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SPECIFIC EXAMINATION, SYMPTOMATOLOGY, DIAGNOSIS In nearly all books on surgery paragraphs of the following kind appear, often under various types of diseases. This one is on the Ovaries. "The diagnosis of inflammatory disease of the ovaries can rarely be made by the symptomatology or the physical findings alone. Usually the true character of the condition is only determined by an operation." (The Encyclopedia of Medicine, Surgery and Specialties, Vol. II, page 12. F. A. Davis Company.) Exploratory operations are a common practice. It is evidence of the inability, as yet, to make a correct diagnosis in very many cases. And it must be admitted that in many different types of diseases symptoms and physical signs are similar and therefore confusing. But many cases submitted for exploratory operations are psychosomatic and perhaps if physicians were trained to better observe the mental phase, there would not be so many. See "Fundamentals of Applied Psychiatry," Lake, page 33. In view of the fact that manipulative physicians do not make exploratory operations, they have some other methods which, if diligently applied, will lead to very high average in accurate diagnosis. The reader of this book will note the steps taken in a diligent search for a proper diagnosis. 1. Discovering location of all diseases and possible foci of infection. 2. Feeling the tissues for excessive hardness or softness. 3. Searching for subluxations in the segment of spine under suspicion. 4. Putting the fingers in the gutter of the spine to see if it is tight, ropy, constricted or relaxed. 5. Make the hand and finger examination for sensations of warmth, heat, coolness or coldness, and for mild or intense vibrations. 6. Note the color of the skin, and the contour of the body. 7. Make the necessary blood and urine tests and also bacteriological tests. 8. Study and differentiate the symptoms of the suspected disease, from other diseases. 9. Use the X-ray for diagnostic purposes and not exploitation. 10. Use the tuning fork and stethoscope regularly enough until proficiency is a matter of course. 11. Practice listening to the patient’s personal history
until all the facts he knows are given, and in that way the cue may be
given whether the emphasis is on the physical or the mental examination,
or whether equal emphasis should be put on both.
THE ABDOMINAL EXAMINATION The first step would be observation of pulsations in the abdomen. This may be visible through the abdominal wall. They can often be felt in the epigastrium. Lay hand on lightly, if pulse is vigorous, there can be an aortic insufficiency, or exophthalmic goiter. A slight swelling in the epigastrium with heavy pulsations suggests aneurysm of the aorta, or a tumor overlying or attached to the aorta. If it is a tumor the pulsation will stop with the patient in the knee chest position. The normal abdomen should be soft to this gentle palpation except in those who are ticklish. A strong sense of resistance with fever may be due to peritonitis, without fever it may be due to spinal irritation. Tumors can be felt as various sized lumps with different degrees of resistance. The pelvic colon examination can begin in the lower left quadrant. If there is a sausage-like mass. The size of it will depend upon the quantity of fecal matter with its lumen. If spastic the tube is long and narrowed and gives some symptoms of irritation and slight pain on pressure. The left distal colon is the part most frequently involved in all types of colitis and diverticulitis. Rolling the colon under the fingers, one can ascertain whether it is stiff and hard from the lower pelvis to the spleen. This indicates some form of perversion, not only in that location, but the stiffness and hardness may be a reflex from a perversion in some other part of the colon. The transverse colon is not easily examined except in very thin persons, and those who have ptosis. The ascending colon is easily felt and its size and mobility noted. In colitis or colon stasis, pressure will send a pain and some nausea to the epigastrium. This may be also noted in the beginning of appendicitis. While examining the colon the physician can have in his mind the symptoms of the various types of abnormalities that can occur in the large and small intestines. Appendicitis, colic, enteritis, enterocolitis, colitis, diverticulitis, dysentery, diarrhea, spasms, carcinoma, inflammations, and tumors. There are many conditions which may cause ulceration of the intestines. The most common cause is infection with germs. The irritant produces an arterial dilatation, pericellular infiltration, and the outwandering of a large amount of phagocytes. The mechanical pressure of the infiltrated fluid may kill the cells. The excretion of the germs is poisonous to the cells, and increases the ulcerative process. The ulceration at first affects only the epithelial cells lining the intestinal canal; they are pushed off, leading to the production of a small ulcer, the base of which is the sub-mucous connective tissue. The ulcer may proceed no further than this. Through the activity of the phagocytes and the removal of the irritant, repair may take place and a new layer of epithelial cells cover the denuded spot. When this does not occur, the ulceration may proceed through the connective tissue coat, finally through the muscular to the peritoneal coat, so that the contents of the bowel are only separated from the peritoneal cavity by the this peritoneal coat. When the ulceration has proceeded to this depth, the danger is exceedingly great and it may perforate through the thin peritoneal coat and allow the contents of the intestines to escape into the peritoneal cavity. The contents of the intestines always contain a large number of micro-organisms, and when an ulcer perforates into the peritoneal cavity, the peritoneum becomes affected and death usually results. Another danger which always accompanies ulceration of the intestines
is the danger of hemorrhage. If the ulcer is close to a large blood vessel,
and the ulcerative process destroys the wall of an artery, serious hemorrhage
into the bowel may occur, the quantity of blood lost being sufficient at
times to produce death. Ulceration occurs in typhoid fever, chronic diarrhea,
dysentery and tuberculosis of the intestines. Ulceration may occur in very
violent, acute forms of diarrhea and dysentery. An ulcer heals by the multiplication
of connective tissue cells, and where the ulceration has been deep scar
will result. The newly formed connective tissue contracts, and if the ulceration
extends over a large area, the contraction may produce a stricture of the
gut and serously interfere with the passage of material through the bowel.
The treatment of these conditions is to remove the irritant as quickly
as possible, and the regulation of the viscero-motor and arterio-motor
mechanisms.
STRICTURE OF THE GUT Stricture of the gut often follows the healing of an ulcer. A large
ulcer, which has involved a considerable portion of the circumference of
the gut, heals; the newly formed connective tissue contracts, and through
this contraction, the caliber of the gut is lessened. Stricture may occur
in any part of the intestinal tube. It is most apt to occur in the small
intestines, or in the rectum.
INTUSSUSCEPTION A form of obstruction that occurs most frequently in children is intussusception. This most frequently in the small intestines and is the telescoping of one part of the gut into another. The loop which is inside may be pushed downward through the large bowel, and has often appeared extruding from the rectum. The mechanical pressure producing interference as it does, with the circulation of the intestines, results in a swelling and infiltration of a part, so that the complete obstruction to the passage of fecal matter occurs. The pressure around the obstructed portion may be so great that the circulation in the telescoped part of the intestine is absolutely shut off; adhesion takes place; the telescoped portion of the gut sloughs off, and is passed out of the alimentary tube as a mass of dead matter, and the integrity of the intestinal tube is preserved by a union of these two points. Intussusception is brought about by an increased activity of the viscero-motor mechanisms, which takes place in an irregular and incoordinated manner. Occasionally the contraction of the circular and longitudinal muscle cells in the gut as so coordinated by peristalsis, the longitudinal fibers contracting suddenly, the telescoped part is pushed up and over the recording peristaltic waves; it is continually pushed up until freed. This condition comes on suddenly in children, is accompanied by great
pain, distention of the abdomen, and obstruction to the passage of fecal
matter. Fever usually occurs, because toxic material from the intestines
is absorbed, and unless the condition is relieved, death frequently takes
place in the course of a short period of time. The abdomen, in these cases,
is very much distended and tense, and frequently a sausage-shaped tumor
can be felt. Here the use of posture is of material assistance. The control
of the viscero-motor mechanism of the part enables you to bring about a
relaxation of the lower segment, and allows it to slip down and off the
enclosed segment above. If the condition has existed for any great length
of time, the case becomes a surgical one.
NEW GROWTHS OF THE ALIMENTARY CANAL The most common form of new growth, which produces obstruction of the
intestine, is Cancer of the Bowel. Beginning in the mucous lining of the
bowel and increasing in size, it may absolutely obstruct the lumen of the
gut and prevent the passage of feces. It most frequently occurs in the
rectum, the sigmoid flexure, the hepatic flexure, the splenic flexure and
the head of the caecum. Other forms of growth may produce the same results
such as Sarcoma, or a fibrous tumor.
FOREIGN BODIES Obstruction may be produced by the presence of foreign bodies in the
intestines; gall stones and various solid substances occasionally may produce
obstruction, although this is rare in man.
VOLVULUS Volvulus is a condition which nearly always occurs in the colon and
is particularly apt to involve the sigmoid flexure. It is a condition that
occurs in old people in the majority of cases, and is due to the fact that
the ligaments supporting the large bowel become relaxed, and, either through
peristalsis or some movement of the body, the sigmoid becomes twisted upon
itself. The twisting becomes so great as to prevent the passage of feces
through this part of the bowel. If the obstruction persists, the mechanical
pressure of the twisted loop interferes with the activity of the cells;
their resisting power is lessened, infection takes place through the intestinal
walls and brings about suppuration, and the patient dies through the absorption
of the poisonous products. These cases, when seen early, respond very readily
to treatment. By direct treatment of the abdomen through the abdominal
walls, with delicacy of touch which you require, you will be able to distinctly
feel the twisted mass of intestines. You can accomplish much by altering
the position of the patient, by placing the patient on one side or the
other side, or by elevating the lower extremities, depending upon the position
of the loop and its relation to other parts. The twisting that takes place
in the sigmoid usually produces a distinct mass that can be felt through
the abdominal walls. In addition to this, there is an absolute obstruction
to the passage of feces. Accompanying this, there is pain due to the pressure
on the ingoing pathways from the twisting of the gut. The obstruction to
the passage of feces, the pain and a mass made up of the twisted intestine
(felt usually more to the right side) are the most important indications.
EXAMINATION OF THE LIVER AND GALL BLADDER While standing on the left side of the patient the liver can be palpated. The right hand is put back of the ribs and the arm lays on top of the ribs. Pulling upward with the right hand, and pressing downward with arm on the ribs, while the left hand is going up under the ribs, the liver can be palpated. If the liver can be palpated without going through the above process, then a ptosis or an enlargement is indicated. In a healthy state right lobe of liver occupies right hypochondrium, lying completely in hollow formed by the diaphragm, rarely descending below free border of ribs, or extending upward above the fifth intercostal space; left lobe reaches across to left of median line an inch or more. The surface is velvety on touch, there is no pain on pressure. In cancer of the liver irregular nodules of various sizes are distinctly felt through the abdominal wall projecting from that portion of the enlarged organ which is below the free border of the ribs. These prominences are usually harder than the surrounding hepatic tissue and there is more or less tenderness on pressure over them. May or may not be accompanied by ascites. The lay of the hand on the liver area gives a cold and moist sensation. In cirrhosis of liver, small hard liver. Cool to the touch of the hand. There is coated tongue, anorexia, fullness and distress after eating and often vomiting, in various stages there is flatulence, constipation and cloudy urine. Congestion of liver: Space below the ribs is occupied by a smooth, hard, resisting enlargement, corresponding with natural shape of liver. This is important to the Neuropath because it is usually the beginning of retentive diseases. The spinal liver segments will be soft and putty-like. fatty liver partakes of practically the same contour as congested, both are usually without pain on pressure. The difference between them is that in the latter there is an infiltration of liver with fat. They occur under two opposite conditions. One in which there is general obesity, and fat accumulates in the liver in common with the other parts, the other form in which there is general emaciation and a consequent impairment of the oxygenating power of the blood. The sound of fluctuation on pressure can be felt by the hand. Hepatitis catarrhal. An inflammation of the liver. Symptoms of gastro-duodenal catarrh usually precede, IE coated tongue, anorexia, fetid breath, epigastric distress, vomiting and perhaps diarrhea. Also obstructive jaundice indicated by yellow skin and conjunctivae, light stools and dark urine. In acute cases slight fever and swelling of the liver which is tender to touch. Hypertrophic cirrhosis. In which the connective tissue hyperplasia started from the periphery of the capillary bile ducts instead of from ramifications of portal vein as in atrophic form. Jaundice marked, liver large, yellow and surface smooth or finely granular. the lay of the hand is warm and moist. Abscess of liver. There is an enlargement, great pain on pressure. Fevers and sweats are indicative symptoms. The lay of the hand on will show the periphery dry and hot. Amyloid liver. Enlarged due to deposits of albuminoid substances. Anemia is present, there is no pain. Spleen is enlarged also, and laboratory test shows albumin in the urine. The gall bladder. It is not easy to palpate the gall bladder unless
it is swollen with obstructive jaundice, cancer and acute cholecystitis
with distension or empyema. Tenderness and pain are indicative of some
ill condition on pressure. Striking the abdomen just below the costal margin
with a sharp blow with the ulnar surface of the hand during inspiration
will elicit pain if the gall bladder is abnormal. The use of the X-ray
is then indicated. Diseases are abscesses, adhesions, stones, fistulas,
t
Irritants contained in systemic circulation are carried to the liver by the Hepatic Artery, while the Portal System carries to the liver the irritants which are absorbed from the alimentary canal. The irritants may be toxic products of bacteria or chemical poisons. They produce primarily a constriction of the blood vessels, and, if the irritant continues its action, an active dilation of the blood vessels of the liver occurs. This is followed by pericellular infiltration; the liver becomes swollen; the activity of the organ is for a time increased, and large quantities of bile are manufactured. This condition of active dilation of the blood vessels of the liver is inaccurately called a “bilious attack.” These attacks are often produced by the absorption of toxin products from the intestines due to an improper action of the bowels, or to the ingestion of irritating food material. It may also occur after the excessive use of alcohol. The alcohol is rapidly absorbed, carried to the liver, and acts as a chemical irritant. Repeated attacks of this sort, whatever may be the cause, lead to a chronic dilation of the blood vessels of the liver, which is not due to hyperactivity of the arterio-dilators, but to a loss of constrictor tone. The constant congestion and infiltration of the liver, due to the loss of arterial tone, interferes with the functions of the organ, and many people suffer for long periods of time with this condition, having occasionally acute attacks. If the dilation lasts for a great length of time, and excessive formation of connective tissue occurs in the liver. The liver is covered with a fibrous capsule which almost entirely surrounds it; this capsule sends fibrous septa into the liver tissues, which divide the epithelial cells of the liver into groups of lobules. The chronic congestion of the liver, due to a loss of arterial tone, is accompanied by pericellular infiltration, which is followed by an excessive formation of connective tissue cells between the lobules of the liver. For a time, the connective tissue cells become so great that they are unable to get a proper amount of nourishment, and, as a result of this, they begin to contract and press upon the lobules of the liver. This condition is called “Cirrhosis of the Liver.” Primarily, in this perversion, the liver is enlarged, due to an increased amount of blood present and to the increased amount of connective tissue which has been formed. The newly formed connective tissue finally contracts. The contraction of the newly formed connective tissue leads to a decrease in the size of the liver, and very seriously interferes with its function. The shrinking connective tissue presses upon the liver cells and finally kills them. The dead cells are then removed by the phagocytes, and large areas of the liver are occupied entirely by connective tissue. The contraction of the connective tissue, where it is attached to the surface, results in the formation of little nodules on the surface of the liver, and to this condition the name “Hobnailed” or “Gin Drinkers’ “ liver is applied. Whether the irritant has been present in the bile ducts primarily or in the blood vessels, the final results are practically the same. The presence of the irritant in the bile ducts results in the formation of connective tissue, particularly around the bile vessels rather than in the interlobular septa. This perversion produces other conditions due to the retention of bile and the interference with this formation, and this is called “Biliary cirrhosis.” This perversion affects the bile capillaries, and is much more apt to produce jaundice or the absorption of bile into the blood. In Cirrhosis, where the interlobular septa are involved, jaundice very rarely occurs. The majority of cases of Cirrhosis of the Liver are produced by the excessive use of alcohol. Chronic diseases such as syphilis, gout, malaria, tuberculosis, chronic heart and lung diseases, causing an alteration in the composition of the blood and a contraction of its circulation, the contraction may progress so far as to produce an obstruction to the flow of blood through the hepatic artery, and also through the portal vein, which is followed by the backing up of the blood in the veins of the abdomen, and increased pressure in the capillaries of the peritoneum. Large quantities of the liquid portion of the blood are poured out, the abdominal cavity becomes partially or completely filled with fluid. The fluid that is poured out is not true plasma. The obstruction to the venous flow is followed by the out pouring of water and salts, with a very small amount of proteid material from the blood. This fluid therefore contains only a small proportion of albumin. The abdomen may become enormously distended in this condition. The obstruction to the normal flow of blood through the portal system is followed by an attempt upon the part of nature to compensate for this by the development of collateral channels. The blood from the lower extremities and the lower part of the abdomen and the pelvis is carried up to the heart through the Inferior vena cava. The blood from the abdominal walls below the umbilicus is carried downward by the veins which begin close to the umbilicus, and finally empty into the veins of the pelvis. The normal flow of blood in these veins is from above downward, and if the finger is