Pain as a Factor in Diagnosis.

C. C. THOMAS, M. D., ASHLAND, WISCONSIN

I desire to consider some of those forms of pain which depend upon specific conditions but which occur as reflex phenomena from causes which in themselves may or may not be more or less obscure.

I have at this time under observation a case of cardiospasm in a strong, vigorous man, in which he is able to anticipate an attack of the pain by an acute excruciating pain in the left elbow, this pain occurring some moments before the gastric trouble appears and remaining after the spasm has been controlled. In pain from ulcer at the cardiac orifice the pain may be located under the top of the shoulder blade or in the top of the shoulder.

A pain similar to that just mentioned above, in the shoulder and left arm, is common in the various forms of heart disease, and especially in certain valvular disorders.

I have had under observation for a year a case of occipital pain of excruciating character, which was found to depend upon a constricted cervix with retained toxines from insufficient menstruation. So normal was the menstrual function that several physicians overlooked that toxic condition as the cause of the pain.

Pain in the top or back part of the head is not uncommon in other uterine disorders. It will occur also with severe cystic irritation and in the various forms of bladder inflammation.

Pain in the temple or behind the ear may be induced by a decayed tooth, while on the other hand I have frequently observed patients to complain of unbearable toothache which I found to be accompanied with extreme gastric acidity, and which I have permanently relieved by a single full dose of bicarbonate of soda.

Disease of the liver is a common cause for pain under the right shoulder blade. At times the pain is in the top of the shoulder, at other times there is hyperesthesia in the area of distribution of the eighth to the twelfth dorsal nerves. The area at the tip of the right shoulder blade becomes very

sensitive and there are stitch-like pains and a persistent tired aching sensation under the shoulder blade and through the muscles of the shoulder, which especially is very common to neurasthenic patients.

Pain between the shoulder blades, sometimes affecting both alike, accompanies stomach disorder.

When the spleen is affected the pain is located under the left shoulder blade and may extend upward to the shoulder.

The location of severe pain immediately in the stomach, is common with patient suffering from gall stone, and the diagnoses of liver trouble, stomach trouble, or disease of the pancreas is sometimes extremely difficult from the location of the pain. In colitis or in fecal impaction in the colon, the pain may be located in the small of the back.

It is common with weak women to have a pain in the side above the crest of the ilium. This is due to ovarian congestion and increased by ovarian displacement. This induces pain also, down the inner side of the thigh, with pain on the outside of the thigh as far down as the knee, while hyperesthesia or anesthesia of the entire area may result from irritation in the sexual organs, or from congestion. It also occurs in epididimitis.

I at one time treated without results an unbearable pain located in the tendo Achilles which resulted from spasm of the seminal vesicles with epididimitis and general sexual irritation. It occurred just at the moment of the orgasm in sexual intercourse.

I have at the present time an extreme case of pain in the heel and bottom of the foot which results from a neuritis affecting the sciatic nerve. Pain in the heel is quite a common symptom in lithemic conditions.

The well known symptom of pain in the knee from incipient hip joint disease is very common. This symptom can be depended upon as a diagnostic factor in most cases.

When pains of this character recur constantly, a persistent and careful insight <into> the real cause of the condition to determine where the real disease is located, is necessary in order that the pain may be cured. Some of these symptoms are indications for specific remedies which are used to excellent advantage when the cause of the pain is not determined. In these cases morphine or active anodines, or nerve sedatives, while temporarily controlling the pain, should not be continuously given. It is positively necessary that the real cause of the pain be determined and that a plan of treatment be instituted which will remove those causes, and in that manner remove the pain.

Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.