Treatment. The first essential is complete rest from writing. In mild cases this is sometimes sufficient to effect a cure in one or two months. Dr. Gowers then insists that on again beginning to write, the patient should learn to write from the shoulder entirely. In more severe cases a much longer rest is required, and if writing is necessary to the patient, he may learn to write with the left hand or use a type-writer. Occasionally, but by no means always, the newly-educated left hand also becomes affected. Various devices have been invented, or are improvised by the patients themselves, to save the strain on the muscles of the fingers, such as running the pen through a cork, which gives a larger grasp; holding a wooden ball in the hand, upon which the pen is fixed at the required angle. Nussbaum has invented a "bracelet" which carries the pen, and surrounds the fingers, so that they hold it by muscles (abductors) different from those employed in writing. But, as a rule, all these instruments only postpone the time at which complete rest must be taken. A return to the normal condition of nerve- and muscleaction may be sought in the use of general and nervine tonics, such as iron, quinine, arsenic, and strychnia; and in local treatment such as electricity, gymnastic exercises, and massage. The first is recommended in the form of a continuous current with the anode stationary upon the brachial plexus, or upon the peripheral nerves and muscles concerned, the kathode on the cervical spine. Dr. Poore advises the combination of electricity with regulated exercises of the muscles. Passive manipulations and massage of the affected limb have been of late employed in a systematic way by specialists, and, it is stated, with great success.

The treatment of the other occupation-neuroses must be the same in principle as that already described for writers' cramp.

DISEASES OF THE ORGANS OF RESPIRATION.

PHYSICAL EXAMINATION OF THE CHEST.

Since the lungs are contained almost entirely within the bony thorax, or chest, the diseases of these organs are likely to reveal themselves by modifications in the shape, in the movements, and in the acoustic phenomena yielded by the chest. A consideration of these various physical signs or indications of lung diseases must precede their systematic description.

For purposes of accurate description it is necessary to divide the surface of the chest into regions. Front and back, right and left, suggest themselves at once, but these are too extensive. Some writers have drawn horizontal and vertical lines, and given different names to the quadrangular areas thus indicated, but in practice it is not easy to remember the exact situations of the lines. The same purpose is sufficiently served by a reference to certain points or surfaces in front or behind, the regions being named according to their situation in relation to these points. Thus we have the sternum, the clavicles, and the nipples in front, the scapula behind, the axilla at the side, and we may recognize accordingly the following regions: From above downward on each side in front, supra-clavicular, clavicular, infra-clavicular, mammary and infra-mammary; in the middle line, supra-sternal, upper sternal, mid-sternal and lower sternal; at the side, axillary and infra-axillary; behind, supra-spinous, infra-spinous, infra-scapular and inter-scapular. These occur on both sides of the body, except the sternal regions, which are in the middle line. Such regions, it is true, are not perfectly defined, but sufficiently so for many observations. Where perfect accuracy is called for it can only be obtained by stating on which rib or intercostal space the point under investigation is situated, and how far from some fixed line or point, like the middle line, the edge of the sternum, the angle of the rib, or the nipple.

The modes of examination of the chest are inspection, palpation, mensuration, percussion and auscultation.

INSPECTION.

By simply looking at the chest in front, behind, and from above, any alteration in its shape and movements can be detected. The chief points to be noticed in a healthy chest are as follows: It has a somewhat flat oval form—that is, the antero-posterior diameter is much less than the transverse;

its greater breadth is at the lower part; the clavicles are only slightly prominent, with but little recession above, and scarcely any below them; the position of the nipple is on the fourth rib, or on its upper or lower border; the angle (epigastric angle), which has its apex at the ensiform cartilage, and is bounded on each side by the seventh and eighth costal cartilages, is from 95 to 105 degrees; the scapula is closely adapted to the posterior part of the thorax, and the spine is straight. In inspiration the chest should expand from 11⁄2 to 2 inches in circumference, the two sides should move symmetrically, the epigastric angle should be widened, the sternum thrown forward, the lower ribs lifted, and there should be only very slight recession of the lowest intercostal spaces on deep breathing.

By inspection in disease we may see that one side is larger or more contracted than the other, that the movement is deficient on one or other side, or that the intercostal spaces are unduly sucked in; and we may also see at once the position of the heart, which may be disturbed by lung disease.

The deformities of rickets and of angular and lateral curvatures, which are not due to diseases of the lungs, but may seriously impair the action of these organs, should be specially noted.

PALPATION.

By this is meant the act of laying the hand upon the surface of the chest, either to test its movements or to study the vibrations which the voice or cough produces in its walls. For the former purpose a hand is laid at the same time on each side below the clavicle, or in the infra-scapular or infraaxillary region, when the absolute and relative amounts of movement can be gauged with some accuracy. For the latter purpose the hand is placed flat upon the chest in different parts successively, and the patient speaks in a loud, clear voice. In health, the chest-wall is thrown into vibrations which are plainly perceptible to the hand laid upon it (tactile vocal fremitus, or tactile vibration). For this it is necessary that there shall be a normal vibration of the vocal cords, and normal conductivity of the lungs with patent. bronchial tubes and spongy lung-tissue. The amount of vibration differs in healthy people; it is greatest in adult males with deep sonorous voices; it is least, or it may be absent, in females and children.