pressed above Ponparts Ligament, over these veins, so as to obstruct the blood flow, the veins fill above the finger. In this perversion, the excessive back pressure of the blood in the vena cava will lead to a reversal of the flow in these veins, which unite with veins above the umbilicus, and the blood then, instead of flowing downward, will flow from below upward. The development of a collateral circulation is followed by an enlargement of the veins around the umbilicus, so that the umbilicus is very often completely surrounded by a convoluted network of dilated veins. In addition to the enlargement of the veins, which can be seen upon the surface of the abdomen, the obstruction to the Vena Caga also produces an enormous dilation of thee hemorrhoidal veins, and the development of hemorrhoids, or piles. If the perversions are allowed to progress, death may result from interference with the functions of the liver, from exhaustion, or from the great accumulation of fluid in the abdominal cavity, or finally from perversions which may occur secondarily in other organs, such as the kidney and the heart. The accumulation of fluid may be so great, that not only is the abdomen filled with it, but the legs also become infiltrated, and finally the pleural and pericardial cavities leading to actual drowning in the patient’s own fluid. These cases are not usually jaundiced, the skin does not become yellow, but a common condition which may occur during the course of this perversion is a hemorrhage into the stomach, or into the intestine. This is brought about by the obstruction to the venous flow from the organs. The obstruction to the portal vein, which receives as its tributaries, the splenic, the gastric, and the veins from the Small and part of the Large Intestines, would result in back pressure of the blood and sometimes to rupture of the vessels. The pressure in the hemorrhoidal veins may result in rupture and hemorrhage from thee lower part of the rectum and anus. These hemorrhages often relieve the suffering of the patient temporarily. Arterio-motor perversions of the liver produce alterations in the composition of bile, and if the arterio-motor perversion involves the gall-bladder, the mucous membrane of the gall-bladder becomes perverted. The altered bile and perverted mucous membrane may result in the formation of gallstones. Gallstones may be formed in any part of the bile vessels, the bile ducts, or the gall-bladder. The bile capillaries empty into small bile ducts; the small bile ducts empty into the hepatic duct, which passes down and joins the cystic duct, which has a peculiarly convoluted arrangement of its mucous membrane, and forms a spiral valve, the two being continued downward as the Common bile duct, which empties the bile into the intestines. Between periods of digestion, the liver is constantly manufacturing bile, which passes through the hepatic duct into the cystic duct and into the gall-bladder, where it is stored. At the time of digestion, the liver manufactures bile in large quantities, which is poured into the intestines. The gall-bladder, through the muscle cells in its wall, contracts and forces the bile which it contains into the intestines, so that a large quantity of bile is poured into the intestines during the period of digestion. If the formation of bile is absolutely normal, and the circulation to the gall bladder is absolutely normal, there cannot be a formation of gallstones, but if any irritant gets into the gall-bladder, it will produce disturbances of its circulation and alterations in the formation of mucus from its lining membrane; disturbances of the liver may also produce alterations in the composition of bile, and as a result of this, the salts present in the bile are precipitated and stones are formed. This is particularly apt to occur in the gall-bladder, and the presence in the gall-bladder of any solid particles - such as flakes of mucus or germs will serve as nuclei, lead to a constant precipitation of bile salts around them and the formations of stones. These stones are at first small, but they gradually increase in size. The small stones pass through the cystic duct without causing much disturbance, possibly a slight attack of pain, but as they become larger, the difficulty with which they are extruded increases, and if the stones increase in size rapidly they remain in the gall-bladder and cause piratically no disturbance. Only those stones that are small enough to get into the duct produce attacks of biliary colic. When these stones get into the duct they may cause a violent attack of pain; they may also lodge in the duct and obstruct it completely. When this occurs, the gall-bladder becomes enlarged and the obstruction produces a condition which favors the formation of other stones, and while the bile may or may not get into the gall-bladder itself; this fluid is not true bile. The dilation of the blood vessels in the walls of the gall-bladder results in an outpouring of plasma, and pericellular infiltration of the wall of the gall-bladder. Obstruction to the Cystic Duct is not necessarily followed by the absorption of bile into the blood and the occurrence of jaundice. The stone lodged in the Cystic Duct may get into the Common Bile Duct. The Common Bile Duct and the Pancreatic Duct empty into the intestine rather obliquely, and there is a dilatation of the Common Bile Duct just before it empties into the intestine. The stone may lodge in this diverticulum, although it may lodge anywhere along the Common Bile Duct. When it lodges in the Common Bile Duct, it obstructs the flow of bile from thee gall-bladder, and also from the liver. This produces back pressure in the bile vessels of the liver and is followed by the absorption of bile into the blood and jaundice occurs. It sometimes happens that gallstones lodge in the diverticulum of the common duct, and act like a ball valve. In addition to the occurrences of jaundice, the stools become clay-colored and very offensive odor. This is due to the fact that the absence of bile has allowed to process of putrefaction to take place. The absence of bile from the alimentary canal also produces serious disturbances of thee digestion and nutrition. Obstruction may also occur in the hepatic duct before it joins thee cystic duct. This obstruction produces disturbances just as serious as obstruction in the Common Bile Duct, excepting that it does not produce enlargement of the gall-bladder. Obstruction in the Hepatic Duct produces back pressure of bile in the liver an jaundice, and also prevents the bile from getting into the intestinal canal. Gallstones may lodge either in the Cystic, Hepatic or Common Bile Ducts, and the difference in the conditions produced determines the position of thee stone. If the gall-bladder empties readily and the patient is jaundiced, the obstruction is in the Hepatic Duct. If the gall-bladder does not empty readily and the patient is not jaundiced the obstruction is in the Cystic Duct. If the gall-bladder does not empty readily and the patient is not jaundiced the obstruction is in the Cystic Duct. If thee gall-bladder does not empty readily and the patient is jaundiced, and bile is absent from the stool, the obstruction is in the Common Bile Duct. Gallstones may be present in the gall-bladder without indications and may never be known unless an examination of the body after death reveals their presence. This is the case when the stones are too large to pass into the cystic duct. In the majority of cases, when the stones are small enough to pass into the duct, they cause an attack of Biliary Colic. The wall of the cystic duct contains involuntary muscle cells, and the duct is lined with epithelium. It is well supplied with ingoing arterio-motor paths and those of common sensation. A stone in the duct causes or acts as an irritant. Messages are sent through the ingoing arterio-motor paths, and the ingoing paths of common sensation, and bring about reflexly a constriction of the blood vessels; also an active contraction of the walls of the duct, which are peristaltic in character, the contraction being from above downward, which tends to force the stone onward through the duct. The constriction of the blood vessels is followed by an active dilation of the arterioles, and pericellular infiltration of the walls of the gall-bladder and duct results. This leads to an increasing outpouring of mucus from the mucous cells. Sometimes nature is successful, through the contraction of the muscle cells in the walls of the duct, in forcing the stone through the Cystic Duct into the Common Bile Duct, and extruding it into the intestines. These attacks are accompanied by severe pain. The contraction of the muscle cells in the wall of the duct is forcible; the delicate mucous membrane is pressed against the hard stone, the stone is often irregular and rough, and produces violent, sharp pain which is felt in the region of the liver, and extends to the lower dorsal region of the back. The pain is continuous but with periods of increase. The walls of duct contract in an endeavor to force the stone along, and with each contraction the pain is increased. The pain at intervals is so severe that the patient may become absolutely prostrated. Sweat pours off the body in great quantities, the heart becomes rapid, and patients have died from the excruciating pain in an attack of Biliary Colic. The duration of the attack may last for a short period of time, or the pain may persist for a number of hours, and if the stone is not extruded from the duct, nature may cease her efforts from fatigue. The pain will then for a time disappear, to recur at irregular intervals. The recurrence of Biliary Colic may be due to periodical attempts at the extrusion of the stone, or to the fact that new stones have been formed and passed into the duct from time to time. In addition to the acute attacks of Biliary Colic which the stones cause, they produce serious disturbances of the body by interference with the flow of bile, and the function of the liver. If the stones are in the Cystic Duct, there may be little disturbance between the attacks, because there is no obstruction to the flow of bile through the Hepatic and Common Ducts, but an obstruction in the Cystic Duct produces an enlargement of the gall bladder. In this condition, the gall bladder is filled with fluid which is not true bile, but is bile mixed with plasma, which has leaked through the walls of the dilated blood vessels and into the gall. The gall bladder may become the size of an egg or even larger, and form a distinct, smooth, movable tumor in the abdomen. The walls of the gall bladder are strong and capable of resisting a considerable amount of pressure. If gallstones do not completely obstruct the Cystic Duct, the fluid escapes from the gall bladder; there is then less enlargement and a tendency to a thickening of the walls of the gall bladder. There may be little discomfort between the attacks, but repeated attacks of Biliary Colic are liable to occur. When the Common Bile Duct is obstructed, there is, in addition to the repeated attacks of Biliary Colic, a retention of bile in the vessels of the liver, which is absorbed into the blood, and perversions are also produced by the absence of bile from the intestinal canal. In obstruction of the Common Bile Duct, the liver becomes enormously distended, as well as the gall bladder. The absorption of bile into the blood is indicated by the presence of jaundice, or a peculiar yellowish hue to the skin, due to the deposit of bile pigment. This is usually first seen in the mucous membrane of the eye. As the condition progresses, the skin becomes of a yellowish color. The presence of bile in the blood produces indications of general poisoning. The bile in the circulation slows the heart. The appetite is poor; vomiting may occur and a general feeling of relaxation and weakness is produced. The absence of bile from the intestinal canal interferes with the process of digestion and produces emaciation. The presence of bile in the blood produces perversions of the blood itself, lessening its coagulability, and leading to the occurrence of hemorrhages, which may become serious. This makes any surgical measures which may be undertaken particularly dangerous. Patients have died due to the fact that hemorrhage occurred and was uncontrollable. Indications of perversions of the nervous mechanism of the gall bladder, and also of the liver, are present. The pain in the back is usually on the right side of the spine, in the region where the neural units of the liver and gall bladder are located. Attempts are made upon the part of nature to get rid of the bile through the kidneys, and large quantities of bile are found in the urine. The urine becomes yellowish or brown in color, and the presence of bile coloring matter can be detected by the addition of a small amount of fuming nitric acid. The presence of bile salts may be detected by adding a few drops of urine to a small amount of cane sugar. The sugar may be dissolved in the urine and a drop of sulphuric acid allowed to mix with it; if bile salts are present, a purplish color will appear. The stools are of clay color, and the odor is very offensive. These same indications would be present in obstruction of the Hepatic Duct, excepting the enlargement of the gall bladder. The liver converts the products of proteid metabolism into urea. The carbohydrates are stored up in the liver as glycogen; the liver also destroys certain poisons that may be absorbed from the Alimentary Canal is increased because of the absence of bile in the Alimentary Canal, and the inability of the liver to destroy the poisons. The glycogenic functions of the liver are also disturbed, or interfered with, and this produces serious disturbances of he nutrition of the body. The liver is no longer able to perform its work of the conversion of the waste products of proteid metabolism into urea; instead of completely converting them into urea, they are converted into uric acid. The bile in the liver retained by the obstruction undergoes alteration, produces a dilatation of the biliary ducts and mechanical pressure upon the liver cells, causing them to become cloudy, and later filled with granules of fat, and many of the cells are destroyed. The liver is increased in size, due to the dilatation of its blood vessels and the accumulation of bile in the bile ducts. If the condition persists, a decrease in the size of the liver occurs, due to the destruction of the liver cells. Absolute obstruction to the Hepatic or Common Ducts leads to general perversions produced by the absorption of poisons and the interference with the functions of the liver and of other organs, finally causing death. Occasionally stones form in the small bile ducts. These stones produce disturbances in a localized portion of the liver, and the perversions of the body in general are not so serious. It may not be possible to remove the stone from the duct at the first treatment and probably, in the majority of cases, several treatments will be necessary to remove the stone from the duct. Any stone that can get into the duct can be removed, unless it has been allowed to remain there until ulceration has taken place, and has been followed by a stricture in the duct. The obstruction by the stone is only one of the things which has to be removed. In addition to the removal of the stone, treatment must be directed to the removal of the underlying causes. These causes should be kept under observation for a few weeks after
the obstruction has been removed, and for a period of six months afterward,
at regular intervals, to prevent the formation of stone. The patient should
be examined three or four times a year, so that the gall bladder may be
emptied, to prevent future formation of gallstones. The patient should
be kept under observation after the removal of the obstruction, so that
the underlying cause of the gallstones may be treated. The patient may
have, in the course of a very short time after the removal of the stones,
an attack of pain, which may be due to the formation of small plugs of
mucous that pass into the duct and obstruct it.
ABSCESS OF THE LIVER Abscesses of the liver may be very minute and scattered through the entire liver substance, or there may be one or two large abscess cavities in the liver. This perversion is due to an infection with germs, or to the amoeba colli. This perversion is not very commonly seen in this climate, but is of quite common occurrence in some of the tropical regions, and usually occurs in the course of Chronic Dysentery, which is due to an infection of the large bowel by one variety of the amoeba, called Amoeba Colli, because they are found in the colon. The presence of this amoeba in the colon irritates the paths of entrance of the ingoing neural units, which results in an arterial dilatation, excessive outpouring of plasma, pericellular infiltration, and hyperactivity of the mucous cells, the excessive pericellular fluid finally pushes the cells from the mucous membrane of the colon into the gut, leaving ulcers on the walls of the colon. These amoeba may get into the circulation and be carried to the liver, where they may multiply in the interior of the liver. Their excretions act as poison and produce abscesses. These abscesses produce an irregular enlargement of the liver, the enlargement often extending upward and pressing the lung. The pus in the abscess cavity produces certain general disturbances of the body, the chief of which are gradual wasting and loss of strength, and the irregular occurrences of a chill, followed by a rise in temperature, and ending in a profuse sweat very much like the chill of malarial fever. Wasting of the body occurs, and the patient may die from exhaustion due to the poisonous products absorbed from the abscess, or the abscess may rupture into the peritoneal cavity, causing profuse suppuration due to the infection of the peritoneum, and cause death from peritonitis. The abscess may rupture into the lung, and when this occurs, the pus is discharged by expectoration. The expectoration is a brownish red color, mixed with yellow pus. The pus may be expectorated in large quantities, as much as a pint at a time, and the patient may recover, but in all cases the perversion is a serious one. If the rupture takes place in the lung and the abscess does not have free access from the bronchial tubes, infection of the lung will occur, and the lung may become consolidated, resulting in pneumonia. These cases are, as a rule, for the surgeon. Occasionally these cases are seen in this climate, but they are comparatively rare, occurring sometimes after a person has returned from the tropics with dysentery. The indications in this perversion, aside from the enlargement of the liver and the occurrence of signs of the presence of pus in the body, fever, sweat, and general wasting; the stools are composed largely of blood and mucous, and if the mucous is examined under the microscope and the slide is kept at the temperature of the body, the amoeba may be seen moving about under the field of the microscope. They resemble very closely the white corpuscles, except that they are larger. The other form of liver abscess is due to infection of the liver with various germs, and usually occurs due to infection in some other part of the body; the germs are carried to the liver through the circulation, and get into the bile ducts. The liver may become completely studded with minute abscesses, varying in size from the head of a common pin to a pea. Prognosis in these cases is not favorable. Sometimes it occurs in the later stages of typhoid infection. The typhoid germs get into the bile ducts, and produce minute abscesses and great destruction of the liver cells; blood poison follows, which results from absorption of the poisonous products. There is another germ called the colon bacillus, which is always found in the larger bowel, and under ordinary conditions - where the mucous membrane is healthy - it does not produce any perversion; but where there is a disturbance of the circulation, the bacillus may become virulent, infect the liver and produce multiple abscesses. The colon bacillus is also liable to affect the gall bladder, and form a nucleus for the formation of gallstones. Another variety of germs, which is apt to cause multiple abscesses of
the liver, is the bacillus PYOCYANEUS, or the bacillus of blue pus. This
usually affects the liver primarily, and its path of entrance into the
liver is sometimes impossible to find; it is probably carried by the circulation,
or through the bile ducts, and leads to multiple abscessed. After the abscesses
have formed, there is little to be done, except to increase the phagocytic
activity and relieve the arterial dilation of the part. Abscesses of the
liver are not frequently met with. If these cases are seen early enough,
and where the germs have not multiplied in too great a number, phagocytic
activity would prevent further increase.
