A treatise on clinical medicine

Front matter

HX641 17804 RC61 .T38 A treatise on clinic

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SiQ^t in tlye Qlttg of N?«i f nrk

Preface

A TREATISE on Clinical Medicine should chiefly consider those subjects which concern the physician when he deals with the sick. Knowledge gained in the laboratory or at autopsies, while indispensable, yet should in time precede all prescribing. It is the condition of the living patient which then demands exclusive attention.

We begin, therefore, with the meaning of certain common but always important symptoms. In each instance that meaning is neither vague nor uncertain, but rather should be thoroughly understood before we go any further in deahng with the case.

A chapter then follows on the use of remedies and how they can be most conveniently classified according to their special appHcations.

Then follows the section on that greatest cause of disease and death, namely, infections by living micro-organisms. A good classification of these agents would be of great service, and such is attempted.

The last section deals with diseases of particular organs and tissues.

Throughout the book the aim of the author has been to serve the physician while he is actively engaged in the performance of his professional duties.

William Hanna Thomson.

New York City.

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Chapter II. — Acute Infections Directly Communicable or Contagious 80

Plague or Pestis, 80 — Small-pox, 83 — Scarlet Fever, 87 — Measles, 93 — Rubella, 96 — ^Typhus Fever, 96 — Diphtheria, 99 — Whooping-cough, 107 — Mumps, no — Influenza, in — Chronic Infections Directly Communicable or Contagious, 113 — Syphilis, 113 — Tabes Dorsalis, 124 — Parasyphilitic Affections, 124 — Paresis, or General Paralysis of Insane, 133 — Gonorrhea, 134.

Chapter III. — Infections Commxhsticable by Intermediate Carriers 138

Lobar Pneumonia, 138 — ^Typhoid Fever, 146 — Parat3^hoid Fever, 161 — Meat-poisoning, 161 — Asiatic Cholera, 161 — Anthrax, 166 — Tuberculosis, 167 — Leprosy, 184 — Rheumatic Fever, 186 — Chorea, 192 — Cerebrospinal Meningitis, 195 — Erysipelas, 197 — Pyemia, 202 — Dengue, 202 — Beriberi, 203 — Pellagra, 204 — Actinomycosis, 206 — Relapsing Fever, 206 — Malta Fever, 207.

Chapter II. — Diseases of the Circulatory Apparatus 249

Examination of the Blood-vessels, 249 — Diseases of the Capillaries, 257 — Pulse, 257 — Heart-block or Stokes- Adams' Disease, 259 — Arteriosclerosis, 260 — Aneurysm, 267 — Endocarditis, 272 — Malignant Endocarditis, 276 — Pericarditis, 278 — Peri-pericarditis, 281 — Bradycardia, 281 — Chronic Valvular Disease, 282 — Aortic Stenosis, 284 — Aortic Regurgitation, 285 — Mitral Stenosis, 287 — Mitral Regurgitation, 288 — Paroxysmal Tachycardia, 291 — Angina Pectoris, 291 — False or Neurotic Angina Pectoris, 294.

Chapter IV. — Diseases of the Bones and Joints 297

Chronic Fibrositis, or Chronic Muscular Rhevmiatism, 297 — Arthropathies, 298 — Arthritis Deformans, or Rhetmiatoid Arthritis, 298 — Osteomalacia, or Fragilitas Ossium, 301 — Pulmonary Osteo-arthropathy, 301 — Phosphorus Necrosis, 302.

Chapter V. — Diseases of the Respiratory Apparatus 303

Nose, 304 — Coryza, 304 — Epistaxis, 305 — Asthma, 306 — Hay-fever, 310 — Acute Laryngitis, 312 — Edema of Glottis, 313 — Chronic Laryngitis, 3i3^Tubercular Laryngitis, 313 — Laryngismus Stridiilus, or Spasmodic Croup, 314 — Bronchitis, 314 — Fibrinous Bronchitis, 317 — Bronchopneumonia, 318 — Bronchiectasis, 320 — Gangrene of the Lung, 321 — Pleuritis, 322 — Pneumothorax and Hydropneumothorax, 327 — Cirrhosis of the Lung, 328 — Emphysema, 329 — Empyema, 331 — Hiccup, 332.