In disease it is diminished or abolished by anything which obstructs the bronchial tubes or compresses the lung, so as to convert its spongy tissue into solid. It is increased under some conditions of consolidation of the lung-tissue with patency of the bronchial tubes, especially pneumonia.

By palpation also can be recognized the vibrations of pleural friction, of bronchial narrowing (rhonchi), and of some sounds produced in cavities. The corresponding sounds are described under Auscultation.

MENSURATION.

The chest may be measured in various ways. The ordinary tape measure gives the circumference, and if measurements be taken during expiration and full inspiration, the difference will give a rough idea of the expansion of the chest, or vital capacity. The tape should be applied opposite the nipples. By calipers the transverse and antero-posterior diameters can be estimated. The cyrtometer consists of two long pieces of soft metal, joined loosely together by one end of each. The point of junction is applied to the spine, and the metal rod on either side is wrapped round the side of the chest at any desired level, so as to take a mould of its shape or curve. The instrument is then carefully removed, without disturbing the moulded curve, and, if it is laid out on a large sheet of paper in the position it occupied while applied to the chest, a pencil can be traced round it, and a permanent record of the shape of the chest is thus obtained.

More complicated instruments for the accurate measurement of the movements of the chest have been devised. The stethograph of Riegel, and the thoracometer of Sibson record the movements of the chest-wall on a dial or paper. The spirometer of Hutchinson records, in cubic inches, the air which is breathed out of the chest; the fullest possible expiration after a deep inspiration gives the vital capacity (complemental, tidal, and supplemental air together), and this has been found to have a definite relation to the height of the individual. It is on an average 174 cubic inches for a person five feet high, and rises 8 cubic inches for every inch of height. Waldenburg's pneumatometer measures the force of inspiration and expiration by means of a mercurial manometer. The inspiratory force raises from 70 to 100 mm. of mercury, and the expiratory force from 90 to 130 mm.

PERCUSSION.

In percussion the chest is struck with the fingers or with an instrument called a hammer, so as to elicit a sound. In immediate percussion the chest is struck directly with the hammer or with the tips of the fingers, generally the fore, middle and ring fingers, of the right hand. In mediate percussion a finger of the left hand, or a small piece of ivory or other material, constituting a pleximeter, is laid upon the chest, and this is struck with the finger or hammer. An advantage in using the left finger as the pleximeter in mediate percussion, is that the vibrations of the chest can be felt at the same time that the sound is heard.

Percussion over the healthy lung elicits a sound, which varies in different parts of the chest, but which has the general characters of what is known as pulmonary resonance. It is rather a full and low-pitched note; it extends on the right side from just above the clavicle to the upper border of the sixth rib, over the whole of the sternum, on the left side from above the

clavicle to the upper border of the fourth rib internal to the nipple, and down to the sixth rib, where it passes into the resonance of the stomach. In the right lateral region it extends from the axilla to a horizontal line cutting the eighth rib in the mid-axillary line; on the left side the axillary resonance is limited below by the upper border of the ninth rib. Posteriorly, the chest is resonant from the apices to the lower border of the eleventh rib on the left side, and to its upper border on the right side. The resonance extends a finger's breadth lower than these limits on deep inspiration. The fullness and loudness of the note are most marked in the second intercostal spaces in front, and over the infra-scapular region behind. Over the clavicle and sternum it is less full, and of higher pitch; and over the supra-spinous fossæ the note is often deficient, especially in very muscular or fat people. Along the fifth right intercostal space corresponding to the liver along the third left intercostal space, and for a finger's breadth running vertically just within the left nipple, and along the eighth left space above the spleen, the percussion note is less resonant, and approaches the want of resonance below these levels: it is called transitional dullness.

The healthy percussion note is due to vibration of the chest-walls and of the columns of air in the lung beneath the point struck. The percussion note is variously modified in disease by alterations of the tissue of the lung. The intensity of the note is diminished by solidification of the lung substance. There is then said to be impairment of resonance, or dullness. The intensity is increased by the lung-tissue becoming more open in structure, and less finely spongy. This happens in emphysema, and the note is called hyper-resonant.

The pitch of the note is raised by an increase of tension in the chest-wall, by an increase of tension in the lung-tissue, and by a less length of the underlying air columns. It is of course lowered by the converse conditions. It frequently happens that diminution of intensity coincides with elevation of pitch, when the solidification of a portion of the lung shortens the columns of vibratile air under the part percussed.

A tympanitic or drum-like note is often obtained very similar to that which may be obtained by percussing the distended stomach. This is a purer note than the normal percussion-note, and is due to vibrations taking place in a single large unbroken space. It occurs over the large cavities of phthisis, and in pneumothorax, where one pleural cavity is distended with air. A somewhat similar note, but higher-pitched, is heard over the upper part of the lung in cases of pleuritic effusion occupying the lower half or two-thirds of the chest. It is known as Skodaic resonance, and is probably due to partial compression, relaxing the tissue of the lung, and thus giving it, so far as vibrations are concerned, some of the characters of a large continuous cavity.