GROWTHS OF THE LIVER The liver is frequently the site of malignant growths, the most common of which are cancer and sarcoma. Cancer of the liver may occur either primarily or secondarily to cancer elsewhere in the body. Cancerous growths, when they occur secondarily in the liver, are carried from the original site to the liver by means of the circulation. As a result of this, the secondary growths of the liver begin in the interlobular septa, and afterwards extend and involve epithelial cells of the liver. A primary growth of liver usually begins in the lobules themselves. It begins as an atypical and abnormal growth of the epithelial cells. These growths may either be single or multiple. The multiple is the most common condition found. The growths usually increase in size rapidly, and lead to an enormous enlargement of the liver, producing serious disturbances of its functions. Jaundice may or may not be present, due to the fact that the bile capillaries may or may not be interfered with. These growths present characteristic indications. The liver is enlarged, tender to the touch, and usually extends a considerable distance below the costal margin. Its surface is rough, due to the projection of cancerous nodules, which are felt as roundish elevations and are somewhat umbilicated or depressed in the center. There may be a single large nodule, or, more frequently, a number of small nodules. Cancer in the liver may produce secondary cancer in various other organs of the body. The duration of the cancer is from the pressure of its growth, and from the poisoning which is produced by the absorption of the poisonous products resulting from thee growth of the cancer; the entire body becomes perverted. Cancer of the liver precludes any local treatment of the organ itself. All that can be done must be accomplished through a regulation of the nervous mechanism of the liver. The involvement of the liver tissue with cancer makes the liver friable, so that it may be easily ruptured, and direct treatment to the liver might lead to spreading the cancer to other parts. It is not probable that anything can be done in the advanced stages of this perversion, except to make the patient more comfortable. Here we have a contra-indication to local treatment of the liver. In
cancer of the liver, there are indications of perversions of the arterio-motor
mechanisms of the liver. When the attacks of pain are severe, there are
indications of an excessive amount of blood in those segments of the cord
from which the liver is supplied, and an active dilation of the blood vessels
of the liver.
SARCOMA OF THE LIVER In Sarcoma of the Liver, either of the following kinds of cells may
be found in the liver; the small round cell, the large round cell, the
giant cell, or a peculiar form of pigmented cell may be present, known
as "Melanotic Sarcoma." These growths occur either primarily or secondarily
in the liver. When they occur as secondary growths, the cells have been
carried to the liver by the blood vessels. Their growth is exceedingly
rapid. They may completely destroy the liver, and they are liable to form
secondary growths in other organs. Sarcoma is usually rapidly fatal. The
liver is enlarged and instead of possessing the hard, nodular, umbilicular
masses found in cancer, the enlargement is more uniform and softer; the
masses are apt to be larger. The progress of the perversion is much more
rapid than that of cancer. Sarcoma produces practically the same results
and the same disturbances. What has been said in regard to the management
of cancer of the liver applies to Sarcoma of the Liver. The melanotic Sarcoma
is usually limited to the liver, and the choroid coat of the eye. It is
characterized by a large amount of black or bluish-black pigment, and the
peculiarity of these growths is that they produce a secondary pigmented
or Melanotic Sarcomata of the skin. These growths are exceedingly rapid
and malignant.
HYDATID CYSTS OF THE LIVER The hydatid Cyst is the result of the ingestion of the ova of an intestinal
parasite, which leads part of its existence in the alimentary canal of
the dog, and the remainder of it in man. This parasite is known as Echinococus.
It is a variety of worm that affects the alimentary canal of the dog. The
ova are laid in the dog's intestines and are extruded with the feces, and
through many accidental concurrences may get into the alimentary canal
of man, from where they are carried to various parts of the body, the liver
being one of the most common sites. Where the ova undergo a certain amount
of growth and development, resulting in the formation of a cyst, which
increases in size, and from the walls of this cyst are continually forming
more small cysts, which finally become detached from the wall, and fill
the interior of the original cyst. These cysts may be found in the liver,
in the brain, kidney, the tissues back of the abdomen, the lungs, and various
other parts of the body.
EXAMINATION OF THE STOMACH There are so many abnormal conditions that can affect the stomach that only a few can be touched on here. Ptosis is the first thing that can be locked for, this can be ascertained by immobilizing the abdomen with one hand underneath the stomach, then with the other palpating the contour of the stomach. In patients with abdominal pendulosity and visceroptosis it is often important to ascertain the relationship of a complaint to drag on the visceral supports. The physician standing behind the patient raises the lower abdomen, holding it in that position. If the patient claims relief from this support, the test is positive. Cancer can be determined by the pain on palpation, with the cold moisture that is present. The superficial lymphatic glands are enlarged. The main features are a history of pain, dyspepsis, vomiting, extreme anemia, loss of flesh. Pyloric obstruction is ascertained by noticing a bulge over the epigastrium. Vomiting may be prolonged for hours or a few days, and may consist of all that has been eaten for that time. The stethoscope or ear can detect a splashing sound made by the effort of the contents to leave the stomach. Sometimes these sounds are so loud they can be heard at a distance. Ulcers of stomach. There is a history of dyspepsia, pain, sharp, stabbing or burning in the epigastrium and back after eating. Vomiting occurs soon after eating. There is a loss of considerable blood by the hemorrhage and loss of weight and strength. On palpation the surface is warm to hot over the ulcers which are usually multiple and situated in the lesser curvature and in the posterior wall of the stomach near the pylorus, and vary in size from a few millimeters to five centimeters. The conditions mentioned above are the most serious, but the lesser ones should not be overlooked because they might bee the beginnings of serious inflictions, thrush, stomatitis, nausea, belching. The stomach lies beneath the diaphragm and the liver, toward the left side of the abdomen. The stomach is a dilated portion of the intestinal tube which has become specialized as a receptacle for food, and for a certain part of the digestive process. The larger end of the stomach lies toward the left, while its smaller end lies toward the right. The stomach is partially covered by the liver, the liver lying beneath the diaphragm on the right side. The greater portion of the large end of the stomach lies behind the lower ribs on the left side, filling up the concave space beneath the diaphragm. The stomach is lined with columnar epithelial cells; some of these cells form mucous glands, and others of them have developed into glands which manufacture gastric juice. The glands at the larger end are rather long and somewhat branching. These glands are lined with epithelial cells and also peculiar oval cells which lie next to the wall of the gland - called the acid cells. These cells manufacture hydrochloric acid. The other cells which line these glands manufacture pepsin. In the smaller end of the stomach, there is another group of glands which manufacture only pepsin. Beneath the mucous membrane, there is a coat of connective tissue, upon which the epithelial cells rest. Beneath this is a coat of muscle cells arranged into three layers - a longitudinal, a circular, and an oblique layer. These muscle cells are of the involuntary type. Outside of the muscular coat is the peritoneal coat, which covers the stomach and forms folds which serve as ligaments to support it. A fold passes from the stomach downward, and envelops the transverse portion of the colon. Above the stomach, a fold passes upward and backward to the liver. The stomach is supported in the abdominal cavity largely by this ligament and other folds which attach it to the under surface of the diaphragm. The stomach is also supported by the contents of the abdominal cavity below it. In addition o the support of the contents of the abdominal cavity and the ligaments, the abdominal muscles form an important support for the stomach, as well as for the other contents of the abdominal cavity. The stomach is also supported by the contents of the abdominal cavity below it. In addition to the support of the contents of the abdominal cavity and the ligaments, the abdominal muscles form an important support for the stomach, as well as for the other contents of the abdominal cavity. The stomach serves primarily as a receptacle for food that has been chewed and swallowed, enabling us to take food at longer intervals of time than would otherwise be possible, because food can bee taken into the stomach in considerable quantities, and the process of digestion will go on for a number of hours. The glands of the stomach manufacture juice that acts upon thee proteids. The hydrochloric acid converts proteids into acid albumin; then pepsin converts proteids into acid albumin; then pepsin converts them into proteoses and peptones. Very little absorption takes place in the stomach, but small amounts of sugar are absorbed; but even a glass of water usually passes through the small intestines before much absorption takes place. If fluids are absorbed readily in the stomach it would interfere with the process of digestion in the intestines. We have acquired unnatural habits of feeding ourselves. We take into the stomach many substances which are irritants; the spices, pepper, red pepper, pickles and various sauces that are used on meat and in soups. Under normal conditions, the stomach will stand a great deal of this sort of treatment without producing any serious discomfort, but the continued use of those substances results in irritation of the stomach. The irritants produce, first, a constriction of the blood vessels of the stomach, which is followed by an active dilatation of the same vessels. This results in an increased formation of juice in the stomach, and disturbances of the nervous mechanisms of the stomach, and finally a loss of arterial tone of the blood vessels of the stomach which is followed by the multiplication of connective tissue. The connective tissue finally contracts; if this continues, atrophy of the mucous membrane occurs and an improper and insufficient amount of gastric juice is manufactured. The loss of viscero-motor tone which occurs results in a dilatation of the stomach. Through a relaxation of its muscle cells. If the stomach is overloaded, the excessive strain upon the ligaments of the stomach results in an over stretching of the muscle cells and the elastic issue of the walls in the stomach. The alterations which have taken place in thee central nervous system have lessened the tone of the muscle cells and the tone of the ligaments of the stomach, resulting in a dilation of thee stomach; the relaxed ligaments allow the stomach to drop downward. The same conditions may be produced by disturbances primarily in the central nervous system. The loss of arterio-motor tone produces a disturbance of the formation of juice of the stomach, which, in the beginning, is apt to be excessive, resulting in almost constant irritation of the mucous membrane of the stomach, which is often accompanied by eructations of gas; sometimes fluid comes up into the mouth - fluid which is burning and irritating in character, due to the presence of hydrochloric acid. This is called "Water Brash." The presence of an excessive amount of hydrochloric acid in a comparatively empty stomach also produces the condition called "Heart Burn." The hydrochloric acid acts on the walls of the stomach and also upon the pharyngeal walls, when it is belched up. The cause of these disturbances may either be in the stomach itself, or primarily in the central nervous system. In the great majority of cases, the underlying cause of the perversion is a disturbance of the arterio-motor and viscero-motor mechanisms of the stomach, placing it in a condition in which it is less resistant to the disturbances produced by taking improper food. Acute disturbances of the stomach are usually due to the presence of some irritant in the form of improper food, or poisonous substances present in the stomach as corrosive sublimates, the strong alkalies, or ammonia. These substances are all violent irritants, and many of them are capable of destroying the epithelial cells in the mucous membrane. The irritating action of these substances usually brings about vomiting, and the stomach is emptied of its contents, but even though the irritant remains in the stomach for a brief period of time, it may produce very serious disturbances. The strong corrosive irritant may cause destruction of the entire mucous membrane of the stomach. In very violent forms of poisoning, the destructive process may involve not only the mucous membrane, but the entire wall of the stomach, causing a rupture of the stomach. Its contents leak out into the peritoneal cavity and death results. In corrosive poisoning, the irritans must be removed from the stomach as quickly as possible and its action stopped by the use of some substance which destroys it or renders it inert. The removal of the contents of the stomach is much facilitated by having the patient drink large quantities of lukewarm water, which serves to dilute the irritant, and facilitates the removal of it from the stomach by vomiting. There are various conditions or substances that act as antidotes to these corrosive poisons, which destroy them or render them so that they do no damage. After the damage has been done by the irritant, it is necessary to withhold food and allow the stomach to rest, as the presence of food aggravates the condition; if necessary, food may be administered by the rectum. Acute perversions of the stomach that result from improper food or overeating are usually only of a temporary duration. As soon as the stomach is relieved of the irritant, the condition rapidly disappears. In such cases, the patient should avoid food for twenty-four or forty-eight hours so as to give the stomach a rest. Ulceration of the stomach or ulceration of the mucous membrane of the stomach is most common in young people "particularly in women" and in the interior of the stomach are found small areas where the mucous membrane is entirely destroyed; the epithelial calls have disappeared, and a peculiar punched out ulcer (usually round) is produced, surrounded by a zone of dilated blood vessels. The presence of this zone of blood vessels is evidence of Nature attempting to repair the damage. The cause of these ulcers is primarily a disturbance of the arterio-motor mechanism of the gastric mucous membrane, or occasionally a clot or rather nodular, and is usually tender on pressure. It may produce obstruction to the pylorus, and result in an enormous dilation of the stomach and retention of the gastric contents, which are usually removed by the act of vomiting. The vomiting in these cases is quite characteristic. The surface of the cancer is often altered, hemorrhages occur slowly in the stomach, the blood is acted upon by the gastric juice and mixed with the food, and the vomited material has a peculiar characteristic appearance, described as "Coffee ground vomit." The disease is accompanied by a peculiar petechia (which is characteristic of malignant growths}, rapid loss of flesh and strength, and finally death from exhaustion. One of the most common forms of malignant growth in the stomach is Cancer. They may be eighter the Scirrhus or hard cancer; Medullary or soft cancer; or the Colloid cancer. These growths are all malignant and generally end in death. The duration of cancer of the stomach is on the average not over a year; sometimes it may be extended to two years. Cancer is usually not recognized until after it has reached a considerable size, so that it can be felt as a distinct tumor. The Scirrhus cancer may appear in any part of the stomach. It is most common around the outlet of the stomach, and is very apt to cause obstruction and prevent food from passing from the stomach into the small intestine. It may also occur in the anterior and posterior walls of the stomach, around the inlet, or at the greater or lesser curvature of the stomach, after it reaches a moderate size, it can be easily felt through the abdominal walls, and can be recognized by its general character and the conditions which accompany it. The patient loses flesh rapidly, because the process of digestion is interfered with, and poisonous substances are absorbed from the cancer. If the growth is about the outlet and does not completely obstruct it, the passage of gas or fluid through the outlet can be distinctly felt beneath the tumor, and if the stethoscope be placed over the growth at this region, we may be able to force fluid and air through the outlet, and the air passing out can be distinctly heard. As the growth increases in size, ulceration of its surface is apt to occur, and the ulceration of the surface of the cancer may result in hemorrhage into the stomach, which in the majority of cases, is slow. The blood mixed with food material is vomited. The vomit is dark in color resembling coffee grounds. Sometimes a large artery is opened in the ulcer, and a rapidly fatal hemorrhage occurs. In Cancer of the Stomach, secondary cancerous growths are apt to occur in other parts of the body, and this is brought about through the lymphatics. Cells of the cancerous growth escape into the lymphatics and may be carried to the liver, to the pancreas, or to the lymphatic nodes, lodge in these places and result in the formation of secondary growths. When this occurs, the cas progresses more rapidly and the outlook is much less hopeful. Where the growth obstructs the outlet, it results in dilatation of the stomach, due to the fact that it is difficult or impossible for food to pass through into the small intestines. Food then accumulates in the stomach, and through the disturbance of the viscero-motor and the arterio-motor mechanisms of the stomach, the muscle cells in thee walls of the stomach lose their tone, and the weight of the food contents, stretches the stomach more and more, and finally results in an enormous dilatation of the organ, so that the lower border of the stomach may extend below the umbilicus. Normally, the lower border of the stomach is about one-half way between thee umbilicus and the ensiform cartilage. A ppeculiarity of the juice of the stomach in these cases is the absence of hydrochloric acid. Hydrochloric acid is one of the most important factors in preventing fermentation in the stomach, and when it is absent, and (as in these cases) the food is retained in the stomach for several days at a time, various fermentative and putrefactive processes take place. A form of fungus growth, the Sarcinae, is apt to be found in the contents of the stomach. If the contents of the stomach are examined under the microscope, these are seen as little cubical bundles divided by lines passing at right angles into a number of smaller cubes. As a result of the putrefactive process, various irritating substances are formed such as lactic acid, butyric acid, etc. when the outlet is obstructed, vomiting occurs periodically, as this is the only way the stomach can empty itself of its abnormal contents. The vomiting is characteristic because of its periodical occurrence and because of the fact that large quantities of material are ejected; a quart or two of brownish, ill-smelling material, at intervals of 48 or 72 hours, containing altered blood coloring matter is found, fragments of undigested food of all sorts, and large numbers of micro-organisms. Occasionally in the vomit, distinct nests of cancer cells, which have been separated by the ulceration of the cancer, may be present. They are recognized by the atypical growth of the epithelial and their atypical arrangement. When the cancer is not located near the outlet and does not cause an obstruction, the stomach may not become dilated, but the growth progresses its surface becomes ulcerated, it produces intense pain upon the taking of food and finally results in death by exhaustion, and by the involvement of other organs with secondary growths. Vomiting occurs in these cases, and is of practically the same character as described, except in quantity, is not so large. These cases progress slowly and result in emaciation, and finally death from complete exhaustion. The Scirrhus, or hard cancer, is of a slower growth than the other varieties. The medullary, or soft cancer, only differs from the Scirrhus or hard cancer, in the fact that it contains a larger number of cells and less connective tissue between them. In the Scirrhus cancer, the cell nests are small and the amount of connective tissue between them large. The medullary cancer has comparatively large cell nests, with a smaller amount of connective tissue between them. These growths usually progress much more rapidly and involve a much greater portion of the stomach than the Scirrhus Cancer. They produce the same emaciation and secondary growths in other parts of the body, and bring about death in the same way, only the progress is much more rapid. The Colloid Cancer occurs much more rarely. It is characterized by the face that in the cell nests there is a certain amount of colloid material. These are also of a rapid growth. The occurrence of Medullary and Colloid cancers results in growths of considerable size in the stomach, sometimes involving the entire stomach wall, both anterior and posterior. They can be felt as large, rather hard masses in the region of the stomach. The diagnosis between Scirrhus and other forms of cancer is made from the character of the growths and the rapidity of the progress. The Scirrhus is a hard and rather nodullary mass, usually not of large size. The Medullary and the Colloid present larger and softer masses which may involve the whole of the stomach. The stomach may also be the seat of other forms of growth which are not malignant. Sometimes little growths are found in the stomach, made up of fibrous tissue. These cause no disturbances unless they be situated where they act as a valve and obstruct the outlet. These growths have been frequently found after death and have produced no signs of disturbance during life. They grow slowly; do not, as a rule, attain a large size, and are not dangerous, except where they are located in a position to cause obstruction to the outlet of the stomach. The scar left by the ulcer in the stomach frequently predisposes to
a Scirrhus cancer later in life. The underlying cause of all these perversion
is, primarily, a disturbance of the arterio-motor mechanism.
