Part 30

Not infrequently the seat of disease may be at some distance from that of pain, as in the familiar instances of pain at the top of the head in uterine derangement; in the glans penis from calculus in the bladder; in the knee from hip-joint disease; under the shoulder-blade in liver disorder; about the heart or between the shoulders from dyspepsia.

Anæsthesia, loss of sensibility, has much value as a symptom in neurotic affections, as paralysis, etc. Its discussion will find place in connection with diseases of the Nervous System in other portions of this work.

As an example of the diversified associations of pain, cephalalgia (headache) may be mentioned as having at least the following possible causes: congestion of the brain, neuralgia, rheumatism of the scalp, uterine irritation, disease of the kidneys, early stage of remittent, typhoid, or yellow fever, alcoholic intoxication, chronic disease of the brain.

Abdominal pain may, in like manner, be traced, in different cases, to many morbid conditions, such as flatulent colic, lead colic, neuralgia or rheumatism of the bowels, intestinal obstruction, dysentery, passage of a gall-stone or of a nephritic calculus through one or the other duct {166} respectively; cancer, aneurism of the aorta, caries of the spine; in the female, dysmenorrhoea, metralgia or ovaralgia--i.e. neuralgia of the uterus or ovaries.

Similar diversity in the origins of pain might, but for want of space, be pointed out in morbid states of the contents of the chest and of other parts of the body.

Subjective symptoms often affect the special senses.

Taste and touch have been already referred to. Of sight we may have photophobia, connected with exaggerated sensibility of the retina or of the brain; muscæ volitantes, specks, rings, or chains of spots from floating semi-opaque particles in the vitreous humor; diplopia, double vision; hemiopia, seeing only half of an object at a time; amblyopia, indistinctness of vision of all objects.

Hearing is affected, besides all possible degrees of deafness, with the subjective sensations of ringing, whistling, or roaring sounds--tinnitus aurium. One form of this (as I conclude from observation in my own ears) depends upon spasmodic vibration of the tensor tympani or stapedius muscle. Sometimes the seat of the sensation is in the auditory nervous apparatus proper. It has, not seldom, a marked connection with brain-exhaustion. An attack of Menière's disease (labyrinthine vertigo) is often preceded by it. No constant signification, however, can be attached to aural tinnitus. Large doses of quinine or of salicylic acid will occasion it in many patients.

Very briefly, deafness may be here disposed of by mentioning that, in greater or less degree, it may be produced by accumulated wax in the ear; obstruction of the Eustachian tube; thickness of the membrana tympani; perforation of that membrane; mucus or pus in the middle ear; disease of the ossicles of the ear; paralysis of the auditory nerve; typhus or typhoid fever; excessive doses of quinine or salicylic acid.

Vertigo is chiefly of two kinds, dizziness or giddiness (swimming in the head), and reeling vertigo, or a disposition to fall or turn to one side or the other. Giddiness is produced by running or whirling many times in a circle, or, in some persons, by swinging rapidly or sailing. Reeling vertigo is mostly observed in connection with disorder of the brain or of the labyrinth of the ear (Menière's disease). Dizziness, with nausea, is common as a symptom of cholæmia (cholesteræmia of Flint) in what is popularly called a bilious attack.

Delirium is present in many acute disorders, and not infrequently at a late stage in pulmonary phthisis. Its special study will be taken up in connection with the special articles upon these affections.

Coma, or stupor, is met with chiefly in the following morbid states: severe typhus or typhoid fevers; malignant scarlet fever; small-pox; rarely in measles; pernicious malarial fever; uræmia; apoplexy; opiate narcotism, or that from chloral or alcoholic intoxication; asphyxia from inhaling carbonic acid gas, ether, chloroform, etc.; fracture of the skull with compression of the brain.

For an account of aphasia and other morbid psychological manifestations the reader is referred to the articles on Aphasia, Insanity, Hysteria, etc. in this work.

Physical and Instrumental Diagnosis will be treated in connection with those diseases in which they have special importance.

{167} PROGNOSIS.