Chapter VI. — Diseases of the Organs of Digestion 333

Stomatitis, 331 — Oral Sepsis, 335 — Bad Breath, 336 — Affections of the Esophagus, 337 — Disorders of the Stomach, 338 — Introduction, 338 — Acute Gastritis, 344 — Chronic Gastritis, 344— Phlegmonous Gastritis, 346 — Gastroduodenal Ulcers, 347 — Chronic Gastroduodenal Ulcers, 351 — ^Acute Gastric Dilatation, 355 — Chronic Gastric Dilatation, 355 — Hyperc];ilorhydria, 357 — Achylia Gastrica, 360 — Achlorhydria Haemorrhagica Gastrica, 360 — Foreign Bodies, 361 — Intestinal Disorders, 361 — Diarrhea, 361 — Peritonitis, 364 — Ascites, 366 — Intestinal Motility, 367 — Ileus, 369 — Enteroptosis, 369 — Intestinal Discharges, 372 — Choleraic Diarrhea, 374 — Appendicitis, 377 — Mucous Colitis, 379— Bacillary Dysentery, 386— Amebic Dysentery, 388— Rectal Ulcers, 390 — ^Hemorrhoids, 391.

Chapter VII. — Diseases of the Liver 392

Hepatitis, 392— Chronic Capsulitis (Perihepatitis), 392— Jaundice, 393— Cholelithiasis, Cholecystitis, and Stenosis, 395 — Cirrhosis of the Liver, 406 — Alcoholic Cirrhosis, 406— Fatty . Cirrhotic Liver, 409— Syphilitic Cirrhosis, 409— Hypertrophic Cirrhosis (Hanot), 411— Pylephlebitis, 412— Abscess of the Liver, 412— Acute Yellow Atrophy, 413— Amyloid Degeneration, 414— Movable Liver, 414.

Chapter IX. — Diseases of the Pancreas 4i6

Pancreatic Hemorrhage, 417— Acute Pancreatitis, 418— Chronic Pancreatitis, 419 — Pancreatic Calculi, 419.

CONTENTS 15

PAGE

Chapter X. — Diseases of the Urinary Apparatus 420

Acute Nephritis, 420 — Chronic Nephritis, 423 — Chronic Interstitial Nephritis, 427 — Arteriorenal Sclerosis, 431 — Uremia, 432 — Nephrolithiasis (Oxaluria;, 435 — Cystitis, 437 — Pyelitis, 438 — Hydronephrosis, 440 — rerinephric Abscess, 441 — Morbid Conditions of the Urine, 442 — Indicanuria, 442 — Lithuria, 443 — Phosphaturia, 443 — Chyluria, 443 — Cystinuria, 444 — Melanuria, 445 — Bacterinuria, 445 — Tumors of the Kidney, 445 — Cysts of the Kidney, 445 — Movable Kidney, 446.

Chapter XI. — Diseases of Metabolism 447

Gout, 447 — Diabetes Mellitus, 451 — Diabetes Insipidus, 459 — Rachitis, or Rickets, 460 — Scleroderma, 461 — Obesity, 461 — Fatty Tumors, 462.

Chapter XII. — Diseases of the Ductless Glands 463

Introduction, 463 — My.xedema, 464 — Diseases of the Thymus Gland, 465 — Diseases of the Pituitary Gland, 466 — Acromegaly, 466 — Diseases of the Adrenals, 467 — Addison's Disease, 467 — Diseases of the Thyroid Gland, 469— Cretinism, 469 — Graves' Disease, 473.

Chapter XIII. — Diseases Caused by Animal Parasites 494

Cestodes, or Tapeworms, 494 — Hydatids, or Echinococci, 496 — Trichiniasis, 498 — Ascarides, 499 — O.xyuris Vermicularis (Pin-worms), 500 — Ankylostomiasis (Hookworm Disease), 500 — Balantidium Coli, 502 — Dracontiasis (Guinea- worm Disease), 502 — Filariasis, 503 — Other Nematodes, 503 — Parasitic Arachnoids, 504 — Scabies, 504 — Parasitic Insects, 505 — Affections from Caterpillars, 506.