EXAMINATION OF THE HEART AND BLOOD VESSELS The blood is kept in motion by the rhythmical contraction and relaxation of the muscle cells of the heart, the elastic recoil of the large arteries and the rhythmical contraction and relaxation of the muscle cells of the heart, the elastic recoil of the large arteries and the rhythmical contraction and relaxation of the muscle cells in the arterial walls, especially in the arterioles, and its flow through the veins is facilitated by contraction of the voluntary muscles. The flow of blood is kept in one direction through the arrangement of valves in the heart and valves in the veins. The flow of blood in the arteries is rapid, its rapidity deceasing as it approaches the arterioles, and in the capillaries the flow of blood is exceedingly slow, while in the veins the flow is again accelerated largely through contraction of the voluntary muscles. The blood vessels form a system of closed tubes with the heart as a central double pump. The two sides of the heart are separated from each other by a muscular septum. The right side of the heart is connected with the pulmonary circulation, and the left side of the heart with the systematic circulation. The heart is a modified blood vessel and is lined with endothelial cells. The heart is largely made up of muscular tissues. The muscle cells of the heart are peculiar to the heart, and are not found anywhere else in the body. They are involuntary muscle cells, and differ from other involuntary muscle cells in their shape and that they are striped very much like voluntary muscle cells. The ends of the muscle cells of the heart are square and many of the cells are branching. Each cell is surrounded by a thin membranous wall, and each cell contains a nucleus. The muscle cells of the heart develop most perfectly the function of contractility, and their activity is rhythmical; they alternately contract and relax. During the periods of relaxation the muscle cells of the heart obtain their rest. Throughout life the muscle cells of the heart rhythmically contract and relax. This property is possessed by the muscle cell itself, but in order that the contraction of the muscle cells of the heart should occur in a coordinated manner, they are governed by a double nervous mechanism, consisting of two groups of neural units, one group of neural units which is accelerating in function, and the other group which is restraining in function. Through the activity of those two groups of neural units the rhythmical co-ordinated beat of the heart is maintained. The restraining neural units are located in the posterior brain cavity and in the nucleus of the tenth cranial nerve. Their paths of exit are distributed with the cardiac branches of the tenth nerve to the ganglia of the heart. The neural units in the ganglia of the heart send their paths of exit to the muscle cells of the heart. Through the activity of these neural units relaxation of the muscle cells of the heart is brought about, and this group of neural units is in a constant state of activity, so that there is a constant tendency upon the part of these neural units to cause the heart muscles to relax. The accelerating neural units are located in the floor of the posterior brain cavity and in the cervical and first dorsal segments of the spinal cord. Their paths of exit pass to the inferior cervical and first thoracic ganglia. Neural units in these ganglia send their paths of exit to the muscle cells of the heart, and activity upon the part of these neural units bring about a contraction of the heart muscle. This group of neural is only occasionally active. The heart, therefore, is governed by a double nervous mechanism, one which is restraining in function and one which is accelerating in function. The restraining neural units are constantly active, and through the activity of these two groups of neural units the rhythmical contraction and relaxation of the muscle cells of the heart is maintained. A perversion of either of these two groups of neural units leads to a perversion of activity of the heart, and no perversion of the heart can occur without involving one or both groups of these neural units, either primarily or secondarily. In addition to these two groups of neural units, there are in the heart the beginnings of the paths of entrance of depressor neural units. Their paths of entrance pass upward in the tenth cranial nerve to cell bodies in the ganglia of the tenth nerve. From these cell bodies, paths of exit pass upward through the tenth nerve to come in contact with the constrictor portion of the arterio-motor nucleus. Messages sent in through this pathway lessen the functional activity of the constrictor portion of the nucleus, and bring about a relaxation of the blood vessels, especially those of the abdomen. There are also beginning in the heart, paths of entrance of common sensation. With each contraction of the heart, the size of its chambers are lessened, and the blood is forced out of the heart into the aorta and pulmonary artery. Immediately after contraction, the heart relaxes and it again fills with blood from the great veins, the superior and inferior vena cava filling the right auricle, and the pulmonary veins filling the left auricle. The normal rate of the beat varies in different individuals and at different periods of life. In the newly born child, the pulse rate is about 140 to 150 per minute. The rate falls after birth and during the first year it is between 110 and 120. For the first three or four years of life, the pulse rate is about 100. It then gradually falls, and by the tenth or twelfth year the pulse rate is between 80 and 90. The pulse rate in the adult varies between 68 and 84, being slower in man than in woman. The average rate in man is between 68 and 76, and in women from 76 to 84. The strength of the beat of the heart increases with the growth of the child because the heart keeps pace in its growth with that of the body, and as the heart increases in size, its beat becomes stronger. The heart obtains its rest during the periods of relaxation. When the heart is beating at the rate of 75 per minute, the contraction takes about one-third of a second, and relaxation one-tenth of a second, and then the heart is quiet for about four-tenths of a second, and the entire cycle being about eight-tenths of a second. The heart is only working while it contracts. It is therefore only working three-eights of the time or about 9 hours in 24, while it is resting fine-eighths of the time or 15 hours in 24. Anything which increases the rate of the heartbeat robs it of its normal rest, and if the rate of the heartbeat be much increased and persists for any great length of time, the heart gradually becomes fatigued and later completely exhausted and unable to contract, so that there is always a certain amount of danger where the rate of the heart is increased much above the normal and persists for any great length of time. In health the heart can usually be felt of the left side through the chest wall in the fifth interspace about one-half inch inside the mid-clavicular line; this is called the apex beat. The sounds of the heart in health are two in number, called the first and second sounds. The first sound of the heart is produced by the contraction of the muscle cells in the heart and by the closure of the auriculo-ventricular valves, while the second sound of the heart is produced by the sudden closure of the aortic and pulmonary semi-lunar valves. The first sound is low-pitched and booming in quality, while the second sound is sharp and clicking. The sounds of the heart may be altered in intensity or altered in their quality. The first sound may be increased or decreased in intensity. Increase in intensity of the first sound of the heart indicates that the heart is contracting with more force than usual or normal. Decrease in the intensity of the first sound of the heart is usually due to some perversion of the muscle cells of the heart which interferes with their contractile power, or it may be due to some condition which interferes with the transmission of the sounds to the ear. For instance, the accumulation of fluid in the pericardium or a thick chest wall. Perversions of heart may be classified as follows: 1. Perversions of the rate of beat. 2. Perversions of the strength of the beat. 3. Perversions of the valves of the heart. 4. Perversions due to structural changes of the heart. Alterations in the quality of the first sound are produced by perversions of the valves, or by perversions of the muscle cells of the heart. When the mitral or tri-cuspid valves are perverted and fail to perform their functions properly, the quality of the first sound is altered by the leaking back of the blood into the auricles. As the blood leaks back through the valves, the blood is thrown into currents and eddies which produce a distinct sound. Alterations in the quality of the first sound, due to disturbances of the muscle cells, which prevents them from contracting properly, lead to the loss of muscular quality of the sound and to predominance of the valvular quality. Perversions of the semi-lunar valves, either the aortic or pulmonary, may also occur, affecting their intensity or their quality. Their intensity may be increased and an increase in the intensity of the sound of the pulmonary or aortic semilunar valves indicates an increase in the pressure in the pulmonary artery or the aorta. For instance: an increased intensity of the second pulmonary sound indicates that there is increased pressure in the pulmonary circulation, which is very common in pneumonia when the lungs are infiltrated, which would mechanically interfere with the passage of blood through the pulmonary vessels, and produces a marked increase in the intensity of the second sound at the pulmonary area. An increase in the intensity of the second sound at the aortic area indicates increased pressure within the systemic circulation, and is most frequently due to abnormal constriction of the blood vessels and is also a very common condition in certain perversions of the kidneys, particularly those perversions of the kidneys which lead to an increased production of connective tissue in the kidneys. The second sound at the aorta is also increased where there is any interference with the flow of blood through the blood vessels. Excessive increase in the amount of fibrous connective tissue in the walls of the blood vessels or the hardening of the arteries, such as occurs in old age, also produces an increase in the intensity of the second aortic sound. Perversions of the quality of the second sound most frequently occur at the aortic area. Perversions of the valves which alter the quality of the heart sounds produce "murmurs", and by listening over the heart in the proper areas, we are able to determine which of the valves is perverted. If we listen over the apex or just above it, and hear a murmur with systole, which either modifies or completely takes the place of the first sound, it usually indicates a perversion of the mitral valve, and a back flow of blood from the left ventricle into the left auricle. This is called "Mitral Regurgitation" or leaking at the mitral valve. If the valve is perverted so that it obstructs the flow of blood from the left auricle into the left ventricle, the murmur is heard just before the beginning of systole (contraction) of the ventricle or while the auricle is contracting and forcing the blood into the ventricle the blood in passing down through the contracted opening produces a murmur, which is presystolic. This murmur is usually harsh and transmits distinct vibrations to the chest wall, and if the hand is placed over the heart a peculiar thrill can be felt, which is very much like the purring of a cat. (Stenosis.) The murmurs produced by perversions of the tricuspid are best heard over the middle of the sternum where the fourth rib joins it. They occur in systole (contraction), and indicate that the blood leaks back from the right ventricle into right auricle. It rarely happens that there is a presystolic murmur at the tricuspid area. Murmurs at the aorta are best heard at the right edge of the sternum in the second interspace, and they may either occur with systole or diastole. If there is any obstruction to the flow of blood from the left ventricle into the aorta, the blood is thrown into vibrations and makes a distinct sound with systole. Or if the valve is perverted so that the blood leaks back from the aorta into the left ventricle, a sound is produced with diastolic, and at the second right interspace we hear a to-and-fro murmur with systole and diastole. There may be no obstruction to the flow of blood into the aorta, and very frequently the sounds produced with systole in this area are due to the fact that the aorta is really larger than normal. A deposit of lime salts in the aorta may also occur and the passage of blood over this rough surface would produce a sound. Normally at this region we simply hear a short, sharp, clicking sound, indicating the closure of the valve. In murmurs with diastole, instead of a short, sharp click, there is a prolonged rumbling sound. Another point that serves to distinguish these murmurs from each other, is the direction in which they are transmitted. Murmurs which are produced by a leak at the mitral valve are not only heard over the apex of the heart, but are transmitted toward the left axilla and sometimes may be heard at the angle of the left scapula. The presystolic murmur is heard just above the apex and is not transmitted. It is only heard in a very limited area, usually not larger than the size of a silver dollar, while the systolic murmur heard at the aorta is transmitted along the arch of the aorta. If it be a diastolic murmur, the direction of the leak is backward from the aorta into the left ventricle, and the murmur will be transmitted down the sternum. The indications of perversions of the heart are murmurs, distress or
discomfort in the region of the heart, shortness of breath and swelling,
especially in the lower extremities, due to pericellular infiltration which
usually occurs in the latter part of the day. In addition to these indications
there is a distinct blueness of the skin, particularly in the extremities,
in finger nails, the toes, the ears, the tip of the now, and the mucous
membrane of the lips, due to deficient oxygenation of the blood. Perversions
of the heart may either be due to disturbances of its muscular structures,
the valves of the heart, the nervous mechanisms of the heart, or the nervous
mechanisms of the blood vessels.
