10 6 12 24 

eruption. J ^ eruption.) 

The normal order of eruption of teeth may be represented thus : Milk 
teeth, C, 9, 18, 12, 24 months ; and Perbianent teeth 7, 8, (11), 9, 10 ; 
G, 12, 24 YEARS. These details are worth remembering, because defective 
or deficient teeth are nowadays an extremely frequent cause of faulty 
digestion. 

The presence of decayed teeth is one of the commonest causes, if not 
the commonest, of the dyspepsia of modem times, and it is an ominous 
feature that a very large proportion of the candidates for the Army and 
Navy Services are rejected because of bad teeth. They decay early in 
rickets, in cretinism, and in some other constitutional conditions. 

The teeth are altered in shape after stomatitis in early life, which may 
be due to mercury, etc. {vide § 146). In these circumstances the teeth 
present transverse and vertical ridges, with or without alteration of shape. 
" Hutchinson's teeth " show alterations in the shape of the permanent 
teeth, due to hereditary syphilis, and present a valuable means for the 
identification of this disorder, as they are of very frequent occurrence in 
that disease, and bear lifelong testimony. They are set apart and are 
both pegged and notched — that is to say, the transverse measurement is 
smaller at the free edge than the part near the gimi, and on the edge of 
each tooth there are one or two notches (see Fig. 3, § 11). 

§ 143a. Toothache (odontalgia) is caused most frequently by decay 
(caries) of the teeth ; but there are other causes, the chief of which, as 
given by Mr. C. S. Tomes, are as follows : 

1. Morbid conditions of the tooth-pulp, including irritation, acute and chronic 
inflammation of the pulp, pressure from confined matter in the pulp cavity, and 
deposit of secondary dentine in its substance. 2. Exposure of sensitive dentine, 
with or without caries, is probably the commonest cause of toothache — a " hollow 
tooth,'' as it is called. 3. Morbid conditions of the alveolar periosteum, odontoma, 
and exostosis, including inflammation of the periosteum, acute and chronic alveolar 
abscess, lesions manifested by alterations of the roots of the tooth. 4. Morbid con- 
ditions of the periosteum of the jaw — e.g., traumatic, rheumatic, strumous, or syphilitic 
periostitis. 5. Irritation of the dental nerves by causes not productive of visible local 
lesions. This may include malposition and retarded eruption of wisdom teeth, and 



144,146] THE QUM8—PY0RRH(EA ALVE0LARI8 219 

pressure due to insufficient space for the teeth. 6. Inflammations and ulcerations of 
the miLcous membrane and submucous tissue. 

This is merely an approximate clekssification. The character and degree of the pain 
is greatly modified by the condition of the patient. The pain is genorally more or less 
intermittent. It is oftan absent at periods of full vigour — e.g., after breakfast or 
dinner. Pain due to irritation, or to chronic local inflammsbtion of the pulp, partakes 
of a neuralgic character, and the patient is often unable to point out the affected tooth 
or teeth. The suffering induced by acute inflammation of the pulp is excessive, 
particularly if there be no exit. It ceases more or less abruptly from the consequent 
death of the pulp. The recumbent posture or active exercises serve to aggravate the 
pain by increasing the vascular supply. 

The Treatment belongs to the dental surgeon, but a good deal of temporary relief 
may sometimes be obtained by constantly rinsing the mouth with hot carbolic lotion 
(1 in 100). A formula for drops to apply to a hollow tooth is given in Formula 23 at 
the end of this book. 

Although the term Eptdis should be restricted to new growths of a malignant 
character springing from the alveolar portion of the jaws, it is often employed to 
indicate any proliferation of tissue in that situation. The commonest form is that of 
a papillomatous proliferation of granulation tissue at the base of a carious tooth. 
This should be removed with a small portion of the periosteum. True epulis starts 
in much the same way, but is in reality a fibro-sircoma growing from the periosteum. 
It spreads along the gum, and should be excised early. A myeloid growth from the 
cancellous tissue of the jaw may simulate epulis ; so may an epithelioma. The true 
epulis is a periosteal growth. 

§ 144. The Gums. — ^The pallor of ansBmia, the purple line of lead- 
poisoning, the red and ulcerated condition in stomatitis, the sponginess 
in mercurialism and scurvy are all useful local indications of some general 
condition. A swelling of the gums with greenish discharge suggests 
Actinomycosis. Bleeding from the gums is apt to occur in scurvy, purpura, 
the hsemorrhagic diathesis, and even in apparent health, when the teeth 
are covered with tartar and the gums recede. In some people the gums 
very readily bleed, and suck'mg them may produce bleeding, which enables 
malingerers and hysterical persons to simulate diseases of the lungs or 
stomach. It is detected by being only in small or moderate quantity, 
and by its intimate mixture with saliva. There is one disease of the gums 
— Pyorrhoea Alveolaris — the importance of which has only recently been 
recognised. 

§ 145. Pyorrhoea Alveolaris (Riggs* disease or Suppurative Gingivitis) 
is a raw ulcerating condition of the gums around the sockets of the teeth 
or stumps. When tartar is allowed to collect upon the teeth, it gradually 
pushes the gum back ; and by degrees a pocket or fossa is formed around 
the neck of each tooth, and there is considerable sero-purulent and often 
blood-stained discharge from the pockets thus formed, which not only 
imparts an offensive odour to the breath, but, being continually swallowed, 
is absorbed, and sets up a chronic toxsemic condition, which it is now 
recognised may produce a large number of troublesome symptoms.^ Dys- 
pepsia, even apart from difficulties of mastication, invariably ensues 
sooner or later. But even before the dyspepsia becomes established the 
patient is listless, languid, and unfit for work, and complains of a great 

* This subject was the topic of an interesting discussion at Roy. Med. Chir. Soc, 
June, 1900. The blood-stained discharge is liable to be mistaken for serious disease 
of the stomach or lungs, as in cases mentioned at that discussion. 



220 THE MOUTH, TONGUE, AND GULLET [ j 146 

variety of functional nerve symptoms. A large proportion of my out- 
patients at the Nerve Hospital who complain of functional neuroses owe 
their troubes to pyorrhoea alveolaris. Among the symptoms due to this 
cause I may mention headache, neuralgia, pains or tingling in the limbs 
and prostration, attacks of flushing, or giddiness ; a feeling of heaviness, 
and swelling of the limbs which is sometimes attended by cedema of the 
ankles, wrists, and other parts, which differs from ordinary anasarca in 
requiring longer pressure to produce the pit. Great depression is usual, 
and even melancholia may result; one of my patients committed 
suicide. Rheumatoid arthritis and fatal ansBmia may also occur. 

Treatment. — All these symptoms may arise when, for instance, stumps 
are left beneath an artificial plate. If the pyorrhoea, as frequently hap- 
pens, be not identified as the cause and removed, no treatment is of much 
use. The tartar must be removed at intervals of a week or so by a skilled 
person, and the suppurating pockets must be carefully dressed daily by 
the patient, with sulphate of copper, iodine, or peroxide of hydrogen. 
The only radical cure is the removal of the stumps or teeth if these 
are at fault. Recently vaccines prepared from organisms cultured from 
the gums have been employed in conjunction with local treatment. 

§ 146. Stomatitii is a generalised inflammation of the mouth, evidenced by redness, 
swelling, tenderness, and pain of the mucous membrane, swelling and protrusion of 
the lips in severe cases, offensive odour of the breath, and usually, but not always, 
excess of saliva. This, the simplest form of stomatitis, such as occurs in dentition 
or the application of caustics, is known as (a) Catarrhal or Erythematous Stomatitis, 
{b) Aphthous Stomatitis, also known as Vesicular or Herpetic Stomatitis, occurs in badly- 
fed children, and it presents, in addition to the above features, small grey patches, 
with a red base and sharply-defined circular margin, resembling vesicles, which may 
be very painful to the touch, (c) Ulcerative Stomatitis occurs in a mild, and also in a 
severe form. In this we find, in addition to the features belonging to variety (a), 
irregular ulcers, especially on the gums which recede from the teeth, so that the teeth 
become loosened. In the severe form there is great f oetor of the breath, considerable 
enlargement of the glands, submaxillary and cervical, and constitutional disturbance ; 
and the teeth may drop out of the ulcerating gums. The ulcers often have a yellowish 
or grey coating, resembling a membrane, and it is therefore sometimes called *' pseudo- 
membranous stomatitis,'* or ** phagedenic gingivitis." {d) Gangrenous Stomatitis 
(Cancrum Oris, Phagedena Oris, Noma Oris) is a gangrenous inflammation starting 
at one spot, usually on the cheek or on the lips. At first there is acute pain, 
but as this passes off a black spot forms (usually both internally and externally), 
which spreads and leads to perforation of the cheek. The inflammation may spread 
to the gums, and the teeth become loosened. This is a severe disease, attended by 
considerable prostration, and, at first, a subnormal temperature. It is apt to follow 
measles or other exhausting illnesses in weakly children exposed to bad hygienic con- 
ditions.^ (e) Pyorrhcea Alveolaris has been separately described above (§ 146). 

^ Micro-organisms probably plav a more important part than is at present recognised 
in the pathology of stomatitis, and the entry of these or^nisms into the mouth, where 
they may perhaps lodge on some chance abrasion, mi^t possibly account for some 
of those hitherto inexplicable cases of the disease. For instance, it seems highly 
probable that that extremely serious condition, Cancrum oris, may be connected with 
one of the group of bacteria which has lately attracted attention, and which includes 
the Bacillus aerogenes capsulatus, B. clematis maligni, B, emphysemaiosis, and other 
microbes found in connection with ** acute spreading traumatic gangrene," malignant 
oedema, gangrene foudroyante, eto. See, e,g., a paper by Comer and Singer on " Acute 
Emphysematous Gangrene/* the Lancet, November 17, 1900 ; and Discussion at the 
Patn. 1^., Lond., in the Lancet, 1900, vol. ii, p. 1651. 



§ 146 ] STOMATITIS 221 

Etiology of Stomatitia. — (1) Certain local conditions, of which the commonest are 
dentition, tartar, and a want of cleanliness, the local irritation of a jagged tooth, 
excessive smoking, dirty feoding-teats in children, the application of hot fluids and 
caustics, new growths (simple or maklignant), and gummata. In most of these oases 
the stomatitis takes the form of (a) or (6) above. Mouth-broathing and chronic 
gastric catarrh are said also to give rise to stomatitis occasionally, and necrosis of the 
jaw may lead to an ulcerative stomatitis. , 

(2) Certain drugs and chemical substances are apt to cause stomatitis. Chief amongst 
these is meronry, which gives rise to a very characteristic ulcerative stomatitis, with 
"P^^'^Sy gums and great fostor of the breath. Arsenic and iodides may produce 
catarrhal stomatitis. Phosphorus produces ulcerative stomatitis, with necrosis of the 
jaw. The blue line of lead may be attended by a certain amount of catarrhal stoma- 
titis. 

(3) Chief among the constitutional conditions which cause stomatitis is (i.) the 
lowered vitality met with in phthisis and other wasting disorders, or in badly-fed 
children, in whom the stomatitis may bo aphthous or ulcerative. Thrush often 
accompanies catarrhal stomatitis in these circumstances, (ii.) Syphilis is aocom 
panied by a special variety of the catarrhal form, and is attended by whitish, semi- 
transparent patches on the tongpie and mucous membrane, resembling " snail-tracks.** 
Later on ulcerations may occur (§ 1 13. Throat). It may also take the form of flattened 
white papules, (iii.) Measles and other acnte specific fevers are apt to be followed 
by cancrum oris in children expoS'ad to bad hygienic conditions. Diphtheria is at- 
tended by both stomatitis and rhinitis when the membrane affects the mouth and nose, 
(iv.) Scurvy and purpura are attended by swollen and spongy gums and ulcerative 
stomatitis. The acute blood diseases (acute lymphsemia and myelssmia) are accom- 
panied by an extreme degree of stomatitis, due to the presdnoe of small pin-head to 
sago-grain-sized lymphoid nodules on the gums which readily ulcerate. Not in- 
frequently such causes are treated without any suspicion of the true nature of the 
disease, although the nodules in question are very characteristic, (v.) Gastro-intes- 
tinal derangement, as in dyspepsia and fevers, leads not infrequently to catarrhal 
and sometimes aphthous stomatitis, (vi.) A lowered state of health, with insanitary 
environment, gives rise to epidemics of ulcerative stomatitis, sometimes taking a fatal 
form, in jails, hospitals, and camps. Occasionally this condition is met with in indi- 
viduals in private life. (viL) Foot-and-Mouih Disease (Syn. : epidemic stomatitis ; 
aphthous fever) is an acute infectious disease attacking pigs, sheep, cattle, and other 
domestic animals. Epidemics have bsen reported in which the disease was trans- 
mitted to man, with symptoms of fever, gastro-intestinal derangement and vesicles 
on the lips, mouth, and pharynx, and sometimes near the nails of fingers and toes. 
Death has occurred, but recovery is the rule, (viii.) Sprue and Pellagra show stoma- 
titis in their early stages. 

(4) Certain skin lesions may invade the mucous membrane of the mouth, such as 
the rashes of small-pox, chicken-pox, measles, and herpes iris. In measles certain 
spots, first described by Koplik, appear on the inner sides of the cheeks, opposite the 
bicuspid or molar teeth, before the skin eruption occurs. They most often take the 
form of a greyish-white stippling on a slightly raised purplish base, and afford con- 
siderable aid in the early diagnosis of the disease. Lichen ruber planus may affect 
the mucous membrane of the mouth and tongue, and it may be present there even 
before it appears on the integument. In this situation it hsks a whitish appearance, 
much resembling secondary syphilis, for which it has sometimes been mistaken. Lupus 
may affect the palate. 

Prognosis of Stomatitis, — ^As a rule, stomatitis is not a serious disease, except that 
form known as phagedenic stomatitis, in which the mortality is 80 per cent. Catarrhal, 
aphthous, and ulcerative stomatitis generally end in recovery in a week or two. Those 
cases due to constitutional conditions are, as a rule, far more serious and obstinate 
than those due to local or removable conditions. The stomatitis of mercury may 
be extremely severe, but is, happily, only rarely seen nowadays. When aphthous 
stomatitis occurs in adults, accompanying a lingering disease, it is very obstinate, 
and is, in itself, a very grave omen. The prognosis is grave in the epidemic form, 
which is probably of miorobic origin. The complications of the phagedenic form are 



222 THE MOUTH, TONGUE, AND GULLET [ § 147 

diarrhoea, broncho-pneumonia, and gangrene in other parts of the body, especially 
the organs of generation (noma pudendi). 

Treatment, — In all varieties the indications are (1) to remove the cause, (2) to 
alleviate the local inflammation, and (3) to attend to the general health. The teeth 
should be scaled and any septic stumps removed. Carious cavities and ulcers on the 
gums should be thoroughly swabbed over with 1 in 40 carbolic. It is important to 
cleanse the pocke ts at the sides of the teeth which are met with in pyorrhoea alveolaris. 
After every meal the mouth should be cleaned of debris with a soft brush, by rinsing 
repeatedly with warm water, then with an antiseptic solution. One of the best is 
hydrogen peroxide {2\ to 10 vol.) ; others are 1 in 100 carbolic, 1 in 30 boracic. and 
sodium bicarbonate 1 in 20. When swelling is pronounced and prevents free access 
of these remedies, glycerine of tannic acid may be rubbed on the gums. If the mouth 
is very dry, glycerine of borax is useful. A " bad taste in the mouth " may some- 
times be overcome by taking tni. of pure carbolic in "^i. water twice daily. Tablets 
containing formalin may be sucked at frequent intervals, and are of especial use 
when dealing with children. 

Aphthous and Ulcerative Stomatitis are best treated by touching the sore places with 
solid nitrate of silver or sulphate of copper. For the pain, a solution of cocaine H to 
3 per cent.) may be used. In the ulcerative form chlorate of potash is especially useful. 
In the Gangrenous form (cancrum oris) prompt measures are necessary to avert a fatal 
issue. The affected area should be as freely excised as possible, and any suspicious 
tissue left or subsequently appearing may be burnt with the actual cautery. Plastio 
operations may be necessary later, but attempts to save tissue at the time are always 
fatal. Free use of stimulants and nourishment is called for. 

The Tongue. 

The alterations to which the tongue is liable will be referred to under six 
headings : (a) Furring of its Surface ; (6) Ulceration ; (c) White Patches ; 
(d) Acute Swelling ; (e) Chronic Swelling (Hypertrophy), and Atrophy ; 
(/) Warts, Fissures, and Cicatrices. A mother sometimes speaks of her 
child being " tongue-tied " when the frenum is too short. In some cases 
this is really so, or the structure may be attached to the tongue too far 
forward, but it exists much less frequently than parents suppose. 

§ 147. Purring of the Tongue. — The appearance of the dorsum of the 
tongue used to be looked upon by older authors as an indication of the 
state of the stomach, and with certain reservations it is still regarded as 
some aid in the investigation of that organ {§ 195), though it is a better 
guide in the prognosis of fevers and other grave constitutional disorders. 
Five varieties of tongue have been described by authors : (1) The fale^ 
large, flabby tongue, with broad tip and indented edges, and a uniform thin 
white coating, is the commonest abnormality. It is met with after alco- 
holic excesses, in atonic dyspepsia, in anaemia, and in gouty persons. 
(2) A red tongue, with sharp red tip and edges, in which the hypersemic 
papillae contrast strongly with the slight white coating in the centre, is 
found in subacute gastritis and irritable dyspepsia. (3) The coated tongue, 
with a imiform white layer over the surface, is foimd in acute gastritis, 
feverish conditions, anaemia, and nervous depression. Two forms of this 
tongue have been described : (i.) The strawberry tongue, having a slight 
white coating through which the fungiform papillae protrude at the tip 
and edges, is very typical of scarlatina and other highly febrile states, 
(ii.) The plastered tongue, where the coating is considerably thicker. 



§ 148 ] FURRING AND ULCERS OF THE TONGUE 223 

The amount of coating on a tongue varies directly with (o) the amount of 
dryness of the mouth — that is to say, the deficiency of salivary secretion 
(e.g,, in fevers and profuse perspiration) ; and (b) with the immobility of 
the tongue, owing to eating food that does not require mastication. The 
plastered tongue may pass on to — (4) the furred tongue. The coated 
papillae stand out separately, giving a shaggy appearance. It is met with 
in states of marked prostration — e.g., coma, abdominal cancer, advanced 
phthisis, profound anaemia, and other asthenic states. The prognosis is 
grave when the tongue becomes encrusted and its dryness increases. 
From any cause it may became dry, brown, and crusted, and then pass on 
to — (5) the denuded red tongue, which generally follows the preceding as 
the crust falls off. This tongue is red, shiny, smooth, and often cracked. 
It is found in advanced states of the preceding conditions, in diabetes, 
and other severe chronic ailments. The appearance of this tongue in a 
disease is of very grave prognosis. Aphthous stomatitis may supervene. 
(6) A pale flabby tongue with marked atrophy of the mucous membrane is 
often seen in association with Addisonian (pernicious) anaemia. 

Apart from disease, there is no doubt that there are wide individual 
peculiarities in the character of the tongue. On this account some^ go so 
far as to say that the tongue is of little importance as a cb'nical indication. 
Undoubtedly we should make sure in any given case that the tongue 
condition before us is not due to these personal peculiarities, to smoking 
in excess, or to previous disease. 

As regards Treatment, it is an old saying that a red tongue requires 

alkalies, and a white tongue acids. The former of these is true to some 

extent, but not the latter. With the exception of diabetes, a dry tongue 

indicates no appetite, and deficient gastric secretion ; therefore the patient 

should be fed on fluids, animal soups, and other things requiring no great 

digestive power ; (4) and (5) call for alcohol and other stimulants. In the 

prognosis of enteric fever the tongue ia a valuable indication. 

That rare condition, black or " Jutiry " tongue, must not be mistaken for a furred 
tongue. It is due to elongation of the papillaB at the back of the tongue ; they resemble 
dark hairs. The cause is unknown. The condition is best left alone, as it usually 
disappears spontaneously. 

§ 148. Ulcers of the Tongue may be Simple, Syphilitic, Malignant, or 
Tuberculous. 

I. Simple Ulcers of the tongue are known by their superficial character, 
by the presence of some local cause, such as a jagged tooth or other local 
irritation (see also Ulcerative Stomatitis). The frenum is apt to be ulcer- 
ated in whooping-cough. This is probably of mechanical origin, but it is 
a useful aid in diagnosis. 

II. SvpHiLrrio Ulcers are of two kinds : (a) superficial, (b) deep. 

(a) Suj>erfictal Syphilitic Ulcers of the tongue are met with usually at 
the side, or in the form of fissures on the dorsum (cp. § 113) or superficial 
circular " punched-out " ulcers. 

* E.g., Sir Jonathan Hutchinson, Med. Press and Cir., July, 1883. 



224 THE MOUTH, TONGUE, AND GULLET [ § 149 

(6) Deef Syphilitic Ulcers are preceded by the formation of a roundish 
nodule (a gumma) which ulcerates. They are recognised by (i.) their site, 
which is usually on the centre of the dorsum ; (ii.) their raised, ragged, 
and sometimes undermined edges; (iii.) the yellow slough which covers 
the base ; and (iv.) the fact that they leave deep stellate scars. Syphilitic 
ulcers are usually multiple ; difficulty in diagnosis arises in the case of a 
single ulcer as to whether it be syphilitic or cancerous. Syphilitic ulcera- 
tion is differentiated by (1) the relative absence of surrounding induration, 
and consequently there is less interference with the movements of the 
tongue ; (2) the site of ulcer on the dorsum ; (3) there is less glandular en- 
largement, and the glands have a shotty feel ; (4) the age of the patient, 
malignant ulcers rarely occurring before forty ; and (5) there is a history 
of syphilis, and the disease heals under iodide of j>otassium. 

III. Malignant Ulcer of the tongue is known by (i.) its site, which 
is chiefly on the side of the tongue ; (ii.) its hard, raised, everted edges, 
and its uneven warty base, with foul discharge and tendency to haemor- 
rhage ; (iii.) the induration around, and the early involvement of the 
glands ; and (iv.) the early impairment of the movements of the tongue 
with great pain. These are the characters in an advanced case when 
diagnosis from syphilis is relatively easy. In an early stage it may be 
very difficult. In that stage a cancerous ulcer has flat sloping edges and 
scanty secretion, its progress is very slow, and it does not yield to iodides. 
Before a suspicious ulcer has existed for any length of time, a small piece 
should be excised for microscopic examination. 

IV. Tuberculous Ulcers are not common. They are superficial, 
with a yellowish discharge, and there is generally a history of tubercle in 
the lung or throat. The tubercle bacillus may be found in the scrapings. 

Prognosis, — Simple ulcers are easily dealt with, but other ulcers of the 
tongue are dangerous chiefly from their liability to haemorrhage and 
because of the important structures around. The diagnosis of sjrphilitic 
from malignant lesions is as important as it is difficult, for however ad- 
vanced the former may be, they yield to appropriate remedies, but the latter 
are necessarily fatal unless removed early. The deep ulcers often seen in 
advanced Sjrphilitic glossitis are dangerous, as the deeper parts may be 
afiected by malignant change. 

The Treatment consists of the usual surgical measures. In syphilitic 
ulcers iodide should be given in large doses. It is rarely given in sufficient 
quantity. 

§ 149. White Patches are not infrequently met with on the tongue, and may result 
from : I. Thrush ; II. Leucoplakia ; III. Goographioal tongue ; IV. Aphthous Stoma- 
titis (§ 146) ; V. Syphilitic Patches (§ 113). The two last are described elsewhere. 
The stellate cicatrices so characteristic of syphiltic lesions must not be confused with 
any of these. 

I. In Thrush (parasitic stomatitis) there are white membranous patches, like 
milk curd, sometimes with an areola round them. They are distinguished from other 
similar affections by (i.) leaving a bright bleeding surface when they are scraped off, 
and (ii.) by the detection of the fungus Oidium albicans {Saccharomycea albicans, 
Fie;. 59) on microscopical examination. It usually starts on the tongue, but may 



ilM] WHITE PATCHES— GLOSSITIS 226 

invade the lips and tlia whole of the interior of tho mouth. The disease occura chieQy 
in infancy, also in the later stages of exhausting diwases in adults. In the adult it 
only occurs at the end of wasting disorderB, and not JnfrequenUy forms one of the 
indications of approaching death. In infanoy it generally arises in hand-fed children 
under bad hygienic conditioos. and is often attended by diarrhcBa. It is contagious 
from child to child. In children it has no veiy great significance, and readily yields 
to glycerine and borai, or weak carbolic lotion (1 in 500). Tho diet and method of 
feeding should always receive attention in such cases. In such children it sometimes 
happens that excoriations are noticed around the anus, and tho mother thinks the 
" thrush has gone through the child " ; but these are more frequently due to congenital 
syphilis oreczema intertrigo. 

II. Leckoplakia LiitQtr.x (synonym, Ichthyosis Lingun) is a term ap[diod to flat, 
whitish, homy-looking, silvery patches on the t«ngue, due to a heaping up and con- 
densation of the epithelium. The disease generally involves a conaiderable area of 
the tongue. In a later stage the tongue beconcs red and glazed. The patches 
themselves are often cracked, and form a pavement- 1 ike surface, which has the 
appearance of ichthyosis of the skin. They give rise to a gr^^at deal of discomfort 
and tenderness. It is most frequently met with 

in tertiaiy syphilis, and. according to most ob- 
servera, it is always an evidence of that disorder. 
But others attribute the condition to excessive 
smoking, jagged teeth, drinking, and dyspepsia. 1 
cannot say that I have met with a case which could 
not be attributed to syphilis. The TrealmtTit is, as 
a rule, very unsatisfactory, unless the disease be met 
with in the early stages. A mouth-wash, consisting 
of bicarbonate of soda (20 grains to the ounce), or a 
ttatiirated soluUon of chlorate of potash, sometimes 
relieves the symptoms. But the best treatment, in 
my experience, is the local application of chromic 
acid [5 to 10 grains to the ounce. gTaduslly increased), 
painted on d^y. It should be accompanied by anti- 
syphiliUo remedies, though they do not hhve a vety 
marked effect. Alcohol, smoking, and other irritants 
must be avoided. The tongue should be carefully 
watched leat malignant disease supervene. Flj, Eis.— OiflUK albicans. 

III. Oeooraphkul or " Mapped "tengue is a con- ob Thkcsh FuNoca. 
dition in which the normal desquamation of tho 

tongue takes place irregularly, with the fonnation of more or less circular patches 
surrounded by margins of slightly proliferating whitish-grey epithelium. The cause 
is unknown. It may disappear spontaneously. 

SIW. Aont* SwalUng of th« Tonne — i.e., swellingof the tongue coming on rapidly — 
may be due to either (ft) AcuU Qlossitia or {b) AcuU (Edema. In both of these the 
tongue rapidly enlai^s, and may even protrude beyond the teeth. A great deal of 
pain is present, and there is a difficulty of swallowing and spraking. 

(a) AoCTE Glossitis may be due to various local cause Et—«. if., the ating of an insect, 
a septic wound, biting of the tongue, acute ulcers — or it may be duo to constituljonal 
conditions — e.g.. mercurial salivation, and, according to Erame, acute specilic diseases, 
such as erysipelas. The onset of acute glossitis ia rapid* though rather less so than 
acute (Bdema ; the swelling rarely extends beyond the tongue, and the glands are 
sometimes involved. Trtalment consists of the use of mouth-washes, espeoiully 
chlorate of potash, painting with a cocaine solution (10 per cent.), the administration 
of chlorate of potash, iron, and bark internally, with purging and antiphtogietio 
remedies generally. Free incisions may be necessaiy. 

(6) AocTB GioBMA OF THB ToKOnE is a serious disorder, because of its liability to 
involve the glottis. It may accompany urticaria, angio-neurotJc cedema. or it may 
be, like the angina Ludovici (S 116), of an eiysipeloid nature. The cedema comes on 
suddenly, and in the oouroe tJ a few hours the tongue may protrude from the mouth. 
The swelling rapidly extends to the throat, nose, and down the (esophagus and trachea. 



226 THE MOUTH, TONGUE, AND GULLET [ §$ 161-15S 

It is attended by an inability to speak, to swallow, and sometimes even to breathe. 
Its Causation is obscure, but it is said to be usually of an urticarial nature, and to 
occur in those who have had urticarial attacks. This condition is Diagnosed from 
simple acute glossitis by (i.) its rapid advent in the course of an hour or two ; (iL) the 
rapid extension to the throat and other parts ; (iii.) the presence sometimes of an urti- 
carial rash, or a history of attacks of angio-neurotic oedema. Without the last feature 
the diagnosis is difficult. 

