Illustrations of the Difficulties which beset the Diagnosis of some
Cases of Disease. By Thomas Poyser, Esq., Fellow of the Royal
College of Surgeons of England.—I have been much gratified by the
perusal of a paper in the London Journal of Medicine for May, by Dr.
Semple, on “Diseases of the Nervous System.” The cases which he
so candidly and graphically describes, are familiar to all who are in ex-
tensive practice, and show but too clearly, that in a great variety of
cases which terminate fatally, the symptoms during life do not develope
the true seat and nature of the malady. The great attention that has of
late years been paid to general and morbid anatomy, and to pathology,
with the mechanical aids that have been had recourse to, for the investi-
gation of diseases, as well as the more patient and inductive method of
studying them by those who practice medicine as a science, have no
doubt tended materially to render diagnosis and symptomatology more
clear and specific; yet there is still a wide field open, in this most im-
portant department of medical practice, for future explorers.
To ascertain the true pathological cause of disease is confessedly the
most difficult, as it is the most important part of medical practice. In-
deed, as Celsus has well observed, “ aestimatio caus® saepe morbum
solvit.” Many causes, however, concur in practice, but more especi-
ally in the country, to render the patient observation of disease
difficult, if not almost impracticable. Extensive practice, while it
renders the practitioner familiar with the phenomena of disease and its
terminations and best means of cure, leaves rarely much leisure for the
niceties of physical and chemical exploration, required in obscure cases.
They who have the most extensive field of practice, are apt, in the
hurry of business, to depend on tact, a sort of intuitive gift, like the tac-
tus eruditus of the surgeon : and hence their examination of cases is
apt to become habitually superficial, and a routine mode of prescribing
is also, from the same cause, too often allowed to usurp the place of
rational treatment.
I do not state this to the disparagement of the general practitioners,
than whom a more painstaking, intelligent or consciencious body of
men does not exist, in our own or any other profession. But we can-
not expect impossibilities; and the multiplicity and diversity of cases
which the well-employed medical man has to visit daily, if spread over
a great extent of country, forbid that minute attention and examination
which are frequently required.
Another hindrance to the complete investigation of disease, when it
terminates unfavorably in the country, is the great repugnance to pos/-
mortem examinations. In large towns and public institutions this preju-
dice is not so strong; but in some rural districts, a request to have a
post-mortem inquiry almost invariably gives offence to the relatives, and
is very rarely permitted. The country practitioner has seldom, there-
fore, an opportunity of verifying his diagnosis by a post-mortem exami-
nation ; and if he had doubts on his mind as to the cause and seat of
the disease, during the life of his patient, those doubts have little chance
of being cleared up by his death.
Occasionally, however, a post-mortem examination is allowed, and
then we sometimes find that the true seat of the disease is revealed,
which during life was not suspected, nor indicated by the symptoms.
These unlooked-for terminations of disease are seldom given to the pub-
lic ; as they imply, (though often unjustly,) a want of skill, or perspica-
city, in the medical attendant: while periodical works teem with cases
terminating favorably, or where the examination after death proves the
diagnostic skill of the narrator. In systematic treatises, too, and mono-
graphs on particular diseases, the general history of the symptoms,
treatment, and termination of the ailment, proceeds too smoothly to meet
the exigencies and stern realities of actual practice. Untoward and un-
looked for terminations of disease are seldom adverted to, or recorded ;
and yet these furnish the most important and instructive part of the
history, as they are beacons or landmarks for future inquiries.
In the short but elegant preface to the transactions of the College of
Physicians, written, as is generally supposed, by the late Dr. Heberden,
is this paragraph : “ It is to be wished, that writers would not confine
themselves to relate only their successful practice. A physician of great
experience might write a very useful paper, if he would have the cour-
age to give an account of such methods of cure only, as he had found to
be ineffectual or hurtful.” With the wish to further a suggestion com-
ing from such high authority, I published a few years ago, in the fifth
volume of the Transactions of the Provincial Medical and Surgical Asso-
ciation, some cases and dissections “ to show the uncertainty and diffi-
culty of diagnosis; from the symptoms during life not being indicative
of, or bearing any proportion to, the extent of morbid lesion discoverable
after death.” The cases to be offered to the readers of the London
Journal of Medicine, may be regarded as a continuation of these re-
ports. Having no system to establish, or theory to support, they will
be selected indiscriminately, from notes taken at the time : and although,
perhaps, but little may be learned from them in the way of practice, yet
I trust that, from the reasons above stated, they will not be found un-
interesting or useless. An important object will be answered by their
publication, if it induce others, whose opportunities of observation from
public hospitals and other sources are much greater than mine, to publish
such results of their experience, as may illustrate the difficulties which
beset the diagonsis of some cases of disease.