PERVERSIONS OF THE LEFT SIDE OF THE HEART If the mitral valve becomes perverted so that it does not close properly, a certain amount of blood will leak back into the left auricle. This will bring about changes in the heart as well as perversions of the circulation through the lungs. And as the blood leaks back into the auricle from the ventricle, the flow of blood from the lungs into the left auricle is interfered with because the auricle already contains blood which has leaked back from the ventricle. This leads to an engorgement of the pulmonary blood vessels, back pressure in the veins, and also interferes with the flow of blood through the pulmonary artery. This perversion produces an enlargement of the heart, which is an endeavor upon the part of nature to compensate for the leak. In order to supply the system with a proper amount of blood, the ventricle becomes larger and stronger. The muscular wall of the ventricle thickens and its cavity enlarges, so that a sufficient amount of blood is present in the ventricle at the beginning of each systole to send out the proper amount of blood needed by the body, and to allow for a certain amount of leakage back into the auricle. In addition to the increased size of the ventricular cavity, the thickening of the wall of the heart increases its strength, so that the blood is sent out with a greater force than occurs in the normal heart. The enlargement of the heart produced by this conditi0on ordinarily is not great, and in the majority of cases where there is a leak at the mitral valve a compensation is established. As long as the compensation is perfect, there are no external indications of any perversions in the circulatory system, and many of those cases go through life without suffering any discomfort and never know that they have a perversion of the heart until an examination is made. These cases are liable to a loss of compensation, and when this occurs, indications of disturbances of the circulation appear. If the heart muscle does not increase in strength sufficiently to compensate for the leak, then the system begins to suffer from an insufficient supply of blood because the blood does not circulate with the proper velocity. The blood then begins to accumulate in the dependent portions the lower extremities toward the heart has to overcome the force of gravitation, and the heart must impart to the blood sufficient force to send it through the arteries, the capillaries, and start it well on its way through the veins. When the heart is enfeebled, the force with which the blood is sent down to the extremities is not sufficient; the blood then stagnate in the veins of the lower extremities and leads to an excessive out pouring of plasma producing pericellular infiltration. When the heart is doing its work fairly well, the infiltration of legs may be not very marked, but toward the end of the day the ankles become swollen and the tissues doughy. If the finger is pressed upon the skin, a little dent is made because the pericellular fluid is displaced. This condition is inaccurately called "dropsy of the lower extremities." As the heart loses its power the infiltration increases, and is not only present at the end of the day, but is constantly present, increasing toward evening after a time not only are the ankles affected, but the infiltration extends through the entire leg. The veins of the abdomen also become engorged, back pressure occurs, and fluid leaks out and accumulates in the abdominal cavity. If the perversion progresses sufficiently, the abdomen fills with fluid, then fluid accumulates in the cavity of the chest, in the pericardium, and finally the patient practically drowns in his own fluid. When the heart begins to lose its power to compensate for the leak at the valve, shortness of breath comes on. This is partly due to the feebleness of the heart and partly due to the fact that back pressure in the pulmonary vessels causes a certain amount of engorgement and infiltration of the lungs. If this becomes sufficiently marked, it interferes with the oxygenation of the blood in the lungs. In perversions of the mitral valve, which leads to a leakage back into the left auricle, the first sound of the heart is altered, and instead of the distinct "lub" which is heard normally, it either is entirely displaced by another sound or is very much altered, and this is called a murmur. The murmur occurs with the contraction of the heart and is best heard just above the apex. The sound produced is transmitted to the left axilla and sometimes as far as the angle of the left scapula. In all murmurs their location and direction of their transmission are their chief characteristics, and are the indications which serve to distinguish one kind of murmur from another. The character of the murmur varies from another. The character may be rough, harsh, soft, long or short. The entire first sound may be displaced by the murmur. The loudness of the murmur is no indication of the degree of perversion. A loud murmur usually indicates that the heart is still strong and forcibly contracts, so that the blood is thrown into vibrations that can be distinctly heard. It is the soft, indistinct murmurs that most frequently indicate a dangerous condition of the heart, indicating that the heart is losing its power of contracting, the contraction being so feeble that a very feeble murmur is produced. The murmur itself indicates only that there is a leak at the mitral valve. If there are no indications of perversions of circulation, the heart has compensated for the leak. The most common cause of perversions of the mitral valve is an infection of the valve leaflets with germs, which very frequently occurs as a complication in the acute infections, particularly scarlet fever, diphtheria, pneumonia, smallpox, and in rheumatism. It is estimated that seventy percent of the perversions of the mitral valve result as a complication of the perversion inaccurately called "acute articular rheumatism" in the acute infections, the resisting power of the cells of the body is more or less interfered with by the excretions of the germs. The germs get into the circulation and are carried to the various parts of the body and leaflets of the valves of the heart, and there produce the usual effects of an irritant. First, a brief constriction of the blood vessels, followed by a dilation of th blood vessels, an outpouring of plasma and pericellular infiltration of the valves. The valve becomes thickened, the irritant leads to the multiplication of connective tissue cells, and after a time the connective tissue contracts and the valve becomes distorted and pulled out of shape, and is no longer able to close the auriculoventricular opening, and a leak occurs which is indicated by a murmur. Instead of there being a leak back into the auricle from the ventricle, there may be such a perversion of the mitral valve as to produce an obstruction to the flow of blood from the auricle into the ventricle, and this produces indications which are characteristic. The leaflets of the valve may grow together so that only a small opening is left for the blood to pass from the auricle into the ventricle. The flow of blood from the auricle into the ventricle is greatly interfered with, and the auricle is constantly overfilled with blood and is unable to empty itself. The auricle increases in strength, its muscular wall thickens in order to overcome the obstruction, and the auricle contracts forcibly in its endeavor to force the blood through the contracted orifice, and as the blood is forced through the constricted orifice, a murmur is produced and occurs immediately before the first sound of the heart. This murmur is best heard a short distance above the apex beat, and is not transmitted. It is only heard over a small area. The murmur is usually harsh or grating in quality, and quite loud, and is often accompanied by a distinct vibration of the chest wall, which can be felt. The first sound itself may be clear and unaltered, but just before the first sound, this murmur is heard. It rarely occurs that there is obstruction to the mitral orifice without there being also a leak back into the auricle, and then a murmur which occurs with the first sound as well as a murmur which occurs immediately before the first sound. The obstruction to the flow of blood from the auricle into the ventricle leads very rapidly to an increase in the size of the auricle, thickening of its walls and a backing up of the blood into the lungs, and interference with the oxygenation of the blood. This condition when it is marked, is accompanied by a shortness of breath and blueness of the lips and nails, due to the deficient oxygenation of the blood. As these cases progress, perversions occur in the right side of the heart. The back pressure of blood in the lungs interferes with the flow of blood through the pulmonary artery, the pressure in the pulmonary artery is constantly above normal; the pulmonary artery becomes stretched and after a time the semilunar (Pulmonary) valves are unable to close the orifice, and the blood leaks back into the right ventricle. The right ventricle becomes distended; it may become so stretched that the tricuspid orifice becomes too large for its valve to close; then a leak also occurs into the right auricle, and the blood is backed up in the great veins, and in this perversion a distinct pulsation of the veins of the neck can be seen and pulsation of the liver can be distinctly felt. Perversions may also occur of the aortic valve which obstructs the flow of blood from the left ventricle into the aorta, and there are certain characteristics which serve to distinguish this from perversions of the mitral valve. If a perversion occurs which interferes with the flow of blood from the left ventricle into the aorta, a murmur is produced with each contraction of the heart, and this murmur is best heard on the right side of the sternum where the second rib joins it. At this point in the normal heart, no first sound is heard, but at the beginning of relaxation is heard the sharp click due to the closure of the aortic valve. If there is an obstruction to the flow of blood from the left ventricle into the aorta, with each contraction of the heart we hear at this point a murmur and this murmur varies much in quality. It may be very loud and harsh or very soft, it may be very short or it may be long. A murmur heard with the first sound over the aortic region also indicates that there is some condition present which throws flood into vibrations. Lime salts may be deposited in the walls of the aorta, or the aorta may be dilated, and when the blood passes over this rough surface it is thrown into vibrations. The valves at the aorta may be so perverted that the blood leaks back into the ventricle, and this is one of the most dangerous of the perversions of the valves of the heart. The aortic valves may become very much affected by germs which act as irritants, leading to distortion of the valve, and immediately after each contraction of the heart the blood leaks back into the ventricle. The murmur is heard at the beginning of the relaxation, and instead of the sharp click normally heard, indicating the closure of the valves, a prolonged murmur is heard as the blood leaks back from the aorta into the ventricle. This murmur is also best heard at the second interspace on the right side, and is transmitted down the sternum toward the left ventricle. (Aortic regurgitation.) This perversion leads to a greater alteration in the heart muscle than
any one of the other valvular perversions. The leaking of the blood back
into the ventricle (left) immediately after each contraction leads to an
overgrowth of the walls of the ventricle, and increased strength of the
contraction of the heart; for the heart has to pump out with each contraction,
not only the blood it has received from the auricle, but also the blood
which has leaked from the aorta. The ventricle becomes stretched and in
order to prevent over stretching, the muscle becomes thicker and the heart
in these cases sometimes becomes enormously enlarged. The increase in the
size of the heart is an effort on the part of nature to compensate for
the leak, and for a long time the compensation may be perfect. As the size
of the ventricular wall increases, after a time it fails to get a sufficient
supply of nourishment, because the coronary arteries do not enlarge with
the enlargement of the muscular tissues of the heart. The increase of the
muscular tissue reaches a point where the coronary arteries are unable
to feed the muscle cells properly, and they begin to suffer from an insufficient
supply of blood. Loss of muscular tone takes place, the walls become thinner,
dilation of the heart occurs, and indications of the failure of compensation
comes on.
PERVERSIONS OF THE RIGHT SIDE OF THE HEART Perversions of the right side of the heart are, in the most cases, acquired
during foetal life, except when they are secondary to valvular perversions
on the left side of the heart. These perversions during the very early
periods of development interfere with the development of the entire body.
The valve most commonly affected in foetal life is the pulmonary semi-lunar
valve and the perversion may be of such character as to produce either
obstruction to the flow of blood from the right ventricle into the pulmonary
artery, or to allow the leakage of the blood from the pulmonary artery
back into the ventricle. An indication of this perversion is a murmur which
is best heard at the left side of the sternum where the second rib joins
it. If there is an obstruction to the flow of blood, a murmur is heard
with each systole, and is transmitted upward and toward the left. These
murmurs are usually harsh in quality and frequently quite loud, and nearly
always indicate some obstruction to the exit of blood from the right ventricle
into the pulmonary artery. The valve may be affected so that a leak of
blood occurs back into the ventricle from the pulmonary artery. When the
blood leaks back into the right ventricle there occurs first a slight increase
in the size of the cavity; later increased thickness and strength of the
muscular walls, and finally, a dilation of the cavity just as occurs in
the left ventricle of the heart. As a result of the dilation the blood
is not sent to the lungs with sufficient force by the feeble heart, the
ventricle becomes more and more dilated, the orif8ice between the ventricle
and the auricle becomes stretched, the tricuspid valve is no longer able
to close the opening, and the blood begins to leak from the ventricle into
the auricle. It rarely happens during foetal life that the tricuspid valve
is primarily affected by an infection, and this may lead either to an obstruction
or to a leak from the ventricle back into the auricle, and the same secondary
changes occur that occur on the left side of the heart. The murmur produced
by perversions at the tricuspid valve are best heard over the sternum where
the fourth rib joins it, and they occur with the systole. Very rarely does
it occur that the tricuspid valve is so perverted that it obstructs the
flow of blood from the auricle into the ventricle.
PERVERSIONS OF THE HEART MUSCLE The heart is made up largely of muscle cells which are peculiar to the heart itself. Each muscle cell is surrounded by a stream of flowing plasma, from which it obtains nourishment and oxygen. We cannot conceive of any muscle cell in the heart becoming perverted if it is supplied with the normal quantity and quality of plasma, and has its waste materials removed in the proper manner. Under lying all of the perversions of the muscle cells of the heart are alterations in the quality or quantity of plasma surrounding them. The most common perversions of the muscle cells of the heart are those which are produced by the presence in the blood of certain poisonous materials, especially the toxins produced by germs, and in many of the infections where the toxins circulate through the body, the heart muscle suffers from the effects of these poisons. The effect of the toxins produces distinct structural changes in the muscle cells of the heart. The muscle cells of the heart are transversely striped; they are usually somewhat branching, and contain a distinct nucleus. Their protoplasm is clear. When the toxin of the germs or a chemical poison acts upon the heart muscle cells the first change which is produced is a cloudiness of their protoplasm. The outlines of the muscle cells appear swollen and their nuclei become less distinct than normally. If the action of the poison persists for any length of time, the cloudiness of the protoplasm gives way to another change, which is due to the accumulation of fat globules in the protoplasm of the muscle cells, and instead of the uniform cloudy appearance of the protoplasm, it becomes dotted with minute granules of fat, and if the condition persists the protoplasm may be largely or almost completely replaced by fat, and instead of the muscle cell being larger than normal it tends to shrink. With the accumulation of fat, replacing as it does the protoplasm of the cells, the contraction of the muscle cells becomes more and more feeble. The alterations which occur in the individual cells of the heart also lead to alterations in the appearance of the heart as a whole. When the cells become cloudy, the entire heart is swollen, due to the enlargement of each individual cell and due to the infiltration of the pericellular spaces with fluid. The cloudiness of the protoplasm gives the heart an appearance as if it had been cooked. When fat accumulates in the muscle cells further changes take place, and the heart, instead of becoming larger than the normal, begins to shrink and the normal brownish red color disappears. The heart then becomes yellowish in color, due to the accumulations of fat in the muscle cells. Both of these conditions lead to serious interferences with the functions of the heart. These perversions are common in the severe infections. In the majority of cases, the disturbances of the structure of the heart muscle cells does not go beyond the cloudiness of the protoplasm, and this condition is readily recovered from when the toxins are is removed. If fat accumulates to a great degree in the muscle cells, permanent damage is apt to result. In practically all the severe infections, such as smallpox, typhoid infection, scarlet fever, and diphtheria, the muscle cells of the heart are quite seriously affected by the excretions of the germs, and this is indicated during the course of infection by an increase in the rate of the heartbeat, the increased rate being in part an endeavor upon the part of nature to compensate for the decreased force of each contraction. There are distinct signs of loss of muscular power in the heart, and this affects most markedly the first sound of the heart. When the muscle cells of the heart are interfered with, as they would be in the case of an infection, the muscular quality of the first sound is deficient, while the valvular quality becomes predominant. In perversions where the contractile power of the muscle is interfered with, the low-pitched booming sound or muscular quality of the first sound is lessened or may absolutely disappear, and the valvular or clicking quality predominates, so that in feebleness of the heart muscle, the first sound approaches the second sound in character and this is one of the most important indications of this condition. Interference with the contractile power of the heart muscle seriously disturbs the circulation throughout the body, depending upon the degree of the perversion of the muscle cells of the heart. And if the heart becomes too feeble to give the blood the proper impetus, the blood begins to stagnate in the dependent portions of the body, an increased out pouring of plasma from the small vessels occurs, producing an infiltration and swelling, which usually affects the lower extremities first. The deficient force of the heart also fails to send the blood through the lungs and the process of oxygenation is interfered with, and after a time blue ness of the skin and mucous membranes and signs of deficient oxygenation is interfered with, and after a time blueness of the skin and mucous membranes and signs of deficient oxygenation of the blood appear. When the condition passes from simple cloudiness of the protoplasm to an accumulation of fat within the muscle cells, the danger of complete failure of the heart becomes great and is the cause of death in many of the infections, due to the fact that the heart muscle cells have been so poisoned by the toxin that they are no longer able to perform their function. This same condition may be produced by various chemical poisons. Among the poisons which affect the heart in this same manner are a number of the coal-tar compounds, phosphorus, arsenic, mercury, and a large number of substances which act upon the heart very much as does the toxin produced by germs. Another perversion that may occur in the muscle cells of the heart is due to an increased amount of work thrown upon this organ. This produces an increased strength of the heart for a time and an enlargement of the organ. This condition is very commonly found in athletes -- runners and jumpers. Violent exercise demands a greater amount of work from the heart, and to meet this demand the number and size of the muscle cells in the heart increases, and this produces an enlargement of the heart. Within certain limits this produces very little disturbance, especially so long as the exercises are continued, but very frequently in athletes, when they cease to exercise vigorously, signs of disturbances appear and also discomfort in the region of the heart, because the heart contracts more forcibly than is necessary. If this does not go beyond certain limits, the individual may go through life with very little disturbance, but unfortunately the coronary arteries, which supply the heart with blood, do not enlarge in keeping with the size of the heart muscle, and when the enlargement has reached a certain stage, the cells begin to suffer from an insufficient supply of nourishment. The coronary arteries are comparatively large vessels and they supply the heart under normal conditions with sufficient amount of blood, but in enlargement of the heart the muscular tissue sometimes increases to two or three times the normal amount, and the coronary arteries are then unable to supply a sufficient amount of blood to nourish the cells. When this condition is reached, the muscle cells of the heart begin to suffer from an improper quantity of food material and oxygen, and this leads to an accumulation of fat globules and a decrease in the size of the cells. As a result of the insufficient supply of food and oxygen, the heart muscle loses its tone and it then becomes stretched. The cavity of the ventricle increases in size at the expense of the thickness of the muscular walls. Each contraction of the heart muscle subjects it to a considerable amount of pressure, and the blood within the ventricle constantly tends to distend and increase the size of the cavity, and the walls become thinner and thinner. A period is then reached where the thin walls of the ventricle are unable to contract with sufficient power to force the proper quantity of blood into the arteries. When this occurs, signs of failing circulation appear, and, if the condition is allowed to continue, a period is soon reached where the heart is unable to perform its work. The thin wall of the ventricle first becomes fatigued, finally exhaustion comes on and sudden death may occur. These perversions begin primarily in the structure of the heart itself. None of these perversion occur without secondarily involving the nervous mechanisms which control the heart, and in both valvular perversions and muscular perversions are found indications in the Central Nervous System of disturbances of the nervous mechanisms of the heart. The cause of perversions in the function and structure of the heart may lie in its nervous mechanisms primarily, instead of in the heart itself, and a disturbance of the circulation to the neural units in the medulla, which are restraining in function to the heart, or a perversion of the circulation to the neural units in the medulla, the cervical and the first dorsal segments of the cord, which supply the accelerating neural units to the heart, may alter the functional activity of the organ. The rhythmic action of the heart, both as to the strength and rate of its beat, depends upon the exact balance between these two opposing governing mechanisms. A perversion of either one of these two mechanisms may interfere with the rate and strength of the heat, and secondarily may lead to structural alterations in the heart. If the restraining mechanism to the heart has its functional activity increased, it will tend to overcome the action of the accelerators and this will tend to decrease the rate and decrease the strength of the heart beat. If the accelerating mechanism has its activity increased, it will overcome the effects of the restraining mechanism and then the heart will beat faster and with greater vigor. If the accelerator and the restraining mechanisms are balanced, the rate and strength of the heart beat are normal. The restraining mechanism is more often perverted than the accelerating, because the restraining mechanism is constantly active and is consequently most subjected to fatigue and the action of irritants, and because of this it is one which is most likely to produce indications of perversions. The accelerating mechanism, which acts only occasionally, may also become disturbed and produce its effect upon the activity of the heart. The following table will explain how perversions of one or both groups of neural units may affect the heart beat. Restraining normal-accelerator hyperactive -- Increased beat of the heart. Restraining subnormal-accelerator hyperactive -- Increased beat of heart. Restraining hyperactive-accelerator normal -- Decreased beat of heart. Restraining hyperactive-accelerator subnormal -- Decreased beat of heart. New growths may also be present in the heart and interfere with the
contraction of the muscle cells. These are not very common. In syphilis
the heart muscle may become affected by a growth of round cells in the
muscular substance in the form of a growth that is inaccurately called
a gumma.