Prognosis and Treatment, — ^The disease comes on rapidly, and runs a very rapid 
course, subsiding in the course of twenty-four hours, unless the patient die in the 
meantime. It is apt to cause suffocation. Prompt measures are necessary. A strong 
purge should be given at once (croton oil, 1 minim, if it can be swallowed) or a turpen- 
tine enema. Cocaine (5 or 10 per cent.) should be kept constantly painted on the 
tongue. ScariBcation is often required, and the practitioner should be prepared to 
perform tracheotomy if necessary. 

§ 161. Chronic Swelling, Hypertrophy and Atrophy of the Tongue. 

I. Chronic Glossitis is a chronic inflammation of the tongue, in which either the 
surface or the substance is mainly involved. The surface is covered with irregular, red, 
raw, tender patches and cracks (unless it be secondary to, or attended by, leucoplakia). 
If the substance be affected, the organ is enlarged, indented by the teeth, and in course 
of time it becomes indurated. It is more frequently due to some local irritation, such 
as a jagged tooth or an ulcer, in which case the enlargement is generally limited to 
one part of the tongue. Qlossitis may arise from alcoholism, syphilis, chronic dys- 
pepsia, or excessive smoking, and many of the other causes of stomatitis (q.v.). The 
treatment is directed to the removal of the cause, and the employment of chlorate of 
potash and astringent mouth- washes. Tumours of the tongue are rare ; for diagnosis 
and treatment of these a surgical work must be consulted. Oveigrowth of the 
lymphadenoid tissue at the base of the tongue (the ** lingual tonsil ") is found in local 
septic conditions and in the acute blood diseases. 

II. Macroglossia is due generally to a congenital overgrowth of the connective tissue, 
accompanied by a dilatation of the lymphatics of the tongue. Its causes are obscure. 
It is found in mongolism and with acquired syphilitic lesions. Persistent application 
of mild caustics or the galvanic cautery to the tongue is the only remedy. 

III. Atrophy of the Tongue (microglossia) may arise from nerve lesions. It may 
occur in bulbar paralysis, and is then usually bilateral. In unilateral cases the lesion 
is either situated in the nucleus or trunk of the twelfth nerve of one side (vide Chap- 
ter XIX., § 622). 

§ 162. Warts, Fiisores, and Cicatrices. 

Warts are simple or S3rphilitic. Simple warts are distinguished by the fact that 
they are soft ; they are raised, and often pedunculated, and there is but little secretion. 
The glands are not shotty to the touch. Syphilitic warts are hard, with infiltration ; 
they are never pedunculated, secretion is present, and the glands of the neck and else- 
where are shotty. Fissures are also divided into simple and syphilitic. The simple 
can generally be accounted for by some such cause as the irritation of a ragged tooth, 
and are n€f7er infiltrated. On pinching syphilitic fissures between the fingers, infiltra- 
tion is found to be present. CiCATRiCBS.---Simple ulceration rarely leaves a scar, but 
if so, it is never hard. Hard, stellate soars are invariably indicative of syphilis. 



« The Gnllei 

§ 153. Symptomatology. — ^Diseases of the oesophagus have practically 
one symptom which is common to all — namely, dysfhagia — i.e., a difficulty 
in swallowing. There are certain features about this symptom which it 
is important to investigate : 

First, does the difficulty apply to both liquids and solids ? This gives 
us an idea of the degree of the obstruction. Secondly, does the food return ? 
and if so, after what interval ? This is sometimes a guide to the seat of 



§ 164 ] PH Y8IGAL EXAMINATION 227 

the obstruction. Obstruction within the oBs&pJiagus has to be distin- 
guished from obstruction at the pyloric end of the stomach (i.) by the easy 
way in which the food regurgitates as compared with the vomiting which 
accompanies pyloric stricture ; and (ii.) by the absence of acidity in the 
material returned. Thirdly, is there any pain ? What is its situation, 
and is it only present after the ingestion of food ? Constant pain is a 
feature of malignant disease. Fourthly, what is the duration of the dys- 
phagia ? Has it been persistent, and become progressively and steadily 
worse ? The last named is the leading feature of organic, as distinguished 
from functional, dysphagia, which is frequently intermittent, and by no 
means progressive. Fifthly, is there any regurgitation through the nose ? 
This feature implies paralytic dysphagia, with paralysis of the soft palate. 
Sixthly, is there any emaciation, or are there any symptoms referable to 
other Cleans ? Marked emaciation coming on early in a patient beyond 
middle life is characteristic of carcinoma. 

§ 154. Physical Examination. — (a) A careful insfedion of the throat 
should be made, because the dysphagia may arise from tonsillitis or other 
pharyngeal conditions. The paralysb of the palate which succeeds diph- 
theria may thus be detected. Any swelling should be carefully examined, 
such as retro-phar3mgeal abscess or tumour of a foreign body in this situa- 
tion. I have known the bristle of a toothbrush entangled in the pharynx 
give rise to very serious difficulty in swallowing. 

(h) In cases of dysphagia of any duration the fosaage of ar^ OBsophagecd 
hougie, or, at any rate, a soft stomach-tube, should always be made.^ 
The solid bougie is preferable, both for purposes of diagnosis and of treat- 
ment, but if carcinoma be suspected, great care must be exercised. The 
chest should always first be examined for aneurysm, and if this cannot 
certainly be excluded, the bougie should be avoided. The bougie must 
first be dipped in hot water in order to make it more flexible, and glycerine 
if necessary for lubrication. There is not much fear of it entering the 
larynx, provided the tube be passed to one or other side, and instruction 
given to the patient to put his head horizontally forwards and swallow 
during the operation. As the entrance to the stomach — ^from the teeth to 
the cardiac orifice — is a distance approximately of 16 inches, it is a good 
plan to tie a thread round the bougie 16 inches from its point ; then one 
can tell when it hets reached the stomach. The oesophagus starts at the 
cricoid cartilage, opposite the sixth cervical vertebrse and ends opposite 
a point between the ninth and tenth dorsal vertebrs9, a distance of 
10 inches. The presence of acute fair^ during the passage of the instru- 
ment indicates ulceration, either simple or malignant. The presence of 
Uood, and perhaps cancer cells adhering to the end of the tube, should be 
looked for as having the same significance as the foregoing. The presence 
of dilatation may be suspected when the end of the tube is not gripped, 

^ Dr. J. 8. Biistowe, with oharacteristio candour, narrates a oase showing the conse- 
quences which arose from a neglect of this procedure in his " Clinical I^tures and 
Essays/* p. 43. The case was really one of dilatation of the oesophagus, which re- 
mained undiscovered until after death. 



228 THE MOUTH, TONGUE, AND GULLET [§§166,166 

but is loose and easily movable. Occasionally a diverticulum or saccule 
of the oesophagus is fonned, which by its pressure on the gullet above or 
below it causes obstruction. In such cases a bougie, which coidd not be 
passed before, may be passed after vomiting has occurred. 

(c) Auscultation afiords a valuable means of detecting both the presence 
and position of an oesophageal stricture. Place the chest end of a binaural 
stethoscope over the interval between the xiphoid cartilage and the left 
costal arch. Two gurgling sounds can be heard in this situation if the 
patient swallows one gulp of fluid ; the first is when it passes from pharynx 
to oesophagus, the second is when it passes from oesophagus to stomach. 
The normal interval between these two is six secondsy but if there be any 
obstruction in the gullet this interval becomes increased. If the first 
sound cannot be distinctly heard, the moment of its occurrence can be 
judged by looking at the throat. Again, by placing the stethoscope on 
the left side of the neck in a healthy person a gurgling sound will be heard 
during the act of swallowing. This normal sound may be traced round 
and down the hack on the left side of the vertebral spines as low as the 
tenth dorsal vertebrae. But if a stricture be present it will be delayed or 
absent below the seat of stricture, 

(d) X-ray examination with a bismuth meal is an important method 
for detecting the presence of stricture or diverticulum. 

(c) The oesophagoscope may be used by skilled hands. 

§ 155. Causes of Dysphagia. — '' When a ^patient complains of difjvculty 

in swaUomr^y or that the food returns to his mouthy the practitioner should 

first think of thoracic aneurysm, secondly of cancer y and thirdly of some other 

kind of ulceration,^' ^ The commoner causes are — 

I. A tumour pressing upon the gullet from the outside. 
II. Cancer of the gullet. 

III. Simple or non-malignant stricture. 

IV. Spasm. 

V. Foreign bodies, acute oBsophagitis. and simple ulcer. 

Less frequent causes are — 

VI. Paralysis of the gullet. 
VII. Dilatation of the guUet. 

§ 156. A Tumour pressing upon the gullet from without is perhaps the 
commonest cause of dysphagia, although malignant or simple stricture 
and muscular spasm are regarded by many as of equal frequency. Any 
intrathoracic timiour may, by its pressure, narrow the lumen of the gullet, 
and undoubtedly the commonest of these is aneurysm of the aorta. Other 
tumours are cancer of a neighbouring viscus, retropharyngeal abscess or 
tumour, enlargement of the bronchial glands, lympho-sarcoma or other 
mediastinal tumour, goitre, pericardial effusion, and diverticula of the 
gullet filled with food (§ 162). The features common to all such tumours 
are the slowly progressive character of the dysphagia, the symptoms of 
pressure on other viscera, and sometimes, although usually not until 

* Bryant, quoted by Fagge and Pye-Smith, " Prin. and Pract. of Med.," vol. ii., 
p. 316, second edition. 



157, 168 ] GA USES OF D YSPHA GIA 229 

late in the case, the physical signs of the tumour in question. For the 
rest, the differential features vary according to the nature and position 
of the tumour. In aortic aneurysm the amount of dysphagia is rarely 
very great at any time, although it is slowly progressive. Rest in bed will 
generally ameliorate the dysphagia. Difficulty of swallowing is only one 
of the pressure symptoms in this disease, and others should be looked for — 
^'9'y dyspnoea, abductor paralysis of the left vocal cord, and inequality of 
the pupils. The physical signs of aneurysm are commonly wanting in 
such cases on account of its deep-seated position. 

§ 157. Malignant Disease of the oesophagus is due in the large majority 
of cases to an epitheliomatous growth in the wall, usually primary, which 
goes on to ulceration, and forms a stricture from 1 to 4 inches long. Rarely 
the growth is sarcomatous. The diagnostic features of epithelioma of 
the oesophagus are : (i.) The patient is past middle life. It is said to be 
more common in males, (ii.) The dysphagia becomes steadily and pro- 
gressively worse ; in rare cases it may be intermittent. At first a difficulty 
exists only with solids, but later on fluids also are returned. The duration 
of the whole illness rarely exceeds twelve to eighteen months, (iii.) Emacia- 
tion and other evidences of cachexia occur quite early in the illness. 
There may be evidences of cancerous deposit elsewhere, especially within 
the abdominal cavity ; or there may be enlarged glands, especially above 
the left clavicle, (iv.) Pain and haemorrhage, those frequent accompani- 
ments of all malignant growths, are usually present and the pain is 
persistent and independent of, although aggravated by, food, (v.) The 
passage of a bougie is attended by considerable difficulty. The favourite 
sites of malignant stricture are opposite the cricoid cartilage, 6 inches from 
the teeth ; opposite the bifurcation of the trachea, 9 inches ; and at the 
cardiac orifice, 16 inches from the teeth. 

Fibroma and Myoma, and other benign growths in the oesophagus, sessile, or in the 
form of polypi, are very rare. They may simulate simple or malignant stricture, and 
there may be hsemorrhage ; but the absence of any cachexia and the long duration 
without any increase of symptoms ai'e the only means of suspecting the condition. 



§ 158. Simiftle or Non-Malignaiit Strictiire of the oesophagus s most fre- 
quently caused either by the narrowing due to a syphilitic infiltration or 
the contraction which it subsequently leaves. It may also arise from the 
cicatrisation which follows a simple ulcer of the gullet or stomach ; or, 
thirdly, as the result of swallowing a corrosive liquid. Dilatation may 
take place above the stricture. The differential features of this condition 
are : (i.) The dysphagia comes on gradually, and, having reached a certain 
degree, is apt to remain stationary ; the patient may be unable to swallow 
solids, but lives for many years on liquid food, (ii.) The passage of 
bougies gradually increased in size is possible, and this procedure gives 
some relief, (iii.) The patient may be young, or he may be of any age ; 
the cachexia of cancer is wanting ; and pain is not a prominent feature 
in the case, (iv.) The gullet is apt to dilate above the stricture, and the 
food returns after an interval, which becomes progressively longer as the 



230 THE MOUTH, TONGUE, AND GULLET [ §§ 169-161 

dilatation becomes greater, (v.) There is nearly always a history of one 
of the three causes above mentioned. 

§ 169. Spasm of the Pharynx or (Esophagus is, in the author's experience, 
one of the commonest causes of dysphagia. It is not infrequently associated 
with hysteria and other functional neuroses. Its differential features are 
fairly characteristic : (i.) The dysphagia is never progressive. It may 
come on somewhat suddenly, dating perhaps from an emotional shock or 
trouble, and it is very often intermittent, the patient being well enough 
in the intervals. Sometimes solids can be taken, while fluids are regurgi- 
tated, or vice versa, (ii.) It is unaccompanied by emaciation or cachexia ; 
indeed, the patient sometimes appears to be in perfect health, a feature 
in which it differs from all other causes of dysphagia. There is usually 
little or no pain, and never any bleeding, (iii.) The dysphagia may last 
intermittently for a considerable time. I have known cases persist in 
varying degree for seven, twelve, and sixteen months, (iv.) The passage 
of a bougie, or flexible stomach- tube, is possible with a little steady pressure, 
and with the patient under chloroform it is easily done. This procedure 
generally results in curing the condition, at any rate for a time, (v.) The 
patient is most frequently of the female sex, and often presents other 
evidences of hysteria. It certainly occurs also in males, and gout or 
rheumatism are said to predispose to it. 

§ . 160. Foreign Bodies, Acute (Esophagitis, and Simple I]lcer. — ^Tho 
symptoms of these conditions are much alike. Acute oesophagitis occurs 
after traumatism, as after swallowing corrosive fluids,^ or in a localised 
form from the presence of foreign bodies. It sometimes occurs in the 
course of the specific fevers, and in infants at the breast from unknown 
causes. A slighter degree of localised inflammation arises by no means 
infrequently when a fish-bone, needle, pin, bristle of a toothbrush, or other 
solid particle, sticks in the folds of the oesophagus. This dysphagia takes 
the form of a difficulty and pain during the act of swallowing, at one 
particular spot. The symptoms here start suddenly and reach a maximum 
at once. This source of trouble is very apt to be overlooked when the 
patient has forgotten the incident which led to the lodgment of the foreign 
body. When the inflammation is generalised, there is great pain, with 
consequent spasm and regurgitation on attempting to swallow. Thirst 
and, if the condition be severe, feverishness are present. Mucus, pus, and 
blood may be vomited if idceration ensue. 

Simple Ulcer of the gullet is very rare. It is sometimes due to sjrphilis. 
Acute pain and tenderness are prominent features, with spasm on swallow- 
ing or on attempting to pass a bougie. But the affection cannot be diagnosed 
with certainty. 

We now turn to the rarer cansef of Dyiphagia. 

§ 161. Paralysii of the Oallet — Paralysis of the upper part of the gullet — i.e., of 
the pharyngeal constrictors — is not uncommon as an accompaniment and complication 

^ fluids which are simply irritating, such as boer contaminated by the substances 
used to clean the pewter pots, may cause the condition. 



$§ leS. IM ] PR0QN08I8 AND TREATMENT OF DYSPHAGIA 231 

of diphtheria. Difficulty of swallowing under these circumstances may be ono of tho 
first evidences of diphtheritic paralysis. It also occurs in Bulbar Paralysis, and at 
the end of some slowly progressive exhausting diseases. All these differ from the other 
causes of dysphagia by being attended by regurgitation of fluids through the noso, 
owing to the paralysis of the soft palate. Paraljrsis of the gullet below the pharynx is 
a much rarer condition. It may sometimes accompany and be due to the same causes 
as the above. It also arises as an occasional complication of general paralysis of the 
insane, cerebral tumour, diseases of the nuclei in the medulla, and lesions of the vagus. 
The dysphagia in these cases is not absolute, the normal ossophageal sound on ausculta- 
tion is absent, and a bougie passes without hindrance. The condition can only be dis- 
tinguished from simple dilatation when there is no regurgitation or pseudo-emesis of food. 

§ 162. Dilatatioii or Diverticnliim of the Gullet is not frequent, and the causes are 
obscure. It may take the form of (a) generalised dilatation of the whole tube ; (6) a 
fusiform dilatation above a stricture, (c) It may occur as a diverticulum., or sac, 
which is said to be formed in one of two ways : (i.) A pressure diverticulum or saccule. 
due either to weakness of the wall after injury, or sometimes to congenital weakness 
of some part of the tube, with consequent hernia of the mucous through the muscular 
wall ; and (ii.) a traction diverticulum, due either to adhesions between the cssophagus 
and neighbouring glands, or other strictures, pulling out the cssophageal wall as they 
contract. 

(a) A general dilatation has but few or no symptoms, {b) The symptoms of form 
(6) are masked by those of the stricture below. The occurrence of dilatation (with 
stricture) is evidenced by the regurgitation of food at shorter or longer intervals. On 
this account such oases are very apt to be mistaken for the vomiting of pyloric obstruc- ' 
tion {vide feature 2, § 153). There is an unusual mobility in the bougie just before it 
reaches the obstruction, (c) The diverticular varieties are very rare, but, as far as 
we know, their symptoms are as follows : (i.) There is regurgitation of food after an 
interval varying from a few minutes to a few hours after ingestion. It is apt to be 
mistaken for persistent vomiting, but the ease with which the food is returned, and 
the absence of acid in it, should make us suspect this condition, (ii.) The regurgita- 
tion gradually increases in amount, and the breath is foul from the decomposition of 
food in the gradually enlarging pouch, (iii.) In cases of pressure diverticula a bougie 
which could not be passed before can be passed after vomiting, because the sac full 
of food forms a swelling that presses upon the gullet and so leads to obstruction, 
(iv.) Sometimes the pouch forms a definite tumour in the neck. 

§ 168. Prognosis and Treatment op Dysphaola. — Dysphagia is in 
most cases a symptom of considerable gravity, and in severe cases it com- 
monly enough results in death by starvation. Of all causes, malignant 
stricture is the most serious, and, in spite of the means which modem 
suBgery has placed at our disposal, patients rarely live more than a year or 
eighteen months. The length of time depends on the maintenance of 
the nutrition of the individual. Next in order of gravity come tumours 
pressing on the oesophagus, when the prognosis depends on the nature of 
the tumour and its amenability to treatment. 

Patients with simple stricture, and with dilatation, may live for many 
years on fluid diet, with or without gastrostomy, but diverticula are much 
more serious. Of all causes functional spasm is the most curable, although 
it is apt to return. 

The cause of death in dysphagia is usually starvation or a low form of 
pneumonia. This may arise from perforation into the bronchus, or by 
the food passing into the glottis. In either case death is expedited by 
the lowered vitality of the patient. Perforation may occur in other direc- 
tions — «.gr., a case of malignant disease of the gullet under my care died 
from haemorrhage consequent upon perforation into the aorta. 



232 THE MOUTH, TONOUE, AND GULLET [§198 

Treatment op Dysphagia. — The indications are to remove the cause 
of the obstruction, to maintain the strength and nutrition of the patient, 
and to relieve any concurrent symptoms. The question of three surgical 
procedures may arise in these cases : the passage of bougies of different 
sizes, the use of Symonds' tubes, and gastrostomy. If possible, a bougie 
should be passed in all cases, not only for purposes of diagnosis, but also 
as part of the treatment. It may be of little use in malignant stricture, 
but simple stricture may be dilated or prevented from further contracture 
by this method. Symonds' tube, a funnel-shaped tube with a string 
attached to prevent it slipping down, changed every three weeks or so, 
undoubtedly prolongs life both in malignant and advanced simple strictures. 
An early gastrostomy offers the best chance of prolonging life in every 
case of malignant stricture. In malignant stricture if, when the case 
comes under treatment, debility is very marked, complications are present, 
and there are evidences of cancer elsewhere, gastrostomy is the only treat- 
ment of any avail. Radium is now employed with success in early cases. 
In addition to the above treatment, the only indication in mcUignafU 
stricture is to soothe the pain by morphia, opium, or cocaine. 

In simple stricture, bougies of gradually increasing size should be 

passed and left in for some hours at a time. Force must not be used in 

so doing. In very narrow strictures a Symonds' tube would be better. 

If syphilis be suspected as the cause, potassium iodide must be given. 

IvL functional spetsm a bougie should be passed, and cold douches given 

along the neck and the spine. The general condition must be treated, 

valerian in hysteria, combined with special diet in cases with gastritis. 

Electricity may be useful. In 'paralysis and dilatation, especially the 

diverticular type of dilatation, the patient must be fed by a stomach- tube. 

If the diverticulum is high up in the neck, the surgeon may be able to 

remedy it. In aciUe cesophagitis the pain must be soothed by morphia 

hypodermically, by cocaine lozenges, or by opium given with tragacanth. 

Thirst may be allayed with spoonfuls of iced water, in which small doses 

of opium, cocaine, and milk may be administered. During the acute stage 

the patient may require nutrient enemata. Foreign bodies in the gullet 

need prompt attention but very careful measures, else they may pierce 

the tube and injure the aorta or other structures around. 

Feeding hy a stomach-tvhe is a measure available in a fair proportion of cases, espe- 
cially in Causes I., III., IV., VI., and VII. {supra). The only apparatus necessary 
consists of a long flexible rubber tube (5 feet long) one end of which is blunt, with the 
** eye " at the side or the end (according to choice) and the other end tied to a funnel. 
The method of passing the tube is either the same as that used in passing a bougie 
(§ 154) or it is passed through the nose. In the latter case the size must be smaller. 
The operator then pours into the funnel the fluid food, previously prepared, from a 
jug. 



CHAPTER IX 

THE ABDOMEN 

The abdomen contains a large number of very important organs and 
structures, but just as their physiology and pathology are in many instances 
obscure, so also are the means at our disposal for their thorough clinical 
investigation imperfect. However, it is in this region that we have to 
deal with symptoms which on the one hand may be of quite a trivial 
order, or on the other may be of extreme gravity ; symptoms and condi- 
tions the issue of which will largely depend on the promptitude, know- 
ledge, and skill of the medical man in attendance, and upon his adequate 
comprehension of their true meaning. 

PART A. SYMPTOMATOLOGY. 

§ 164. Local Symptoms. — ^The symptoms referable to disease situated 
within the abdominal cavity are necessarily of the widest and most varied 
kind, but there are only three which are sufficiently constant to be regarded 
as cardinal symptoms, all of which are referable to the abdomen itself — 
viz.. Abdominal Pain, Generalised Enlargement, and Localised 
Tumour. 

Vomiting is a fairly constant accompaniment of all acute abdominal 
conditions, whether the stomach is involved in the lesion or not. Its 
causes are discussed in § 191. 

The presence of Diarrhoea and Constipation depends very largely on 
whether the intestinal canal is affected, and these are fully dealt with in 
Chapter XI. The other symptoms also depend largely upon which of 
the abdominal organs is affected, with one important exception — viz., 
" Indigestion." In all chronic abdominal disorders, no matter which 
organ is affected, we are often consulted for " Indigestion " ; in fact, 
nausea and all the other symptoms of pronounced dyspepsia may be due 
to disease quite unconnected with the stomach, and located, for instance, 
within the uterus, kidneys, liver, spleen, or pancreas. Some cases of 
" dyspepsia," after resisting treatment for months or years, have been 
cured by the stitching up of a dislocated kidney. 

Abdominal Pain, if acute and sudden, is a medical emergency of the 
most important kind ; if chronic, it presents many difficult questions for 

233 



234 THE ABDOMEN [ § 165 

diagnosis. It will therefore merit the most careful study and analysis 
(§ 168). The diseases outside the abdomen which may give rise to it are : 

1. Diaphragmatic pleurisy^ or a basal pleuro-pneumonia, may give rise 
to acute abdominal pain of sudden onset and to abdominal rigidity and 
other symptoms of acute peritonitis, which can only be difierentiated by 
the pulse-perspiration ratio and the concurrent symptoms. Pericarditis 
sometimes causes severe abdominal pain. 

2. Neuralgia of the intercostal and other spinal nerves may be referred 
to the abdomen. In this way spinal caries, especially in children, the 
crises of locomotor ataxy, and other diseases of the vertebr© or cord, may 
be mistaken for various abdominal diseases. 

3. An abscess in the abdominal wall, a bruise, or a ruptured muscle may 
be similarly mistaken, but these shoidd present no difficulty. 

4. Diabetic coma is occasionally heralded by pain simulating appendicitis. 
(See a case : the Lancet, March 9, 1912.) 

Abdominal Enlargement and Abdominal Tumour are considered in 
Parte. 

§ 165. The (General or Remote Symptoms met with in abdominal disorders 
are, as just mentioned, of an extremely varied nature, and our endeavour 
should be to correctly associate these symptoms with the abdominal organ 
which is affected. 

Collapse and Pulse-Temperature Ratio. — In connection with the 
general symptoms of abdominal diseases, one fact needs special mention — 
(1) the profoimd collapse which is so apt to be associated with all acute 
abdominal conditions. A blow on the abdomen may result in fatal col- 
lapse, and so also may perforative peritonitis. This tendency to collapse 
possibly finds an explanation in the fact that the chief centre of the sym- 
pathetic is situated within the abdomen. Now, a subnormal temperature 
is one of the symptoms of collapse, and for this reason the temperature 
rarely ranges very high even in the gravest abdominal inflammations, 
especially in their earlier phases. In acute peritonitis, for instance, an 
extensive inflammatory process affects the peritoneum, which acting alone 
might produce a temperature of 105° F. or more, but by reason of the col- 
lapse it is rarely more than 102° or 103° F. (2) In the pulse, however, we 
find our best guide to the severity of mischief within the abdomen. In all 
acute diseases, other than abdominal, we find a rough general proportion 
between the height of the temperature and the rate of the pulse. Thus, 
a temperature of 100° F. will correspond roughly with a pulse of 100, 101® 
with 110, 102° with 120, 103° with 130, and so on— an increase of about 
10 for every 1° F. But in acute abdominal conditions this is not so. The 
pulse-temperature ratio is disturbed, for although the pulse rate increases 
with the severity of the abdominal mischief, the temperature never in- 
creases proportionately. Indeed, in many of the worst cases, the tempera- 
ture is one or more degrees below normal. The pulse, however, is an 
almost infallible guide, and one may say (1) that if the pulse remains 
under 100 nothing very serious is happening within the abdomen ; 



§ 166 ] PH Y8I0AL EXAMINATION 235 

and (2) that the rate of the pulse and the pulse-temperatuie ratio are 
great aids to the diagnosis, and in some sense measures, of acute abdominal 
disorder, especially when that disorder has reference to the peritoneum. 

PART B. PHYSICAL EXAMINATION, 
§ 166. In the examination of the abdomen we must proceed systematic- 
ally, as in the examination of the thorax, by Inspection, Palpation, 
Percussion, Mensuration, and occasionally auscultation ; though of all 
these measures palpation by the educated hand is at the present time 
the most valuable means we have. X-rays assist in certain cases, but 
this method is not always available. 

