Then, again, pain of very alight character in a fanciful person is sometimes said to be aggmvated by lying on the affected side ; whereas pain of a rhea inatic character may be relieved by it. In congestion of the liver, although there be pain on the right side, a still more painful sensation of dragging is felt on turning t,o the left. In the pain of colic, the patient may receive so much relief from pressure as to be induced to lie on his face.
Pain dependent on inflammatory action is always increased by pressure, frequently by movement, and hence we may generally conclude that it has this source, when it obliges the individual to maintain one constant posture. A most striking instance of this is afforded by acute peritonitis, when the patient lies flat on his back, with his knees drawn up and afraid even to breathe, lest, by any possible movement, the pressure on the abdomen should be increased or the relation of the viscera disturbed. What a contrast is this to the effect of pain in colic The absence of pain or serious discomfort, on the other hand, induces a patient who has any feeling of weakness to lie quiet, without his being in any way constrained to remain in the same position. This, however, is very distinct from the stillness which is expressive of complete prostration, or of loss of muscular power ; the one patient may be characterized as listless, the other helpless. It is impossible to describe all the differences in words, and yet, to the experienced eye, how instructive the observation I Watch. for example, the apathy of the patient first seized with malignant typhus, and his subse quent helplessness, and compare with them the quietude of the convalescent, and the powerlessness of the paralytic. Observe, again, the marked stillness of acute rheumatism, when, for example, the patient sees some one accident ally about to touch a painful joint, and knowing that that touch is agony, yet he dare not move the limb out of danger.
Information may also be derived from seeing the patient in bed, which may aid in determining the reality and amount of alleged want of power, by ascer taining how far he can move those muscles in bed which seem to be useless when be is up.
These and similar indications must only be trusted to in so far as they are borne out by other iymptoras, and, in fact, derive their chief value from point ing out the probable seat of disease and leading to further examination.
b. Out of 'bed, the presumption is strong that the disease is not active or acute; yet this is not to be absolutely relied on, because of the difference in sensations and constitution already referred to, which lead one person to regard as trivial what is considered of serious import by another. An erect posture indicates a state
of general health and strength, and freedom of respiration ; a crouching one, general feebleness or labored breathing. The gait may be halting on one side, or equally imperfect on both ; dnd here it is very important to notice whether the imperfection arise from stiffness or loss of power ; in the one case the movement is firm and steady, though impeded; in the other, it is irresolute and unsteady. The features, too, are sometimes disturbed by paralysis.
The action in rising up or sitting down is often of use in determining this point with reference to the legs ; and in the upper extremities the manner in which the limb droops, when raised by the hand of the observer, best discrimi nates stiffness from loss of power.
Paralysis will be subsequently discussed. Stiffness leads to inquiry into the state of the joints, and especially as to rheumatic affections.
As a striking contrast to these conditions, we have the involuntary jerking movements of chorea, and the quick, hurried, and rather tremulous actions of delirium tremens; we may also observe the inconsistent proceedings of one completely delirious, and the perverse stupidity of the imbecile.
4. The sensations of the patient have not much reference to his general state. They include those pertaining to temperature, of excessive heat or cold, feverishness or chilliness, which sometimes contrast strangely with the actual temperature of the skin; feelings of weakness, malaise, or pain; in somnia, giddiness, or headache ; shortness of breathing; hunger, thirst, and their opposites ;—all the subjective phenomena, whether related in the history of the case, or in answer to our inquiries regarding general symptoms, serve to point out the direction which subsequent investigations ought to take. We note not only their actual existence at the time, but also their previous occurrence in the past history of the case; both in their bearing on the gene ral state of the patient, and in the light they may throw upon special patho logical conditions, when the various organs subsequently pass under review, bearing in mind the sympathetic and indirect, as well as the more evident and more direct sensations. Sometimes they are such as we feel assured can have no existence in reality, and then we are led to inquire into disordered innerva tion, distorted imagination, or perverted function of the brain.