PERVERSIONS OF THE PERICARDIUM When germs are carried to the pericardium, they act as irritants and
produce first a constriction of the blood vessels of the pericardium, which
is followed by an active dilatation of the blood vessels and an excessive
outpouring of plasma into the pericellular spaces, and thence into the
pericardial sac. The first effect of the irritant makes the pericardium
abnormally dry, so that the two surfaces rub together with each beat of
the heart. Normally the fluid present in the pericardial sac is sufficient
to prevent friction. But when the pericardium becomes dry, we hear a to
and fro friction, due to the rubbing of the dry surfaces of the two membranes
together. The friction usually lasts only for a short time; the contraction
of the blood vessels causing the dryness of the pericardium, is followed
by an active dilation and an outpouring of plasma, and the pericardial
sac becomes filled with the fluid and the friction disappears and new indications
appear. The accumulation of fluid in the pericardial sac is sometimes very
great, and the heart is displaced upward and toward the left, so that the
apex beat, instead of being felt in the fifth interspace inside the mid-clavicular
line, is felt in the third or fourth interspaces outside the mid-clavicular
line. With the accumulation of fluid in the pericardium, the heart is tilted
upward and assumes a more horizontal position. The fluid also interferes
with the transmission of the heart sounds to the ear; the sounds seem to
bee muffled and indistinct. The accumulation of fluid also lends to alterations
in the dullness which the heart normally gives. By means of percussions,
we can in the normal individual outline the position and size of the heart.
The heart, being a solid organ, filled with fluid, gives forth a dull note,
while the lungs, which are filled with air, give out a resonant note. Normally,
the cardiac dullness is somewhat triangular with the base upward and the
apex downward toward the left. With the accumulation of fluid in the pericardium,
there is an area of dullness which is much larger than the dullness of
a normal heart, and it is triangular with the base downward. In addition
to the dullness found in this area, which has increased in size and altered
in shape from the normal dullness of the heart, there is found in the back
on the left side, between the vertebral column and the scapula, between
the fourth and sixth interspaces, a distinct dull spot, which is normally
absent. This is particularly well marked in children, where the chest is
comparatively narrow. In addition to the alterations in the size and shape
of the cardiac dullness and the appearances of the dull spot in the back,
the muffling of the heart sounds and the alterations of the position of
the apex beat, there are indications which are produced by disturbance
of the functional activity of the heart. The pressure of the fluid within
the pericardial sac interferes very seriously with the work that the heart
has to do, and where fluid has accumulated in considerable quantity, there
are signs of failure of the circulation: these are shortness of breath,
due to deficient oxygenation of the blood, and usually pain and discomfort
in the region of the heart. The pain is not so severe at this stage of
the perversion as it is in the earlier stages when the two surfaces of
the pericardium rub together. This produces sharp acute pain, which gradually
subsides as the fluid accumulates. Another indication of this perversion
is the bulging forward of the chest wall. Normally the interspaces between
the ribs are somewhat depressed. With the accumulation of fluid in the
pericardium, the soft muscular structure in the interspaces are pushed
forward, so that they are on a level or even project further forward than
the ribs themselves. Small amounts of fluid in the pericardium may be absorbed
and leave after them very little disturbance, but as the quantity of fluid
increases, the danger becomes greater, and after a certain point is reached,
the heart is so pressed upon by the fluid in the pericardial sac that the
heart ceases to beat. Instead of there being a small accumulation of fluid
in the pericardium, which is simply altered plasma, there may be an accumulation
of pus. When the germs which produce pus infect the pericardium, they are
very apt to form pus in the pericardium. And in addition to the mechanical
disturbances produced by the pus, there are serious general disturbances
of the body, due to the excretion of the germs which are absorbed, and
produce chills, fever, sweating and also interference with the nutrition
of the cells of the body, and usually death from poisoning, due to the
excretion of the germs. Sometimes the quantity of pus is exceedingly small
and may be absorbed, but where pus is formed in any considerable quantity,
the cases are usually fatal. When pus is small in quantity, it may be followed
by an adhesion between the two surfaces of the pericardium, and this same
condition may also occur when there are small accumulations of fluid, and
the outer layer may grow fast to the inner layer. If these adhesions occur,
and only a few of them, they may be broken up through the contraction of
the heart. Where this is not possible, the adhesion remains and binds the
two layers together. Sometimes when the perversion has been very severe,
both layers of the pericardium may grow together all the way round, and
this condition seriously interferes with the activity of the heart, and
may produce perversions of the circulation, due to the fact that the heart
is unable to perform its function properly. The pericardium is a dense,
fibrous membrane, with very little elasticity, and when the outer layer
grows fast upon the inner layer, it interferes not only with the relaxation,
but also with contraction of the heart. Instead of either clear fluid or
pus accumulating in the pericardial sac, due to rupture of a pericardial
vessel, the patient may recover and the blood afterward be absorbed, without
producing any serious disturbance. But when the heart ruptures so that
blood is poured into the pericardial sac, death usually occurs in a very
short time, due to the fact that with each contraction of the heart, more
blood is forced into the pericardium, and as the quantity of blood is forced
into the pericardium, and as the quantity of blood increases in the pericardial
sac, the functional activity of the heart is seriously interfered with
by the mechanical pressure of the blood in the pericardial cavity. These
cases, except those which occur from accident, usually occur in extreme
dilatation or thinning of the heart muscle. Instead of the dilatation occurring
uniformly in the ventricle, it may occur first in some localized spot where
the wall becomes exceedingly thin, and form what is called an aneurism
of the heart. This condition is extremely dangerous, for with each contraction
of the heart, the blood within the cavity is pressed upon; the pressure
which tends to distend the ventricle is increased and the weak spot is
apt to give way and the blood escapes in a large stream into the pericardium
and rapidly produces death.
PERVERSIONS OF THE BLOOD VESSELS In nearly everything which has been written in regard to perversions of the blood vessels, especially the arterioles, and the literature which has been written upon perversions of the blood vessels is usually limited to distinct structural alterations of the blood vessels, which are classified as "hardening of the arteries." These are only later stages of distinct perversions of the arterio-motor mechanisms which control the local and general distribution of blood. Practically no perversion can occur in the body without involving the arterio-motor mechanism of the part. So long as any group of cells in the body is supplied with a proper quantity and quality of plasma and have their waste materials removed in the proper manner, perversions can not occur; so that in the great majority of cases, underlying the perversion is a disturbance of the arterio-motor mechanism, and in many cases of so-called heart disease, the heart itself is not perverted but a perversion of the circulation lies in the arterio-motor mechanism. The heart and blood vessels are so related to each other that the functional activity of the one largely determines the functional activity of the other, and by means of the nervous mechanisms of the heart and the blood vessels, the circulation automatically regulates itself. The blood vessels are a system of closed tubes with elastic and contractile walls; the large arteries containing a large amount of elastic tissue; the arterioles contain a considerable amount of muscular tissue. The blood in the vessels and in the heart constantly tends to distend or stretch the walls of the heart, as well as the blood vessels, and this constant force which tends to stretch the heart and the walls of the blood vessels constitutes what is called blood pressure. In order that the circulation should be carried on at the proper rate and the blood distributed properly, the blood pressure must be maintained within certain limits, and this is maintained by an automatic mechanism by which the degree of functional activity upon the part of the heart is kept in unison with the contracted or dilated conditions of the blood vessels. Blood pressure is largely maintained by two factors; rhythmic action of the heart, by which at regular intervals a certain amount of blood is sent out into the arterial system, and secondarily, by the partial contraction of the muscle cells in the walls of the arterioles. Whenever the tone of the blood vessels is decreased, blood pressure tends to fall and it would fall were it not for the fact that the contraction of those vessels reflexly produces a slowing of the heart. Beginning in the heart are the paths of entrance of depressor neural units. Their paths of entrance pass upwards in the tenth cranial nerve; to the cell bodies located in the ganglia of the tenth cranial nerve; their paths of exit pass upward through the tenth nerve to the constrictor portion of the arterio-motor nucleus in the medulla, there to come in contact with neural units in the nucleus. When any blood vessel, or the blood vessels in general in the body, are abnormally contracted, the heart has to pump harder in order to force the blood through the vessels. As soon as it feels the necessity for harder and more vigorous contraction, which would fatigue the heart muscle, messages are sent or carried in through the depressor pathway to the arterio-constrictor nucleus, lessening the functional activity of the nucleus, and in turn lessening the arterial tone by bringing about a dilation of the blood vessels, so that an abnormal contraction of the blood vessels automatically brings about secondarily a relaxation of the vessels through the depressor pathway, which affects the tone of the constrictor neural units. If the blood pressure tends to fall because the heart is not pumping with sufficient force an a sufficient rate of speed, the arterioles in turn contract and maintain the pressure. This double mechanism automatically regulates itself so that the two parts are kept in absolute harmony and the blood pressure is maintained and the blood is properly distributed. One of the very common perversions of the arterial system is due to a loss of tone in the muscle cells of the arterioles, due to fatigue or exhaustion of the constrictor mechanism. The constrictor mechanism is always active and preservers a partial contraction of the muscle cells in the arterioles, and maintains arteriole tone. When the constrictor neural units become fatigued or exhausted, the muscle cells relax and arterial tone is lessened. When this condition occurs, the heart pumps harder and faster in its endeavor to keep up blood pressure. It frequently happens in perverted conditions of the circulation especially where the current of blood is abnormally slowed from a feeble heart, or from some obstruction of the vessels, that the blood clots within the artery, producing what is commonly called a thrombus. If the endothelial lining cells break down, nucleo-albumin is formed; the current of the blood is possibly slowed, and the blood coagulates and may completely obstruct the lumen of the vessel. When this occurs, it shuts off the blood from the parts supplied by the vessel. In most cases, the part does not die, but the circulation is re-established by the blood taking other paths around the obstruction, by the formation of a collateral circulation, and in the case of the Brachial Artery, for instance, the thrombus occurring above the elbow, the vessels anastomose about the elbow joint; they enlarge, unite with each other and convey the blood to the radial, the ulnar and the inter-osseus arteries, which re-establishes the circulation. This occurs in the great majority of cases. The exception to the establishment of a collateral circulation is where an exceedingly large vessel is affected. In mos cases, nature re-establishes the circulation by the enlargement of collateral branches. In the case of clotting of the blood in large vessels, like the aorta, so that the blood is shut off absolutely, death usually occurs within a very short time. Quite frequently a thrombus or clot occurs in the small blood vessels and shuts off the supply of blood to a limited area of an organ. This sometimes happens in organs in which the vessels do not anastomose with their fellows, and the blood is permanently shut off from a certain area. For instance, in the brain, the circulation is largely through what are largely called terminal blood vessels. The same is partially true of the vessels of the spleen and to a certain extent in the lungs and when a clot of blood occurs in one of the branches of the splenic artery, the blood is shut off from a wedge shape area which is supplied by the artery. The vessels in that area then become filled by the back pressure of blood from the veins and capillaries; after a time the blood is absorbed and a mark is left which is filled up by connective tissue. This is called an infarct. Frequently these occur very shortly before death, and when the organ is examined after death, a wedge shaped area filled with blood, which is usually partly coagulated, is seen very distinctly when the organ is cut through. Consequently areas may be thus affected and deprived of blood for a time without producing serious general disturbances of the body, depending, of course, upon what part of the body is affected. When the clot occurs in the cerebral blood vessels and the blood supply is shut off from a certain group of neural units, these neural units gradually die and produce what are called areas of softening in the brain. They disintegrate and a soft mass, involving a greater or lesser portion of the brain, follows. In the majority of cases, nature is able to compensate by means of the collateral circulation established to bring about a return to a normal condition, except where the clot occurs in extremely large vessels, or in what are called the terminal branches of blood vessels. Care must be taken in the treatment of these cases in the beginning, when the clot is soft, to avoid direct treatment to the place at which the clot is located, for while the clot is soft, handling of the part in any way may lead to a separation of a portion of the clot, which would be carried to some other part of the body. This is a particularly dangerous when the clot is in a vein instead of an artery and it sometimes happens after confinement, and after some of the infections that clots form in the femoral and splenic veins, and great care must be taken not to force off a piece of the clot which may be carried to some other part of the body, where it may produce serious consequences. After a clot has become organized, it can safely be handled. Phagocytes come out in large numbers, burrow into the clot, the connective tissue of the wall of the blood vessel multiplies by cell division, and through the phagocytes and the development of connective tissue cells, the vessel is filled with a newly formed connective tissue, which contracts and finally the artery is practically obliterated, the location of the thrombosis being afterward marked by a contracted area in the vessel which is filled with connective tissue. All that can be done then is to facilitate the establishment of a collateral circulation by regulating the functional activity of the circulatory apparatus in general, and to place the parts affected in such a condition that they are able to receive the blood supply with the least difficulty. Underlying nearly all of these conditions are found perversions of the arterio-motor mechanism. A portion of the clot may be separated in a vein or an artery and carried to some other part of the body. This is called an embolus. However, an embolus is not always produced by a portion of the clot which has become separated; an embolus may be produced by some foreign substance getting into the blood vessels. Sudden death has occurred after a fracture of the leg, due to small particles of fat getting into some of the veins and being carried to the heart and blocking one of the coronary arteries, or more commonly, one of the blood vessels of the lungs. This may also be produced in some of the infections, where germs are present in the blood, and is quite common in the condition called "general blood poisoning," where the germs virulent pus forming germs are the streptococci. It is common in general blood poisoning for the vessels to be blocked up by masses of these germs. In this perversion, the blood vessels contain many streptococci. They are carried into the minute vessels and a mass of the streptococci may block up one of the small vessels. The germs multiply and produce an abscess. This is the common manner in which large numbers of abscesses are produced in blood poisoning. The circulation may also become perverted by the entrance of air into the vessel; the entrance of air into the blood vessels is dangerous when it gets into the large veins at the base of the neck. The air getting into the vein is carried directly to the heart and interferes very seriously with the action of the heart, usually stopping it. However, the danger of air getting into the veins has been greatly exaggerated. The circulatory system may be disturbed mechanically by the blocking of vessels from the coagulation of blood in their interior, by clots of blood obstructing the small vessels, or by poisons or foreign bodies, such as germs or globules of fat, or even bubbles of air. PERVERSIONS