1. Carefnl inspeotion of the abdomen should on no accoimt be omitted ; 
much can be learned in this way. The best point of view is that from 
the foot of the bed, or by bending over the patient's feet, so as to view the 
abdomen from below. The mere fact of enlargement may thus be verified, 
and whether the enlargement be generalised and uniform, or whether it 
be localised or asymmetrical. Notice whether the umbilicus is centrally 
situated, and also whether the surface presents dilated veins, such as 
occur in abdominal cancer, or when the portal vein or vena cava is ob- 
structed. Dilatation of the abdominal veins is met with chiefly in three 
conditions : (1) In liver cirrhosis, these veins being part of the conservative 
collateral circulation which gradually becomes established ; (2) the veins 
without being much dilated or prominent are unduly apparent in cases 
of abdominal carcinoma. It is a sign of considerable value and constancy. 
(3) Extreme dilatation and varicosity of the superficial veins occurs only 
when the inferior vena cava is obstructed. This is generally due to a 
gummatous deposit in or around the posterior border of the liver where 
the vena cava passes through it. The veins of the legs and testes generally 
share to a less extent in the dilatation.^ Notice also whether there is any 
thickening or infiltration round the umbilicus such as may occur in cancer 
and tuberculous peritonitis. An abdominal enlargement due to the 
presence of air or gas is rounded anteriorly, but when due to fluid it is 
usually flattened in front and the flanks bulge ; when there is obstruction 
of the large intestine the flanks bulge ; whereas in obstruction of the small 
intestine low down the swelling occupies the centre of the abdomen. 
Incidentally you may notice the presence or absence of the white lines 
(linese albicantes) left by a previous pregnancy, the knowledge of which 
may be medically useful. The presence of hernia or of tumours of the 
wall may be recognised by inspection. The amount of movement of the 
abdominal wall with inspiration should be noticed, for diminished or 
absent movement constitutes an important sign of peritonitis. If the 
peritonitis is local, the abdominal wall over that area may move badly, 
whilst elsewhere abdominal respiratory movement is normal. Pulsation 
may sometimes be seen, most often in the epigastrium, and may be due to 

^ A case is recorded by Dr. W. Chapman. Clin. Soc. Trans., 1899 and 1900, and 
Lancet, December 2, 1899. 



2S6 THE ABDOMEN [ § 166 

the right ventricle or an engorged liver secondary to heart failure. Some- 
times aortic pulsation is unduly visible, especially in neurotic dyspeptic 
women, or it may be transmitted by a pyloric tumour. Rarely the 
pulsation is due to an abdominal aneurysm. Visible peristalsis should also 
be looked for, and if present its position and direction should be noted. 

The Regional Anatomy of the Abdomen is important as a guide to 
the seat of disease (Fig. 60). 

2. Palpation. — Considerable experience is necessary for satisfactory 
abdominal palpation. The hand should be warmed and always laid flat 
on the abdominal wall ; then by gently dipping in the fingers, by flexing 
the metacarpo-phalangeal joints, we have the most ready method of 
ascertaining (1) the presence of any tumour ; (2) the boundaries of some 
of the solid organs. The patient should lie on his back with the knees 
drawn up and the shoulders somewhat raised, so as to relax the abdominal 
muscles. Do not use the tips, but only the pads of the finger, for the tips 
stimulate the recti muscles to contract, and thus to simulate a tumour 
where none exists. Many patients ofier considerable involuntary or 
voluntary resistance, and this must be overcome by placing them in an 
easy posture and distracting their attention, or asking them " to let the 
breath go.'' Relaxation may be obtained by immersing the' patient in 
a hot bath ; in some cases it may be necessary to use chloroform. Much 
obesity is another obstacle to palpation. Palpation reveals the presence 
of localised resistance and tenderness which denote underlying inflam- 
mation. Tumours, flatulence, and the movement of fluid within the 
abdomen can also be detected by palpation. The palpation and 
percussion boundaries of the diflerent organs are described in later 
chapters. 

']. Percussion of the abdomen is done with the same precautions as in 
the case of heart and lungs, and the student will now find it very convenient 
to be able to percuss with either hand indifferently. Normally the anterior 
surface of the abdomen is resonant (when the stomach and intestines are 
empty) as far upwards as liver and spleen, downwards as far as the pubes, 
and outwards as far as the outward border of the colon. By this means 
we ascertain the presence of solid and fluid, which are dull, or of gas, which 
is resonant. When the fluid is free the dulness alters with the position of 
the patient. 

4. By measurement we ascertain the amount of increase in size. As 
a general rule, horizontal measurement should be taken at the level of the 
umbilicus, and it should be recorded for future reference. In order to 
ascertain whether the enlargement is symmetrical, we measure from the 
umbilicus to the ensiform cartilage above and the pubes below, and from 
the umbilicus to the anterior superior spine on each side. These four 
measurements should be approximately equal. From these data we ascer- 
tain very slight deviations from symmetry. 

5. Auscultation and ausculto- percussion are useful in certain cases 
to delimit the boundaries of an organ (§ 197). 



PHYaWAL EXAMIXATIOX 



The FALLACIES of abdominal enlargement are : (1) Fat in the ometUvm 
is referred to under fluid enlargement {§ l^>). {'2) PharUotn tumtntr is de- 
scribed under abdominal enlargement due to gaa (§ 183). (3) Pendulous 



LeTBl of GUI Tib, 
Stomach. 



Oair-bluldei. 



Ob[lterat«d 

hrpoeuUir. 

im and apptu- 



SlBmold Seiure. 

UruliiD. 

Ulddle of Foui>art'> 



Fig. 00,— RtniONg Of THE ADDOlll 


EN. 




1 regiona, which are bounded by 


two imaginwy IIiih numlng vertically upwards on each aide ol 1 


■he abdomen, from the middle ot 


Ptnirart'a ligament to (be coalo-ibondral arttculmion iibiive, and f 


■ horiionlal line* running round 


thn abdomen on a level with the end ot th» ninth co.UI cartilage 


and the antcrlOT (Uperior aplnca 










The right lobe ol the llvec The middle and pyloric end 


The .plenic end ot the 


and (be gall-bladder, the dno- of the itomacb. left lobe and 


.lomach, the .pleen and e^- 


deoum, pancreaa, hepatic lobulnt Spiflelll ol the Uvei, 




Beiore ol the colon, upper part and the pancreu. 


the splenir Heiure o( the rolon. 


of the right kidney, and tbe 


upper ball of the lelt kidney 






The tranivsne colon, part 




of the great omentum and 
KtffM j.B»uar. meeenterj', traiuverM part of 


Lffl Lumbar. 
' DcMendina colon, part of 


ol the Tight kidney, and tome volutJone ot the JelUDDm and 
eonvolntiona ot the imall In- Ileum. 


the omentum, lower part ol 
, the left kidney, and eome con- 
1 voluUona of the amall Intea- 


mteatioe*. 1 Htirotalrie Rrgim. 








Rw« Ili«. ln<«tl„r^il the bWdlrin 


Ltjl Hit. 




Sigmoid aoxure ot the colon 




and ureter. 



dorluf piegnancy. 



abdomen, so frequent in elderly women, is often thought by the patient 
to be a " tumour," but it ie due only to weakness of the muscles of the 
abdomen and of the intestinal tube. (4) Pregnancy and distended bladder 
are frequent causes ot error (g 188), (5) In rachitic children the liver and 



238 THE ABDOMEN [ §| 167, 168 

spleen may be pushed down by the deformity of the costal arches, and 
so produce the appearance of an enlarged abdomen. (6) Apparent en- 
largement of the abdomen may be caused by the pressure of some thoracic 
tumour. (7) The most frequent cause of abdominal enlargement is the 
presence of gas in the intestine. 



PART a ABDOMINAL DISORDERS : THEIR DIAGNOSIS, 
PROGNOSIS, AND TREATMENT. 

§ 167. Boatine Frocediire and Classifleation. — ^Having first ascertained 
that the patient's leading symptom is one of those above referred to, we 
secondly inquire into the history, and especially whether the condition 
came on acutely and suddenly, or is chronic and long-standing. The 
procedure to be adopted in acute cases and that suitable in chronic cases, 
will be given under their respective headings. Thirdlyy proceed to the 
physical examination of the abdomen, the routine method in ordinary 
cases consisting of (1) Inspection ; (2) Palpation ; (3) Percussion, to map 
out the boundaries of the liver, spleen, and other organs ; and (4) Mensura- 
tion. In any doubtful case the rectum, vagina, urine, and fsBces must 
certainly be examined. 

If severe abdominal pain, which came on saddenly and acutely, be the 
leading symptom, first turn to § 168. 

If abdominal pain of some duration and running a chronic course be 
the leading symptom, turn to § 174. 

If there be a generalised abdominal enlargement, turn to § 182. 

If there be localised tumour, turn to § 187. 

§ 168. Acute Abdominal Pain, coming on saddenly, includes amongst 
its causes some of the most serious conditions with which the physician or 
surgeon can have to deal ; and on account of the large number of organs 
contained in the abdominal cavity, these causes include many pathological 
processes situated in various and often unsuspected positions. 

The causes of abdominal pain may be conveniently classified for clinical 
purposes into nine groups : 

A. Abdominal Pain coming on suddenly, with collapse. 

I. Perforation of some organ or cyst (perforative peritonitis) . . § 169 
II. Acute peritonitis due to causes other than the preceding . . § 170 

III. Acute intestinal obstruction (hernia, intussusception, internal 

strangulation, and appendicitis) . . . . . . • • § 228 

IV. Displaced enlarged (or gravid) uterus ; V. embolism of the 

mesenteric artery ; VI. acute pancreatitis . . . . § 171 

B. Abdominal Pain coming on saddenly, without collapse. 

VII. Colio^(Inte8tina], renal, biliary) . . . . . . • . § 172 

VIII. Appendicitis (some cases) ; floating kidney ; splenic embolism ; 

and some other obscure organic affections . . • • § 173 

IX. Visceral Neuralgias . . . . . . . . • • § 173 



§ 168 ] ACUTE ABDOMINAL PAIN 239 

In the first six the acute abdominal pain is usually attended by col- 
lapse, but not in the last three. This, however, is only relative, and in 
any doubtful case the whole should be passed in review. 

In order to ascertain which of these causes is in operation, and in view 
of the gravity of some of these cases, it will be desirable to consider the 
METHOD OP PBOCEDUBE in some detail. 

(1) Regarding the cardinal or leading symptoms, inquire carefully, as 
in all cases of *' pain," concerning its position, character, degree and inten- 
sity. The position of the pain is not always a guide to the organ affected, 
for it rapidly tends to become generalised ; but the direction in which it is 
radiated is of great help in the diagnosis of the three kinds of colic. More- 
over, local disease may be accompanied by generalised pain, and wide- 
spread disease may give rise to a localised pain. Whenever the three symp- 
toms — ABDOMINAL PAIN, VOMITING, and CONSTIPATION — come ou together 
suddenly, with collapse, the condition is very probably due to either 
Peritonitis (which may be due to perforation), or Intestinal Obstruc- 
tion. 

2. As to the History of the lUthess, it is useful to note if there had been 
any illness previous to the onset of the pain pointing to ulceration, dys- 
pepsia, or other derangement of the abdominal organs. The occupation 
may shed some light on the cause — e.g., sudden strain, working with lead. 
The description of the mode of onset may assist — e.g., "something was 
felt to give way." 

3. In the Examination of the Patient — (i.) his cige is an important aid 
in the diagnosis of the cause of the pain. In childhood it is very probably 
some intestinal affection, such as colic, or intussusception ; in adolescents 
and young adults, appendicitis, while cancer and tabetic crises may prob- 
ably be excluded. In adults we think of hernia and ulcer of the stomach ; 
in old age after middle life we think of cancer, or if the patient is a female, 
biliary colic, (ii.) The sex may aid us, for in yoimg females we may 
suspect an ulcer of the stomach even without previous symptoms ; and in 
older women the rupture of an ectopic (extra-uterine) pregnancy, a con- 
dition which is frequently overlooked, or gall-stones, (iii.) The presence or 
absence of tenderness is of considerable aid ; tenderness points to the exist- 
ence of imderlying inflammation, (iv.) AU the organs of the abdomen must 
be as carefully and as thoroughly examined as circumstances will permit. 
Never forget to examine per rectum and vagina, because stricture of the 
former or a pelvic tumour may throw considerable light upon the case, 
(v.) The patient's general symptoms must also be carefully investigated. 
If the temperature and the pulse be normal, we may exclude inflammatory 
conditions. The temperature alone is not a sufficient guide in this respect 
(see § 165), but in general terms no serious acute abdominal condition exists 
without the jndse rate exceeding 90 or 100. If the patient is much emaci- 
ated, in adults we must bear in mind obscure malignant disease, and in 
children the presence of tubercle. Examine the urine for sugar. 

If the pain, which is severe and has come on suddenly, is attended by 



240 THE ABDOMEN [ § 169 

marked collapse, first turn to § 169. If it is unattended by collapse, turn 
first to § 172. It must be remembered, however, that any severe pain will 
cause a certain amount of prostration. 

I. The patient complains of acnte abdominal pain, which has come on 
suddenly, tvith symptoms of severe collapse, attended by vomitinq and 
CONSTIPATION ; the pulse is rapid (over 100). The case is probably one of 
three conditions^ Perforation into the peritoneum, Acute PERiroNms, 
or Acute Intestinal Obstruction. 

§ 169. Rupture of a Cyst, Abscess, or Organ, or Perforation of the Aliment- 
ary Canal (which shortly develops into Perforative Peritonitis). The cysts 
which may rupture are hydatid or simple cysts of the liver, kidney, pancreas, 
or other organs, ovarian and parovarian cysts, and the abscesses those of 
the liver, gall-bladder, kidney or other organs, or of mesenteric glands 
and perityphlitic abscess (§ 175). Rupture of an Organ, with consequent 
extravasation of blood, causes similar symptoms, and of such may be 
mentioned ruptured Fallopian tube (in cases of extra-uterine pregnancy), 
ruptured abdominal aneurysm, rupture of the liver or kidney (following 
injury). Perforation of the alimentary canal may at any time occur when 
an ulcer is present. These ulcers are, in order from above downwtird, 
simple ulcer of the stomach (which is usually met with in young ansemic 
women), simple ulcer of the duodenum (which occurs in males), ulcer of 
the lower part of the ileum (due to tuberculosis or enteric fever), ulcer 
of the caecum or appendix, ulcer of the large intestine, especially the 
sigmoid flexure (usually cancerous, dysenteric, or syphilitic). 

Symptoms, — Pyrexia at first is absent, and the temperature may be 
subnormal because of the collapse. The pulse is thready, feeble, and 
rapid. The pain is probably very severe, and the ashen pallid face, with 
its cold, clammy sweat and sunken eyes, is very characteristic. Vomiting 
is rarely absent ; it may be incessant, distressing, and even stercoraceous. 
A certain amount of constipation is generally present on account of the 
paralysis of the bowel consequent on the pain. Perforated gastric ulcer 
is perhaps the commonest of the conditions above mentioned, and may be 
taken as a type. We should inquire for a history of dyspepsia and other 
symptoms (§ 207), but in not a few cases rupture has occurred without 
previous symptoms of any kind whatever. On examination there is ten- 
derness, rigidity of the muscles most marked in the epigastrium, and a 
tympanitic note over the whole abdomen. The disappearance of the 
liver dulness in a case presenting these symptoms has been considered 
pathognomonic of ruptured gastric ulcer. After a few hours there is a 
deceptive period of repose, during which all symptoms of discomfort are 
diminished. On examination several hours later, however, symptoms of 
collapse are found with acute peritonitis (§ 170), generalised or localised. 
The symptoms of perforated duodenal ulcer may be the same as those of 
gastric ulcer, but the condition occurs usually in men. The symptoms of 
perforation of another part of the intestine, or rupture of a cyst, are much 



§ 170 ] PERFOBATI VE PERITONITIS U\ 

the same, and one can only hazard a diagnosis as to its situation by the 
site of the pain and tenderness, and the previous history. There are three 
degrees of severity met with when perforation of the intestine occurs : 
(a) When there are adhesions the peritonitis may be localised or partial ; 
(6) when there are no adhesions, but a small leakage, it may be only 
moderately sudden in its onset; (c) when the leakage is large it is 
extremely sudden and severe in its onset. 

The latent feriod which ensues shortly after an acute onset deceives 
many clinical observers. The pain may subside, all symptoms decrease, 
and the temperature become normal or subnormal. But (1) the fulse 
rate remains persistently high, and (2) in the blood there is marked leuco- 
cytosis. These are sufficient to indicate immediate exploratory abdominal 
section. Perforative peritonitis may have to be diagnosed from diaphrag- 
matic pleurisy and pneumonia of the base, where the pidse-respiration 
ratio is disturbed, but not the pulse- temperature ratio.^ 

Treatment and Prognosis, — ^Laparotomy should be performed at once. 
If deceived by the period of repose into thinking the patient is recovering, 
in a few hours general peritonitis will have set in, and operative interference 
wDl be too late. In cases where patients have been operated upon within 
the first twelve hours 79 per cent, have recovered ; if after twenty-four 
hours only 294 per cent, have recovered (GoflEe). The after-treatment 
depends on the cause. In the case of rupture consequent on injury 
internal haemorrhage may take place with a rapidly fatal result, but even 
in such cases early laparotomy has been performed with success. 

II. The patient complains of severe abdominal pain, extreme prostration, 
and voMrnNG ; there is thobacio respiration, and the temperature is 
ELEVATED. The discose is Acute Peritonitis. 

§ 170. Acute Peritonitis (General Peritonitis) is an acute inflammation 
of the peritoneum. It is rarely a primary disease, but its onset is usually 
sudden. 

Symptoms. — (1) The aspect is very characteristic ; the countenance 
has an anxious pinched look, the cheeks flushed, and the skin cold and 
clammy. (2) The pain is severe and constant, but liable to exacerbations 
on account of the intestinal peristalsis and the passage of wind along the 
bowel.2 It is also increased by any kind of movement, even by the 
respiratory movements. Consequently (3) the respiration is thoracic, 
and careful inspection will show that (4) the abdominal walls are im- 
mobile and rigid. There is acute tenderness on pressure, so much so that 
the weight of the bed-clothes can hardly be borne. (5) The posture of 
the patient is very characteristic as he lies on his back with legs drawn up 
to relax the abdominal muscles. (6) Pyrexia, often ushered in with 
sudden rigors, and attended by a small, wiry, rapid pulse of 100 to 140 

^ See Report of Clin. Soc. Lond., the Lancet, April 19, 1902. 
^ The aoate peritonitis which complicates enteric fever is of a latent character, and 
unaccompanied by pain. This and puerperal peritonitiB are the only exceptions. 

16 



^42 THE ABWMM [ § lyO 

per minute. The temperature is elevated only 2° or 3° F. above normal, 
and maintained there continuously, unless pyaemia be present, in which 
case there are rapid variations of wide range. In some cases — e.g., per- 
foration — it may be subnormal at first {vide supra). There is marked 
prostration, as in all abdominal inflammations, and a great tendency to 
collapse, even from the beg'mning. (7) The bowels are constipated, and 
there is persistent vomiting. Hiccough is often present, and if persistent 
is a very bad sign, as in all abdominal disorders. There is diminution of 
urine, which may amount to suppression. The urine is abundantly charged 
with indican. Death occurs from collapse or asthenia, and the mind 
remains quite clear until the end in uncomplicated cases. Peritonitis is 
seldom a primary affection, and careful inquiry should reveal the cause. 
. In acute localised peritonitis the symptoms are those of acute general 
peritonitis, but are less severe, and are more confined to the affected region. 
The Causes of acute peritonitis may be grouped under seven headings : 
(i.) Injury or Operation. — ^In cases occurring in women without obvious 
cause, the possibility of criminal procedure for abortion should always 
be remembered. As regards surgical operations on the belly, modern 
experience has shown that it is not so much the actual injury as the intro- 
duction of septic organisms, which produce the peritonitis, and that if 
these be excluded mere damage to the peritoneum will not cause a general- 
ised peritonitis, (ii.) Extermon of inflammation from the thorax, or from 
various organs of the abdomen — e.g., appendicitis, gonorrhoeal salpingitis, 
inflammatory conditions of the intestines (typhoid, dysenteric, and other), 
(iii.) Blood Infections of various kinds — e.g., pneumococcal, streptococcal, 
staphylococcal, and gonorrhoeal. Idiopathic Peritonitis was the name 
formerly given to the disease when no cause could be discovered. Peri- 
tonitis is apt also to complicate scarlatina and the other acute specific 
fevers. Puerperal Peritonitis is due to the introduction of a pyogenic in- 
fection through the raw uterine surface. A chronic form of the disease 
arises in urcemia. BactUi ccli communis may produce peritonitis either as 
part of a septicaemia, or primarily, (iv.) ChiU, under certain conditions, 
such as bathing during the menstrual period, is sometimes included as a 
cause, though this usually leads to a chronic localised peritonitis (peri- 
metritis). The true explanation of peritonitis after a " chill " is to be 
found in microbic infection, (v.) Rupture of an organ or some ab- 
dominal cyst, such as ovarian cyst, or an abscess of the liver, or rupture of 
the gall-bladder, etc. (§ 169). Rupture of a Graafian follicle may give 
rise to a monthly peritonitis, but this is usually localised and less serious, 
(vi.) Perforation of some part of the alimentary canal, which had previously 
become thin by ulceration — ulceration of the appendix vermiformis, 
simple ulcer of the stomach (malignant ulcer rarely or never perforates 
because of the infiltration around), typhoid ulcer of the ileum, etc. (see 
Perforative Peritonitis), (vii.) Any condition such as volvulus, in which 
the resistance of the intestinal wall to the passage of organisms is dimin- 
ished, may be a cause of peritonitis, local or general. 



S 170 ] ACUTE PERITONITIS 243 

Acute general peritonitis has to be Diagnosed from four diseases : 
(1) Acute intestinal obstruction, in which the constipation is absolute and 
no flatus is passed ; there is usually no pyrexia, and the constitutional 
disturbance is usually less. (2) In coliCy although the pain is also very 
severe, there is an absence of tenderness, and pressure may give relief. 
Pyrexia and collapse are absent, and the pulse is normal. (3) In catarrhal 
enteritis there is pain, and there may be vomiting and tenderness on 
pressure, but in this disease there is profuse diarrhoea. (4) In certain 
cases of hysteria, acute peritonitis may be very accurately simulated, 
though the temperature and pulse aie normal, there is very little collapse, 
and there are evidences of the hysterical stigmata. 

The Prognosis of general peritonitis is always very serious. As regards 
etiology, perforative peritonitis, formerly considered the gravest, is prob- 
ably now the most hopeful if promptly dealt with. Modem surgery has 
done much for the rescue of such cases, and undoubtedly the most favour- 
able of them is that due to appendicitis. Cases of this disease, if properly 
managed, should hardly ever be lost. The prognosis in any particular case 
depends therefore on the time elapsing before operation, and secondarily 
on the cause and the severity of the collapse, the dyspnoea, and the 
hiccough. 

Treatment, — The treatment of acute peritonitis depends upon whether 
it is general or local. If general, the only rational treatment is by opera- 
tion immediately a diagnosis has been made. A fatal issue is almost 
invariable in cases not operated upon, since the condition is rarely primary, 
and a definite local lesion is usually present. If for any reason an opera- 
tion cannot be done, recourse must be had to the older methods of treat- 
ment. In local peritonitis medical treatment is indicated, but even in 
this condition, if there are signs which make it probable that pus has 
formed, an exploratory incision should be made. Medical treatment com- 
prises keeping the patient in bed and relieving symptoms. The diet should 
be fluid, consisting of soups, jelly, milk, to which stimulants may be added 
according to the condition of the pulse. Rectal feediiLg may be necessary. 
Local applications may give relief, especially cold in the form of icebags, 
or ten or twelve leeches to the abdomen. Fomentations, either simple or 
with tincture of belladonna, relieve the pain. The most valuable drug is 
opium, for it relieves the pain, and reduces the peristalsis of the bowel, 
and so gives local rest. It may often be given in fluid form by the 
mouth, and can be tolerated in large doses. If vomiting persists it should 
be administered h3^odermically. If there is any doubt as to the advisa- 
bility of a surgical operation, either immediately or later, opium should 
be withheld, for by masking the symptoms it may lead to a continuation 
of medical treatment when operation is called for. It is therefore of use 
chiefly in local peritonitis, or in general peritonitis where an operation is 
not permitted. Purgatives are better avoided, but the lower bowel should 
be opened by means of enemata. The hiccough may be relieved by giving 
ice to suck, and by opium or chloral.- 



244 THE ABDOMEN [ f 171 



III. The jxUient complains of acute abdominal pain which is attended 
by coUapsey and the pulse is bapid ; there is absolute constipation, 
tinth inability to pass even flatus, and vomiting (at first of food, then of bile, 
and finally of stercoraceotis matter) — the condition is Acute Intestinal 
Obstbuction. 

Acute Intestinal Obstruction — i,e., obstruction coming on suddenly, is 
always a matter of serious importance, and every practitioner should be 
thoroughly acquainted with its several causes. In actual practice, when- 
ever the three symptoms, constipation, vomiting, and abdominal pain 
occur together, one of three conditions should be suspected — ^acute peri- 
tonitis, intestinal obstruction, or colic. 

The various causes of acute intestinal obstruction — the chief of which 
are External Hernia, Internal Strangulation, and Intussusception — are 
fully dealt with under Intestinal Disorders (Chapter XI.). Appendicitis 
is mentioned by some as a cause of intestinal obstruction. Appendicitis 
may first present itself as an acute disease ; it is described in § 175. 

§ 171. The patient complains of acute abdominal pain, with more or less 
collapse ; the temperature is probably normal or subnormal, but the symptoms 
do not quite conform to any of the preceding — some of the rarer causes are 
probably in operation, such as the following : 

IV. Diiplaoement of a Ora?id Uterus is known by the pain being referred to pelvis, 

and examination revealing the local mischief. It may occur when jumping from a 
height, and performing active exercise, espeoiaUy in early pregnancy (Chapter XIV.}. 

V. In Embolism of the Mesenteric Artery, a cause of embolism, such as endocarditis, 

is present. It is rarely diagnosed during life. The absence of symptoms pointing 
to the other causes may lead one to suspect embolism. Embolism of the sjileen may 
also cause severe symptoms. 

VL Acute Pancreatitis. — (1) The pain here is very sudden and severe, usually in 
the upper part of the left side of the abdomen ; (2) vomiting and constipation are 
usuaUy present ; and (3) there is usually tympanitic abdominal distension (see also 

S 181). 

Via. HsBmorrhage into the Pancreas is attended by : (1) severe and sudden pain in 
the upper part of the abdomen, and that part soon becomes tender ; (2) vomiting of 
increasing severity ; (3) symptoms of collapse, with the restlessness and subnormal 
temperature which accompany collapse when it is due to haemorrhage (§ 181). 

The Diagnosis of both of these conditions from intestinal obstruction or peif oration 
into the peritoneum is usually impossible before laparotomy. In both diseases death 
f it)m collapse is the usual result. 

VI 6. Acute inflammation (adrenalitis) or haemorrhage into the suprarenal capsules 
X>roduce8 symptoms similar to those of acute pancreatitis. There is sudden abdominal 
(epigabtric) pain, with vomiting and collapse. Death may occur in a few days. Or 
there may be convulsions and coma, or extreme muscular weakness for some days 
before death. It is rarely diagnosed during life. 

YII. The patient, whUe apparently in good health, complains of acuta 
abdominal pain, which has come on suddenly, withoat definite oollapse; 
the pulse does not exceed 1(X) ; there may be vomiting and conslipcUton, 
The case is probably one of the three kinds of Colic, though Appendicitis, 
Visceral Neuralgia and some other affections may start in 
this way. 
' § 172. Crolic is a somewhat vague term applied to spasmodic paroxysmal 



im] 



COLIO 



245 



pain situated in the abdomen. There are three kinds — ^intestinal, hepatic, 
and renal colic — and they have the following features in common : (1) The 
pain is extremely severe, and sudden in its onset ; (2) not infrequently 
there is vomiting from the severity of the pain ; (3) the face is pale and 
** anxious," and in severe cases the pulse is rapid and feeble, though it 
practically never exceeds 100 ; (4) the temperature is neither above nor hdow 
normal ; (5) the physical signs in the abdomen are negative, and the pain 
may even be relieved by pressure. In intestinal colic a hardening of the 
bowel may be appreciated by the palpating hand. 

(a) Intestinal Ccdio is due to distension and spasm of the bowel. The 
pain of intestinal colic is characteristically twisting, paroxysmal, and 
limited to the abdomen, principally around the umbilicus, and is relieved 
by pressure which distinguishes it from peritonitis. The abdomen may 
be distended with flatus. Sometimes it is followed or accompanied by 
diarrhoea, or, as in lead colic, by constipation. The pain of colic due to 
lead-poisoning may be the first sign of lead-poisoning, or may be accom- 
panied by a slow, hard pulse, with other sjrmptoms of plumbism, such 
as a blue line on the gums ; and a history of working amongst lead is 
obtainable (§ 405). 

(6) In Hepatic Crolic which is due to the passage of a gall-stone into the 
bile duct, the pain shoots upwards to the right shoulder and backwards, 
never downwards ; a dull pain continues during the intervals between the 
spasms. After lasting a few hours or a day or two it is followed by jaun- 
dice. A history of previous attacks assists the diagnosis. 