The elements of medical prognosis are essentially involved in diagnosis. Our ability to anticipate the mode of progress, duration, termination, and results of any case of illness depends upon our knowledge--1, of the nature of the malady, with its tendencies toward death, self-limitation, or indefinite continuance; 2, the soundness or imperfection of the patient's constitution, with or without special predispositions or the consequences of previous ailments; 3, the present state of his system as to the performance of the general functions, his strength, and vital resistance or persistence; 4, the probable modifying influences of medical treatment, and also those of situation, surroundings, and nursing--i.e. the care of those attending to the patient during the absence of the physician and having the duty of carrying out his directions.

1. As to the nature of the malady. While every sickness must be supposed to encroach somewhat upon the vital energy of its subject, very few diseases (leaving aside deadly poisons and surgical injuries) are, ab initio, certainly fatal. Hydrophobia (rabies canina) has been, until latterly, regarded as incurable, and always mortal within a few days or a week or two. A few cases have, during the last few years, been reported as cured, but the diagnosis of these continues to be somewhat doubtful.

Cancer exhibits a tendency to extend its destructive malnutrition so as to render death inevitable unless it can be removed early and completely, or unless the morbid process can be arrested in some manner not yet known. Remedies, such as condurango and Chian turpentine, which furnished hope of such an effect, have, after prolonged trial, been abandoned as not justifying the confidence of the profession.

Tubercular phthisis was once considered to be almost necessarily a fatal disease, although with a very indefinite period of duration. Under improved hygienic management, with mild palliatives and recuperative medication, a not inconsiderable minority of cases now end in recovery. This term may be properly applied when, with cicatrization of a cavity or cavities in the lungs, no more tubercle is deposited and lung-substance enough is left for good respiration, even although the structurally changed portions of pulmonary tissue do not undergo entire repair.

Tubercular meningitis is a nearly always incurable affection. Yet a few instances of lasting recovery have been reported where the diagnosis was as certain as it can be in that disease in the absence of post-mortem examination. A child attended by myself, in whom the symptoms had been of the most unfavorable kind, became apparently quite well, and continued so for a month. Then it was attacked suddenly with convulsions, which were almost unremitting until it died within a day or two.

Gangrene of the lung is very seldom recovered from, but, unless the diagnosis from examination of putrescent sputa has been at fault, there have been cases in which, with the limited destruction of the affected lung, it was not fatal.

Pseudo-membranous croup destroys life in the majority, but not in nearly all the cases of its occurrence. It is most likely to end in death when distinctly a part of an attack of epidemic or endemic diphtheria.

{168} Valvular heart lesions were formerly regarded as incurable, in the sense of restoration of the normal condition and action of the valves impaired, yet not incompatible with years of life. This restoration certainly very seldom takes place. But the experience of many close observers leads to caution in anticipation of necessary and permanent disability of the heart because of murmurs, or even functional disturbances, seeming to prove either aortic or mitral insufficiency or stenosis.

Aneurism of the aorta is very seldom recovered from, but, besides a variable duration, whose period can almost never be anticipated with exactness, there appear to have been some cases of disappearance, or at least prolonged quiescence, of the tumor and of its morbid effects.

Yellow atrophy of the liver is one of the disorders most rarely ending otherwise than in death.

With a course altogether indefinite in time, there appears to be a tendency to exhaust vital energy, without self-limitation, in the different forms of organic degeneration, such as fatty heart, Addison's disease, chronic Bright's disease, diabetes mellitus, cirrhosis, and amyloid degeneration of the liver, etc. The same may be said also of the different forms of cerebral and spinal sclerosis, of pernicious anæmia, and of myxoedema.

Lastly, it is an exception to a very general rule of fatality when a case of trichinosis, with well-marked abdominal, muscular, and general symptoms, ends otherwise than in death within a few weeks.

Self-limitation is familiar in the natural history of typhus and typhoid fever, relapsing fever, yellow fever, cholera, diphtheria, whooping cough, mumps, small-pox, varicella, scarlet fever, and measles. In the sense of a definite duration of each paroxysm intermittent and remittent fevers are self-limited. Are they so also in tending toward recovery, without curative treatment within a certain time? This has been asserted, and in the case of remittent there is evidence that spontaneous cures do sometimes happen. Some observers aver that ague tends toward cessation of the chills after six, eight, or ten weeks. The obstinacy of the attacks in many instances under anti-periodic medication seems to make it probable that spontaneous recovery from intermittent hardly belongs to the typical natural history of the disease.