Chapter XVI. — Diseases of the Nervous System 520

General Introduction, 520 — Functional Nervous Diseases, 523 — Epilepsy, 523— Catalepsy, 533 — Infantile Convvdsions, 533 — Vertigo, 534 — Hysteria, 538 — Paralysis Agitans, 541 — Gastric and Other Neuroses, 544 — Neiorasthenia, 545 — Migraine, 549 — Raynaud's Disease, 553 — Erythromelalgia, 554.

Chapter XVII. — Organic Nervous Diseases 555

Lateral Sclerosis, 555 — Disseminated Sclerosis, 556 — Amyotrophic Lateral Sclerosis, 559 — Acute Anterior Poliomyelitis, 560 — Chronic Anterior Poliomyelitis, 566 — Chronic Atrophic Paralysis, 566 — Progressive Muscular Atrophy, 566 — Bulbar Paralysis, 568 — Syringomyelia, 569— Affections of Brachial Plexus, 572 — ^Lesions of Individual Nerves of the Plexus, 573 — ^Affections of Lumbar Plexus, 575 — Sciatica, 577— Herpes Zoster, 579— Landry's Paralysis, 581 — Myelitis, 581 — Pott's Disease, 582 — Neuritis, 583— Angioneurotic Edema, 584.

Chapter XVIIL— Diseases of the Cranial Nerves 586

Olfactory Nerve and Tract, 586 — Optic Nerve and Tract, 586 — Albuminuric Retinitis, 587— Optic Neuritis, 588— Optic Atrophy, 588— Trigeminus or Fifth Nerve, 589 — Trigeminal Neuralgia, 590 — Paralysis of Facial Nerve, 593 — Spasm, 594 — Affections of Auditory Nerve, 594 — Glossopharyngeal Nerve, 598 — Pneumogastric Nerve, 598— Spinal Accessory Nerve, 600 — Hypoglossal Nerve, 601.

Chapter XXII. — Malignant Diseases 626

Introduction to the Study of New Growths, 626 — Cancer of the Esophagus, 631 — Cancer of the Stomach, 631 — Cancer of the Intestinal Tract, 633 — Cancer of the Liver, 634 — Cancer of the Breast, 635 — Cancer of the Lung, 635 — Sarcoma, 636 — Treatment of Cancer and Sarcoma, 638.

Index 641

Chapter I Pathology Of Chill Affecting Localized Areas

OF THE SKIN

Outside of hot, moist climates, the most common cause of disease and of death is from "catching cold." I first drew attention to the etiology and mechanism of this derangement in my inaugural as president of the New York Academy of Medicine in 1899. Yet it should be clearly understood that this disorder, however local, is always caused by an interference with the supply of arterial, and not of venous, blood to the part. This fact was plainly illustrated by the experiment of Overbach, who found that clamping the renal arteries for only forty minutes, so as to obstruct the flow of blood through the kidneys, was followed by albuminous urine for twenty days. We may conclude, therefore, that any local shutting off of arterial blood will promptly induce nutritive changes in the territory of that arterial distribution, which are at least analogous to the local inflammatory changes which we trace to "catching cold."

Now the arterial flow, in distinction generally from the venous, is under the regulation of a special department of the nervous system, called the vasomotor nerves. This is well shown in the circulation of organs which are in symmetric pairs, such as the two eyes, the two ears, the two hands, and the two feet, but this association does not obtain in the pair-organs which are not symmetric, such as the two lungs and the two kidneys. As to the symmetric organs, if thermometers be placed in the axillae, and then one thermometer be held in the left hand while the right hand is plunged in ice-water, the thermometer 2 17 in that hand will fall 2° to 5° F. from arterial contraction in it, while those in the axillas are unaffected. If the semitranslucent ears of a rabbit are held up to the hght the readily seen pulsation of the arteries in one ear is found to cease at once when the other ear is pinched. Now, Overbach's experiment shows that the integrity of the tissues of a most important organ can be seriously deranged by only a very temporary withdrawal of arterial blood.