(c) Renal Ccdic is due to the passage of a calculus along the ureter. 
The pain radiates dovmwards from the loin to the thigh and the testicle of 
the same side, which is often retracted. It may last for a day or two. 
During the attack micturition is frequent ; sometimes there is hsematuria 
or strangury. There will probably be a history of gravel in the urine, or 
attacks of a similar nature. 

The Diagnosis of the forms of colic is given in Table XIII. 

Table XIII.— Dugnosis of Colic. 



Charader and DittribtUion 
of Pain. 



Intestinal. 



Biliary. 



Banal 



Aitoeiated Symptoms, 



Twisting, around umbiU- j Constipation (or diarrhosa). 
cus, paroxysmal ; re- No jaundice, 
lleved by pressure. 

I In right bypochondrium 
shooting upwards to right 
shoulder, constant, but 
also in paroxysms. 

In loin, shooHng down to 
thigh and testicle or 
ovary of same side. 



Jaundice soon supervenes. 
Other hepatic symptoms 
may be present. 

Crjrstals or other urinary 
change, hsematurla. Xo 
jaundice. Sometimes 
frequent micturition or 
strangury. 



Age and Sex of 
Patient. 



Any age or sex. 
Sometimes evi- 
dence or history 
I of plumbism. 

, Female sex. At or 
after middle life. 



Usually male. Chil- 
dren and adults. 



246 THE ABDOMEN [ {{ 17S, 174 

Prognosis, — The course of an attack of colic is short and severe. 

Treatment. — ^Por all fonns of colic some of the following measures — ^hot 
fomentations, a hot bath, belladonna, turpentine, opium, or chloroform, 
as local applications, and hypodermics of morphia (gr. ^, with atropin 
gr. vV) — ^^7 ^ necessary to alleviate the extreme pain. Large draughts 
of warm water shotild be taken. For intestinal colic in particular, a full 
dose of castor oil, with 20 minims of laudanum, should be given, followed 
by saline purgatives. For lead-poisoning, see § 405. Hepatic colic is 
treated under gall-stones (§ 241) and renal colic (§ 301). 

§ 178. Vni. ^rnong the rarer cantei of aoale aHominal pain without oollapse are 
Tarious OBscuBE OBOAino AFFECTIONS of the abdomen, evidenced at first only by 
pain. Two may bo mentioned which came under my notice, Pangrsatio Galcui«us 
and Obtubatob Hebkia, in both of which the only symptom for some time was pain 
coming on suddbkly without collapse. In the former the pain was extremely severe, 
and of a paroxysmal character, situated just below the umbilicus ; later on it was 
associated with fat in the faeces, emaciation, and glycosuria. 

Dislocated or Floating Kidney (§ 177), which is a moro frequent condition than 
Is usually supposed, may be attended by a constant (chronic) pain, or give rise to 
severe attacks (Diotl's crises), hardly distinguishable from intestinal colic. 

Appendicitis is also a cause of abdominal pain, which may be of sudden onset 
Sir William Macewen told me of the case of a young man who was suddenly seized 
with severe abdominal pain in jumping out of a hansom cab. But appendicitis is 
rarely so acute, and is therefore treated of more fully in § 175. 

In Splenic Embolism the pain is generally sudden in onset, but is not usually 
very severe or lasting, and is referred to the splenic region. Its most common cause 
is acute or chronic endocarditis, evidences of which are present (§ 47). 

In most obscure organic affections the pain comes on gradually, and is of a 
chronic character. Acute pain occurring in attacks of varying duration is met with 
in oases of membranous or mucous Colitis, and the Viscebal Neubalous. 
Diabetic Coma is sometimes heralded by pain, usually in the epigastrium, which may 
be very severe (§ 164). 

IX. In Viioeral Venndgin abdominal pain may come on suddenly and acutely, 
and may be for a long time the only symptom. 

1. Ofutralgia, or gastric neuralgia, is rare, but it is the most typical and best-known 
visceral neuralgia. The pain is severe, periodic, but usually relieved rather than 
Aggrav&ted by food or by pressure. The skin may, however, bo very sensitive to the 
flick of a handkerchief (§ 206). 

2. The gastric crises and neuralgia of the bladder or other viscera in association 
with tabes dorsalis, 

3. Neuralgia, or *' colic " of other viscera (i.e., pain in the viscus without functional 
or organic derangement), have been described by various authors — e.^., ovarian colic, 
vesical or splenic neuralgia, etc. — though these cases sometimes turn out to be con- 
nected with an undiscoverable organic disease, or with tabes dorsalis, 

4. The neuralgia which accompanies or follows herpes zoster. 

5. Angina Pectoris Is in some oases referred more to the abdomen than it is to the 
chest, but it is recognisod by the circulatory disturbances, etc. (§ 41). 

6. Migraine is certainly met with, alternating with abdominal pain. 

§ 174. By Chronic AMowinal Pain I mean that kind of abdominal pain 
which has come on somewhat gradually, and is running a chronic course. 
Chronic abdominal pain may be produced by a large number of causes 
which it would be impossible even to enumerate. It is only possible here 
to refer to those conditions which do not psssxnt signs or symptoms 
distinctly pointing to scone affection of the stohaoh, tiVER, spleen, or 



§ 175 ] CHRONIC ABDOMINAL PAIN 247 

other ABDOMINAX viscus. Abdominal pain is the leading or only symptom 

in the following conditions : 

L Appondioitis . . . • . . . . . . . • • • § ^^^ 

II. Chroixio intestinal obstniotion (malignant strictnie, simple strioture, 

pressure by a tumour, paralysis of the bowel, etc.) . . . . S 229 

III. Chronic peritonitis . . . . . . . . • • § 176 

IV. Movable kidney . . . . . . • • § 177 

V. Intestinal dyspepsia; VI. Enteroptosis ; VII. Obscure visceral and 

spinal disease ; VIII. Pancreatic disease . . . . §{ 178-181 

The history must be thoroughly investigated, and every organ thoroughly 
examined. Three features may afford us important clues : 

1. The POsmoN, character, degree, and constancy of the pain, and the presence 
of tendemew must be observed, (i.) If the pain and tenderness bo generalised, one 
may suspeot Tubercle or Cancer of the Peritoneum, (ii.) If they be situated chiefly 
in tho lower abdomen, one may suspect Appendicitis or incipient disease of the 
Bladder or Uterus, (iii.) If the pain be chiefly in the upper abdomen, incipient Gastric 
or liver disease. Thorough and espsatbd examinations of the abdomen, rectum, 
and vagina are nearly always necessary. The urine also should be repeatedly examined 
for gravel, etc., and the fceces (§ 215) for gall-stones. If there be general abdominal 
enlargomont, turn to { 182 ; if a localised tumour, turn to § 187. 

2. The AGS of tho patient, and the history and duration of the illness should be 
inquired into. In children perhaps the commonest of the obscure causes of chronic 
abdominal pain are intestinal worms and tuberculosis of tho peritoneum ; in the aged, 
incipient cancer of some organ. 

3. The STATS or thx bowsls, both previously and at the time of examination. 
In I., U., and III. above there is constipation, while in most of the other causes there 
is diarrhoea or irregularity of the bowels. 

The Abdominal Pain U constant^ hut liaUe to exacerbations, especially 
after exercise ; there is tenderness in the right iliac region ; the pulse is 
RAPID, and the temperature elefxited from time to time ; the patient is 
young. The disease is probably Appendicitis. 

§ ITS. Appendicitifl is much more common than used to be suspected, 
yet it is still frequently overlooked, especially in chronic cases. Appendi- 
citis may consist simply of a catarrhal inflammation of the vermiform 
appendix, which may go on to Ulceration, Peritonitis (usually localised), 
or Perforation, If it subsides, there is usually left some degree of inflam- 
mation which may be insufficient to cause appreciable symptoms, yet 
predisposes to attacks of a more acute nature. Acute appendicitis is often 
associated with an impaction in the appendix of intestinal concretions, 
which may have formed around some foreign substance such as a fruit- 
stone or toothbrush bristle. Inflammation may extend to the csBcum 
(typhlitis) or the surrounding tissues (perityphlitis). If the lumen is 
blocked, as by any foreign body, an abscess forms in the tip of the appendix, 
with localised peritonitis. If the disease subsides at this stage, adhesions 
are formed which, when they contract, may kink the lumen and give rise 
to another attack. The inflammation may go on to ulceration and per- 
foration, and a localised peritonitis, again with the formation of adhesions, 
may result. On the other hand, adhesions due to a former attack may 
not be dense or widely distributed enough to prevent the occurrence of a 
generalised peritonitis. If the localising inflammatory reaction of tho 



248 THE ABDOMEN [ 1 176 

peritoneum is adequate, an abscess will form, and may give rise to very 
few symptoms, or may gradually extend until its subsequent treatment 
becomes very difficult and fraught with grave danger to the patient. 
The results of such extension, which may be very slow or extremely 
rapid, are subdiaphragmatic abscess, pyosalpinx, rupture into the bowel 
or bladder, or externally above Poupart's ligament. It is very rarely 
now that cases are allowed to reach such an advanced stage that the last 
complication can occur. In acute cases the complications most to be 
feared are general peritonitis, perinephric abscess, and implication of the 
liver by spread along the vessels or lymphatics. 

There are two clinical forms of appendicitis : Acute or recurrent, and 
chronic appendicitis, (a) In Chbonic AppENDicrris there may be no 
symptoms other than pain in the right iliac region increased after any 
over-exertion. Sometimes the pain is referred to another part of the 
abdomen ; sometimes there is also alternating diarrhcea and constipation ; 
there may or may not be local signs of swelling or tenderness, and a history 
of general malaise. One form of chronic appendicitis is due to malignant 
disease or tuberculosis of the appendix. 

(6) Recurrent Appendicitis consists of recurring acute attacks. Here 
again the course of the disease is essentially a chronic one, with a constant 
liability to a recurrence of the inflammation. After this has subsided the 
patient may go on for many months in apparent health. Possibly he may 
never be troubled again, but in the vast majority of cases a fresh attack 
of inflammation occurs sooner or later. 

Symptoms, — ^In a typical acute attack of appendicitis there are three 
symptoms, which, occurring in a young person, point to appendicitis — 
pain with tenderness, local resistance or swelling, and quickened pulse. 
(1) The chief symptom, as above mentioned, and sometimes the only one, 
is pain with tenderness, usually situated in the right iliac region. The 
tenderness is generally fixed, and is nearly always in this situation ; but the 
pain has a tendency to radiate, and it may be referred to the umbilical, or 
even to the left inguinal region. Special tenderness is present at " Mac- 
Bumey's point" — i.e., midway between the umbilicus and the right 
anterior superior iliac spine. (2) There is a feeling of resistance or rigidity, 
or an indefinite tumour, with dulness to percussion, in the right iliac fossa. 
This local swelling may be due to abscess formation or to septic infiltration 
of the subcutaneous tissues. (3) The pulse is quickened and thready. It 
forms the best single indication of the acuteness of the progress of the 
attack. The temperature very often falls with the onset of gangrene, but 
the pulse, except in very rare cases, remains rapid. The temperature 
usually rises soon after the onset of the pain, and remains about 100^ to 
102*' F. for a few days (Fig. 106, § 384). (4) Vomiting may be urgent at 
the onset of an attack ; when it continues for many days the prognosis is 
imfavourable. Constipation is usually present, so that the case is apt to 
be mistaken for intestinal obstruction ; but in some cases the attack is 
ushered in with diarrhoea. The urine is scanty, and the bladder irritable. 



§ 176 ] APPENDICITIS 249 

Course and Prognosis. — When an acute attack, as above described, sets 
in, there are three possible events — recovery, local abscess formation, or 
general peritonitis. (1) In a favourable case the temperature falls about 
the third day, the swelling disappears, pain and other symptoms subside, 
and the patient may be well in ten days. In other cases slight fever per- 
sists for a few weeks, and there is left an indurated swelling due to adhesions. 
The patient may go about for months or years with chronic appendicitis, 
and apart from vague pains, general malaise, and dyspeptic symptoms 
suffer no inconvenience. At any time, however, he is liable to have a 
recurrence of the acute symptoms. (2) When the general symptoms show 
no improvement by the third day, and the local swelling progressively 
increases, it is probable that an abscess is forming. (3) Perforation, with 
generalised peritonitis, may occur at any time. The general symptoms 
in such cases are much more severe, vomiting persists, and the abdomen 
is distended and motionless by the second or third day. There is no 
disease in which it is more dangerous to hazard a prognosis. An appar- 
ently convalescent case may develop general peritonitis and die within 
twenty-four hours ; on the other hand, a case presenting every sign of a 
large and extending abscess may clear up entirely and prove free from any 
subsequent attack. Apart from the great improvement in the prognosis 
when immediate operation is performed, the only indications of value 
for the purpose of forming an opinion are the condition of the patient as 
regards shock, collapse, and age. The younger the subject, the more 
likely is the disease to prove fatal. 

Treatment. — Rest in bed and light diet are essential. Hot fomentations 

locally are useful for the pain. Opium in small doses (short of causing 

drowsiness) is also admissible for the relief of pain after the diagnosis is 

established. It should not be given for long, as it confines the bowels. 

Other hypnotics may be employed. * 

The question of operation requires careful consideration, and a surgeon should be 
early in touch with the case. The largest proportion of recoveries is recorded in cases 
operated on within twenty-four hours of the onset of symptoms which enabled a 
diagnosis of appendicitis to be made. The subsidence of symptoms is not necessarily 
a oontra-indication to operation. The onset of gangrene, in particular, may cause a 
sudden subsidence of all signs of acute disorder ; even the pulse rate may return to 
within normal limits. The most valuable sign, in the absence of clinical indications, 
is the presence of a leucocytosis. If this goes above 20,000, or is found to be rising 
when two or more estimations are made at intervals, there is so strong a presumption 
of pus formation that immediate operation is indicated. If, by this or by other moans, 
the presence of pus is diagnosed, operation must not be delayed. Delay for even a 
few hours, as, for instance, when the patient or his friends are unwilling that he should 
be removed to a hospital or home ** until the morning," has on many occasions proved 
fatal from the onset of collapse of such severity that the patient's strength was not 
sufficient to carry him through even the shortest operation. 

In addition to chronic abdominal pain, there is a history of constipa- 
tion, gradually increasing to complete stoppage of the bowels, with the 
gradual supervention of vomiting. The case is probably one of Chronic 
Intestinal Obstruction. 



260 THE ABDOMEN [ § 176 

In Chronic Intestinal Obstniotion (§ 229) the abdominal pain is more 
or less generalised and intermittent. The constipation may at first have 
alternated with diarrhoea, but after a time it is so complete that not even 
flatus can be passed. Vomiting, at first of food, and later fseculent matter, 
a rapid pulse, and other constitutional symptoms ensue if the condition 
is not relieved. The four commonest causes are Malignant Stricture, 
Simple Stricture, Pressure of a Tumour, and Paralysis of the Lower Bowel. 

The abdominal pain is chronic and generalised ; it is attended hy 

CONSTITUTIONAL SYMPTOMS, and SOme ABDOMINAL ENLARGEMENT OT Other 

local signs. The disease is probably Chronic Peritonitis. 

§ 176. Chrohic Peritonitifl nms a slow and chronic course, and is usually 
attended by a certain amount of generalised pain. There is a simple or 
idiopathic chronic peritonitis, but two more frequent forms are : (a) That 
due to tuberda, and (6) that due to cancer — two conditions which, by the 
way, are met with at the opposite extremes of life, and which present a 
very marked contrast both in their clinical and anatomical features. 

In Chronic Tuberculous Peritonitis (tuberculosis of the peritoneum, 
abdominal tuberculosis) the patient is nearly always a child. There is a 
deposit of tubercle in the peritoneal tissues, and the intestines become 
matted together hy adhesions. Sometimes fistulous openings form between 
different portions of the bowel. (1) Pain and tenderness are present, but 
are not very marked features, except during one of the subacute or acute 
exacerbations which arise. (2) Tuberculous peritonitis is contrasted with 
cancerous peritonitis by its marked tendency to the formation of adhesions 
without fluid, while in cancerous peritonitis there is effusion of fluid without 
adhesions. As a consequence of the adhesions and the deposit of tubercle, 
knots or thickenings can be felt through the abdominal walls, which have a 
very characteristic doughy or " boggy" feeling. (3) Fluid may be present 
when the disease occurs in young adults, and in acute cases. As the 
disease advances there is considerable tympanitic distension. (4) Local 
tumours may be felt in some cases, the most characteristic being a sausage- 
shaped band produced by the rolled and infiltrated omentum running 
transversely across the abdomen below the edge of the liver. Hard 
tuberculous masses can often be felt aroimd the umbilicus. Other tumours 
are produced by matted mesenteric glands or cystic collections of fluid. 
(5) There are emaciation and hectic fever — i.e., morning temperature 
normal and an evening rise of 2° or 3° F., as in all active tuberculous 
processes. (6) Tubercle is generally found in other parts also, especially 
in the lungs. (7) In one form of this disease in children a tuberculous 
abscess forms, which points at the umbilicus, and gives rise to a fersistent 
discharge from the navd {/cecal fistiUa), 

Diagnosis. — The acute variety, especially when active near the caecum, 
suggests appendicitis, but is recognised by the course of the disease. 
Cirrhosis of the liver is rare in children, and in adults tuberculous 
peritonitis is rare ; both may be overlooked. In the latter jaundice and 



S 177 ] ^ CHRONIC PERITONITIS 251 

dilated umbilical veins are absent, and rectal examination may detect 
enlarged glands. A positive tuberculin test assists diagnosis in difficult 
cases. The ascitic fluid in cirrhosis contains chiefly endothelial cells ; in 
tuberculous peritonitis Ijonphocytes predominate. Inoculation of guinea- 
pigs with the fluid is a crucial test. 

Prognosis and Treatment, — The prognosis is very serious, though not 
so bad as formerly. Much may be done by treatment on the same lines 
as for pulmonary tuberculosis. Sedatives may be used if much pain be 
present. If the temperature is raised, the patient should be kept in bed. 
Guaiacol, thiocol, and iodide of iron are the most useful drugs. The 
abdomen should be kept at rest by bandaging, and rubbed with blue oint- 
ment. Starchy foods causing flatulence should be prohibited. Tuberculin 
treatment has been tried. Laparotomy is contra-indicated in generalised 
peritonitis, but is called for where there is local abscess formation. 

Chbonic Cancerous Peritqnitis (Cancer of the Peritoneum) is always 
attended by much pain, constant, but also in paroxysms. There is a 
great tendency to the rapid formation in the abdominal cavity of fluid 
which is nearly always tinged with blood. It arises only in late middle or 
advanced life. Its recognition is easy in typical cases on account of the 
age, acute pain, and ascites (under which heading it is described, § 185). 
Sarcoma of the peritoneum is rare. 

Chronic PsitiTOinns of the simple or idiopathic type is very difficult to diagnose 
in the majority of oases, because of the extieme variability and vagneness of the 
symptoms. (1) Pain and tenderness, sometimes localised, are present, worse at times 
and with exertion ; (2) dyspepsia, often constipation, sometimes vomiting ; (3) malaise 
with pyrexia from time to time ; (4) palpation may detect localised thickenings and 
areas of resistance ; (5) ascites is present in some cases ; in other cases it is absent, 
and the abdomen is very flat. 

Etiology, — (1) After an attack of. acute peritonitis ; (2) inflammation of any organ 
may cause localised peritonitis ; (3) after paracentesis without strict asepsis ; (4) idio- 
pathic, due to unknown causes. It may occur with Bright's disease and other general 
conditions, in which two or more of the serous membranes (pleura, pericardium) 
become simultaneously affected (polyorrhomenitis or polyserositis). 

The Diagnosis has often to be made by a process of exclusion, especially when 
there is no history of acute peritonitis nor of inflammation of any organ. Sometimes 
it is indistinguishable from tuberculous and cancerous peritonitis. Abdominal pain 
simulating gastralgia or colic may be due to peritoneal adhesions. When ascites 
reappears after repeated tappings peritonitis is usually present. 

The Prognosis as to life is good in mild cases, though chronic invalidism is apt to 
ensue. Subacute attacks are liable to occur, and there may be great exhaustion and 
emaciation from involvement of some part of the alimentary canal, or from the 
formation of local abscess. Adhesions may lead to intestinal obstruction. 
. Treaknent, — Rest and supporting belts may give relief. Inunction with blue oint- 
ment or applications of Tr. Iodine (1 in 3 of water) are useful. Paracentesis and 
surgical treatment may be required. 

The pain is of a ^*^ dragging " character y increased by exertion, accom- 
fanied by dyspeptic and oAer vague symptoms. The disease is possibly 
Dislocation of the Kidney. 

§ 177. Movable Kidney (also called Dropped, Dislocated, or Floating Kidney, 
according to the degree of mobility). — ^This condition is by no means uncommon, and 



262 THE ABDOMEN [ § 178 

does not usually givo rise to symptoms unless the degree of mobility is oon- 
siderable.^ 

The Physical Signs can only be discovered by palpation of the abdomen, with the 
patient lying down. The method of palpating the kidneys is given in § 292. With 
the patient in the erect or sitting posture, the ^dney comes down more during inspira- 
tion than when lying down. After a little practice she will be able to lean forward 
and relax her muscles, which is an important aid to the observer. The left kidney 
rarely falls below the umbilicus, but the right one may be displaced into the iliac 
fossa, and even into the pelvis. 

Symptoms. — In a few cases two kinds of pain may be experienced : (a) A constant 
dull, dragging pain in the back, or perhaps only an uneasiness in the loin, radiating 
down to the groin and inner side of the thigh, relieved by rest ; (6) attacks like renal 
colic, which may be followed by the passage of blood and albumen, and are due to the 
kinking of the ureter. Such are called " DietFs crises." Sometimes hydronephrosis 
results. Neurasthenia is often associated, with mental depression or symptoms of 
dyspepsia, vertigo, diarrhoea, or constipation. 

Etiology, — ^The fact that a very much larger percentage of women than of men 
have movable kidney is attributed by Suckling to the wearing of corsets. A fall or 
strain will also displace the organ, and that is why it is advisable for those with spare 
abdominal muscles to wear a belt when at work in the gymnasium. Attendants at 
refreshment bars, who have to draw beer or draw corks often suffer from movable 
kidney. It is said to be extremely common among those who suffer from migraine 
(owing possibly to the retching which is a feature of that condition), and it occurs more 
often in tall than in short people. Rapid loss of fat, or lowering of the intra-abdominal 
pressure, such as occurs after delivery, are frequent causes. 

Treatment, — Bromides and rest will relieve the patient for a time, and any con- 
current dyspepsia must be remedied ; but the radical treatment consists either in 
the wearing of a proper form of belt, or an operation for stitching up and attaching 
the kidney in position. The abdominal belts usually supplied by instrument makers 
are not very successful, but Suckling has designed an apparatus ^ for applying additional 
pressure outside the belt, which he claims does away with the necessity of operation, 
and is permanently successful. Fattening of the patient is often a successful means of 
relieving the symptoms. 

Among the rarer oaosM of chronic abdominal pain may he mentioned Visoerai« 
Nbubalols (§ 173), Intestinal Dyspepsia, Entbboptosis, Incipient Spinal or 
Visceral Disease, and Disease of the Pancreas. 

§ 178. Inteitinal Dyspepiia and Intei tinal Catarrh are conditions which it is some- 
times difficult to distinguish, and some doubt whether they ought to be described as 
separate entities. The patient complains of obscure and erratic pains in different 
parts of the abdomen, and of irregular attacks of diarrhoea and constipation brought 
on by slight dietetic errors or exercise. There is generally a good deal of flatus passed 
per rectum ; the faeces are offensive, very often fermenting, and contain a good deal of 
undigested food. When there is rectal or intestinal catarrh, there is a certain amount 
of mucus (see § 215) and specks of blood (not streaks, such as come from piles) in the 
faeces. Excess of inorganic ash in the faeces points to catarrh, especially of the colon. 
There may be prostration, nervousness, and ready fatigue. The disease is inconvenient 
and often intractable. In view of the large number of organisms normally found in 
the intestinal contents, any continual damage of the intestinal wall is to be deprecated, 
since the bacilli can more readily make their way through a damaged wall, and in this 
way give rise to what used to be called idiopathic peritonitis and other troubles. 

Treatment. — ^The indications are : (1) To prevent the decomposition in the intestines ; 
(2) to allay the catarrh. Forbid those articles which are not digested. In some, fruit 
and vegetables cause the dyspepsia ; in others, carbohydrates. The patient may 
derive benefit from diet consisting entirely of boiled milk for a time. Constipation 
should never be allowed ; castor oil (which can be given in capsules) is useful Intesti- 
nal antiseptics are beneficial, such as salol and salicylate of bismuth. Enemata or 

1 Dr. Hector Mackenzie, the Lancet, vol. i., 1907, p. 1362, and vol. ii., 1907, p. 1140, 

2 Supplied by Messrs. Salt, of Birmingham. 



§S 179, 180 ] ENTEROPTOaia 263 

large antiBoptio intestinal douches (3 to 5 pints) are given once a week in ohronic oases 
with excellent results. (See Colitis, § 221.) 

§ 179. Enteroptoiii (synonyms : visceroptosis, Gl^nard's disease, abdominal ptosis, 
dropping of the viscera) is a condition in which there is a general ptosis, or downward 
displacement or dropping of one or more of the movable abdominal viscera. Any of 
the viscera may be dropped in this way, owing to laxity of their ligaments or mesentery 
— ^liver, spleen, kidneys, and even intestines (Gl^nard). In many oases no symptoms 
are present. The most constant are : (1) Pain or a sense of weight or dragging in 
the abdomen, and sometimes in the back, accompanied by a feeling of sinking, or of 
emptiness or hollowness, is frequently present. ITrom time to time the pain may 
assume a colicky character. It has been noticed in many cases that there is tender- 
ness at a localised spot a little to the left of the middle line, just above the level of 
the umbilious. (2) There is generally nausea, and from time to time vomiting. 
Symptoms of dyspepsia are usually present. (3) Sometimes there is diarrhoea, but 
more often constipation, and it is a special feature that aperients seem to cause con- 
siderable distress. (4) Groat depression, nervousness, a general unfitness for all forms 
of exertion, and, indeed, all the symptoms of neurasthenia, may ensue, and the 
patients are apt to drift gradually into hyperohondriasis. (6) The examination of the 
abdomen should be made while the patient is standing erect. The position of the 
viscera should then be marked, and afterwards an examination should be made with 
the patient in a recumbent posture. X-ray examination after a bismuth meal its 
used to reveal ptosis of the intestine or stomach. In marked cases the symptoms 
are considerably aggravated by the erect position, and they may be relieved by 
lying down, by pressing on the lower abdomen, or by wearing a supporting bolt. 
Undoubtedly in many cases a displacement of the viscera can thus be made out, 
and when the patient is upright, a normal sized liver, or even a kidney, may be mis- 
taken for a tumour. 

• The Prognosis as regards recovery ia very uncertain. On the other hand, the 
condition is not fatal, and much can be done by judicious treatment if the physician 
secures his patient's confidence. The lives of these patients are often very miserable. 

Treatment. — The indications are : (1) To relieve the nervous symptoms ; (2) to 
relieve the dyspepsia ; (3) to support the viscera. Much relief may be derived from 
wearing a well-fitting, adjustable abdominal belt. Flannel is the best material if 
the patient's skin tolerates it. The treatment of the neurasthenic symptoms and 
dyspeptic symptoms respectively is given elsewhere (Chapter X.). In severe cases 
which resist milder measures the idea of operative procedure should certainly bo 
entertained. Cases have been recorded in which all the symptoms disappeared after 
a simple abdominal incision, and the subsequent compulsory rest. In other cases 
definite organic lesions were found within the abdomen, which had not been detected 
during life, and which apparently caused the displacement. 

i 180. Incipient or Obicnre Viiceral or Spinal Diiease. — (a) In oases of chronic pain 
QEKEBAUSED ovEB THB ABDOMBN, and in the absoncc of constipation, diarrhoea, or 
any of the causes mentioned under § 174 onwards, one might suspect cancer of the 
intestines, of the pancreas, or of the kidney, cancer or tubercle of the supraronals 
(i.e., Addison's disease, in which pain over the stomach is a constant sign), or other 
incipient disorders, rheumatism of the abdominal muscles, enteroptosis, or movable 
kidney. Children may su£fer from recurrent attacks of abdominal pain for which 
no cause can be found. Such cases should be treated as incipient intussusception — 
that is to say, avoid puigatives and give digestible foods and small doses of opium. 