Case i. Obscure Neuralgic Pains : Disease of the Brain, and
Enlargement of the Liver. Mrs. —, aged 40, the mother of a large
family, and a lady of great intellectual attainments, who had usually been
in the enjoyment of good health, was attacked in the Autumn of 1844
with acute pain in the right groin, or rather in the inner and upper mar-
gin of the ilium. The pain was limited in extent, and might be covered,
as she expressed it, with her finger, but was so acute as to deprive her
almost entirely of sleep, and to render any motion of the part nearly
insupportable. There was no swelling, redness, nor any appearance of
inflammation. This pain continued some months, without varying its
seat or character, and but little controlled by treatment.
It was considered to be neuralgic; and every means that could be
suggested, both constitutional and local, were tried by an eminent surgeon
who then attended the case. During the progress of this affection,
Mrs. — herself discovered, while in bed, (to which she had long been
confined by the neuralgic pain,) a swelling in the right side below the
liver. On examination, this viscus was found much enlarged, extending
four or five inches below its normal size and situation, of a stony
hardness ; but unattended with pain or tenderness on pressure. It seemed
to account for the pelvic pain, inasmuch as the pressure from this
indurated mass on the nerves might occasion it. Mercury with taraxa-
cum, and iodine and mercurial frictions, were therefore had recourse to,
without any alleviation of pain, or diminution of the hepatic disease.
In the Spring of 1845, the patient was removed to her mother’s house
in this neighborhood, and on April 5th I saw her. In addition to the
enlargement of the liver, and the acute pain on the inner margin of the
crista ilii, there was now tympanitis, the bowels being enormously dis-
tended with flatus. There was no pain in the head, no fever, and the
pulse and tongue were natural: but there was a degree of irritability of
mind and fretfulness which was remarkable, as Mrs. —’s natural dispo-
sition was peculiarly placid and gentle. It is unnecessary to detail the
treatment, as but little or no relief was obtained from it.
The tinctura cannabis indicse soothed and tranquillized the nervous
feelings ; and the unguentum aconiti as a local application, (suggested
by Sir Benjamin Brodie, who was consulted,) in some degree assuaged
the pain ; but the general character of the symptoms continued unaba-
ted; till about the middle of April, when the pain began to diminish, and,
in two or three days, went off altogether. After the removal of the
pain, Mrs.—’s spirit and appetite improved ; she was able to sit up
and walk about her room; and although the tympanitic swelling and
enlargement of the liver did not diminish, yet she was cheered by the
freedom from pain, and the prospect of recovery.
On the 28th of April, while sitting in her chair, Mrs. — had an apo-
plectic seizure, which deprived her of speech and the power of swallow-
ing, from which she never rallied. She expired May 3rd.
JI post-mortem examination was made thirty-six hours after death.
On removing the calvarium, the external part of the brain presented no
diseased appearance ; but, on cutting into the left hemisphere, it was
found to be quite degenerated in structure. The whole of the anterior
lobe was converted into a thick purulent fluid ; and, in the middle of
this large abscess, there was a clot of blood of the size of a walnut. This
coagulum appeared to be of recent formation. The leftmiddle lobe was
pulpy and diseased, but the other parts of the cerebrum and cerebellum had
a firm consistence and healthy structure. The abdomen was very large,
from the bowels being enormously distended with flatus, but there was
no extravasated fluid or gas in the cavity. The left lobe of the liver pre-
sented a very diseased appearance. It was enlarged to more than twice
its usual size, had almost a stony hardness, was mottled and tuberculated
externally, and on cutting into it, its texture was gristly and exhibited that
diseased structure termed mammary sarcoma. The inner edge of the ilium,
where the pain had existed so many months, was carefully examined, but
there was no morbid appearance discoverable in the part, or in the nerves
leading to it. The thorax was not opened.
Remarks. This case is, I think, interesting, and worthy to be re-
corded. It shows that the symptoms did not point to the true seat of
disease, till a short time before the patient’s death ; and that extensive
disorganization may be going on in the brain, without impairing its func-
tions, or manifesting those signs by which it may be detected. The
fretful and altered manner of the patient led to the apprehension that
softening of the brain might be going on ; but the total absence of pain in
the head, and of rigors, or any indication of inflammatory action, rendered
the diagnosis very difficult. It is highly probable, that the pain in the
right side of the pelvis was occasioned by disease of the left side of the
brain, and furnishes an additional instance to those recorded by Sir
Henry Halford, where neuralgia was the effect of cerebral disorganiza-
tion. When the latter disease had so far advanced as to disqualify the
nerves from suffering so exquisitely, then the pain ceased. The case
shows the importance of attending to the brain, in all long-continued and
obscure neuralgic pains, although the functions of that organ may not
be impaired.—London Journal of Medicine.