In the firstplace, it is evident that "catching cold" is a very different thing from being chilled by cold; that is, from a general cooling of the body; for its most typical, as well as disastrous, results may occur while a person sits with his entire body wrapped carefully in winter clothes, but the feet meantime soaked, because he went out without his rubbers into melting snow. A cold draft on the back of the neck, however induced, may, according to individual susceptibiHty, cause a rhinitis, a pharyngitis, a laryngitis, a bronchitis, a pneumonia, or a pleuritis. How do such purely local impressions of cold occasion such widely distributed organic mischief? As we have remarked, we must look to the nervous system for our chief explanations. One of the first clews toward the solution of this problem was furnished by an observation of Cohnheim, that, after long-continued anemia of the rabbit's ear by ligature, the blood-vessels became so permeable that the restoration of the normal circulation was followed by pronounced edema of all the tissues and degenerative changes in their cells.

The principle, therefore, which we would elucidate here is that the integrity of the tissues of the body depends upon the constant circulation through them of arterial, and not of venous, blood. Whatever interferes with the circulation of arterial blood, though it be but a short interference, nevertheless produces serious damage to the tissues. Guided by this principle, we can understand what "catching cold" means, because every organ of the body, particularly if it be very vascular, is sensitive to the withdrawal or interference with its arterial circulation, and hence this leads us to inquire into the special mechanism of the arteries as they are governed by their vasomotor nerves.

The vasomotor nerves are but rarely acted upon by a general stimulus. Instead, vasomotor stimuli are definitely local, and yet subject to certain special laws. A study of these laws will throw much Ught upon our subject of "catching cold." Thus, as we have seen, the first law is illustrated by the intimate association of the vasomotor nerves supplying symmetric organs in pairs. In the case of the hands I once made use of this property in a boy who had a pistol shot

PATHOLOGY OF CHILL AFFECTING LOCALIZED AREAS OF SKIN 1 9

perforate the palm of his hand so as to sever the pahnar arterial arch. This necessitated both the cut ends being Ugated, but the hemorrhage was so troublesome that I could not secure the vessels until his other hand had been dipped in ice-water, whereupon the bleeding was checked enough for me to find and tie the vessels without difficulty.

A second law is the intimate association between the vasomotor nerves of any area of the skin and those of the internal parts underneath that area. This is an important law, as it affords the explanation of a great many chnical facts. Thus, external applications, according to their nature, can produce marked stimulative or else sedative impressions upon the circulation of the parts underneath that area. This explains why poultices may so reheve pain and inflammatory irritation when appUed to the skin ; but Hkewise we find this law operative where it is important to stimulate the circulation in the stage of venous stasis.

Thus, after the subsidence of the acute stage of inflammation, we have a powerful stimulant to the internal circulation by dry cupping, which is especially useful in the bronchitis of adults. Likewise the appHcation of a bhster is actively stimulant to the internal circulation, but should not be apphed in the first stage of the inflammation.

These considerations lead directly to the whole subject of counterirritation. Thus, the effect of local bloodletting is always sedative. I have relieved the agonizing paroxysms of dyspnea from a thoracic aneurysm by a single leech applied at the notch of the sternum. A further illustration of this law is found in the saving of Hfe from a quickly fatal postpartum hemorrhage by dashing cold water upon the abdomen or, better yet, by the sudden, intense cold of the ether spray. Of course, this arrest of the hemorrhage is not due to the general cooling of the parts involved, but acts only through reflex vasomotor association.

But this law has also an obverse application of much practical importance. Every internal inflammation causes a marked hyperesthesia of the skin over the inflamed organ, which leads to any irritation of it being reflected inward to the aggravation of the inflammation. I once saw a distinguished clinician expose the chest of a woman with pericarditis for nearly an hour, so that each of his students might successively hsten to the pericardial rub. The result was that in a very few hours the patient's life was despaired of from a spread of the inflammation to the whole pericardium.

Another important law is, that through the vasomotor system special associations occur between certain widely separated parts of the body. All vasomotor nerves are particularly susceptible to the irritant impression of cold. This is illustrated in the case of the association existing between the feet and the circulation of the pelvic viscera. So girls can have recourse to a very dangerous suppression of the menses by putting their feet into cold water. It is surprising how long this injurious impression is retained by the pelvic nerves, so as to cause long-continued amenorrhea. On the other hand, I have found no agent so effective in restoring the function of menstruation as that of dry (not moist) heat, appHed for prolonged periods to the feet. Likewise, no patient with an irritable stricture of the urethra should allow his feet to get wet and cold, and the same may be said of cases of cystitis. Also due to the same vasomotor association, if profuse bleeding occurs during operations about the rectum, the hemorrhage may be largely controlled by immersing the feet in cold water.