(6) In various spinal affections the pain is frequently referred to the fbont of 
THB ABDOMEN, and among the more obscure causes may be mentioned abdominal 
aneurysm pressing on the spine, and cancer or caries of the vertebrae. The first of 
these occurs mostly in male adults, the second in the aged, and the third (Pott's 
disease) in children. In the latter the child frequently refers to the pain as '" stomach- 
ache," worse after running about. The girdle pain of chronic and acute myelitis 
should also be borne in mind. 

(c) If the patient complain of pain situated chiefly in the lower abdomen, 
one might suspect appendicitis {vide supra), cancer or other disorders of the bladder, 
peri- and para-metritis (in which there is a good deal of pain shooting down the legs). 



254 THE ABDOMEN . [ § 181 

extia-utorine pregnancy, pyosalpinz, dysmenorrhoea and all its causes, uterine neu- 
ralgia, tubercle or cancer of the prostate or testes, and obturator hernia. Hemor- 
rhoids are sometimes attended by pain in the abdomen (which disappears upon the 
cure of these), and so also are new growths and various ulcers of tiie lower bowel. 
Among the unsuspected causes I have seen pelvic hydatid in a boy of ten. The 
fatigue pains of debilitated women may be referred to one or other iliac region. 

{d) Pain situated chiefly ik the ttppeb abdomen may bo due to various affec- 
tions of the liver, stomach, and spleen. Among the painful affections of the livtr, 
perhaps passive congestion, gall-stones and acute cholecystitis, perihepatitis, and 
cancer are the commonest ; hydatid is one of the obscure conditions, tiiough it is 
rarely painful. Abscess above or below or within the liver should be suspected in 
those who have resided in tropical countries. Among the painful affections of the 
stomach may bo mentioned gastric (or duodenal) ulcer, gastritis (acute or chronic), 
cancer of the stomach — ^which in its most usual form, scir^us of the pylorus, is com- 
monly veiy obscure in its early stages — and gastralgia. Painful affections of the 
sjdeen are not common, the chief being infarction, but the capsule is sometimes the 
seat of a painful inflammation. The enlargement of the organ aids the diagnosis. 

§ 181. DifeasM of the Pancreas are fortunately rare, for they are always very obscure, 
and are often unrecognisable during the life of the patient. 

As far as our present means of investigation go, the Sympknns to which they give 
rise are : (1) Abdominal pain, deep-seated in the epigastrium, radiating to the loft 
shoulder, and round the left loin ; (2) nausea, and vomiting of glaiiy mucus, anorexia, 
and acid eructations ; (3) great debility, rapid emaciation, and mental depression ; 
(4) undigested fat and muscle fibre in the faBces ; (5) glycosuria ; (6) frequently jaun- 
dice ; (7) a tendency to htemorrhage ; (8) the pancreatic reaction in the urine. Dr. 
P. 8. Cammidge ^ has described a reaction in the urine, which he believes to be diag- 
nostic of pancreatic disease. Certain crystals are obtained from the urine, which are 
said to differ in cases of pancreatitis from those obtained in cases of pancreatic car- 
cinoma. (9) When salol is admimstered by the mouth for twenty-four hours, it does 
not appear in the urine as carbolic acid. (10) Sahli*s test : the administration of 
glutoids of iodoform, hardened in formalin, is not followed by the appearance of 
iodoform in the urine. As to Physical Signs, a tumour may be felt only when the 
disease is veiy advanced. 

The diseases of the pancreas which have been recognised, chiefly after death, are 
as follows : 

I. HiSMOBBHAOE WITHIN THE Pangbeas, a rare condition, which, if of any extent, 
causes death in twenty-four hours, or less (f 171). 

II. Pancbeatio Cysts. ^ due to obstruction or obliteration of the duct by biliary 
or pancreatic cakub', or cicatricial contraction. An injuiy to the abdomen is the 
chief cause. The swelling appears between the stomach and the colon, and does 
not move with respiration. Fatty diarrhoea is rare. The fluid withdrawn by. aspira- 
tion will emulsify fat, convert starch into sugar, and digest fibrin. The prognosis is 
good with suigical treatment. 

m. Pancbeatio Calculi are small concretions consisting chiefly of carbonate of 
lime. They are visible on X-ray examination, a diagnostic feature which distin- 
guishes them from biliaiy calculL 

IV. Acute Pancbeatitis is met with in three forms : (1) Acute Hmmorrhagic Pan^ 
creatitis, which sc^ts in suddenly with agonising pain, and results in death in one to 
four days (§ 171). (2) Acute Suppurative Pancreatitis begins suddenly with pain and 
iiTogular pyrexia, and may lead to death in three or four hours, but Fitz's cases more 
often became chronic, and lasted some months. There may bo several small or ono 
large abscess. (3) Gangrenous Pancreatitis, in which necrosis of the organ oocurs, and 
it may be passed as a slough by the bowel. Two of Pitz's cases recovered. 

^ Bobson and Cammidge, " Diseases of Pancreas,'* 1908. 

^ A case of retroperitoneal rupture of a pancreatic cyst occurring in a young man 
about twentv-five years of age was admitted in the Paddington Infirmaiy with all the 
symptoms of acute peritonitis. Laparotomy was performMl by Sir Freclerick Treves, 
but nothing was found until after death, forty-eight hours later. The origin of the 
cyst was not even then discovered, but the cellular tissue behind the peritoneum was 
infiltrated with the usual pultaceous materiaL 



§ 1S2 DISEASES OF THE PANCREAS 255 

V. CuRONio PAircREATiTis ^ is a fibiosis of the oigan which mostly runs a latont 
course, but has received considerable attention of late yeais because it is frequently 
associated with diabetes, especially in those cases where atrophy of the gland ensues. 
Tho onset is insidious ; discomfort and distension in the epigastrium is felt after 
meals, and drowsiness. Borboiygmi and offensive stools, anemia and emaciation 
follow. Paroxysmal pain is complained of above and to the right of the umbilicus, 
and tenderness can be elicited there. The pain may be referred to the left scapula. 
Lator, by affecting tho bile-duct, it produces jaundice, with dilatation of the gall- 
gladdor, and thus resembles gall-stones and cancer of the head of the pancreas. 

Tho diagnosis is difficult in early stages, and requires expert analysis of the excreta. 
Cammidge*s '* pancreatic reaction " and the presence in the urine of indican, calcium 
oxalate crystals, bile, and urobilin, are suggestive of pancreatitis. 

Pancreatic Diabetes. — ^The association of glycosuria with pancreatic calculus 
was first pointed out by Cowley in 1788. But it was Lancereaux, in 1877, who 
maintained there was a special form of diabetes dependent on grave alterations in 
tho pancreas (Pancreatic Diabetes), characterised by polyuria, excessive thirst and 
appetite, rapid loss of flesh, and glycosuria. Pancreatic diabetes may, however, 
occur with lesions of the pancreas other than chronic pancreatitis ; and grave altera- 
tions of the organ may exist without diabetes. 

VI. Cancer of the Pancreas may be primary or secondary, and is a rare con- 
dition. It is said to occur in about 6 per cent, of all cancers (Segro). The symp- 
toms are : (1) Pain in the epigastrium, which at first occurs in paroxysms, then 
becomes constant, and runs a chronic course. (2) Symptoms of gastric disorder 
may be present for months before any other symptom. (3) Jaundice, intense and 
persistent from the pressure on the bile-duct, is usually present, and sometimes pain 
like biliary colic accompanies this. (4) Tho other symptoms are those above described. 
(5) Later on a tumour is found in the epigastrium or in the umbilical region, with 
little or no mobility, deep-seated, and hard to define. (6) (Edema of the legs, from 
pressure on the inferior vena cava, may occur. 

The Diagnosis of cancer and other tumours of the pancreas is always difficult. 
A tumour of the liver, pylorus, or transverse colon, is more mobile. Much indican 
in the urine points to an intestinal rather than to a pancreatic tumour. No great 
stress can be laid on the presence of fat in the faeces, or on glycosuria, but abundant 
undigested muscle fibre found in the faeces is more characteristic of pancreatic disease. 
Gross's and Sohlecht's tests for trypsin in the faeces assist the diagnosis of advanced 
pancreatic disease. 

Prognosis. — ^In cancer of the pancreas death usually occurs within four weeks after 
the onset of jaundice, or six weeks after ascites sets in. Emaciation and debility 
may not come on till late in the disease. The complications are : (i.) Symptoms due 
to pressure on the neighbouring organs — intestine, stomach, or portal vein ; (ii.) sudden 
haemorrhage into the alimentary tract or the peritoneal cavity ; (iii.) pulmonary 
embolism. Sudden death occurs in the last two. 

Treatment is mainly symptomatic. Starches and sugars should ]^ limited. Milk 
and casein are the most digestible forms of proteid in pancreatic disease. The 
administration of pancreatin, pancreon, or similar preparations may aid the diges- 
tion. Duodenal catarrh may be allayed by bismuth salicylate ; and urotropin dis* 
infects the biliary passages. Opening and draining the gall-bladder has been suc- 
cessful in cases of pancreatitis accompanied by jaundice, and other surgical measures 
are employed for tJie several diseases of the pancreas. 

GENERALISED ABDOMINAL ENLARGEMENT. 

§182. Classiflcation. — Generalised abdominal enlargement occurs under 
four conditions : 

I. Solid abdominal tumours . . . . . . . . . . § 188 

II. Gas in the intestines (tympanites), or occasionally in the peritoneum § 183 

III. Fluid free in the peritoneum (ascites) . . . . . . • • § 185 

IV. Ac 3r8tic oolleotion of fluid in the abdomen . . , . . . § 180 

^ Cammidge, the Lancet, June 3, 1911. 



256 THE ABDOMEN [ § 183 

The Routine Frocedurey as previously described (§ 167), should be by 
Inspection, Palpation, Percussion, Auscultation, and Mensuration. 

It must be remembered that much fat in the abdominal wall or 
within the abdomen, enteroptosis, and other causes mentioned under 
Fallacies in § 166, may give rise to difficulty in diagnosis of the above 
conditions. 

If a hard tumour can be felt in any part, turn first to § 188. 

If the abdomen is quite soft to palpation and resonant all over, turn 
first to § 183. 

If the abdomen is dull to percussion in the flanks, and presents the 
fluctuation test, turn first to § 185. 

If the abdomen is resonant in the flanks and dull in front, turn first to 
§186. 

The abdomen is uniformly enlarged ; it is soft and yielding to jxUpation ; 
and percussion, systenuUicaUy conducted over the whde area, gives a resonant 
note. The swelling is probably due to tympanites. 

§ 188. Tympanites is the term employed for a flatulent distension of 
the stomach and intestines by gas. It should be remembered that flatu- 
lent distension may accompany and render obscure a small quantity of 
fluid in the peritoneum. 

The Causes of tympanitic enlargement are as follows : 

I. Atonic and other forms of Dyspepsia are the most frequent causes 
of flatulent abdominal distension. It is usually intermittent, and is 
generally greatest after meals (§ 204). 

II. In Atony op the Colon the bowels are constipated, and the patient 
is liable to ** colicky " pains ; but there are few constitutional symptoms 

(§ 227). 

III. In Tuberculous Peritonitis there is a tendency to the formation 
of intestinal adhesions and flatulent distension. In tuberculous peritonitis, 
moreover, the distended abdomen has a doughy feel and here and there 
a patch of dulness on percussion, which is quite characteristic (§ 176). 

IV. " Phantom Tumour " may assume the shape of a generalised more 
or less resonant enlargement, but it more often resembles a localised 
tumour (§ 188). 

V. In Obstruction of the Bowels there is considerable abdominal 
distension, accompanied by pain, vomiting, and other general constitu- 
tional disturbance (§§ 228 and 229). 

Gas in the Peritoneal Cavity gives much the same signs as tympanites, only 
there is extreme distension, and hyper-resonance all over to such a degree 
that the normal dulness of the liver and spleen is obscured. It is met 
with only when perforation of some part of the alimentary canal occurs. 
The patient is collapsed, and presents all the symptoms associated with 
perforation (§ 1G9). A few hours after the occurrence of the perforation 
a delusive liill occurs in the collapse and other symptoms, only to be 



§5 184, IW ] FLUID IN THE PERITONEUM ^ASCITES 257 

sacceeded by a fatal exacerbation. Perforation of gastric tdcer is the 
commonest cause, and one of the diagnostic features of this condition is 
the loss of the normal area of liver dulness. 

There is uniform abdominal enlargement, which is soft and yielding to 
palpation and dull to percussion in parts; the fluctuation sign is 
present. There is Fluid wrrnm the Abdomen. 

§ 184. When there is Fluid in the Peritoneal cavity, either free or 
encjrsted, the belly is soft to palpation, dull to percussion in parts 
(either in the flanks or in front), and the measurements show the abdo- 
men to be um'formly enlarged. 

When the fluid is in any quantity, two special signs can be elicited. 
(1) Fluctuation test, — ^When a large amount of fluid is present, a wave 
of fluctuation may be seen to travel across the surface when we tap or 
" flip " one side. This can only be satisfactorily elicited when the abdo- 
men is full and tense. (2) Percussion test, — ^A percussion wave can be 
transmitted from one hand to the other through the fluid by the law that 
fluids transmit pressure or a blow equally in all directions. Place the left 
hand over one side of the dull portion, and tap sharply with the fingers 
of the right hand over the opposite side ; an impulse will be felt by the 
left hand if fluid be present. In applying the " percussion test " for fluid, 
an assistant should place the edge of his hand vertically on the umbilicus. 
This will prevent the wave or impulse from travelling across the surface 
of the omental and subcutaneous fat instead of through the fluid. Neither 
of these signs can be elicited in a gaseous enlargement or a solid tumour. 
In obese persons considerable difficulty arises in the detection of fluid. 

The fluid may be either (a) free in the peritoneal cavity, when it is termed 
ascites ; or (6) enclosed in a cyst, such, for instance, as an ovarian cyst. 

(a) If FREE in the peritoneal cavity, it will obey the law of all fluids, 
and shijl unth the position of the patient. Thus in ascites (§ 185) when 
the patient is on his back you will find both flanks are dull to percussion, 
and the umbilical region is resonant; then, if the patient turns on one 
side you will find that the uppermost flank which before was dull is now 
resonant, while the umbilical region, if there is much fluid, is dull. Much 
may be learned from the character of the fluid withdrawn by a trocar. 
Ascitic fluid is straw-coloured, with much albumen. HsBmorrhagic fluid 
usually means cancer. 

(b) If the fluid is encysted — e.gr., ovarian cyst, we can still elicit the 
fluctuation and the percussion tests just referred to, but the level of the 
dulness will not alter with the position of the patient (§ 186). 

There is a generalised uniform enlargement of the abdomen, which gives 
all the SIGNS of flxhd, and the fluid alters its level tvith the position of 
the patient. The condition is Ascites. 

§ 185. Ascites is a term applied to an effusion of non-inflammatory fluid 
within the peritoneum (dropsy of the peritoneum). The physical signs of 

17 



258 THE ABDOMEN [ § 185 

fluid have just now been described above. It is sometimes difficult to 
detect a very small quantity of fluid in the peritoneum, but its existence 
is rendered probable (i.) by the dulness on percussion of the umbilical 
region with the patient on his hands and knees, and (ii.) by finding that 
when the patient turns from one side to the other, the flank which was 
dull is now resonant. 

Ascites may have to be Diagnosed from any of the cystic conditions 
mentioned below (§ 186), but certainly the most frequent and important 
source of difficulty is ovarian cyst. In ascites (i.) the flanks bulge, (ii.) the 
front is flat and resonant, and (iii.) both flanks are dull, but if the patient 
turns on his side the upper flank becomes resonant — three features which 
are the exact reverse of those found with ovarian and other cystic tumours 
(see also table on p. 261). Occasionally peritoneal adhesions (especially 
cancerous) may confine the fluid to one part of the abdomen, and then the 
fluid does not shift with the position of the patient. A greatly distended 
urinary bladder may simulate ascites, but the passage of a catheter readily 
excludes this fallacy. 

The other Symptoms which accompany ascites belong to two categories : 
(1) Those due to pressure within the abdomen — e.g., oedema of the feet 
and legs, from pressure on the vena cava and its branches ; later on dilata- 
tion of the surface veins of the anterior abdominal wall may occur from 
the same cause ; albuminuria from pressure on the renal veins, and dyspnoea 
from mechanical impediment in the circulation. (2) There are evidences 
of the condition which has caused the ascites, and of all the causes by far 
the commonest is alcoholic cirrhosis of the liver. The temperature is 
generally normal, except in chronic peritonitis. 

The Causes of Ascites are five in number. In reference to the diagnosis 
of these causes, if there be any oedema of the ankles, it is important to 
ascertain whether this oedema or the ascites came first. For instance, 
when Portal Obstruction is in operation, the dropsy of the feet will 
have started subsequently to the ascites ; in Heart or Lung disease it 
will have preceded the ascites ; whereas in Renal Disease they would 
have started about the same time. Ascites with well-marked Jaundice 
in an old person is extremely likely to mean Cancer of the Liver or 
peritoneum. Ascites with sallowness of the skin in a middle-aged 
person is most probably due to Alcoholic Cirrhosis of the liver. 

I. Portal Obsfarupiion is the commonest cause of well-marked ascites. 
This is recognised in two ways : (a) By a history or presence of the symjh 
toms of portal obstruction (of which ascites is only one) ; and (b) the 
presence or a history of one of the causes of portal obstruction. 

(a) The Symptoms of portal obstruction, in the order in which they 
usually appear, are as follows : (1) A liability to attacks of gastric and 
intestinal catarrh, as evidenced by pain in the stomach, irritable dyspepsia, 
alternating diarrhoea and constipation, and the vomiting of mucus streaked 
with blood, especially in the early morning before breakfast. (2) Haemor- 
rhoids. (3) Haemorrhage, sometimes in very large quantity, from the 



{ IW ] ASCITES 259 

stomach and the bowels. (4) Congestion, and therefore enlargement of 
the spleen. (5) Asoitbs is one of the later results. (6) Enlargement of 
the veins of the abdominal wall from the establishment of a collateral 
circulation. (7) (Edema of the legs also appears subsequent to the 
ascites, and is due to pressure on the large veins in the abdominal cavity 
by the ascitic fluid. (8) Albumen in the urine may arise in the same way, 
or from concurrent disease of the kidney ; in the former case the albu- 
minuria may disappear after paracentesis. 

(6) The Causes of portal obstruction may be grouped into (a) diseases 
within the liver, or (0) diseases outside it. 

(a) Diseases wkhin the Liver. — Cirrhosis of the liver is by far the com- 
monest of all the causes, and this is nearly always due to alcoholism, 
there being a history of this and of alcoholic dyspepsia. Simple ascites 
without marked jaundice or other obvious symptoms is presumptive of 
cirrhosis. Cancer produces portal obstruction usually by the pressure 
of the enlarged glands in the fissure, or by masses protruding outside 
the liver. Perihepatitis sometimes produces ascites by puckering of the 
capsule. Ascites only very rarely accompanies hepatic cangestiotiy and 
never fatty liver, hydatid, or abscess. 

iP) The causes of portal obstruction outside the liver are : (1) Cancer of 
the stomach, duodenum, or pancreas, and various other tumours pressing 
on the vein. (2) Enlargement of the glands in the fissure of the liver 
(cancerous, tuberculous, or syphilitic). (3) Thrombosis of the portal vein 
is rare, and the symptoms are very acute. 

II. In Heart Disease^ either primary {e,g,, mitral disease and cardiac 
dilatation) or secondary to lung mischief, the ascites is generally part 
of the dropsy aSecting the cellular tissues and other serous cavitius of 
the body. Here dropsy of the feet wiU have preceded the abdominal dropsy ^ 
and there will be a previous history of palpitation, dyspaoea, and perhaps 
cough. An examination of the heart will also reveal the nature of the 
disease. 

III. In Kidney Diseaie ascites may be part of a General Dropsy affect- 
ing the face, limbs, peritoneum, pleurae, and pericardium. The fact that 
the dropsy started in all of these situations about the same time reveals 
this cause. Albuminuria is frequently enough a consequence of the 
pressure of the ascitic fluid, but the presence of epithelial casts almost 
certainly indicates that the real disease was primary. It usually takes 
the form of acute or chronic parenchymatous nephritis, rarely waxy or 
granular kidney. 

lY. Chroiiic Peritonitis is another cause of fluid in the peritoneum. An 
idiopathic form oi chronic peritonitis is sometimes described, but it is 
practically never met with apart from a deposit of tubercle (in the young) 
or of cancer (in the aged), § 176. In the tuberculous form adhesions 
rather than fluid are met with ; in the cancerous it is vice versa. 

y. A small amount of eSusion into the peritoneum is found in severe 
unffifwlft and some other blood disorders ; but it is never very great. 



260 THE ABDOMEN [ { IM 

VI. Chylous ascites, or the collection of chyle in the peritoneal 
cavity, occurs as the result of obstruction of the thoracic duct, or 
it may occur after trauma, or in spleno-medullary leukaemia. In 
tropical countries it is more often due to the adult Filaria sanguinis 
hominis. 

The Prognosis and Treatment of Ascites are very largely those of the morbid 
condition with which it is causally related. The Prognosis of Ascites due 
to portal obstruction depends very much on the nature of the intra- or extra- 
hepatic lesion which has produced it, as given above and in Chapter XII. 
The degree of the obstruction is measured by the amoimt of ascites and 
other sjTiiptoms present, 'and still better by the amount and frequency 
of the haemorrhage that has taken place from the stomach or intestines. 
Life may be prolonged for many years even when a considerable amount 
of ascites has accrued, provided it has come on slowly, and time has thus 
been afEorded for the gradual establishment of the collateral circulation 
through the surface veins of the abdomen and other collateral channels. 
It is in this sense that repeated tappings are good, for in this way time 
is gained for the establishment of collateral circulation. In cases of 
alcoholic cirrhosis the habit must be abandoned, otherwise the patient 
cannot live longer than six to twelve months, for ascites indicates an 
advanced condition of cirrhosis ; in cases treated early, recovery may be 
complete. 

The Treatment of Ascites, like its prognosis, must depend upon its cause 
iq.v.). The treatment of ascites due to portal chstructiony and to some 
extent that of other forms, is as follows : (1) Hydragogue purgatives are 
certainly called for, and mag. sulph. and the other salines are the best. 
Elaterium seems particularly valuable if given in sufficient quantities to 
produce three or four watery stools a day. (2) Diuretics are recom- 
mended by some, but in my experience there is no form of dropsy in 
which they are of so little use as in ascites, at any rate imtil the pressure 
has been relieved by tapping. Diuretin, copaiba resin, and cubebs are 
useful, and I have given pil. digitalis co. with some benefit after repeated 
tapping. (3) Tonics are useful combined with the preceding, such as a 
mixture containing pot. bitar., fer. tart., and digitalis. (4) Paracentesis 
is generally called for sooner or later. Some physicians say it should be 
put ofE until it is called for by the urgency of dyspnoea. In cancer this 
is certainly a good rule, but in cirrhosis of the liver it is best to operate 
at once in all cases where there is much fluid, unrelieved by medicine. 
It is often found that medicines which were useless before are efficacious 
after the operation, because the kidneys are relieved from pressure. 
Sometimes complete recovery takes place after repeated paracentesis, 
because time is thus afEorded for the establishment of the collateral cir- 
culation as above mentioned. It is best to use a small trocar with the 
tube conducted to a pail, so that the peritoneum may gradually empty 
itself. With a large one leakage may remain, or peritonitis may ensue. 
In 1896 the Talma-Morison surgical method of promoting the collateral 



§186] 



OVARIAN CYST 



201 



circulation by the artificial production of omental adhesions in cases of 
alcoholic cirrhosis was introduced, and has been attended by a measure 
of success. 

There is a generalised abdominal enlargement which gives aU the siqns 
OF FLUID (§ 184) ; but the fluid does not alter its level toith the jxmtion 
of the 'patient. There is Encysted Fluid (probably ovarian) in the 
Abdomen. 

By far the commonest of such cystic tumours is an ovarian cyst. 
Other and less common cystic abdominal tumours are hydramnios, cystic 
FIBROMA of the uterus, hydro- and pyo-nephrosis, pancreatic cyst, 
a large hydatid, a cyst of the gall-bladder, and an encysted ascftes. 

§ 186. I. Ovarian Gyst^ is centrally situated, and grows from below 
upwards. The enlargement is fairly uniform, and it gives all the signs of 
fluid (§ 184). But the level does not alter with the position of the patient ; 
and whereas the umbilical region is dull qu percussion, the flanks are 
resonant. On palpation it is tense and elastic, and in malignant ovarian 
cysts nodules can be felt in the walls. The diagnostic features between 
ascites and ovarian cysts are given in Table XIV. 



Table XIV. 



Itupeetion, 
Percusiion, 



MeaturemetU.. 



AtcUet, 



Flanks bulge, front flat. 



Ovarian Cyst, 



Flanks flat, front bulges. 



Flanks dull, front resonant. ; Flanks resonant, front dull. 
On turning, upper flank becomes No alteration of dulness on turning, 
resonant. 



UmbUicns to xiphoid greater than' Umbilicus to xiphoid less than um 



umbilicus to pubes. 
Circumference at umbilicus greater 

than slightly below. 
Navel to iliac spine same both sides. 



bilious to pubes. 
Circumference at umbilicus less than 

slightly below. 
Navel to iliac spine greater one side 
than another. 



The features associated with it are (1) a history of it having grown up- 
wards from the pelvis, and (2) these tumours (unlike encysted ascites) may 
be of very rapid growth, and reach quite a large size in three or four months. 
(3) There have usually been menstrual irregularities, though by no means 
always. There may have been no general symptoms of any kind, but 
generally some pain and local discomfort have been complained of. Often 
when the cyst contains pus there is little or no fever. When there is a 
history of attacks of pain, it generally indicates adhesions, an important 
matter from an operator's point of view. An examination of the uterus 
usually reveals nothing. A malignant cystic ovarian growth is indicated 
by (1) the presence of nodules in the walls ; and (2) the age of the patient 
and a history of emaciation, and severe pain. 

* Parovarian cysts are rare. They present much the same symptoms as ovarian cysts. 



262 THE ABDOMEN t § IW 

Diagnosis, — In the earlier stages the diagnosis of an ovarian tumour is 
sometimes difficult. It is an elastic, movable, and globular swelling ; the 
uterus is not enlarged, and it can be defined as quite separate from the 
tumour. In this stage it may have to be diagnosed from h^fdro- or fyo- 
salpinx. Para- and jieri-metric exudation and pelvic hcematocde would be 
very firmly fixed in the pelvic cavity and accompanied by constitutional 
symptoms. In extra-uterine foetation there would be morning sickness, 
a patulous os uteri, and other symptoms of pregnancy, with an empty 
uterus. 

In the later stages ovarian cysts have to be diagnosed from all the con- 
ditions mentioned below. 

II. Prsqnakcy with htdbamnios and a thin uterino wall is sometimes very 
difficult to diagnose from an ovarian cyst, for both develop very rapidly. Experi- 
enced clinicians have been known to fail in the differentiation. The symptoms of 
pregnancy (see § 328), the exactly central position of the tumour, and the softened 
cervix, may aid us in the diagnosis. Hydatid mole presents similar difficulties, but it 
is fortunately more rare. 

IIL Laboe cystic fibroid of the uterus, especially of the subperitoneal variety, 
may produce the signs of a fluid tumour. It is recognised by (1) its connection with 
the uterus, which is enlarged ; and (2) its slow grow&, which may extend over many 
years ; and (3) monorrhagia in some cases. 

IV. A LABGE hydatid CYST of the spleen or liver, a hydro- or pyo-kefhrosis, 
a dilated oall-bladdeb, a large pancreatic, omental, or mesenteric cyst, or a 
large perityfhlitio abscess, may on rare occasions produce the appearance of a 
general fluid enlargement of the abdomen, and may require to be diagnosed from 
ovarian cyst ; but they are nearly always asymmetrical. They grow from, and their 
peroussion dulness is continuous with, the organs whence they rise ; they are rofened 
to among Abdominal Tumours (§ 187). 

V. Encysted ascites is not common. It may result from previous peritonitis, 
of which there will probably be a history. Mora frequently, perhaps, it results from 
tuberele or cancer of the peritoneum (§ 176). In very rare cases congenital deficiency 
or adhesions may exist. In all of these there is a want of symmetry in the onlai^ge- 
ment and in the fluid, an absence of the associated symptoms of ovarian tumour, 
and a history or other evidences of the cause in operation. 

