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SYMPTOMATOLOGY. 833
tion of the sense of pain with the tactile sense ; and the more pronounced
and acute the tactile sense of the part, the more precisely will a minute
injury be located. Hence we find in practice that pain from injuries to
the surface is correctly located by the patient whether he has the oppor-
tunity of individual inspection of the parts or not. This, as I have
indicated, is not the case with internal parts that have not the tactile
sense ; and it is in disease of these parts that we have what is known
as refleeted pain. Reflected pain is a pain located by the mind of the
patient at a distance, more or less great, from the seat of injury or dis-
ease by which it is caused. This is probably divisible into two quali-
ties or kinds of reflection. In the one variety the pain is simply
wrongly located by the mind ; in the other the pain is actually induced
in another place through a perversion of nervous function. Our meagre
knowledge of the modus operandi of the production of pain renders the
very accurate following of this subject extremely difficult ; but when we
see muscular contractions occurring in different parts of the body, the
eifect of disturbance of nervous function by local disease, it is reason-
able to suppose that jDain also may be thus produced. Indeed, these
muscular contractions may be the source of reflected pains which are
accurately located through what is known as the sixth or muscular sense.
Much of the pain in the muscles of the back occurring in woman in con-
nection with disorders of the uterus is of this character. Pleurodynia
may occur as an expression of disturbed nervous function, the result
probably of intense tonic contraction of a few fibres of some one of the
intercostal muscles, or it may be of isolated fibres of several of them.
Much of what we know as reflected pain is, however, generally of a
different character from these latter examples, and its mode of produc-
tion is different. A patient complains of a persistent pain in the knee,
and the surgeon recognizes it as a symptom of disease of the hip-joint.
The cause of the pain is in the hip-joint, but the diseased tissue, being
destitute of the tactile sense—indeed, in this case of any nerves of sense
the pain is wrongly referred by the mind of the patient. A patient has
pain in and retraction of a testicle, and the surgeon will probably be
suspicious of stone in the urinary bladder, and look for the other symp-
toms with which the presence of a calculus is usually associated. An-
other complains of a pain in the region of the scapula (shoulder-tip
pain), from which the physician diagnoses disease of the liver. In
inflammation of the iris the principal seat of pain is in the brow. In
this manner we might go on indefinitely enumerating examples of re-
flected pain, and in every instance it will be found that the diseased
organ is one that has not the tactile sense. The instances given are
among the best known, and most constantly associated with the organs
named, that occur in symptomatology, and serve to illustrate the general
]:)rinciples of the subject. But in very many instances there is no well-
defined point at which pain is felt in diseases of a given internal organ.
Pain may be felt at various points, and may be shifting from one point
to another ; may be in close proximity to the diseased organ or remote
from it ; may be slight or severe. For instance, in case of stone in the
urinary bladder, besides radiating pains and the symptoms that have
their seat in the neck of the bladder and urethra, "spasmodic con-
VoL. I.—53
SYMPTOMATOLOGY. 833
tion of the sense of pain with the tactile sense ; and the more pronounced
and acute the tactile sense of the part, the more precisely will a minute
injury be located. Hence we find in practice that pain from injuries to
the surface is correctly located by the patient whether he has the oppor-
tunity of individual inspection of the parts or not. This, as I have
indicated, is not the case with internal parts that have not the tactile
sense ; and it is in disease of these parts that we have what is known
as refleeted pain. Reflected pain is a pain located by the mind of the
patient at a distance, more or less great, from the seat of injury or dis-
ease by which it is caused. This is probably divisible into two quali-
ties or kinds of reflection. In the one variety the pain is simply
wrongly located by the mind ; in the other the pain is actually induced
in another place through a perversion of nervous function. Our meagre
knowledge of the modus operandi of the production of pain renders the
very accurate following of this subject extremely difficult ; but when we
see muscular contractions occurring in different parts of the body, the
eifect of disturbance of nervous function by local disease, it is reason-
able to suppose that jDain also may be thus produced. Indeed, these
muscular contractions may be the source of reflected pains which are
accurately located through what is known as the sixth or muscular sense.
Much of the pain in the muscles of the back occurring in woman in con-
nection with disorders of the uterus is of this character. Pleurodynia
may occur as an expression of disturbed nervous function, the result
probably of intense tonic contraction of a few fibres of some one of the
intercostal muscles, or it may be of isolated fibres of several of them.
Much of what we know as reflected pain is, however, generally of a
different character from these latter examples, and its mode of produc-
tion is different. A patient complains of a persistent pain in the knee,
and the surgeon recognizes it as a symptom of disease of the hip-joint.
The cause of the pain is in the hip-joint, but the diseased tissue, being
destitute of the tactile sense—indeed, in this case of any nerves of sense
the pain is wrongly referred by the mind of the patient. A patient has
pain in and retraction of a testicle, and the surgeon will probably be
suspicious of stone in the urinary bladder, and look for the other symp-
toms with which the presence of a calculus is usually associated. An-
other complains of a pain in the region of the scapula (shoulder-tip
pain), from which the physician diagnoses disease of the liver. In
inflammation of the iris the principal seat of pain is in the brow. In
this manner we might go on indefinitely enumerating examples of re-
flected pain, and in every instance it will be found that the diseased
organ is one that has not the tactile sense. The instances given are
among the best known, and most constantly associated with the organs
named, that occur in symptomatology, and serve to illustrate the general
]:)rinciples of the subject. But in very many instances there is no well-
defined point at which pain is felt in diseases of a given internal organ.
Pain may be felt at various points, and may be shifting from one point
to another ; may be in close proximity to the diseased organ or remote
from it ; may be slight or severe. For instance, in case of stone in the
urinary bladder, besides radiating pains and the symptoms that have
their seat in the neck of the bladder and urethra, "spasmodic con-
VoL. I.—53