But the vasomotor nerves of the feet form another association which is of much importance, and that is with the circulation of the pharynx and the larynx. Everyone knows that getting the feet wet may quickly produce a sore throat, if not an attack of hoarseness, extending finally into bronchitis.

Still another important association is between the nerves arising at the nape of the neck and the whole arterial circulation of the head and face; in fact, we may say that at the nape of the neck is the chief executive office which presides over the whole circulation above the diaphragm, including, of course, the circulation of the mucous membranes. One domestic remedy, for example, was to check nosebleed in a child by sHpping a cold key down the back of its neck. How local the primary excitation may be is shown by the results of exposing the back of the neck to a cold draft of air. The most extensive inflammation of mucous membranes may result from a prolonged exposure, though the rest of the body may be warmly clad. Nasal catarrh or, in fact, catarrh of the whole respiratory tract may soon follow from thus "catching cold."

But a fact of the highest moment connected with "catching cold" is, that by the local damage to an internal part the way is opened for infecting micro-organisms of the most varied kind to enter the system. Many of these infecting agents may be found throughout hfe occupying the mouth and throat, but doing no harm so long as the epithelium lining of the mucous membrane is intact; such is the case with the pneumococcus and a whole host of similar and powerful infecting agents. The demonstrated seasonal relationships of pneumonia show this very

PATHOLOGY OF CHILL AFFECTING LOCALIZED AREAS OF SKIN 21

clearly. These infecting micro-organisms are as little able to penetrate a healthy mucous surface as the streptococci and staphylococci, which always swarm on the skin, but can do no mischief until the surgeon ventures to make an incision in it.

These vasomotor associations have their widest illustrations in the causation and course of bronchitis. Sometimes getting the feet wet begins, as we have explained, a cold which first makes the voice hoarse, and then, from the larynx, proceeds steadily down the trachea and larger bronchi until the smaller air-tubes become involved. Oftener than that, however, the vasomotor centers at the nape of the neck set up a catarrhal inflammation of the nasal passages, and then, with this derangement in the beginning of the breathing apparatus, it progressively invades the whole respiratory tract. Yet just this sequence occurs also when this tract is directly invaded by the specific . infections of influenza, measles, and whooping-cough. But what we particularly wish to explain here is the mechanism of the many fatal complications of bronchitis.

We begin with the disasters which follow upon the plugging of a main bronchus by the accidental lodgment in it of a foreign body. If this be not removed, death inevitably ensues from a most disorganizing pneumonic process of the part supphed by the bronchus, in which not only are all the air-vesicles wholly destroyed, which they are not in croupous pneumonia, but the interlobular as well as the intervesicular connective framework is rapidly damaged. No ruin of pulmonary tissues compares with this for completeness.

Now, it should be borne in mind that both the larger and the smaller bronchi should never contain anything but air. Their walls are simply moistened by a bland, shghtly saline fluid, and in no part of the body is the sa3dng more true that no mucous membrane should ever secrete mucus. When, instead, its surface is coated with mucus, it is already in a morbid condition, denoting inflammation. In the bronchi this is doubly true, for secretions there, no matter how fluid, are, to all intents and purposes, foreign bodies, and must be got rid of. If they cannot be got rid of, the part supphed by that bronchus is subject to the same disorganization as that described following the plugging of a main bronchus. It is then that we have a locahzed-, but ruinous bronchopneumonia, however small its area may be.