The Prognosis of ovarian tumour is always serious, though in the non- 
malignant form it may be quiescent for some years. If not treated, a 
cyst may go on (1) to rupture and fatal peritonitis ; (2) it may become 
inflamed ; (3) the pedicle may become twisted ; (4) haemorrhage may take 
place into its cavity. 

The Treatment is entirely surgical. The earlier the cyst is removed 
the better. It is best to do this before the occurrence of attacks of 
pain indicating inflammatory adhesions. Tapping is a temporary 
measure only; it certainly increases the risks for future operation, and 
is justifiable only in elderly patients where operation is for some reason 
impossible. 

ABDOMINAL TUMOURS. 

§ 187. Method of Proeednre. — ^We now turn to the second group of 
abdominal enlargements — ^namely, those in which the enlargement has 
originated in, or is localised to, one part — i.e., Abdominal Tumours. It 
is only by repeated and careful examination that mistakes can be avoided 



iW] A BDOMINAL TVMoVM—PALLAOlEa 26^ 

in the diagnosis of abdominal tumours. The same methods are adopted 
here as in general enlargement (§ 167), which should be consulted. (1) /n- 
spection in the recumbent, and sometimes in the erect, posture should never 
be omitted; (2) Palpation, with a flat hand previously warmed and with 
the patient's abdominal muscles thoroughly relaxed by a suitable posture ; 
(3) Percussion, to define the boundaries and nature of the tumour, and 
its continuity with some organ ; (4) careful Measurement made and 
recorded both for the comparison of one part with another, and to note 
the progress made by the growth; and (5) Auscultation, which is especi- 
ally useful in the diagnosis of late pregnancy. 

Fallacies of Abdominal Tumours, — (1) Obesity may oSer a serious 
obstacle to the examination of abdominal enlargements or tumours. In 
these cases the umbilicus is usually depressed. The only way to arrive 
approximately at a correct decision is to place the hand flat upon the 
belly and then dip the fingers suddenly and forcibly inwards. 

(2) The presence of f,uid within the abdomen, together with a solid 
tumour, may prevent our discovering or examining the latter thoroughly. 
The difficulty may be obviated to some extent by suddenly flexing the 
fingers as in the case of obesity. 

(3) FcBoal accumulations may simulate malignant and other tumours, 
though they can generally be indented by the fingers. They are always 
situated in some part of the large bowel. In doubtful circumstances a 
course of castor oil or other hydragogue purgative is desirable. But they 
may exist "for many weeks in spite of purgatives. 

(4) A ^' "phantom tumour " is a swelling (usually tympanitic, sometimes 
dull), produced by irregular muscular contraction, and it is wonderful 
how precisely it may simulate a solid tumour. It is apt to appear and 
disappear suddenly, hence the name. The condition is met with for the 
most part in young hysterical women, and is usually beyond the control 
of the patient. It is a frequent cause of error in diagnosis. It is generally 
due to spasmodic contraction of one or both recti muscles. Spasm of 
the diaphragm may produce a generalised abdominal enlargement by 
pushing the viscera down. The patient should be placed in a position 
of perfect ease for the relaxation of all the muscles of the body, with the 
knees drawn up and the neck slightly bent. Sometimes nothing but tho 
administration of an ansBsthetic to complete narcosis will enable us to 
establish the diagnosis, and this must be done in cases of importance. 

(5) The liver occasionally presents the abnormality of an extra lobe. 
Displaced or movable organs may be mistaken for tumours. (See § 166.) 

Having excluded these fallacies, and being satisfied as to the existence 
of an abdominal tumour, there are five points to which our attention 
should be directed : 

1. The first and most important question is the locality of the tumour^ 
what region is it situated in, or where did it start ? 

2. To ascertain with which organ it is connected, consider what organs 
are located in the region occupied by the tumour, and then see if 



264 THE ABDOMEN [ § 188 

it be structurally continuous by palpation and percussion with one of 
these. 

3. If it moves wUh the breathing of the patient we know that it must 
be connected with the diaphragm, or some organ depressed by it during 
respiration, such as the spleen, liver, stomach, intestines, or omentum. 
If fixed, it is a tumour of the kidney (imless it be dislocated), aorta, 
lymphatic glands, or some other organ unaffected by respiration, or 
bound down by adhesions. 

4. Inquire for a history of any disease or functional disturbance of the 
abdominal organs — e.g., in the case of the kidney, whether the urine con- 
tains, or has contained, blood or pus — although the tumour may appear 
to be far from these organs ; or perhaps there has been jaundice pointing 
to hepatic mischief. 

5. The diagnosis of the nature of the tumour depends very largely upon 
its history and the age and sex of the patient. Tense cystic tumours are 
extremely difficult to differentiate from solid growths, but we can try to 
obtain the percussion and fluctuation tests (§ 184). There is also anothei 
question which very frequently presents itself for consideration — ^viz., is 
the tumour benign or malignant ? The general symptoms of malignant 
disease (cancer) are discussed in § 415 ; but the age of the patient, and 
the rapid course and lethal tendencies of the disease, are the chief means 
of differentiating it. 

§ 188. If there is a visible or palpable tumour in the abdomen^ ascertain 
which REGION the tumour chiefly occupies or originated in, and refer to 
that region in the following summary. Having identified its origin in this 
way, reference must be made to the diseases of the organ affected to ascertain 
the NATURE of the tumour, 

I. Right Hypoohondrium. — The conmionest tumours in this position 

are tumours of the liver, especially cancer and enlargement of the organ. 

The features which hepatic tumours present in common, in addition to 

their position, are : (1) They are not covered in front by resonant bowel, 

and their dulness is continuous with that of the liver ; (2) they move with 

respiration; and (3) there are ascites, jaundice, and other evidences of 

liver derangement. It must not be forgotten that hepatic tumours may 

be simulated when the liver is pushed down by emphysema, or by pleuritic 

and pericardial effusions ; or that it may be puckered by contraction of 

the capsule, and so simulate a tumour or enlargement (Diagnosis of 

Hepatic Enlargements, § 235) ; Riedel's lobe (see below) is another fallacy. 

Dilatation of the gall-bladder (e,g,, by gall-stones) is recognisable as a 

tense rounded swelling below the ninth costal cartilage. There is only 

occasionally a history of biliary colic but always a history of "chills" 

(biliary fever), see § 241. Tumours in this region may also be connected 

with the duodenum or right kidney (see II. and IV.). 

Ritdd's Lobe (lingiform or floating lobe of the liver). — In certain cases, usually 
associated with gall-stones retained within the gall-bladder, a tongue-shaped process 
projects downwards from the right lobe of the liyer, or the lobus quadratus. It may 



5188] ABDOMINAL TUMOURS 265 

raaoh as far as the iliac crest, or even to the iliao fossa. In hardly any of the oases 
in which it has been observed (Gl^nard^ collected eighty), has the condition been 
correctly diagnosed until operation or an autopsy was performed. It has most often 
been mistaken for floating kidney, and has also been taken for distended gall-bladder, 
hydatid cyst, new growth, and omental tumour. It is sometimes tonder, its shape 
more or less that of a pear. Under chloroform its connection with the liver might 
possibly be made out. 

Suprarenal Tumours become manifest in the right or loft hypochondrium, and are 
difficult to distinguish from tumours of the liver, gall-bladder, and spleen respectively. 
Mayo Robson summarises the symptoms thus : (L) Pain radiating from the tumour 
across the abdomen and to the back ; (ii.) pain complained of at the shoulder tip ; 
(iu.) emaciation, with nervous depression, and digestive disturbance ; (iv.) a tumour 
felt beneath the costal margin (right or left), at first movable with respiration, but 
soon fixed ; and it can bo felt posteriorly in the costo- vertebral angle ; (v.) absence 
of urinary and gall-bladder symptoms. More recently other symptoms have been 
doscribed in relation to suprarenal tumours. In children precocious general and 
sexual development may occur, ^ or precocious obesity and hirsutes.^ When the 
tumour is sarcomatous, there is a special tendency to secondary affection of the bonos» 
particularly those of the skuU,^ and to exophthalmos, which may occur befoie any 
abdominal tumour can be felt. Dr. R. S. Frew* finds a different syndrome of symp- 
toms according to whether the primary sarcomatous growth affects the right or the 
kft suprarenall When the left is involved, exophthalmos appears first on the left 
side, and pain in the limbs is common. 

II. In the Epigastric Region tumours may be comiected with the 

liver (vide supra) ; but the first tumour which would occur to one's mind 

would be Cancbr of the Stomach — t.e., a hard irregular swelling attended 

by vomiting, " coffee-ground " in character. The commonest form of 

malignant disease of the stomach, however, is scirrhus of the pylorus, in 

which condition copious vomiting at long intervals and other gastric 

symptoms appear long before any swelling can be detected (§ 208). 

Tumours of the duodenum may sometimes be distinguished from those of 

the stomach by their immobility during a deep respiration. 

Pancreatic cysts may cause a fluctuating swelling in the epigastrium, but their 
detection is extremely difficult. There may bo a histoiy of pain, and symptoms 
of pancreatic disease (soe § 181). Cysts of the small omental sac present a similar 
swelling. Pulsation in the epigastrium is a symptom of that frequent condition, 
dilated right ventricle, and it must not be mistaken for abdominal aneurysm (vide 
infra). 

III. In the Left Hypochondrium tumours of the spleen originate, 
and sometimes they attain to an enormous size. These are fxilly discussed 
in § 260. They move with respiration, and they make their way forward 
m front of the colon. The tumour can generally be moved forwards by 
getting the hand behind it, a procedure which distinguishes them from 
tumours of the left kidney, and they present the characteristic splenic 
notch (§ 260). They resemble tumours of the left lobe of the liver, but 
these latter cannot be displaced downwards by the hand. Other tumours 
in this position may be connected with the stomach, fancreas, liver, kidney, 
and sigmoid flexure. 

1 " Les Ptoses Viso^rales," Paris, 1899. 

2 Bulloch and Sequeira. Trans. Path. Soc., April, 1905. 

3 Guthrie, Trans. Clin. Soc., 1907. vol. xl., p. 175. 

* Hutchison, Quarterly Journal of Medicine, 1907, vol. i.. No. 1. 

* Frew, (quarterly Journal oj Medicine, January, 1911. 



266 TBE ABWMEN [ { 188 

IV. The Lumbar Region may be the starting place for Renal Tumours, 
which are characterised by four features : (i.) Their fixity during respira- 
tion, (ii.) Dulness in one flank, and, unless both kidneys are involved, 
resonance in the other, (iii.) They are always resonant in front, because 
as they make their way forward they push the colon in front of them ; 
and (iv.) there is no resonant part between the dulness of a renal tumour 
and the spine, as there would be in the case of a splenic tumour. In many 
the rounded and reniform shape of the kidney is retained. They are 
distinguished from hepatic tumours by the dulness in the flank not being 
continuous with that of the liver, and by the presence or history of blood, 
pus, or other urinary changes. The commoner forms of renal tumours 
are hydro- and pyo-nephrosis, renal sarcoma (commonest tumour in 
children), and perinephric abscess. Pyo- or Hydro-nephrosis are cystic 
tumours, containing urine tiM or without pus respectively (see § 315). 
Hydro-nephrosis may be almost painless, not tender, and tmattended by 
any subjective or constitutional symptoms; pyo-nephrosis is always tender, 
and attended by hectic fever and malaise. Hydatid of the kidney may 
only be evidenced by swelling ; sometimes it gives a thrill on percussion. 
Other tumours starting in the lumbar regions may be connected with the 
ascending and descending colon. 

Movable Kidney is one of the most frequent of abdominal tumours. 
It may be found in any part of the cavity below the liver. Its mobility, 
rounded or reniform shape are characteristic, but not always easily 
detected. There is a characteristic pain of a dull, aching, or dragging 
character in the back, increased by exertion (see § 177). 

V. The Left Iliac Region may be the seat of a tumour caused by 
Cancer of the Sigmoid Flexure, and this is the most frequent position 
in the bowel for cancerous growth. Cancer and other tumours of the large 
intestines are distinguished generally by their free mobility (unless fixed 
by adhesions). They are, when cancerous (far the commonest neoplasm 
of the intestines), attended by irregularity of the bowels, generally chronic 
diarrhoea. The commonest starting-point for primary cancer of the bowel 
is, as just mentioned, the sigmoid flexure ; but before a cancerous swelling 
can be detected in the left iliac region the patient will have been troubled 
with recurrent diarrhoea and pain, sometimes melsena. These symptoms 
are followed in course of time by oedema of the leg or sciatica. In cancer 
of the peritoneum all the intestines may become matted together, and 
although fluctuation may be detected, there is little or no fluid in the 
peritoneal cavity. Sarcoma of the smaU intestines gives rise to hard, 
irregular, nodular, usually multiple tumours, and, in addition to the signs 
just mentioned, there are the advanced age of the patient and cachexia. 
Constipation, going on sometimes to obstruction, may also be present. 
The prognosis of cancer is given in Chapter XVT. But so-called " colloid 
cancer" of the peritoneum is a remarkable exception in regard to its 
duration, and it may go on for years before death occurs. The treatment, 
which is not very hopeful, is referred to under " Emaciation." 



J 18S 1 ABDOMINAL TUMOURS 267 

VI. The Right Iuao Region is the position ia which Appendioitis is 
usually manifested ; it is fully described under " Abdominal Pain " (§ 175). 
Intussusception of the bowel, which occurs mostly in childhood, gives rise 
to a soft, sausage-shaped swelling generally situated in this region (§ 228). 
Pdvic cdlulitis may form a firm swelling in either iliac region. Its othet 
features are (i.) vaginal examination reveals a tender swelling in the corre- 
sponding fornix, pushing the uterus to the opposite side ; (ii.) there is a 
history of acute pain and fever at the onset of the condition, frequently 
following childbirth or abortion. Cancer of the ccBcum,^ contrary to what 
we might expect, often constitutes a movable tumour in the iliac region, 
and is very apt to be mistaken for masses of feeces. Cancer of the csecum 
may be attended by suppuration, so giving rise to abscess in this region 
with pyrexia. The history of such cases may nm a long course, and, 
except in the age of the patient, resemble chronic appendicitis. Psoas 
abscess may point in this region. 

Vn. The Umbilical Region is the starting place of tumours connected 
with the pancreas, duodenum, mesenteric glands, and aorta, all of which 
are immobile during respiration ; though a tumour in this position is far 
more often connected with the stomach, liver, or large bowel, which move 
with respiration. Enlargement of the mesenteric glands may be sometimes 
detected in spare subjects by grasping the two sides of the abdomen either 
between the two hands or the finger and thumb of one hand. When large 
enough to form a tumour, they are fixed and matted together. 

Aneurysm of the Abdominal Aorta is a pulsatile and expansile swelling also im- 
mobile during respiration. In thin subjects a thrill may be felt, and a murmur 
heard. In auscultating the abdominal aorta we must be careful not to produce a 
murmur by pressure of the stethoscope. It is attended alwajrs by a severe fixed 
neuralgic pain in the spine, and sooner or later breathlessness and cardiac signs. It 
is these latter symptoms which distinguish true aneurysm from " pulsatile aorta '* 
(see below), and from a swelling in front of the vessel to which the pulsation has 
been communicated. An endeavour should be made to grasp the swelling on each 
side, so as to observe the expansile naturo of the tumour. 

PvUating Abdominal ^orto '(throbbing in the belly).— Dyspeptic subjects and 
nervous females are often troubled with marked pulsation of the abdominal aorta, 
which is sometimes obvious both to the patient and the doctor. There is in this 
affection great local discomfort, and even pain, with marked pulsation, obvious to 
both inspection and palpation. The diagnosis from aneurysm rests partly on the 
fact that the pulsation is not limited to any part of the aorta, and partly that such 
rapid and violent action of the heart is not common in aneurysm. 

VIII. The Hypoqastbio Region is the situation whence Bladder, 
Utbeinb, and Ovarian and Tubal Tumours grow. Ovarian tumours 
(which are nearly always cystic) are usually characterised in the early 
stages by their free mobility, unless they are malignant, and their rapid 
growth (§ 186). Tumours of the bladder are usually rendered sufficiently 
obvious by changes in the urine. Tumours of the uterus are similarly 
revealed by uterine symptoms, excepting perhaps some subperitoneal 
fibroids. These may reach a large size without any sjrmptoms at all; 
their origin and relations are readily detected by bimanual examination. 

^ Clin. Soc. Trans., November 24, 1899. 



268 THE ABDOMEN [ § lU 

Pregnancy causes a symmetrical enlargement, starting from the hypo- 
gastric region about the third month of gestation (§ 328). Among the 
rarer tumours in this region pelvic hydatid and pelvic haematoccle may 
be mentioned. 

The Nature, Prognosis, and Treatment of these various abdominal 
timiours are discussed imder the organ with which they are connected. 

§ 189. Flattening or Recession o! <he Abdcmcn is i cU sign of any great 
importance. " Ventre plat, enfant il y a," is a French expression signify- 
ing that the abdominal wall slightly recedes during the first two or three 
months of pregnancy. It is met with in abstinence from food, and in 
wasting disorders, such as cancer and tubercle. It may be present also 
in intestinal, hepatic, and renal colic, and it may occur as a consequence 
of excessive purging or vomiting. A hollow or " boat-shaped " abdomen 
is said to be characteristic of meningitis in infants. It may also occur 
when acute general peritonitis is present, especially in children. 



CHAPTER X 

THE STOMACH 

Two features cannot fail to strike the student in this department of 
medicine. The first is that we are very largely dependent upon sub- 
jective symptoms in the investigation of disorders of the stomach, a large 
proportion of the disorders of this organ being functional. Until the use 
of the ** test-meal " (§ 199), and methods for estimating the motor-power 
of the stomach (§ 198), were adopted, we had to rely almost entirely upon 
the patient's sensations before and after meals to know how the stomach 
had been discharging its functions. The other feature relates to the 
important and widespread efEects which derangements of the stomach 
produce in the general economy. The nutrition, of course, fails; but, 
apart from this, sufferers from gastric disorders are always liable to 
mental depression, which may sometimes be extreme. Prostration is 
apt to occur in all acute abdominal diseases ; but in chronic disorders 
of the stomach the functions of the nervous system may be so profoundly 
disturbed by neurasthenic and other symptoms that the physician may 
overlook the primary cause of the mischief — namely, malassimilation of 
food. 

PART A. SYMPTOMATOLOGY. 

The symptoms which reveal disorders of the stomach may be local 
(viz., epigastric pain or discomfort, nausea or vomiting, hsematemesis, 
dryness or bad taste in the mouth, flatulence, heartburn, water-brash, 
thirst, altered appetite) ; or general and remote (viz., cardiac symptoms, 
various nervous derangements, skin symptoms, and emaciation). 

Among the Local Symptoms of gastric disorder, pain or discomfort 
AFTER FOOD, and NAUSEA or VOMITING, are perhaps the most constant 
and important — t.e., the cardinal symptoms. H^matemesis is less fre- 
quent, but more serious. The other local symptoms are also of much 
value for diagnostic purposes. 

§ 190. Gastric Pain, or discomfort, in diseases of the stomach, is a most 
important local feature. Although it is not in every case sufficiently 
constant in its characters to enable us to establish the diagnosis, never- 
theless it merits the closest study. In some cases it is altogether absent 
(even when simple ulcer or malignant disease exists), but when present, 

269 



270 THE STOMACH [ % 191 

the features which should be noted are its j)osition, its character^ its degree^ 
its constancy y and above all, its relation to the taking of food. 

Its Position is usually over the epigastrium, but pain is very frequently 
complained of between the shoulders, and very severe pain in the back 
may also occur. A very localised pain with tenderness is characteristic 
of ulceration. In ita character it varies considerably. Sometimes it is 
like a dull weight or a feeling of distension, such as occurs in atonic 
dyspepsia and chronic gastritis; or it may be of a burning character, 
and such is the pain of acid dyspepsia ; or it may resemble abdominal 
cramp, as in spasm of the pylorus, or in some cases of gastralgia. Sharp 
or lancinating pain of a continuous character usually attends ulcer or 
cancer of the stomach. 

Its Relation to Food is by far the most important feature of the pain 
in gastric diseases : (a) It comes on at once and lasts a variable time in 
atonic dyspepsia, in acute gastritis and in ulcer (simple or malignant). 
In simple ulcer the pain is at once relieved by vomiting — a very charac- 
teristic feature. (6) When pain comes on an hour or more after food^ it is 
due to excessive acidity, either from hypersecretion or fermentation 
(organic acids). In hypersecretion, pain is relieved by taking food, but 
not in fermentation, (c) Pain coming on without time rdaiion to food is 
characteristic of gastralgia. If pressure over the seat of fain relieves it, 
the condition is probably functional, not organic. 

Fallacies, — Pain of the acute type met with in gastralgia may be mis- 
taken for biliary cclio, but in that condition the pain is greater on the 
right side, and is sometimes followed by jaundice. In hepatic disorders, 
pain is more often limited to the right hypochondrium. The spine should 
always be examined for caries, especially when stomach pain is complained 
of by children. The pain in such cases is referred to the terminations of 
the intercostal nerves. The gastric crises of tabes dorsalis may be mis- 
taken for simple gastritis. Pain in the chest (§ 23) must not be mistaken 
for stomach pain. True angina 'pectoris might be mistaken for that type 
of dyspepsia where the stomach is distended with gas and hampers the 
heart's action. Darting or lancinating pain may be due to growths in- 
volving the nerves near the stomach. In acute pancreatitis there is 
extreme pain of sudden onset in the left hypochondrium, and the case 
usually terminates fatally in a few days. Other pancreatic diseases are 
also attended by pain in the situation of the stomach. 

§ 191. Nausea or Vomiting is, after pain, the most frequent and most 
definite symptom of stomach disorders, though it arises, also, in many 
other conditions. Its causes may be grouped under three headings : 
(a) Local Causes ; (b) Nervous Causes ; and (c) Toxic Causes. Water- 
brash (vide infra) is sometimes spoken of by the laity as " vomiting," but 
is not true vomiting. Regurgitation from a dilated oesophagus is another 
fallacy.! The mechanical discomfort of prolonged coughing may induce 

^ How closely regurgitation from the oesophagus, especially when it is dilated, may 
simulate vomit from the stomach is evidenced by three cases narrated by Dr. J. S. 



{ 191 ] CA USES OF VOMITING 271 

vomiting. Phthisical patients may come complaining only of the vomit- 
ing, and the physician may be led in consequence to treat the stomach 
instead of the lungs. 

(a) Local Causes, producing vomiting, include : (1) Errors of diet, such 
as shell-fish, tinned food, excess of alcoholic and other irritating foods. 
Under these circumstances the vpmiting of the peccant material occurs 
soon after ingestion. (2) Irritant and corrosive poisons and emetics also 
speedily give rise to vomiting. The diagnosis of this cause is aided by 
(i.) an examination of the vomit, which should alioays he preserved; it 
may smell of phosphorus (which is luminous in the dark), or of carbolic, 
or other acids, (ii.) An examination of the mouth for any corrosive 
action, (iii.) The occurrence later of the toxic effects peculiar to the 
several poisons ; and (iv.) a history of poisoning obtained from the patient 
or his friends. (3) Fermentation of the contents of the stomach, such as 
that met with in dilatation, when the vomiting may occur at very con- 
siderable intervals, sometimes of a day or two ; the vomited matter also 
is frothy, and contains sarcinsB and yeast (Fig. 61, p. 282). (4) Diseases 
such as acute gastritis, cancer, and simple ulcer are usually accompanied 
by vomiting. In chronic gastritis the vomiting is of mucus, and occurs 
in the early morning. 

(5) Persistent vomiting and marasmus in young infants are the two chief symp- 
toms of Congenital Hypertrophic Stenotif. The symptoms begin about the end of 
the second week of life — (L) forcible vomiting, which cannot be stopped ; (ii.) progres- 
sive emaciation ; (iii) constipation; and later (iv.) visible peristalsis of the stomach, 
(v.) A small hard nodule (the hyportropbied pylorus) may be made out under the 
upper part of the right rectus. Careful feeding and lavage will sometimes e£feot a 
cure, and operation (pyloroplasty, Loreta's operation, gastro-entorostomy) has been 
successful, but the mortality is very high. 

{b) VoMrrmo or Nervous Origin may be classified under two groups — 
(a) that due to cerebro-spinal irritation, and {/3) that due to visceral and 
sympathetic irritation. 

(a) That due to Cerebro-spinal iRRnAXiON. 1. In Hysterical Vomiting 
the vomiting may follow any or every kind of food, no matter what its 
quantity or quality may be ; or perhaps digestible articles like milk will 
cause vomiting, while indigestible things like cheese may be retained. 
Sometimes this vomiting resembles a simple regurgitation, as compared with 
the urgent vomiting of organic disease, the symptoms of which are wanting. 

2. In Migraine and Bilious Headache the patient perhaps awakens 
with a headache, and vomits only bile (merely an indication that the 
vomiting is urgent, or that the stomach is empty) ; the headache being 
relieved hy the sickness (§ 605). 

3. Another important cause of vomiting is Cerebral Disease — e.^., 
tumour, early meningitis, abscess, M6ni^re'8 disease. This is recognised 



Bristowe (" Clin. Lects. and Essays on Dis. of the Nervous Syst./* pp. 42 ei seq.). The 
chief differential features are the ease and promptness with which food is returned 
from the oesophagus in cases of dilatation and spasm, the absence of an acid reaction 
in the matters so returned, and the absence of signs or symptoms definitely referable 
to the stomach. 



272 THE STOMACH [ f 191 

by : (i.) The vomiting occurs without relation to food ; (ii.) there is no 
nausea ; (iii.) the vomiting may be excited by simple change of posture ; 
(iv.) the presence of other cerebral s3nnptoms, such as vertigo and perhaps 
optic neuritis (Chapter XIX.). Vomiting may also attend the gastric 
" crises " of locomotor ataxy. It occurs at intervals, and is usually severe. 
It is recognised by the absence of the knee-jerk and the presence of other 
symptoms of the disease. 

{P) Reflex vomiting due to Sympathetic or Visceral Irritation may 
be met with in a great many abdominal disorders, such as peritonitis, 
pancreatitis, intestinal, biliary, or renal colic ; in all stages of intestinal 
obstruction, in strangulated hernia, and with intestinal new growths. In 
the last named the attention of the physician is often drawn from the true 
source of trouble. It occurs also with pregnancy, uterine and ovarian 
disorders. If at the end of an operation the surgeon puts in stitches while 
the patient is coming out of the anaesthetic, vomiting is at once excited 
every time the needle is put in ; this is especially noticeable with children. 
Pharyngeal irritation, especially in alcoholics and smokers, leads to pro- 
longed hawking often succeeded by vomiting. 

(c) Toxic Causes are uraemia, Bright's disease, and jaundice. Some 
of the acute specific fevers are accompanied by vomiting, especially at 
their advent. The vomiting of Addison's disease, hyperthyroidism, and 
pernicious anaemia comes under this heading. After anaesthetics vomiting 
may be urgent ; sometimes this is due to blood in the stomach, and will 
cease when it is expelled. 

The Treatment of vomiting must be directed to its cause, but there are 
certain measures which can be applied to relieve the symptom. The 
patient should be kept absolutely at rest in the horizontal position, and 
without food, or only given milk in small quantities at a time, and iced 
water. Milk diluted with barley-water, whey, or peptonised milk are 
given where ordinary milk is not retained. Among the remedies which 
may be employed are effervescing mixtures, alkaliesh, ydrocyanic acid, 
bismuth, drop doses of vinum ipecacuanha or Tr. Iodine, opium, and 
acetanilid (especially in the vomiting after anaesthetics). Sod. Bicarb, oi. 
to Oi. water, seidlitz powder (if the vomiting be due to constipation) or 
calomel. Bromides and hydrocyanic acid are useful for nervous vomit- 
ing ; a mustard-leaf applied to the epigastrium may also be useful. For 
Sea-sichnesSy chlorobrom, bromides, morphia, and recently chloretone and 
validol are recommended very highly. 