OF THE PANCREAS The Pancreas is a compound saccular gland. Its structure is similar to the salivary glands. It lies behind the stomach, it is elongated in shape, and it extends from the right to left side. The largest end of the pancreas lies to the right, the smallest to the left. A duct traverses it lengthwise. The Common bile duct and the pancreatic duct empty into the small intestine together. The pancreas manufactures a juice which id of great importance in digestion. The pancreatic juice contains ferments that act upon all of the food stuffs. These ferments are Trypsin, which acts on proteids; Amylopsin, which acts on starches; Steapsin, which acts upon the fats; and Renin, which coagulates milk. The pancreatic juice is watery in character, alkaline in reaction, due to the presence of sodium carbonate. The most important of the digestive processes are brought about through the activity of ferments in the pancreatic juice. Perversions of the pancreas may occur from arterio-motor disturbances, which produce an alteration in the pancreatic juice, and secondarily, a perversion of the digestive process. Occasionally, through some irritant which acts locally upon the pancreas, an acute arterial dilation is produced, which may be so intense as to result in a rupture of the small blood vessels, and hemorrhage into the pancreas occurs. This is called "Apoplexy of the Pancreas." The hemorrhage may occur from a large vessel and result in the accumulation of a large quantity of blood in the interior of the pancreas. These cases are usually die to infection with germs. They may also be produced by chemical poisons. The attack comes on suddenly. With intense pain in the abdomen, obstinate constipation, and often large quantities of fat are present in the stools. These points which serve to distinguish it from obstruction to the small intestines, are that the pain is usually situated high in the abdomen, well above the umbilicus, while pain in the intestinal obstruction is apt to be below the umbilicus. When the abdominal walls are not too thick, the swollen infiltrated pancreas can be felt and is very tender to the touch. These cases are almost always fatal in a few hours. Acute dilatation of the blood vessels of the pancreas is followed by an infiltration and swelling, which interferes with its functions. Chronic perversions of the arterio-motor mechanism of the pancreas is called "Chronic Pancreatitis." Chronic perversions of the arterio-motor mechanism result in the loss of arterial tone, dilation of the blood vessels, and an infiltration of the pancreas, and the production of an increased amount of connective tissue. The connective tissue finally contracts and producing a hardening of the pancreas; the contraction of the newly formed connective tissue results in Atrophy of the Pancreas, and interferes seriously with its functions. Small stones may form in the ducts of the pancreas, and produce an obstruction to the outflow of pancreatic juice. If this occurs in the large duct, which carries the fluid away from the pancreas into the intestine, the juice accumulates in the pancrease and forms a pancreatic cyst. If it occurs in the small branches of the duct, it results in the formation of local cysts. These cysts sometimes reach an enormous size, and can be distinctly felt behind the stomach as a round tumor containing fluid. When the out-flow of pancreatic juice is entirely obstructed the signs of intestinal indigestion and loss of flesh and strength occur. Fat is apt to appear in the stools, as in the case of hemorrhage into the pancreas. Frequently affected by malignant growths. In the majority of cases, these are secondary to malignant growths of the liver and stomach, but they may occur primarily in the pancreas, and are most apt to occur in the head of the pancreas. These growths produce an obstruction of the pancreatic duct, or to the bile duct, and obstruct the flow of bile from the liver and gall bladder, producing a dilatation of the gall bladder and the retention of bile in the liver, which is absorbed into the blood, and Jaundice occurs. Bile also occurs in the urine in these cases. Cancer of the head of the Pancreas is often mistaken for a stone in the Common Bile Duct, and many of these cases are dot recognized during life. The presence of a malignant growth in the Pancreas is usually indicated by a sense of dull pain, occasionally becoming sharp, in the epigastric region; occasional vomiting without any special signs of disturbances of the stomach; and sometimes by the presence of fat in the stools, and sugar in the urine. Fat in the stools and sugar in the urine do not always occur, but when they are present, accompanied by other signs, it confirms the diagnosis. The growth has a tendency to press upon the Common Bile Duct, which produces dilatation of the gall duct and Jaundice. These are the most characteristic indications of Cancer of the Head of the Pancreas. Secondary growths are very apt to occur, and they are most likely to occur in the liver, the gall bladder, the mesenteric lymph nodes, the stomach, the kidneys and the lungs. These cases usually progress very rapidly and are almost always fatal. Some differentiation must be made in pancreatitis and diabetes mellitus.
In diabetes glucose is constantly present, where in pancreatitis it may
and may not be present, but if present is not constant. X-rays are of value
in suggesting pancreatic enlargement, noting if there is any associated
biliary tract disease, and eliminating confusing pathologic conditions
elsewhere in the abdomen. The most valuable finding in pancreatic disease
is an increase in the duodenal curve. This may be due to tumor at the head
of the pancreas or Hodgkins disease.
PERVERSIONS OF THE KIDNEYS Patient in dorsal position, thighs flexed. One hand is placed over seat of kidney in lumbar region and firm pressure made. Fingers of other hand are placed below the border of the ribs, on a line running through the middle of Poupart's ligament. With each expiration fingers are pressed deeper until renal tumor is reached. Part of abdomen in which the enlarged kidney is felt will vary according to the nature of the disease and the portion of kidney involved. Percussion of Kidney: Unless kidney is much enlarged results of percussion are uncertain. In performing percussion patient should be placed on the abdomen and chest, which posture will allow liquid accumulations in abdominal cavity to gravitate forward, and the intestines to float upward. The external margin of kidney is determined when the tympanitic note of the intestine is reached. Any enlargement will be accompanied by a corresponding increase in area of renal dullness. Conditions such as carcinoma, calculus, nephritis, pyelitis, tuberculosis
and sarcoma, are determined by symptoms of each, by urinalysis, X-rays,
and nerve tracing.
PERVERSIONS OF THE LUNGS Look closely at the chest, note its shape, is there any unnatural prominence or depression, is there any irregularity of expansion? Is the chest phthisic, or showing signs of the consumptive, or rachitic where the sternum is prominent and all tissues around it are flat? Pigeon chest, the emphysematous chest, in advanced cases, the throat is short and round, and the thorax is likewise short but broad, especially in its anteroposterior diameter. This configuration has given rise to the term "barrel-shaped" chest. On respiration there is little expansion, but an elevation of the thorax as a whole. The apex-beat is usually invisible, but an abnormal pulsation is often noted in the epigastrium. The above will give a clue for specific examination to determine by various symptoms, physical signs, and sputum tests, with the Roentgen ray whether any of the following conditions exist: Abscesses, tuberculosis congestions, gangrene, cirrhosis, edema or collapse. Segmental spinal areas, and rubbing the hand over, will verify all laboratory tests. Pleurisy can easily be established by the symptoms of chilliness and
fever, stabbing pain, made worse on coughing or breathing.
PERVERSIONS OF THE SPLEEN The spleen is oval, vascular, ductless, gland situated in the left hypochondriac region between the stomach and diaphragm. Color livid red. Blood-forming organ. The spleen is sometimes classed as an endocrine gland. It appears to have some relation to the parathyroids and probably has a part in the calcium metabolism of the body. Its liquid extract is used in the treatment of urticaria. It is desiccated and combined with bone marrow in the treatment of some forms of secondary anemia. The French use it in the treatment of tuberculosis. This organ is not normally palpable. Since splenoptosis is rarely present even in extreme splanchnoptosis, feeling the splenic edge is usually indicative of enlargement. The ordinary procedure in splenic palpation with the patient lying on the back, is to place the examining hand just below the left costal margin in the anterior axillary line, raising the posterior chest with the left hand while the patient is inspiring. Care should be taken not to press too deeply as the spleen usually hugs the anterior parietes quite closely. Palpation should be repeated with the patient lying on the right side. In some cases a spleen will be felt with ease in this position that is otherwise palpated with difficulty or not at all. A palpable spleen not only descends but also moves toward the midline with deep inspiration. This is of value in distinguishing it from the left lobe of the liver. An effort should always be made to feel the splenic notch in all doubtful tumors in this region. The character of the splenic edge may be of significance - whether sharp and thin, thick and rounded, firm and hard or soft, smooth or uneven and nodular. The only reliable physical signs of disease are those of enlargements to tumors. The tumor presents a smooth, oblong, solid mass felt immediately beneath the integuments extending from the ribs on left side, a little behind the origin of the cartilages; often advancing to the median line in one direction and descending to crest of the ilium in the other, filing the left lumbar region at its upper part. Tumor is usually movable, rounded at its upper portion, and presenting an edge more or less sharp in front, where it is often notched and fissured. Other diseases are abscesses, cysts and syphilis. In these cases the
differentiations can be made by the nerve tracing, hand vibrations and
sensations and skin color. The tuning fork may be of some value. All of
them are primarily due to an unbalance of the arterio motor tone.
THE FEMALE REPRODUCTIVE ORGANS The vagina is a musculo-membranous tube which forms the passageway between the uterus and the (vulva) exterior. It is divided into four walls, two lateral, one an anterior, and one posterior. In the uppermost part, the cervix divides the vagina into four fornices, the two lateral, the anterior and the posterior. It is about 2 ½ inches along the anterior wall and 3 3/4 inches along the posterior wall. In a nulliparous woman all walls approximate each other, making an H shape. The vagina is lined by mucous membrane made up of squamous epithelium. It is surrounded by fascias which allow for easy distensibility. The blood supply of the vagina is furnished from the inferior vesical, inferior hemorrhoidal, and uterine arteries. Functions are, a passage for the intromission of the penis, the reception of the semen and for the discharge of the menstrual flow; also for the delivery of the fruits of pregnancy. Perversions: condylomata, constrictions, cramps, fistula, gangrene, indurations, leucorrhea, morbid growths, neuralgia, polypi, prolapsus, serous cysts, spasms, vaginismus, vaginitis. The physical signs and symptoms of perversions are rather clear on examination, and it is not necessary to dwell in length upon them. There are many types of Uterus. U. Acollis - Uterus without a cervix. U. arcuatus - Uterus with a depressed arched fundus. U. bicornis - Uterus in which the fundus is divided into two parts. U. biformis - Uterus in which the external ox is divided into two parts by a septum. U. bilocularis - Uterus in which the cavity is divided into two parts by a partition. U. cordiformis - A heart-shaped uterus. U. septus - Uterus divided by a septum into two cavities. Subinvolution uteri - The lack of involution of the uterus following childbirth. It is manifested by a large uterus and a continuation of lochia rubra beyond the usual time. The factors in its causation are usually puerperal infection, multiparity, overdistention of the uterus by multiple pregnancy or poly-hydramnios, lack of lactation, malposition of the uterus, and retained secudines. Involution is aided by being certain that the placenta is intact at the time of delivery, and the use of ecbolics to cause contraction of the uterus. Reposition of the uterus should be practiced when malposition is discovered. U. unicornis - Uterus that is only one-half developed and has only one horn. No treatment of any of these types is indicated unless there is severe menstrual distress. Shifting the position by manipulation will often give relief. The normal and abnormal position of the uterus may be described as follows: From infancy to puberty the uterus lies in an exaggerated anteflexed position. At puberty as a general rule it rapidly develops and becomes more erect. Inflammation, then atrophy of the uterine wall may cause a severe anteversion. The cervix falls toward the hollow of the sacrum, and the body of the uterus is rotated forward. In this position it is subject to pressure from the structures above and intraabdominal pressure. These pressures cause painful menstruation, sterility. The pain is of a colicky character and usually appears one to three days or as in some cases, a few hours before the period, and persists during the period. Retroversion - this is the reverse position to anteversion. Here the uterus inclines backward. In many cases this condition causes no symptoms or local disturbances. But in others there is considerable disturbance. The symptoms commonly listed are excessive menstrual flow, dysmenorrhea, leucorrhea, sterility, dyspareumia, constipation, backache. Reflex disturbances are found in the occiput, and in the indicated spinal segments. For examination when the above conditions are suspected, the best position
is the dorsal, with the knees flexed. Clothing about the waistline is loosened
and the bladder and rectum empty. The patient should be relaxed as much
as possible. The finger is then inserted and position noted, then follows
the examination of the motility of the uterus and also noting if there
are any adhesions. Tumors if any are present can also be noted. In the
presence of an intact hymen a rectal examination may be substituted. Other
conditions such as prolapse, acute and chronic cervicitis and endocervicitis
can be noted, particularly by discharge of a greenish yellow pus and sometimes
an odor. It may be tinted with blood. There is, as a rule, more or less
burning and itching about the vagina and vulva, and usually no pain, but
a mild discomfort. A bacterial examination should be made to determine
its type.
TUMORS Fibroids are by far the most common found in the uterus. It has been said that one woman out of every five over forty years of age has a fibroid or some fibroids in her uterus. No one cause can be given for their development, but from the neuropathic view, the first cause was the failure of the nervous system to properly control the circulation after certain irritations had begun to develop. Speaking generally, the growth of these tumors is analogous to what occurs in gall stone formation. Fibroids when small are nothing more than soft muscular tumors, containing very little connective tissue. As they enlarge, however, the proportion of connective tissue not infrequently increases until the term fibromyoma is more properly applied to them. This development of fibrous tissue is, however, pathological and paves the way for certain of the degenerative processes to which these tumors are liable. Fibroids give rise to some very serious disturbances. The menstrual loss is increased by the tumor increasing the vascularity of the uterus and interfering with the retraction of the constrictor nerves and muscles. This bleeding is periodic and not irregular. If there is infection there is a foul discharge postpartum, and in the sepsis, there are bits of sloughing off of the fibroid, or the fibroid diffusely suppurates pus. A small fibroid may not deform or enlarge the uterus at all but all the symptoms of menorrhagia may be present because of its position, projecting into the uterine cavity. The bulk of a large tumor may displace the intestines toward the diaphragm and interfere with respiration and the digestive processes. But the effects due to great enlargements are in most cases in the pelvis. The bladder is affected in some cases by an inability to hold the urine very long. On the other hand in other cases, a severe retention takes place. A sudden retention of urine in a woman of middle age can quickly suggest the possible presence of a fibroid. A distinction between carcinoma of the corpus and fibroids can be usually made from the fact that in carcinoma there is continual bleeding, while fibroids cause menorrhagia. Cancer has three distinct clinical features, bleeding, discharge and pain. At first the bleeding is intermittent, but shortly becomes continuous. It may be only a dribble in some cases while in others it may be a free flow. The discharge is a watery type and may be quite free. It has an offensive odor. The pain may be of a very mild nature and is located centrally and to the sides of the lower abdomen. It indicates that the growth has spread beyond the confines of the uterus. In cervical cancer, the pain is first felt to either side of the midline. It is aching in character and indicates involvement of the paracervical tissues along the side of the pelvis. Pain in the region of the bladder appears as soon as the growth has spread to that viscus. Together with the pain, the patient complains of frequency of urination and of the act hurting her. The urine presently becomes cloudy from the presence in it of pus and blood. Rectal pain is much less common and only occurs when the growth has spread backward to a marked degree. Cancer can be suspected in any woman of any age who exhibits the above
three cardinal symptoms, even in the involutionary period. Physicians should
always be on guard, and not let the matter go too long without some decisive
action, lest the matter advance to the point beyond his or surgical aid.