Bronchopneumonia, therefore, occurs in every disease accompanied by bronchitis whenever, as in children, the powers of expectoration are feeble, particularly in measles and whooping-cough, and is the most common cause of death in all such affections. But its initial mechanical cause should not be lost sight of, the practical aim always being to make the secretions so fluid that they can easily be coughed away. In adults this is usually accomplished with ease. If the secretion, however, is very viscid, the coughing is hard, and in chronic cases leads to emphysematous overdistention, if not rupture, of the air-vesicles. In infants, as already explained, the immediate results are very serious. The small occluded bronchi now lead to the same disorganizing process in the httle lobules supplied by the bronchus, which occurs as the result above described accompanying occlusion of a main bronchus. Scattered pneumonic processes are, therefore, found through both lungs, for bronchitis, unlike croupous pneumonia, is a bilateral affection. In some cases, however, the plug in a small bronchus may act as a valve, interfering with the inspiration but not with the expiration, thus leading to atelectasis of the lobule, so that in bronchopneumonia we find both pneumonic consohdation of lobules along with collapsed lobules, either condition, of course, equally interfering with the breathing. In infants, therefore, this whole process leads to most distressing efforts to get air. The httle patients toss from side to side in their vain endeavors to breathe, until signs of carbonic-acid-poisoning show the last effects of gradual suffocation; but we meet with practically the same conditions in aged patients from their feeble powers to expectorate. Remembering, however, the purely mechanical operation of their respiratory obstruction, I once had an old lady, eighty-four years old, mother of a prominent New York judge, raised feet upward by her nurses, while her head touched the floor, and while in this position assisted her expectoration by pressure on the sides of the thorax during expiration. She thus got rid of large quantities of mucus, and was soon restored to bed quite comfortable, ultimately recovering.

In no disorder of the lungs does this morbid condition so facilitate infection by every variety of micro-organism, including tuberculosis, a not uncommon sequel, especially after measles.

Treatment. — The various conditions above described afford many indications for treatment. Thus, chronic nasal catarrhs point to a weakened susceptibility of the vasomotor centers at the nape of the neck. Nothing so restores the tone of these weakened centers as cold properly appHed. Thus, a cold bath or shower-bath invigorates the circulation, provided always that the reaction from the impression of cold is complete, but if not, or equally imperfect reaction occurs, the patient is worse off than ever; hence, chronic nasal catarrhs are best treated by sudden and very brief douching of the back of the

PATHOLOGY OF CHILL AFFECTING LOCALIZED AREAS OF SKIN 23

neck with cold water, to be followed by active dry friction, to assist or to promote the restoration of the circulation in the parts. During the douche the hair should be carefully protected from the water, for wet hair would only prolong the injurious effect of chill. Meanwhile the nose itself may be treated with insufiflation of a fine powder, composed of 2 drams of subcarbonate of bismuth with 6 gr. of aristol.

Bearing in mind what we have said about internal inflammation causing hyperesthesia or great sensitiveness of the corresponding area of skin over the seat of the inflammation, any area of chronic inflammation should have the corresponding cutaneous surface carefully protected. In health, if a cold hand be placed suddenly over the precordium, the heart will give a bound, but so all cases of heart trouble, whether the result of pericarditis or endocarditis, are very sensitive to surface impressions which would not normally be felt. This explains the beneficial results following apphcations of large belladonna plasters, which should cover the whole area of the skin over the heart, but these facts are equally appKcable in all chronic inflammatory conditions, whether of the lungs or of the pleura. Chest protectors, on that account, are reasonable. I prefer the application of cotton batting to any other such measure. Similarly, every patient mth chronic diarrhea should have his abdomen covered by some equivalent protection. In chronic, long-standing bronchitis I have the patients wear both shirts and drawers made with perforated chamois skin, worn just over a light undergarment. I have often been told by such patients that they could spend their winters at home, when before they used these protections to the skin they were unable to do so. Osier says, in his "Practice of Medicine," "Thus, in the convalescence from measles and whooping-cough it is very important that the child should not be exposed to the cold, particularly at night, when the temperature of the room naturally falls. In a nocturnal visit to the nursery — sometimes, too, I am sorry to say, to a children's hospital — how often one sees children almost naked, having kicked aside the bedclothes and having the night-clothes up about the arms."

In my practice I have all such children, while tossing about struggling for breath, and thus exposing themselves, put into bags of canton flannel, drawn about the neck, so as to prevent them from exposing the skin to the cold air.

Chapter II Significance Of Some Important Symptoms

The first duty of a physician is to recognize the actual condition of his patient. This may involve more than the diagnosis of any special malady which he may have, because the accompanying conditions vary indefinitely in different persons whatever the name of the disease. It may be the accompanying conditions which chiefly determine the nature of the prognosis, whether it be favorable or unfavorable, along with the leading indications for treatment. In other words, the more comprehensive the diagnosis be, the better.