Cyclical or Recurrent Vomitiiig is an occasional condition occurring in 
children. Usually two or three attacks occur in the course of a year; 
they last a few days to two weeks, and come on without assignable cause, 
even with the most careful dieting. An attack comes on suddenly with 
drowsiness, constipation, and perhaps pyrexia ; all food is vomited ; the 
breath smells sweet from the presence of acetone, and acetone and diacetic 
acid are found in the urine (vide § 287). Drowsiness and restlessness 
increase, and cases have been mistaken for meningitis and intestinal 



§ 198 ] OA USES OF HJBMATEMESlJ^ 273 

obatruotion. The condition is probably toxsemic in origin. It is im- 
portant to open the bowels freely. Copious enemata with normal saline, 
and by the month frequent small doses of alkaline carbonates and citrates 
may be tried. 

§ 198« HsBmatemaiiB (Vomiting of Blood). — Bleeding from the stomach, 
unless in slight quantity, is usually accompanied by nausea and vomiting. 
In the first place, it is important to decide whether the blood really comes 
from the stomach and oesophagus. 

Sources of Fallacy, — (1) Blood from the lungs may be mistaken for 
blood from the stomach (see Hsemoptysis, § 73). (2) Epistaxis, the blood 
running down the gullet and being vomited, is a common fallacy in 
children, in whom the blood is apt to be swallowed. The same may 
follow operations on the tonsils or teeth. Epistaxis is recognised by making 
the patient blow his nose. In epistaxis there are no abdomiual symptoms. 
(3) Blood from thQ fauces or gums, especially when the gums are spongy, 
or when pyorrhoea alveolaris exists, may give rise to a sanguineous vomit- 
ing or expectoration, the cause of which is very apt to be overlooked, if 
unsuspected, even by competent observers^ (§ 145) ; but the blood is 
mixed with saliva, and is rarely very large in amoimt. (4) Blood from a 
fracture of the base of the skull and from cesophageal disease may also be 
swallowed and vomited. On the other hand, hcBmorrhagefrom the stomach 
is (i.) preceded by a feeling of faintness and nausea, and (ii.) followed by 
melsBua (tarry stools), (iii.) Blood from the stomach is mixed with food, 
and mostly brown (" coffee-grounds "), though it may be red if the quantity 
is large {e,g,, in ulcer) or if food has been brought up before the blood, 
(iv.) There is an absence of previous history or local signs of pulmonary 
disease, and there may be a previous history of disease or derangement 
of the stomach or liver. 

The Causes of Hcsmaiemesis may be roughly divided into (a) those 
which produce a slight or protracted hsemorrhage, and (6) those which 
give rise to a large quantity at one time. 

(a) fflight or Protracted HsBmorrhages occur chiefly in Chronic Gastritis 
and Cancer. A temporary irritation or congestion of the stomach produced 
by irritating articles in the food or by urgent vomiting, may be attended 
by streaks of blood in the vomit. 

I. Chronic Gastritis, or gastric catarrh, is known by (i.) vomiting 
in the morning — often viscid mucus streaked with blood — or at other 
times, (ii.) It may be accompanied by, and due to, disease of the liver 
(cirrhosis), or advanced cardiac disease, and is foimd especially in alcoholic 
subjects (see § 209). 

II. Cancer op the Stomach or (Esophaqus is recognised by : (i.) The 
patient is usually beyond middle age ; (ii.) pain is complained of — severe, 
constant, and genercdly worse after food ; (iii.) the blood vomited is rarely 
copious, but tjrpically " coffee-ground " in character, and may continue for 

^ Gases of this kind, mistaken at first for oreanio disease of the stomach and the 
longs, have been recorded (see Report Roy. Med. Ohir. Soc., Lancet, June 16, 1900). 

lb 



274 THE STOMACH [ § 102 

weeks ; (iv.) the hsematemesis is very rarely followed by melsBiia, because 
the blood is scanty, and because there is often obstruction of the pylorus ; 
(v.) progressive cachexia is marked, and an abdominal tumour, or evidence 
of cancer elsewhere, may be foimd (see also § 208). 

(6) A Large HsBmoirhage at one time may occur in Simple Ulcer of the 
Stomach or Duodenum, Liver Diseases, other diseases giving rise to Portal 
Obstruction, Aneurysm of the Aorta, Vicarious Menstruation, Gastrostaxis, 
Morbid States of the Blood, or after taking Chemical Irritants. 

III. Simple Uloee op the Stomach. — This is known by : (i.) The 

hsematemesis is copious; therefore the blood is bright red, after first 

being a little black, and melsBua usually follows ; (ii.) characteristic pain 

occurs directly after food, and is relieved by vomiting ; (iii.) it is found 

chiefly in young women, (iv.) who are the subjects of anaemia, but not 

often great emaciation ; (v.) a history of previous attacks of bleeding is 

often present (§ 207).^ 

Ilia. Uloeb of the Duodenum is often difficult to distinguish from gastric ulcer. 
It occurs mostly in men. 

IV. Liver Disease (by causing portal obstruction), especially gibrhosis 
(§ 250). The hsematemesis may be slight, but it is more often very 
copious — ^the most copious met with. 

V. Other Causes op Portal Obstruction (see § 233) — e.g., tumour 
pressing on the portal vein. This, as with cirrhosis, is known by the 
other symptoms of such disease — e.^., (i.) the accompanying and rapidly 
increasing ascites, and (ii.) diarrhoea. 

VI. Aneurysm op the Aorta, or of one of its branches, leaking into 
the bowel, or oesophagus. This is known by (i.) possibly a previous 
history of aneurysmal symptoms (§ 53) ; (ii.) the blood is copious ; (iii.) sud- 
den death is the usual result. This is the usual course, but in certain 
other cases there is a small recurrent leakage from the aneurysm for a 
few days or weeks preceding death. 

VII. Vicarious Menstruation. — It is impossible to be certain in the 
diagnosis of this condition. Its leading features are that it occurs periodi- 
cally, and in women with amenorrhoea. 

VIII. Gastrostaxis. — Under this title are included cases of severe 
haBmatemesis, occurring usually in young anaemic women, due to capillary 
oozing. Such cases were formerly thought to be due to gastric ulceration, 
but more frequent operations and post-mortem examinations have shown 
that no ulcer is present. 

IX. Morbid Conditions op the Blood, such as yellow fever, malignant 
forms of the specific fevers, purpura, leuksemia, and haemophilia. 

X. Chemical Irriiants (e.g., mineral acids), or mechanical injuries 
from articles which have been swallowed. 

In the Differentiation of the causes of hsematemesis (1) examine the 

^ Cases have been reooided of profuse hsmatemesis resembling that of simple ulcer, 
occurring in older patients, which disappeared under antisyphilitic treatment. The 
condition was apparently a syphilitic ulcer of the stomach. — Dalgleish, Lancet, 1898, 
voL ii.. p. 410» 



1198] CAUSES OF HMMATEMESIS 275 

stomach ; (2) examine the liver, especially for Cirrhosis, which is perhaps 
the commonest cause of hsBmatemesis, simple or malignant ulcer being 
the next ; (3) ascertain the approximate quantity of vomited blood, and 
then review the case. 

Prognosis, — Hsematemesis is usually a serious sjrmptom, but its gravity 
depends upon the cause. In portal congestion, hsematemesis not infre- 
quently serves as a safety-valve to relieve the abdominal congestion, and 
in a sense is beneficial. As regards the lesion, aneurysm is the most 
grave of the causal conditions; then, in order, cancer, morbid blood 
states, cirrhosis, and simple ulcer. The amount of haemorrhage is a less 
valuable guide tb prognosis, although where the amount is copious the 
patient will remain debilitated for a considerable time. 

The Treatment of haematemesis must also have reference to the cause. 

(a) When small in quantity, it calls for but little immediate treatment. 

(b) When in larger amount, the patient should not be moved hrom the 
place where the bleeding occurred, but must be kept absolutely at rest in 
the horizontal position. An ice-bag should be placed over the epigastrium. 
Nothing should be given by the mouth except iced water for some time 
(see Gastric Ulcer, § 207). Morphia hypodermically is the best haemo- 
static, and also relieves anxiety and pain. If bleeding continues, give 
astringents by the mouth, such as alum (gr. v.) and dilute sulphuric acid 
(n^^xx.), or ergot. Adrenalin (1 iji 1,000), J-drachm doses every two or 
three hours, is a recent and valuable remedy. Normal serum is also 
recommended by some. In profuse haemorrhages saline transfusion may 
be necessary. 

§ 193. The other Local Symptoms of gastric disorder are of considerable 
diagnostic value. 

1. Bad Taste in the Mouth is very often complained of in gastric 
disorders, and is always most noticeable in the morning. Dryness of 
the Lips is another very constant manifestation, and will often give an 
acute observer the first clue to the existence of gastric disorder. 

2. Thirst is often associated with dyspepsia; it is specially apt to 
occur with dilatation of the stomach, inflammatory stomach lesions, and 
in all cases where there is persistent vomiting. 

3. Flatulence is a distension of the stomach or intestines by gas, 
which may be brought up by the mouth or passed by rectum. This gas 
may be due to repeated swallowing of saliva and air, as in chronic gastritis,^ 
or to decomposition of food. Among its causes are excessive ingestion of 
vegetables, sugars, and starches, chronic dyspepsia, or chronic gastritis, 
and all conditions attended with dilatation of the stomach. 

4. "Heartburn" and Acid Eructations are usually met with 
together. Heartburn is a burning sensation passing up from the epi- 
gastrium to the pharynx, and sometimes mouthfuls of acid fluid are brought 



^ The eemi-voluntaiv swallowing or gulping down of air (aerophagy) is met with in 
lunatics, and in some hysterical or neurotic individuals without gastric derangement. 
It is diagnosed from dyspepsia by the absence of all other symptoms of that condition. 



276 THE 8T0MA0H [ § 198 

up at the same time. It is due to hyperacidity and partial regurgitation 
of the gastric contents into the lower end of the oesophagus. The treat- 
ment of 3 and 4 is discussed in § 204. 

Causes, — ^Hyperacidity, or "acid risings," may be of two kinds, 
(a) Organic acids are met with in diseases where tJiere is deficient gastric 
secretion — some forms of atonic dyspepsia, chronic gastritis, cancer, and 
dilatation of the stomach. HC3 is a germicide, and when from any cause 
it is absent, bacteria flourish ; fermentation ensues within Skfew hcurs after 
food, and is accompanied by pain in the epigastrium. The three principal 
types of acid fermentation are : butyric, lactic, and acetic. 

(h) Hyperchlorhydria, or excessive secretion of BCL This condition is 
met with in one form of acute dyspepsia, and chronic glandular gastritis. 
The name is often misapplied to the acidity due to organic acids arising 
from fermentation. Hero, the pain or " gnawing " generally occurs before 
meals, and is temporarily relieved by food (see also § 205). 

5. Hiccough. — Normally the opening of the glottis synchronises with 
the contraction of the diaphragm, and consequently there is no hindrance 
to the free entry of air. Hiccough is caused by a spasm of the diaphragm 
which occurs at irregular intervals and sometimes at the moment of closure 
of the glottic aperture. The characteristic cough is then heard. The 
important causes of persistent hiccough are : (1) Reflex stimulation of the 
phrenic nerves by gastric flatulent distension or irritation after hot, 
peppery foods and with hepatic disease. (2) Irritation of the peritoneum, 
as in peritonitis, general or local, near an inflamed abdominal organ, or 
in typhoid fever. (3) Disease of the thoracic viscera, especially dia- 
phragmatic pleurisy. (4) Toxic blood conditions, notably ursemia. 
(5) Neurosis. To this cause are assigned certain cases for which no more 
adequate reason is apparent. Hiccough may also occur as a symptom of 
hysteria, of cerebral tumour, and meningitis. 

Prognosis, — Hiccough is not as a rule a symptom of any great sig- 
nificance. In abdominal disease its occurrence is of grave import. Occa- 
sionally it may be persistent and resist all treatment; it exhausts the 
patient, and may be the immediate cause of death. 

Treatment, — The simplest forms of treatment are those directed to 
producing definite physiological contractions of the diaphragm. These are 
such well-known methods as sipping water and holding the breath. Any- 
thing which gives rise to a feeling of suflocation may cause a forcible con- 
traction of the diaphragm, and so stop the spasm ; for this reason tickling 
the nares and taking snufi have been tried, often with success. Dyspepsia 
is the most common cause in operation, and the hiccough is readily cured 
with bicarbonate of soda and peppermint. If these measures do not 
suffice, or if the hiccough recurs frequently, a thorough investigation of the 
patient is called for. When no causal condition can be found and the 
hiccough continues to be severe, one may give sedative drugs by the mouth 
or, if necessary, by the rectum ; the bromides and tinct. opii or -^-^ gr. apo- 
morphine subcutaneously are successful. Peripheral stimuli, such as blisters 



1 104 ] S YMPTOMA TOLOQ Y 277 

to the epigastrium, pinching the lobe of the ear, forcible pulling forward of the 
tongue, and digital pressure on the vagus in the neck, may be tried ; and 
the abdomen may be bound tightly with a bandage or with plaster. 
Chloroform may have to be administered. Of drugs, the opiates, those of 
the acetanilide group and the nitrites have most often been of use. 

6. "Water-brash" (Pyrosis) is the name given to a dear alkaline 
fluid expelled from the mouth in gushes, most often in the morning. 
Sometimes it is expelled without any kind of straining, but more often 
it is attended by retching. It is probably a reflex hypersecretion of saliva 
due to irritation in the stomach, swallowed during the night. It is met 
with in many dyspeptic conditions, and is a fairly constant symptom in 
chronic gastritis. 

7. Anorexia (Loss of Appetite) is not always an indication of stomach 
disease, as it is present in many general constitutional disturbances. Its 
chief clinical importance lies in its presence in the earliest stage of gastric 
cancer. In atonic dyspepsia there is sometimes no appetite before a meal ; 
but the first few mouthfuls of food induce secretion of gastric juice, and 
so excite appetite. Hysterical Anorexia ( Anorexia Nervosa) is known 
by : (i.) The appetite is perverted ; for instance, the patient will only eat 
some unreasonable article — e.g., a penny bun bought at a particular shop.^ 
Such patients may push matters to extremes, almost to the point of 
death. The condition is really a form of hysterical insanity, (ii.) It is 
only met with in the female sex, and (iii.) the hysterical stigmata are 
generally present (Chapter XIX.). 

Increased Appetite is far more often met with, as Shakespeare pointed 
out, in gastric disorders. It is found in some cases of chronic dyspepsia 
chronic gastritis, and dilated stomach, in pregnancy, and during con- 
valescence. A FALSE appetite which is satisfied with the first few mouth- 
fuls of food is sometimes met with in subacute and chronic gastritis, owing 
to the irritated condition of the mucous membrane. Boulimia or ravenous 
appetite is seen in diabetes, in neuroses of the stomach, after acute gastritis, 
in wasting disorders such as mesenteric gland disease, in phthisis, intestinal 
worms, and Graves' disease. Perverted appetiib, excessive fondness 
for acids and sweets, or desire to eat objects such as chalk, pencils, or hair, 
may occur in hysteria, chlorosis, and pregnancy. A foul breath is present 
in some forms of gastritis. It has been proved to be due in some cases to 
an infection of the stomach wall by streptococci and B. coli. 

§ 194. General or Remote Sjrmptoms are very constant accompaniments 
of all gastric diseases. 

1. General Malaise and a sense of ill-health and incapacity for work 
are among the earliest and most constant accompaniments of all derange- 
ments of the digestion, whether functional or organic. The dark rim 
beneath the eyes, and the sallow, "earthy" complexion, so frequently 
associated with town-dwellers, are quite as often due to dyspepsia, just as 

^ An instance of this kind has happened in my experienoe, and the patient, thin as 
a skeleton, was really on the point of death when I first saw her. 



278 THE STOMACH [ § 104 

this latter is often due to defective teeth or to the insufficient use of them. 
Emaciation is not so frequently associated with gastric disorder as might 
be supposed, though in very chronic cases there is sure to be some loss of 
flesh. Early and marked emaciation is, however, one of the surest indica- 
tions of cancer of stomach. 

2. The Cardiac Symptoms met with in dyspepsia are palpitation, pain 
in the region of the heart (pseudo-angina) ; dyspnoea, syncope, and vertigo ; 
intermission of the cardiac rhythm ; and cough, due to pharyngeal catarrh 
or reflex irritation. Collectively, these sjrmptoms may, as previously 
mentioned, give rise to the impression that the case is one of cardiac 
valvular disease, although the heart may be structurally healthy. 

3. Functional Disturbance of Nervous System. — Headache and 
degression of spirits are invariably met with in all forms of dyspepsia. 
A sense of general ill-health and irritability of temper out of all propor- 
tion to the local mischief attend most gastric disorders, and, where 
stomach symptoms are not prominent, may lead the physician away from 
i he true cause.^ Any or all of the symptoms of neurasthenia (Chapter XIX.) 
may undoubtedly result from gastric disorder, and this constitutes one 
variety of what the author has described as Toxic Neurasthenia.^ 

4. DiARRHCEA may accompany stomach disease when the gastric con- 
tents are of an irritating nature ; Constipation is usually found with 

'Ngynple ulcer, cancer, and chronic gastritis. But a more usual condition 
is an IRREGULARITY of the bowels, accompanied by borborygmi (rumbling 
in the bowels). 

5. The Urine invariably exhibits signs which reveal the disturbances 
in the metabolism of the body. The commonest of these, perhaps, is an 
excess of urates, as shown by the pinkish sediment when the urine cools. 
In other cases phosphates form the deposit ; and in certain cases oxalates 
are found (compare § 314). In these circumstances dyspepsia must be 
regarded as a predisposing cause of renal and vesical calculus. 

6. Skin Symptoms. — General prurittis may accompany many forms of 
gastric derangement. Flushing of the face after meals is met with in 
many gastric disorders, especially when they occur in the female sex. The 
face may be swollen so that the case appears like one of acute Bright's 
disease ; but the sudden onset, without much constitutional disturbance, 
and early disappearance on curing the indigestion, distinguish it from that 

^ Gautier and others have shown that certain toxins are being constantly generated 
within the body, and especially in the digestion and metabolism of the food. They 
produce no evil effect in health when not in excess, partly because they are excreted 
by the urine, faeces, and sweat, partly because they are being constantly destroyed 
(chiefly, perhaps, by the liver). But when in excess they produce profoimd disturb- 
ance of uie general economy, and especially of the nervous system. Their compo- 
sition, as far as we know, is analogous to the vegetable alkaloids (morphine, atropine* 
etc.), and they are therefore known as animal alkaloids. There are two kinds — 
(1) Ptomaines, which are produced by the fermentative disintegration of t^ead albu- 
minous substances {e.g., during digestion) ; and (2) Leucomaines, which are produced 
by the activity of living nitrogenous substances (see also Sir Lauder Brunton in the 
Practitioner for October and mvember, 1880). 
^ '' Clinical Lectures on Neurasthenia,'* Glaiaher, London. 



§{ 196, 196 ] PH Y8I0AL EXAMINATION 279 

disease. The occurrence of general urHcaria in certain individuals after 
eating indigestible articles is very common. It may also attend the 
different forms of gastric disorder. 



PART B, PHYSICAL EXAMINATION. 

Disorders of the stomach are investigated by Inspection, Palpation, 
Percussion, Auscultation and Ausculto-percussion, and by Examination of 
matters vomited, or withdrawn from the stomach by a tube. 

§ 195. InspeotioiL (1) The Teeth in all cases must be closely examined. 
Among my out-patients the two commonest causes of indigestion are 
certainly defective teeth and bolting the food. Disorders of the teeth 
are referred to in § 143 and § 145. 

(2) The Tongue and its diseases have been already described, and § 147 
should be specially consulted. At one time the tongue was thought to 
indicate the state of the stomach, but this is by no means always the case, 
and it is a far more certain indication of the patient's general condition. 
But even in this, allowance has to be made for certain variations — namely : 
(i.) Individual variations, since a coated tongue is normal to some, even 
in health, and a clean tongue in others may be associated with disease ; 
(ii.) certain diets — e,g,, milk — produce a coated tongue ; and (iii.) certain 
habits — e.^., smoking and " tippling " — also coat the tongue. The mouth 
may show signs of acid poisoning. 

(3) Inspection of the epigastric region may reveal a tumour, or the 
peristaltic movements of a dilated stomach. Aortic pulsation may be 
transmitted by a pyloric tumour, although no bulging is visible. 

(4) In skilled hands the oesophago-gastrosoope may be employed to examine the 
interior surface of the stomach. 

§196. Palpation. — To palpate the stomach successfully requires con- 
siderable experience. The patient's shoulders should be supported, and 
he should be instructed to open his mouth, to draw up his knees, and to 
" let his breath go." ^ Talking to him is useful to distract his attention. 
The hand should always be warmed, and it should then be laid quite flat 
upon the abdominal wall. Then only can we detect the presence of a 
tumour, tenderness, or other abnormality. 

Gastric Siiccusaion or Splashing is made out by placing one hand on 
each side of the stomach, and suddenly pressing inwards the finger-tips 
of each hand alternately. Listening over the stomach with a binaural 
stethoscope during this procedure materially aids in discovering this sign. 
Splashing can be normally elicited during the process of digestion — i.e., 
during the first hour or two after a meal, especially if much fluid has been 
taken. But if succussion can be elicited after that time, it suggests that 
there is atony of the stomach, either with or without dilatation. 



^ Some say it is better to have the legs extended loosely, and some advise ezamina* 
tion in a hot bath to relax the muscles. Finally, anaesthesia with chloroform or ether 
may be necessary in very obscure cases. 



280 THE STOMACH [ §§ 197, 198 

§197. PercDSfflon of the stomach is not very satisfactory or precise. 
The only diseases in which the area of stomach resonance has to be defined 
are Dilatation (§ 210), and Gastroptosis (§ 211). 

Pebgussiok 07 THE Stomach. — ^The normal stomach is depicted on p. 362, and its 
situation in Fig. 60, p. 237, the oaidiao orifice being under the seventh costal carti- 
lage, about an inch to the left of the sternum. The pylorus is just to the right of the 
sternum, and 2 inches below it. The lesser curvature corresponds closely to a line 
drawn round the tip of the xiphoid cartilage and along its left side. The fundus of 
the stomach is its highest point, and is just behind the heart apex at the fifth rib. 
The position of the greater curvature (lower border) of the stomach varies according 
to the degree of distension ; it ought not to come lower than midway between the 
umbilicus and xiphoid. Its position is hard to define, owing to the proximity of the 
transverse colon. Traubo's space is the name given to the area of resonance to the 
left of the left costal maiigin, the position where the stomach is in direct contact with 
the chest wall. Only the lower border and part of the anterior wall of the stomach 
are normally in contact with the abdominal parietes. The percusson note over the 
stomach is tympanitic, but has rather a lower pitched tone than that over the trans- 
verse colon, which is, of course, also resonant. 

The rough outline of the stomach resonance can be made out by percussion in the 
usual way without any elaborate precautions, but the following method is more 
accurate : The stomach being empty, let the abdomen be stripped, with the patient 
standing. Percuss lightly from above downwards, and mark the change of note« 
the stomach being usually the most resonant of the abdominal viscera. After this 
give the patient a large drink of water. The note over the lower border of the stomach 
is now dull, and the lower level of the dull note so produced can be marked. Finally, 
the area of the stomach can be percussed out, with the patient in the recumbent 
posture, when the lower boundary will be found at a different level. 

Auscvlto-percussion is sometimes employed to define more accurately the boundaries 
of the stomach. Place the stethoscope in the angle between the xiphoid cartilage and 
the left costal margin, and elicit the normal stomach note by percussing or gently 
stroking the skin near it. Then stroke from the periphery of the abdomen towards 
the stomach ; the note changes and conveys a definite sense of impact to the ear as 
soon as the border of the stomach is reached. When there is fluid in the stomach, 
the percussion note varies with the position of the fluid, and then it is necessary to 
percuss the boundaries, first with the patient lying on his back, then on his right, 
and finally on his left side. 

When possible, the X rays are employed to detect the precise position of the lower 
border of the stomach (see { 198). 

Fallacies. — (1) Apparent enlargement of the stomach may arise in contracted 
cirrhotic liver, or fibrosis of the lung. (2) Apparent diminution may occur when the 
liver is enlarged or pleuritic effusion is present. (3) Dislocation of the stomach down- 
wards may simulate dilatation. In such cases the lesser curvature may sometimes be 
seen or felt below its normal position. 

§198. Motor Insufficiency of the Stomach (Grastric Atony or Myas- 
thenia) leads to Dilatation (§ 210). A man can live and maintain weight 
without the secretory and resorptive functions of the stomach being quite 
perfect ; but serious auto-toxic effects and mabiutrition result from a 
retention of food within the stomach. Moreover, motor insufficiency is 
always attended sooner or later by disturbance of the secretory and 
resorptive powers. 

After a normal meal, consisting of 60 grammes of bread, 200 grammes of beefsteak, 
and a glass of water, no solid portions should be found in the stomach in six or seven 
hours. There is, however, considerable individual variation. Recently X rays have 
been found to give reliable information of the motor functions of both the stomach 
and intestine. Two ounces of bismuth carbonate are given with breakfast, mixed 
with arrowroot, milk, or minced meat. This produces a definite shadow when 



§ 190 ] EXAMINATION OF STOMACH CONTENTS 281 

examined with the fluorescent screen, and so its passage down the alimentary canal 
can be observed. Thus motor weakness, dilatation, or obstruction may be detected. 
Carbohydrates have thus been shown to leave the stomach in three hoars, whilst 
proteids and fats are still present in small amount after six. The average time for 
the bismuth breakfast to reach the csBcum is four and a half hours, the splenic flexure 
nine hours, and the sigmoid flexure twenty-six hours. 

§ 190. Examination of Stomach Oontenti.^ — ^First as to the Chbmistby of Dioes- 
TiOK, from a clinical standpoint, and the practical information to be derived from 
clinical examination of the stomach contents. Four processes normally take place in 
the stomach : (1) The conversion of starch into sugar, begun in the mouth, is carried 
on a stage farther ; (2) proteids are changed into peptones ; (3) fat globules are set 
free from their envelopes ; (4) milk is curdled. Delay in digestion may be caused by 
(1) deficient peristalsis of the stomach walls, (2) deficient quality or quantity of the 
gastric juice, (3) the consumption of indigestible articles, or (4) the dilution of the 
gastric juice by drinking too much fluid at meal- time. 

The gastric juice contains HCl, water, pepsin, rennet, mineral salts, and a liUle 
mucus. Pepsin and rennet exist in the secretory cells only as zymogens, which, 
in the presence of the HCl, become active ferments or enzymes. In ^e healthy state, 
as iAio result of digestion, about 30 c.c. of fluid should be obtained from the stomach 
one hour or so after a test-meal (vide infra), straw-coloured, without much odour, 
without organic acid, and with about 0-2 per cent, of free HCl. 

As regards hydrochloric acid, much depends on the time of examination. Hyper- 
chhrhydria is merely a convenient term for excessive secretion of HCl. It has come 
to be somewhat loosely used for " excessive acidity," and thus to be confused with 
the acidity of fermentation (due to organic acids). On the other hand, after a meal, 
a negative result on testing for HCl would indicate the absence of peptic activity, as 
an acid is required to convert the inactive proenzyme or pepsinogen into pepsin. An 
excess of HCl is distinctive of gastric ulcer, as compared with gastralgia ; for in the latter 
the HCl is normal or diminished. HCl is also diminished in all catarrhal conditions 
of the mucous membrane, in great anaemia, and neurasthenia. When there is a difii- 
cnlty in diagnosing malignant disease, the absence of free HCl is a point in favour of 
cancer. 

Lactic acid is not normally present in the gastric juioe after digestion has proceeded 
for one hour, but traces may be found, due to the ingestion of lactic acid in certain 
foods, or to fermentation in the mouth. A decided reaction with Ueffelmann's test 
(infra) is found with cancer of the stomach, but a negative reaction does not have 
equal value in proving the absence of the disease. 

Butyric and acetic acids prove the presence of fermentation, and are found where 
HCl is deficient, or the food is delayed in the stomach, as in dilatation of the stomach, 
or a narrowing of the pylorus. 

The secretion of pepsin, according to most authors, is not interfered with, unless 
there be destruction of the glandular elements of the stomach. The presence of pepsin 
is also indicative of the presence of HCl (which is necessary to convert pepsinogen into 
pepsin), and of the activity of the glands. If only pepsinogen is found, the glands 
are active, but HCl is deficient. The presence of the latter (pepsinogen) is an im- 
portant feature in diagnosing between chronic gastritis, where the glands are destroyed, 
and dyspepsia, or any neurosis of the stomach, where tht glands are not destroyed. 