RECTAL PERVERSIONS In the presence of bowel symptoms the physician will look for evidences of perversions. The perianal skin is inspected and palpated for evidence of fistula, hemorrhoids, abscess and pruritus. The finger should be introduced gently, noting the resistance offered by the tone of the anal sphincter, whether spastic, atonic or normal. Undue pain so induced is usually due to local inflammation in the anal canal, such as ulcer, hemorrhoids, fissure, fistula, abscess, cryptitis or hypertrophied papilla. By carefully palpating along the wall of the rectum, any undue dilation (constipation) or narrowing (stricture) will be found. The presence of fecal matter indicates proctostasis, as the rectum is not a reservoir for feces normally. Rectal examination may also furnish useful information concerning adjacent organs of the prostate in the male and of the cervix in the female. Carcinoma of the rectum is easily identified by palpation, as a rule. If carcinoma is suspected but cannot be palpated, the patient should be asked to strain. At times a growth will be felt during straining which is just beyond the reach of the finger during ordinary palpation. The lower part of the rectum lies in the pelvis, and is surrounded by muscles and connective tissue. Between the tuberosity of the ischium and the rectum are two pyramidal spaces, called the ischio-rectal fossae. These are filled with connective tissue, which is very dense, the meshes of which are filled with fat. The skin over this is very thick, and beneath the skin is a strong layer of fibrous connective tissue. The lower part of the rectum contains numerous folds of mucous membrane. These folds are very apt to catch and retain solid materials contained in the feces - fragments of peach stone, cherry stones, vegetable fibre, etc. these small substances remaining in contact with the mucous membrane for a period of time act as irritants and lessen the resisting power of the cells; they make a favorable place for the infection with germs, which are always present in this part of the alimentary tube. Ulceration is apt to occur, and perforation of the rectal wall into the ischio-rectal fossae. Even if perforation does not occur the walls may become so thin and the resisting power of the cells become so diminished that the germs get into the ischio-rectal fossae, and produce an abscess; arterial dilation, infiltration; outwandering of phagocytes; death of cells and the formation of pus. The pus follows the path of least resistance. The skin overlying the abscess is very thick and very dense, and beneath the skin is a strong layer of fibrous connective tissue. It is very difficult for the pus to break through the skin and escape in that way, so that the pus very frequently works its way through the rectal wall and discharges into the rectum. This is called “internal fistula.” The opening may be some distance from the bottom of the abscess, preventing the complete escape of the pus. The abscess gets no chance to heal; pus remains there, and overflows from time to time into the rectum. Sometimes it may not only break into the rectum, but may break through the skin. Then the abscess drains itself, and a canal remains which opens on the skin and in the rectum. The location of this canal and its relation to, the surrounding parts, and its direction, are such that it does not tend to heal, and we have remaining a canal which is constantly forming a small amount of pus, discharging on the skin and some into the rectum. This is called a “complete fistula.” The most common form is the “internal fistula,” where the abscess ruptures into the rectum. The next variety is a “complete fistula” where there is an opening into the rectum and one on the skin. The first signs of an ischio-rectal abscess, before the formation of
pus, are as follows: The ischio-rectal fossae feels hard, the surface of
the skin is hot and often red. An abscess in this place is no different
from an abscess anywhere else in the body. It only presents certain peculiarities
because of its relation to the rectum, and because of the dense skin overlying
it. In many of these cases the abscess is caused by the tubercle bacillus.
HEMORRHOIDS OR PILES In the lower part of the alimentary tube - the rectum - a common perversion
is a dilatation of the hemorrhoidal veins, producing the condition inaccurately
known as “hemorrhoids,” or piles. This condition occurs where there is
obstruction to the return flow of blood, but there may also be an arterio-motor
disturbance leading to a loss of arterial tone, a loss of venous tone,
and a distension of the veins, so that they may form rounded, irregular
masses. The mucous membrane overlying them becomes infiltrated; they are
tender upon pressure; with each stool they are apt to be pushed down through
the sphincter muscle, so that they appear externally and give a great deal
of pain and discomfort to the patient. They sometimes produce serious hemorrhage
from the rupture of small arterioles, or venules. A sufficient amount of
blood may be lost to produce distinct weakness, or even death, if it be
repeated sufficiently often. When the hemorrhoids project from the mucous
membrane inside the sphincter they are called internal hemorrhoids. When
the condition is due to a dilatation of the veins around the skin of the
anus, and they project as little tumors, outside the sphincter, they are
called “External Hemorrhoids.” The condition indicates the treatment.
SPASM OF THE SPHINCTER MUSCLE OF THE ANUS Spasm of the Sphincter Muscle of the Anus is quite common. This muscle
arises behind the tip of the coccyx and passes down in two slips, which
surround the anal opening, and is inserted into thee central tendon of
the perineum. It is this muscle which gives the corrugated appearance of
the skin around the anus. This muscle is voluntarily relaxed to allow the
passage of feces from the rectum. Sometimes immediately after the stool
the muscle contracts so violently that it produces a great deal of pain.
This is due to hyperactivity of the musculo-motor neural units supplying
the muscle. You will find indications of a perversion in the spinal cord
corresponding to the segments from which the musculo-motor units of this
part arise.
FISSURE OF THE ANUS A fissure, or linear ulcer, extending into the mucous membrane of the
anus, may occur. This is constantly irritated by the contraction of the
Sphincter Muscle of the anus. The condition is frequently found accompanying
“Spasm of the Sphincter.”
ITCHING OF THE ANUS Itching of the anus (inaccurately called “pruritus”) around the margin
of the anus, is usually due to primarily a loss of arterial tone in the
blood vessels supplying the skin of the ano-genital region, and occasionally
aggravated by an active dilatation of these vessels. The skin may or may
not be altered in the appearance, but when the condition has existed for
any length of time, the skin becomes infiltrated; the upper layers of the
skin may be pushed off, so that a certain amount of desquamation takes
place, and the surface may be moist from the exudation of lymph over the
surface. The treatment is indicated by the condition.
PERVERSIONS OF THE MOUTH Perversions of the mucous membrane of the gums and of the mouth are indicated by alterations of its color, being either excessively dry or covered with an excessive amount of mucus, localized swelling, or general swelling and infiltrations, or actual destruction of the tissue in the form of little ulcers. The most frequent change which takes place in the color is due to an arterial dilatation causing increased redness of the mucous membranes. This may either be localized or general. Where there is an active dilatation of the blood vessels of the mucous membrane it becomes excessively red, and often the little arterioles can be distinctly seen. Accompanying this, there is infiltration of the mucous membranes. Where there is a uniform dilatation of the blood vessels in the entire mucous membrane of the mouth, there is some general perversion, an infection of the entire mouth. This may be due to some local irritant; for instance, the taking into the mouth of exceedingly hot fluids. The ordinary acute perversions in the mouth usually do not persist for any length of time, and respond quickly to treatment. The perversion indicates the treatment; the application of cold in the form of small pellets of ice taken into the mouth frequently, and allowed to dissolve. Where there is an infection of the mucous membrane of the mouth, the mouth may be rinsed frequently with salt solution. This may be made by dissolving a level teaspoon full of sodium chloride in a tumbler full of water. This mechanically removes some of the irritating materials from the surface of the mucous membrane. In a local infection of the mouth the first effect of the irritant causes a brief constriction of the blood vessels, because the constrictors are more readily aroused. If the irritant continues for any length of time the dilators are thrown into activity and there is an active dilatation of the blood vessels, and a pericellular infiltration occurs. This active dilatation of the blood vessels must be removed by removing the cause. The tonsils lie in little hollow spaces, and do not project beyond the pillars of the fauces. These are made up of round lymphoid cells, and like the lymph nodes, are filtering plants. The arterial dilatation may result in such enormous infiltration that the tonsils may meet in the middle line, and interfere with breathing and swallowing. In this condition of the tonsils, very frequently little follicles become
distended with yellowish, cheesy material, exuding on the surface.
[For complete examination of open cavities of the head, refer to the writer’s
book Endo Nasal Aural and Allied Techniques, Page 35.]
EXAMINATION AND PERVERSIONS OF THE LUNGS Abscess of the lungs is divided into two main groups. The first known as bronchial abscess, and is due to obstruction of a bronchus by an infected accumulation of material; the second is the interstitial abscess, and is secondary to infection elsewhere in the body. Males are subject to lung abscesses two to one in comparison with females. In an examination of a patient, a history of previous infections of mouth, teeth, and the upper respiratory apparatus should be made. Careful inquiry should be made as to whether while eating or drinking the patient has had a choking paroxysm of coughing before the symptoms of abscess began. Symptoms. Remittent or intermittent fever, rigors, sweets, pallor, and leukocytosis indicate suppuration, Dyspnea, cough, and purulent, offensive sputa containing shreds of lung tissue are usual pulmonary symptoms. Physical examination may reveal bubbling rales and, later, cavernous breathing and resonance. Clubbing of the fingers is common and may appear early. Roentgen-ray examinations are valuable in determining both the presence and the location of an abscess. Multiple embolic abscesses are rarely recognized during life. Note carefully the feel of the hand over the segmental area, and over
the location of the abscess in this and all that follows. Prognosis is
good if all infection is stopped.
PULMONARY EMPHYSEMA Pulmonary Emphysema is an abnormal distention of the lungs with air. The types are as follows: Compensatory Emphysema - This is a vicarious distention of one part of the lung, owing to pathologic changes in another part of the organ. It is primarily physiologic, through atrophy of the walls of the air-vesicles may ultimately ensue. Atrophic or Senile Emphysema - In this form the capacity of the air-vesicles is relatively increased, owing to atrophy of the solid tissue. Hypertrophic or Substantive Emphysema - This is the ordinary form of
emphysema. It is characterized by a great enlargement of the lungs in consequence
of overdistention of the air-vesicles.
PERVERSIONS OF ADHESIONS Peritoneal Adhesions lead to a large part of the constipation from which the public is always suffering, and play an important part in some of the obscure dyspepsias. They cause local irritations and discomfort, and, sometimes lead to strangulation of the tubular structures. They may become pulled out into long strands which ensnare the bowel, or which roll the omentum into abnormal positions, and they may prevent the normal gliding of viscera, and give rise to distant reflex disturbances. Abdominal pain, nausea and vomiting, elevation of the temperature and intestinal obstructions are the acute symptoms. A larger number of gastric and bowel disturbances than at present suspected are due to adhesions. Three methods of determining the presence of adhesions are: First - Filling the stomach with bismuth solution and then making fluoroscopic examination to determine points of interference with gastric motility is now allowing us to make the diagnosis of gastric adhesions freely. Second - The Lyon’s method of using the stethoscope and the tuning fork is as follows: If there are adhesions, or an adhesion between two organs or tissues the sound of the tuning fork will be clear of tympanitic. The adhesions acting as a carrier of the tuning fork vibrations. It does not matter on which organ the tuning fork is placed. But, between two organs it is best to reverse and note whether the vibrations are of the same pitch. Third - The method of manipulation. The tissues are rolled around with
one hand, and the fingers of the other go in at the depth of the rolled
tissue and exploration is made.
THE TUNING FORM IN GENERAL EXAMINATION In the search for general perversions the physician needs patience and experience. He needs to train his hear to the variations in vibrations to a number of perversions. In all the perversions there is a slight dull to a dull sound of vibrations. In a tumor, on careful listening the vibrations go to the very dull. Only by experience on normal and abnormal tissue can the physician learn variation in sounds. No one can teach or tell him the sounds between a mild and full pathology, or the medium pitch found in constitutional conditions. The usual procedure is to hold the tuning fork over the center of the suspected diseased area, and the stethoscope about four inches away, moving the stethoscope all around the tuning fork at that distance. After some practice on normal and known abnormal conditions the physician, in a short while becomes very proficient in detecting at least the gross pathology, for each pathology has a unique vibration of its own. The writer was a long time becoming proficient in this type of examination, and practiced on very sick, half sick, and healthy people before the vibrations began to show any proportionate variations under different conditions. At first all vibrations sounded alike. The writer used the C.128 fork, and the Bazzi-Bianchi Stethoscope for all purposes. Bilstein (7) for testing hearing, makes the following contribution: “In testing for perception of sound through the medium of air the most serviceable instrument is a tuning fork of 256V which is put into vibration by gently striking one of the prongs against the palm of the hand and then held near the patient’s ear. Comparing the distance the fork is held from the ear and the time the vibrations are heard gives us a means of ascertaining the acuteness of hearing and whether the affection is unilateral or bilateral. Much co-operation is needed by the patient so that the physician may know when the patient no longer hears the vibrations of the fork. Most convenient is to ask the patient to raise the hand when perception no longer occurs, and, counting from time the fork is held before the ear until the signal by the patient, the number of seconds is noted. Thus by comparison the ability of each ear to perceive sound can be ascertained. “Frequently in unilateral middle-ear affections, with increased tension of the sound conducting apparatus, the tone of the tuning fork is perceived one-quarter, one-half or even a whole tone higher in the diseased ear. “High and low tones also give us a valued differential diagnosis of
middle-ear and labyrinth affections. A low-toned tuning fork, 128V, is
either heard faintly or not at all in middle-ear affections and may still
be well perceived in labyrinthian affections and auditory nerve diseases.
Thus the failure to perceive low tones is important in diagnosis of obstruction
in the sound-conduction apparatus. A fork of 2048V is used to test the
upper most limit of the scale or a Galton Whistle is employed.
EUSTACHIAN TUBE “In the perception of tone through the Eustachian tube a tuning fork of 256V is used. The forks of high (1024V) or low (128V) vibrations are not suitable for this experiment. This test is used to ascertain the permeability of the Eustachian tube and to establish the presence of an obstruction in the sound conducting apparatus. “In unilateral middle ear affections, associated with impermeability of the Eustachian Tube due to swelling of the mucus membrane or clogging with excretion, the tone of the fork when held before the nostrils will be heard only in the normal ear. If, however, the condition has been established as impermeability of the tube and the sound is louder than in the normal we may conclude that the condition is either temporary or permanent but favorable to a good prognosis. “In those unilateral middle ear affections in which the tube is permeable a vibrating tuning fork will be heard louder in the diseased ear. This condition occurs most frequently in un unilateral chronic middle ear catarrh, and in otosclerosis, also in purulent middle ear affections running their courses with perforation of the membrana tympani. “In bilateral affections, in which one ear is decidedly more affected
this test seldom gives the results described.”
OBSERVATION OF SKIN After completing the abdominal examination, the physician looks at the skin; observation of it may prove of value. The slate blue color may show some metallic poisoning such as silver,
lead, etc. the brown pigmentation of Addison’s disease is well known. The
yellow white or dull white skin may denote Hodgkin’s disease, Arthritis,
Pernicious Anemia, Syphilis, and some other conditions. An unusual amount
and distribution of hair may indicate an endocrine deficiency. Loose ridged
folds of flesh may be due to the skin having been stretched over a long
period are usually due to pregnancy, ascites, tumor or edema.
PAIN REFLEXES ON SPINE Being familiar with the distribution of segmental nerve areas, the physician then begins nerve tracings from pain areas in the spine. For illustration, in active peptic ulcer and cholecystitis, tender and sore areas are found on the right side of the spine from the fifth to the tenth thoracic nerves. Localized areas of pain and tenderness on both sides of the spine, anywhere in whom there is no suspicion of abdominal trouble, is due to an acute condition in the spinal column itself. It may be a curvature arthritis, or a psychoneurotic condition which was not relieved by previous operations on one or more organs of the abdomen. For inhibition treatment of the above condition, or pain, the inhibition treatment is used over the proper segmental area. The fingers of the physician are pressed deeply in the gutter of the spine over the perivascular ganglia and the recurrent spinal nerves of the segments involved. If sedation is necessary in any condition, the treatment is as follows: Patient on side. Physician stands in front of patient. Physician puts the tips of his fingers in gutter of spine and holds with light pressure for 10 or 20 seconds or until he feels a relaxation in the tissues. A segment can be treated, but generally the whole spine is treated. It is best to treat only one side of the spine at a time. If a stimulation or an acceleration treatment is necessary, the fingers are put in the gutter of the spine the same as in sedation. The movements in this treatment are light pressure, then quick jerkings of the fingers up and down without removing the fingers from the spot. Study your segmental areas, on pages 26 to 35, then read on. See also page 156. |