On this account certain common but important symptoms of disease assume an interest quite their own, sufficient to warrant their being made the subjects of separate study. Each of these sjonptoms when present constitutes in itself practical information about the patient worthy of the completest investigation until all its possible bearings are determined. Not infrequently such consideration leads to conclusions of as great clinical importance as any questions about pathology or etiology, besides suggesting many a clue to correct diagnosis.

We begin with the subject of pain as a good illustration of the advantage which the particular study of a single symptom may afford. In diagnostic value alone it is not to be surpassed by any of the common s5rmptoms of disease, enough to warrant, whenever pain is mentioned by a patient, the postponement of all other questions until both its nature and its significance are clearly recognized.

The investigation should begin with a request that the patient show just where the pain is felt most, and where it first began. While he is doing so, the gestures which he uses should be carefully noted, as they often afford truer indications than his language does, because verbal descriptions of pain may be extremely indefinite. As a rule, such gestures are characteristic enough to aid materially in the recognition of the particular variety of pain, if not also of the nature of the affection itself which is present, as the following examples will show.

When the pain is due to inflammation, if external, as with a joint, 24 the patient will avoid touching the most painful part, or he approaches it in a very respectful way. Thus, with an arthritis his hand passes over the joint in a hovering fashion. If deeper seated, the gestures are often expressive of the varying kinds and distribution of the pain, according to the texture inflamed. Thus, the diffused soreness of a mucous-membrane inflammation causes the gesture of bronchitis to be made with the whole hand laid on the sternum, and then passed over and across the chest. A similar movement of the hand across the abdomen never means a peritonitis, but a catarrhal intestinal inflammation. With pleurisy, on the other hand, the tips of the straightened fingers are used to indicate the stabbing nature of the pain. In peritonitis, also, the tips of the fingers are used, but brought down with more caution than in pleurisy. In the localized pain of commencing appendicitis, the open hand is used, as with an inflamed joint. In pleurodynia, the whole hand is pressed firmly to the side, to prevent movement of the ribs. In rheumatic fever, the pointing by the patient to the epigastrium or to the xiphoid cartilage, especially if followed by a movement from the precordium upward or into the left arm, is significant of cardiac inflammation. So also the gesture in gastritis, whether acute or chronic, is wholly different from that in colic. Inflammatory pains about the head may have very characteristic gestures. The use of one finger-tip to localize it on the scalp is strongly significant of intracranial syphihs. The finger-tips passing up the side of the face and stopping on the scalp an inch below the sagittal suture indicates a pain ascending from a tooth, and should not be mistaken for a trigeminal neuralgia. In conjunctivitis, the hand is laid over the eye. In iritis, the finger is pointed toward it, not touching it, and then passed up the forehead to the inner side of the nose or to the malar process. In glaucoma, the gesture may be reversed, as if the pain were emerging from the orbit. All these gestures differ entirely from those of head-pains not inflammatory. Meningitis, whether cerebral or spinal, is significantly indicated by absence or suppression of gesture, for reasons to be noted further on. The exceptions to this are in some cases of tubercular meningitis. But the gesture of myelitis, with both hands passed from the back across the abdomen, to describe the cord or band-like sense of constriction, is almost itself pathognomonic.

On the other hand, the gestures indicating the seat of the greatest pain produced by pressure, as by tumors, abscesses, etc., or cramps, markedly contrast with those of inflammatory pains in showing no apprehension in touching or moving the part. Here the locality indicated at first by the gesture is of importance to note, and whether, on repeating the question, the same place is again started from, because the patient's hand then moves in a fashion expressive of the extension or radiation of the pain from the original focus, although he may describe the pain as equally present at some distance from the spot first pointed out. Hence, his unconsciously repeating the sign with which he commenced is of much significance. Thus, a patient with a growth springing from the lumbar vertebrae always first pressed the point of two fingers deeply into the abdomen below the umbilicus, while the fingers of the other hand moved over the sacrum, where he insisted that his pain chiefly was. A fixed pain in the back, caused by an aneurysm, is often indicated by the extended thumb, and likewise the pain preceding herpes zoster; but no spinal inflammatory pain will elicit such a gesture, nor will the pains of so-called spinal irritation.