Benninogen and Bennin are diminished or absent in the later stages of gastritis and 
cancer. The amoimts of renninogon and rennin present appear to be directly pro- 
portional to the quantities of pepsinogen and pepsin. 

Summary. — ^The two most important questions, therefore, to determine in an 
analysis of stomach contents are : (1) The presence and amount of HCl ; and (2) the 
presence and amount of pepsin and pepsinogen. The latter question is specially 
important, because — 

(a) If the ferments present are chiefly pepsin and rennin, the gastric glands are active, 
and HCl u) not deficient, since this is required to convert pepsinogen into pepsin. 

^ It is not possible hero to give more than a brief outline of this important subject, 
and the excellent treatises of Hem meter and otliers on Diseases of the Stomach may be 
consulted with advantage. 



282 THE STOMACH I } 199 

{h) If thefarmtntt pruent are chitfiy peptirtogen and renninogen, the gutrio gUnds 
are active, but the ECl ia defioient. 

(c) If neUher are present, the gastrio gUnds aie deatroyed or inoetive. 

*"™Hitimi ol OMtrlo Contenb after a Telt-Meal ia a luefal method of investiga- 
tion in casea of eevere and intraotable imJigeelioii or dilated stomach, or when oancor 
ifl auspecfad. It consists of three atopa : (a) Tho adminiatnition of the teat-moal ; 
(b) the withdrawing of tho gastric content* by moans of a atomach-tube ; and (c) tho 
microscopical and chemical examination of the material withdrawn. 

(a) The taal-maaU Buggeatod are of many kinds, but the following anawora ; A pint 
of woak tea ([nfusod only two or throe minutes), with tho addition of not more than 
1 ounce of milk, and eugar if doBirod, or a pint of thin arrowroot, mado with water 
ami about 2 ounces of milk, sugar being added to ta«t«. With thaso a round of thin 
buttered toast should be taken. Tho test-meal should be given in the morning before 
any food ia taken, and drawn oS an hour and a half later.^ 

(b) Methol ol FMfiiiE the Tnbt.~U«i a rubber tube nearly 2 yards long, with Urge 
" eyoB." It should bo thoroughly cleaned, and moistened with warm water or 
glycerine before being passed into the phaiyni. The patient should sit widi the hoad 
erect, the chin being projected forward, and tho mouth open. The tube ia passed into 
the pharynx, whiki the patient ia inatructed to swallow, and the tube is pnabed down 
into tho atomaoh. Then bring tho end down to a lower level than tho atomach, and 
the conlonte ahould siphon out into a receptacle. If tho gastrio content* do not 



Ytmt fnngiii bas a aimllar BlgnlHcance, 

flow at once, the patient should strain, aa if trying to vomit ; or draw out the tube a 
little, leat the end beoomea folded upon itself, or the " eye " stopped by a fold of 
mucooa membrane. It may bo noceaaary to start the flow by suction with a syringe. 
The tube should bo marked at a poaition 16 inches from i(a tip. By this meana we 
know the amount of tube nhich has been passed into the ceaopb^us, hscauea when tho 
mark is opposite tho incisors, the tip ought to have reached tho atomach. A fieiibte 
tube curling up in the cesopbagua is a contingency which may thas be obviated. Its 
use is contra-indicaUd in angina, heart failure, fevers and other aouto discaaea, recant 
hemorrhages, great arterio-sclorosia. aneurysms, and a high degree of emphyaoma and 
bronohitia. 

(e) Examination ot Stomaoh Ooiitaiiti after the test-meal. 

GJESKKAL ExAHiNATiDM. — Appearance, acidity to litmus paper, amoll, conaisteDey, 
and presence of slimy mucua, bile, or bk>od, ahould first be observed. 

HidtoscopiCALLY (Fig. 61) we can detect fat globules, starch colls, vegetable and 
muaolo fibrea, and sometimes fatty crystals, leucin and tyiosin. colls of the mncous 
membrane, lonile corovisiic, or sarcinee. and pus cells. Epithelial calls are present 
in excess in oarcinoma. Tho Oppter-Booa baoillua may sometimes be seen on examina- 
tion under the high power. 

> Dr. W. H. Wileoi, Lancet, Jtme 10, 1906. and July 25, 1908. 



§ 199 ] EXAMINATION OF STOMACH CONTENTS 283 

The stomach oontents ahonld be filtered, and the filtrate used subsequently. 

ChbmicaIiLT we have to answer eight questions : 

(a) Are the contenia acid f can be roughly detected by the use of carefully neutralised 
litmus paper. 

(6) Metiiod of etAimaiing ioUd acidity — f.e., acidity due to hydrochloric acid, organic 
acids, carbon dioxide, and such acids as react acid to phenolphthalein. Titrate 10 c.o. 
filtered gastric contents with decinormal solution of caustic soda (prepared free from 
carbon dioxide), using 1 per cent, solution of phenolphthalein as indicator. Add a 
drop or two of the indicator to the gastric contents, dilute with two or three times its 
volume of distilled water, and then run in the decinormal caustic soda solution from 
a burette till further addition produces a faint purple-red tint. If 5*5 c.c. of deci- 
normal caustic soda are required for 10 c.c. of gastric contents, the acidity may be 
calculated in terms of HGl by multiplying the 5*5 c.c. of the soda solution used by 
0*00364 X 10. The percentage of HCl actually present is therefore 10 x 5*6 x 0*00364 
= 0*2 per cent. 

(c) lefru hydrochloric acid present f Tests : (i.) A 1 per cent, solution of di-methyl- 
amido-azo-benzene in alcohol is used. A drop of gastric oontents is placed on a white 
tile, and a drop of the reagent run alongside. A deep pink-red colour is given by free 
HCl. (ii.) Gunzberg's test : Two or throe grains of phloroglucin aro mixed in a small 
evaporating dish with 1 or 2 grains of vanillin, about 1 c.c. of alcohol is added, and then 
about 1 C.C. of gastric contents. Evaporate on a water-bath, when a bright cherry- 
rod colour indicates froo HCL If much organic acid is prosent. a slight reaction may 
occur in test (i.), which, though more convenient, is therefore not quite so reliable as 
test (iL), which is never given by organic acids. Free hydrochloric is normally present. 
It is always present in gastric ulcer and hyperchlorhydria, hardly ever in caroinoma. 
{d) What is the amount of active hydrochloric acid f The ** active ** hydrochloric acid 
includes (i.) free HCl ; (ii.) the HCl which is combined with proteid and nitrogenous 
organic bases. It does not, of course, include the inorganic chlorides like NaCL 
EstimaHon. — ^Two equal volumes of the filtered gastric contents (10 c.c.) arc taken, 
(i.) One portion is made alkaline with sodium carbonate solution and evaporated to 
diyness on a water-bath in an evaporating dish. The residue is ignited over a small 
Bnnsen flame until it is well charred and all the organic matter is decomposed. (iL ) The 
other portion of the gastric contents is placed in a porcelain evaporating dish (4^ inches 
in diameter), and evaporated to dryness on the water- bath, as in (i.). In each case 
the dish is cooled, and about 60 c.c. of water, 6 c.c. of pure nitric acid, 3 c.c. of 10 per 
cent, iron alum solution, and 10 c.c. of decinormal silver nitrate solution, added. 
Decinormal ammonium sulphocyanide solution is run in until a permanent brownish- 
red tint appears. The active HCl in 10 c.c. of gastric contents is equal to the difference 
of the amounts of ammonium sulphocyanide solution used in (L ) and (ii. ). Example. — 

If in (L) 3 C.C. of — sulphocyanide solution are used, and in (ii.) 8 c.c. of ,^^ sulphocyanide 

solution are used, then the active HCl in 10 c.c. of gastric contents is 5 c.c. of ^ HCL 

Therefore the percentage is 10 x 5 x 0*00365=0*18 per cent. This is the most im- 
portant estimation, and the amount normally is about 0*15 per cent. In carcinoma 
it is usually much hdow 0*1 per cent. ; in simple ulcer it is usually considerably above 
0*15 per cent. It is the most important estimation in the analyses of gastric contents. 

(e) Is lactic acid present f A qualitative test should be made, a weak solution of 
Ueffelmann*s reagent (made by mixing a little 5 per cent, solution of carbolic acid with 
a few drops of liquor ferri perohloridi) being added to the filtered gastric contents. 
The development of a distinct yellow colour indicates lactic acid. 

(/) Wha is the amount of organic adds ? This is given with sufficient accuracy by 
the difference between the total acidity (expressed as HCl), and the active HCl as 
estimated by the method described above. They are in excess in conditions of much 
fermentation and gastric caroinoma. 

(g) Is mucin present in the filtrate f To the filtrate add an equal volume of distilled 
water, and then a 2 per cent, solution of acetic acid, drop by drop. A whit precipitate 
indicates the presence of mucin. It is always present in caroinoma, and sometimes 
in simple gastritis ; usually absent in gastric ulcer. 

(h) What is the ferment activity f The pepsin and pepsinogen may be roughly gauged 
by the carmine-fibrin test ; the rennin and ronninogen may be estimated quantita- 



284 THE STOMACH [ § 199 

tively. The Carmine-Fibrin TeaO — ^Three test-tubes aro taken containing rospoc- 

tively (1) 4 o.o. of gastric contents ; (2) 2 c.c. of gastric contents and 2 o.o. of 0*4 per 

cent. HCl ; and (3) 2 c.c. of gastric contents and 1 c.c. of water. A few shreds of 

washed carmine fibrin are placed in each, and the test-tubes aro incubated at 37^ C 

The test-tubes are shaken every few minutes, and the depth of red colour present 

indicates approximately the quantity of pepsin present. EsHmation of Rennin and 

Benninogen, — ^The following method is exceedingly simple and well adapted to clinical 

purposes : Narrow test-tubes, 5 inches by } inch, are taken. Into each 5 c.c. of fresh 

unboiled milk are added. They aro placed in a water-bath at 40° C. Into the tubes 

are placed seriatim gradually increasing quantities of the filtered gastric contents. 

These are run in from a pipette, which is graduated in -^ J^ths of a cubic centimetre. 

Thus are added 0-01, 0-05, 0-1, 0-15, 0-2, 0-25, 0-3, 0-35, 0-4, 0-5, 0-6, 0-7, 0-8, etc.. of 

gastric contents. The liquids are mixed by gently inverting each tube. The tubes 

are left thirty minutes in the bath, and then it is found that above one point in the 

series the contents of the tube are solid, and do not flow out on inversion, while below 

this point the contents are liquid, and flow out on inversion of the tube. The minimum 

quantity of gastric contents to cause complete clotting, so that the contents of the 

test-tube do not flow out on inversion, gives an accurate measure of the rennin activity. 

In the normal gastric contents of adults about 0*2 c.c. is required ; in children a gpiBater 

amount is normally required. If X=the minimum quantity of gastric contents to 

cause complete clotting, then the quantity of rennin present in the gastric contents = 

0-2 

-— of the normal amount ; e.g,, if 0*05 c.c. of gastric contents was the minimum 

0'2 
amount to cause complete clotting, the quantity of rennin present =^—= four times 

the normal. In gastric carcinoma usually much more is required — e,g,» 0*5 c.c, or 

more. Possibly no complete clotting will occur at alL In gastric tUcer and hyper- 

chlorhydria the rennin activity is usually higher than normal, and never below normal. 

Often 0*05 c.c. or less causes complete dotting. In cases where the acidity of the 

gastric contents is low, and also the ferment activity, most of the ferment is frequently 

present as renninogen, and not as rennin. In these cases the above method of analysis 

should be adopted for the estimation of the rennin, and a separate estimation made for 

the rennin plus renninogen. The renninogen can be estimated by taking the gastric 

contents, adding an equal volume of 0*4 per cent. HCl, which converts the renninogen 

to rennin. The same procedure is adopted as above — ^viz., the addition of the mixture 

of HCl and gastric contents in increasing quantities to the milk in the test-tubos 

respectively, and the minimum amount of the mixture which will cause complete 

clotting, so that the contents do not flow out on inversion, is noted. In the normal 

gastric contents of adults about 0-1 c.c, when mixed with 0-1 c.c. of 0*4 per cent. 

HCl, is the minimum quantity which will clot completely 5 cc of milk at 40*^ C. in 

half an hour; with children a greater amount is necessary. If X=the minimum 

quantity of the gastric contents which, when mixed with 0*4 per cent. Hd, will cause 

clotting (t.e., half the amount of the mixture taken), then the quantity of rennin plus 

0*1 
renninogen present =n^ of normal ; e,g., if in a given case 0-1 c.c. of the mixture of 

gastric contents and 0*4 per cent. HCl was the minimum amount to cause complete 

clotting, then, since 0-05 c.c = the quantity of gastric contents in 0*1 c.c. of mixture. 

0-1 
the quantity of rennin plus renninogen present= . =2 times normal. Sometimes 

where the rennin is below normal the renninogen plus rennin are found to be normal. 
This would contra-indicate a condition such as gastric carcinoma. The importance of 
the estimation of the rennin is accentuated by the fact that the amount present is 
usually directly proportionate to that of the pepsin. 

* The remainder of tliia section is largely composed of a quotation from the Lancet, 
1908, vol. ii., p. 220, by Dr. Wilcox, to whom tlio author is greatly indebted for valuable 
help in its preparation. 



§! 800» 201 ] AOUTE D 78PEP8IA 285 

PABT a DISEASES OF THE STOMACH, THEIR DIFFERENTIATION, 

PROGNOSIS, AND TREATMENT. 

§ 200. The Roatine Investigation of the disorders of the stomach consist 
of three steps : 

First : We must identify the patient's Leading Symptoms as being 
referable to gastric disorder (see Part A.). 

Secondly : Inquire as to the History, and especially whether the 
illness came on acutely and recently, or whether, as is more usual, it came 
on insidiously, and has run a chronic course. Much depends on the skill 
and method with which the history is elicited. Inquire particularly as 
to pain or discomfort and its relation to meals, and as to the other symp- 
toms mentioned in Part A. 

Thirdly : Proceed to the Physical Examination, and ascertain 
whether there be any localised tenderness and pain, and whether any 
tumour or other abnormality be present. 

Classification of disorders of the stomach. 

A. Acute Difeaies of the Stomach. 

I. Acuto d3r8pepsia (bilious attack) : without tenderness . . • • § 201 

II. Acuto gastritis : with tenderness . . . . . . • • § 202 

B. Chronic Diseases of the Stomach. 

(a) WxTHOUT TENDEBNSSS ON PBBSSURB : and pain less marked. 

I. Chronic atonic dyspepsia . . . . . . • • ! 204 

II. Chronic acid or irritable dyspepsia . . • • § 206 

III. Gastralgia (gastric neuralgia) . . • • § 206 

(b) With tenderness on pbsssxjbb : pain a marked feature. 

IV. Simple ulcer of the stomach . . . . . . • • § 207 

V. Cancer of the stomach . . . . . . • ■ § 208 

VI. Chronic gastritis . . . . . . . . • • § 209 

(c) Dilatation op the Stomach . . . . . . • • § 210 

This classification, based on the presence or absence of tenderness, is not very 

satisfactory, and each group will be found to contain many exceptions. It is, how- 
ever, the least unsatisfactory of those clinical classifications possible at the present 
time. The division of Chronic Dyspepsia into Atonic and Acid is also very un- 
satisfactory (see footnote, p. 287). 

If the patient's symptoms have come on gradually, and lasted a con- 
siderable time, turn to Ghronic Disorders of the Stomach (§ 203). 

If, on the other hand, his symptoms have commenced somewhat sud- 
denly and recently, the case is probably one of the two Acute Disorders 
of the Stomach : I. Acute Dyspepsia ; or, II. Acute Gastritis. 

I. The pcUiefU — whose temperature is normal — complains of nausea, 
gastric disoomfort, headache, and depression, which have come on sud- 
denly ; and there is no marked epigastric tenderness. The disea.se is probably 
Acute Dyspepsia. 

§ 201. Acate Dyspepsia C' Bilious Attack ") consists of a sudden dis- 
turbance of the digestion in a previously healthy person, such as occurs in 
association with surfeit, high living or other errors in diet. 

The Symptoms, which come on suddenly, are : (1) Pain, or a feeling of 
oppression or distension in the epigastrium, occasionally accompanied by 



286 THE STOMACH [ { 208 

some tenderness on pressure, though the tenderness is never very marked. 
(2) Nausea and vomiting very generally ensue (but not always). (3) Head- 
ache, depression, anorexia, coated tongue, constipation, scanty urine 
loaded with lithates. (4) The illness is sometimes preceded and accom- 
panied by drowsiness, and not infrequently there is a history of previous 
similar attacks. 

The Diagnosis is not difficult, the only condition resembling it being 
acute gastritis, in which the constitutional symptoms are more apparent, 
the duration of the illness considerably longer, and the tenderness much 
more marked. Irritant poisoning comes on much more suddenly with very 
urgent vomiting (§ 191). 

Etiology, — (1) Too large a meal, especially after previous fatigue. 
(2) Errors in diet, such as excess of alcohol (which retards digestion), 
ice, and many other articles which vary with the idiosyncrasy of the 
individual. 

Prognosis and TrecUment, — ^Acute dyspepsia of the kind here referred to 
usually passes o£E in two or three days. (1) If pain be present, assist 
vomiting by mild emetics, such as copious draughts of salt and water, 
tickling the fauces, etc. Violent emetics aggravate the condition. 
(2) Three grains of calomel, and milk diet for a day or two, generally 
relieve the condition. (3) Bismuth and tonics may be given during 
convalescence. 

II. The patient complains of considerable pain or discomfort, and tender- 
ness IN THE EPIGASTRIUM, toith nausca or vomiting, all of which have come 
on somewhat suddenly. The disease is probably Acute Gastritis. 

§ 202. Acate or Sab-acate GastritiB is relatively a much more serious 
disorder than the foregoing. It consists of a sudden derangement of 
digestion due to inflammation of the stomach. This condition is not so 
much a catarrhal inflammation of the mucous membrane (excepting in 
cases of irritant poisoning) as of the glands of the stomach. 

Symptoms, — (1) Paid, intense and burning, or a feeling of distension 
in the epigastrium, coming on directly after food, and accompanied by 
tenderness on pressure. (2) Vomiting, not always immediately after a 
meal, of undigested food, sometimes with streaks of blood. (3) Malaise, 
anorexia, slight pyrexia, headache, depression, and other constitutional 
symptoms may be present, attended sometimes by great prostration, thirst, 
furred and coated tongue. (4) Diarrhoea may ensue after a day or two. 

The Diagnosis may have to be made from acute dyspepsia (§ 201), and 
from other causes of vomiting (§ 191). 

Recovery generally takes place in about three to six days, the afiection 
rarely lasting longer than eight or ten days. It may go on to chronic 
gastritis. Death rarely takes place, excepting from irritant poisoning or 
in cases of membranous gastritis.^ 

^ One case of this rare condition which recovered is recorded by Dr. Grunbaum in 
the Lancd, August 2, 19C2. 



S dOS ] ACUTE on SUB-ACUTE 0A8TBIT1S 287 

EUdogy. — (1) In the majority of cases simple acute gastritis is caused 
by errors in diet, or by decomposing meat — e.g,, tinned food containing 
ptomaines -} an excessive quantity of normal food will cause it. (2) Irritant 
poisons {e.g,, arsenic, antimony, phospjiorus, etc.). In long-continued 
vomiting, without apparent cause, poisoning should be suspected, and the 
vomited matters examined. (3) In some cases, gout and other constitu- 
tional conditions predispose to or determine an attack.^ Heart, lung, and 
liver disease are predisposing causes. 

TreatmevU, — The indications are : (1) To remove any irritant that may 
be present from the stomach. This can be done by promoting vomiting, 
which is specially indicated if the epigastric pain continues, emplojong the 
means mentioned in § 201. It may be desirable to give a purgative, such 
as 3 grains of calomel, and a seidlitz powder in the morning. Hot fomenta- 
tions or a mustard leaf to the epigastrium may relieve the pain. (2) The 
second indication is rest to the stomach, which is gained by twelve or 
twenty-four hours' abstinence from food, followed by milk in small quan- 
tities. Later on, bismuth combined with opium is the best treatment. 
The milk diet should be supplemented only very gradually. 

CHRONIC DISORDERS OF THE STOMACH. 

§ 208. The patient, whose temperature is normal, complains of *' Chronic 
Indigestion,'* — ^i.e., pain or discomfort in some way connected with his food, 
which has probably come on gradually , and may have lasted a long time. 
There are Six Disorders, from any one of which he may be suffering, and 
there may be Dilatation of the Stomach in addition.^ 

^ The products of the deoomposition of nitrogenous food-stufiEs, especially when 
enclosed in hermetically sealed tins, occasionally give rise to the formation of toxic 
substances. The effects are very severe. Symptoms of acute irritant poisoning 
come on within a short time after the meal. The collapse is extreme, and death may 
take place within a few hours. 

^ 1 remember being called to see a medical man, about forty-five years of age, of 
markedly gouty diathesis, who had previously had gouty manifestations. The 
symptoms were thought at first to resemble those of enteric fever, the temperature 
being 103^ to 105^ F. u>t several days ; but a brisk purge of calomel, salicylates, alkalies, 
and milk diet, produced immediate improvement. 

^ As I have already remarked, this classification is a very unsatisfactory one. As 
more scientific methods of investigation, such as those foreshadowed in §§ 198 and 190, 
come to be employed, we shall be able to classify cases which we now vaguely describe 
as " Chbonio Dyspbpsia " into the following groups — ^groups which tall us wherein 
the chief error of digestion lies : 

I. DiSORDBBS OF SeOBBTION. 

(a) Irritative States.— -{I) Hyperacidity (hyperchylia), hyperchlorhydria, ex- 
cessive formation of HCI. (2) Supersecretion (gastrosuccorrhcsa, a 
continuous flow of gastric juice : doubtful if this exists apart from 
dilatation. 

(6) Depressive States. — (1) Subacidity (h3rpochylia). (2) Inacidity (achylia 
gastrica). 
II. DisoBDEBS OF MoTiUTY, or Pcristalsis. 

(a) Irritative States. — (1) Cramp of the cardia, pylorus, entire stomach. 
(2) " Peristaltic imrest " of Kaussmaul. (3) Nervous eructations. 
(4) Nervous vomiting. 

(6) Depressive States. — (1) Insufficiency of the cardia or the pylorus. (2) Gas- 
troplegia — atony or insufficiency of the entire gastric muscle, leading 
to dilated stomach. 



288 THE STOMACH [ S 

(a) Fnnotioiial diseases of the stomach without tenderness. 
I. Atonic Dyspepsia. 
'> II. Acid or Irritable Dyspepsia. 

III. Gastralgia. 

(6) Organic diseases of the stomach with marked local tenderness and pain. 

IV. Simple Ulcer of Stomach. 
V. Cancer of Stomach. 

VI. Chronic Gastritis, 
(c) There are also many other disorders nnconnected with the stomach which may 
give rise to symptoms -of chronic indigestion, among which the following may b^ 
mentioned : Phthisis (of which dyspepsia is often the earliest symptom), Appondlcitis, 
Aneemia, Abdominal Tumour, Oeirdiac or Hepatic Disease, Renal or Uterine Disease^ 
various Nervous Disorders, and Pancreatic Disease (rare). 

I. The fatient comflains q/' chronic indigestion, and the epigastric pain 
or discomfort comes on soon after a meal. The disease is probably 
Atonic Dyspepsia. 

§ 204. Ghronic Dyspepsia may be defined as deranged digestion without 
gross or inflammatory changes in the mucous membrane of the stomach. 
It may be, and often is, attended by Atony or Dilatation, § 210. It 
occurs in two generally accepted types. 

I. Atonic Dyspepsia (the commoner form) is chronic indigestion due 
to diminished digestive power of the stomach. It is sometimes due to a 
deficiency of the acid in the gastric juice ; the pepsin is said by most to 
remain normal in amount. It may also arise from defective motor power 
of the stomach. In this disease the food may, in process of time, undergo 
butyric acid fermentation, and then it is difficult to distinguish this form 
of dyspepsia from II. 

II. Acid or irritable Dyspepsia (§ 205 ; Synonym, hjrperchlorhydria) 
is a chronic indigestion due to hypersecretion of acid in the gastric juice. 

I. Atonic Dyspepsia is the commoner form of chronic dyspepsia. The 
Symptoms are : (1) Pain or distress, usually in the epigastrium, coming on 
immediately or very shortly after food. The pain may be in the back or 
shoot up to the shoulders ; or there may be no definite pain, only a feeling 
of weight or distension. It is unaccompanied by tenderness on pressure, 
a feature which distinguishes it from gastritis and other organic conditions. 
The pain is often relieved by eructations of wind. (2) Nausea and vomit- 



III. Sensoby Disordebs. 

(a) Irritative States. — (1) Hyperaesthesia. (2) Gastralgia. (3) BuL'mia and 

polyphagia. 

(b) Depressive States, — (1) Anorexia. (2) Acoria (? gastric •auaasthosia). 

IV. Gastric Neurasthenia, and Gastroptosis. 

These various conditions are, of course, mot with most frequently in combination, 
just as paralysis and anaesthesia are met with in disease of the spinal cord. Thus atony 
and dilatation inevitably lead to disordered secretion. But it is of the greatest 
use for purposes of prognosis and treatment to know which particular element in the 
digestive process is at fault. The subject, however, is extremely complex. For in- 
stance, the gastric contents, in cases of Subacidity, may be highly acid from the 
presence of latty acids, the products of decomposition. Those desirous of pursuing 
this subject should consult Hemmeter's '* Diseases of the Stomach " (Blakiston, 
Philadelphia), or the works of Mathieu (*^ Trait6 des Maladies de rfistomao et de 
rintestin," Paris, 1901), Ewald, Roisshmann, Einhom and Rosenheim. 



§ 204 ] CHRONIC DYSPEPSIA 289 

ing are not frequent. (3) The appetite is usually diminished, but some- 
times it is increased ; and the tongue is flabby and indented by the teeth. 
(4) There are languor, depression, and general discomfort and drowsiness 
after meals ; and there may be palpitation, dyspnoea, and other cardiac 
symptoms. Thirst is not usual unless there be dilatation, and pyrexia 
is absent. Urates in excess are constantly present in the urine. Some- 
times erythema faciei and urticaria occur. 

Etiology. — (1) Errors of diet ; (2) overwork, mental anxiety, and other 
nervous derangements ; (3) imperfect mastication in previous years ; 
(4) convalescence from acute diseases, annemia, and debility from any 
cause (e.g,y phthisis), predispose. Dyspepsia is often the earliest sjonptom 
met with in phthisis. (5) Various abdominal disorders — c.gr., pancreatic 
or renal disease, appendicitis, enteroptosis, floating kidney, and abdominal 
tumour, may for some time be evidenced only by symptoms resembling 
atonic dyspepsia. (6) It may be part of organic disease of the stomach, 
such as cancer. 

Diagnosis. — The chief condition from which it has to be distinguished 
is chronic gastritiSy in which there is usually tenderness on pressure ; and, 
while stimulating articles of food (pickles, condiments, etc.), relieve the 
pain of atonic dyspepsia, they tend to aggravate chronic gastritis (see also 
Table XV.). Atonic dyspepsia may have to be differentiated from gastric 
ulcer in the young, or oarhcer of the stomach in the middle-aged and old (q.v.). 
The differentiation from acid dyspepsia is given under that disease (§ 205), 
but it must be remembered that in atonic dyspepsia butyric acid fermenta- 
tion is apt to take place, which is distinguishable from acid dyspepsia only 
by an examination of the stomach contents. 

Prognosis, — ^It is never fatal, but often renders life so wretched as to 
unfit the sufferer for the duties of life. If met with early, treatment may 
be very efficacious ; but, if untreated, it may go on to chronic gastritis 
and dilatation of the stomach, and lead to general malnutrition (§ 194). 

Treatment, — The indications are, to remedy the dietetic errors (see § 212) ; 
to remove the cause ; and to stimulate the secretory and motor power of 
the stomach. The teeth should be seen to. Alkalies and alkaline car- 
bonates shortly before meals, combined with nux vomica, bitters, and 
carminatives (Formula 66), stimulate the secretory powers of the stomach. 
Some cases do best by taking their meals dry, so that the gastric juice 
may be undiluted. Some find aid in pepsin, pancreatin, peptenzyme, 
taka-diastase, or other artificial digestive. Tonics, especially strychnine, 
are useful. Attention to the general health may succeed where stomachic 
treatment alone fails. Abdominal m