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ON BEST AND PAIN. 



ON 



EEST AND PAIN: 



% Course ct S^crturcs 



ON THE INFLUENCE OF MECHANICAL AND PHYSIOLOGICAL 
REST IN THE TREATMENT OF ACCIDENTS AND 

SURGICAL DISEASES, 

Am) THX 

DIAGNOSTIC VALUE OF PAIN. 



DBLrVTBRBD AT THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 

In thb Years 1860, 18G1, jlnd 1862. 



JOHN HILTON, F.R.S., F.RC.S., 

8UB0E0N EXTRAOUDINAKT TO HEU MAJESTY THE QITEEN, CONSFT.TTNO RUROEON TO 
0UY*8 HOSPITAL, MEMBEK OP TUB COLLEGE COUNCIL, LATE PUESIDKNT OF 
THE KUYAL CoLLCGR Ol' SL'KGKONS OF ENGLAND, MEMBEK^ 
COUKT OF EXAMINERS, AND PUOFEiSBOK OF ANj ^ 
AMD bUKOERY, ETC., ETC., ETC. 



EDITED BY 



W. H. A. JACOBSON, F.R. 

ASSISTANT SURGEON TO GUY^S HOSFITAI.. 




This hook is the propoiy oj 

^J5ftg^ER MEDICAL COLLEftEt 

SAN FRANCISCO. CAL. 

aufi ii* not to he remorrd fros:^ fha 



NEW YORK : 
WILLIAM WOOD cfc COMPANT, 

27 Great Jones Street. 

1879. 



' 1 






PKEFACE. 



Teis first edition of these lectures was published, soon after their deliverj, 
at the express request of some who had read them as they appeared at 
intervals in the weekly journals, and by many others who desired to have 
them gathered into a separate form. The first edition, in which I had the 
kindly and liberal help of my personal friends, Dr. Daldy and Mr. Dur- 
ham, at that time Demonstrator of Anatomy at Guy's Hospital, was soon 
out of print. It was my intention at that time to have enlarged the 
volume by additional matter derived from other and different surgical 
diseases, but all having the same purpose in view — namely, tb show how 
largely we are indebted for our professional success in surgical practice to 
the recuperative power of Nature, especially when helped by the sug- 
gestions of a thoughtful surgeon. But, on carefully scrutinizing the 
materials, I foresaw what appeared to be insuperable difficulties; and 
since then, from one cause or another, I have allowed the reappearance 
of these lectures to be from time to time deferred. As, however, I have 
lately been assured, on repeated occasions, that a second edition would be 
welcome and useful to many, I have submitted the lectures to the careful 
and judicious editorial guidance of Mr. Jacobson, who has conferred on 
me a great obligation for the work he has now so well accomplished, with 
the slight aid of my own occasional assistance and supervision. 

It will give me great pleasure and satisfaction to know that the repub- 
lication of these lectures will be useful to the students at Guy's Hospital, 
where I emphatically taught by lectures, and demonstrated clinically in 
my wards, the therapeutic valae of mechanical and physiological rest in 
surgery. 

10 Nkw BaoAD Strxcx, 
SepUmS^ Itt^ 1876. 



EDITOB'S NOTE. 



Whbn I was asked, a few months ago, to undertake the editing of this 
book^ I agreed to do so in the hope that I might thus render a good ser- 
vice to students, more especially to those at Guy's. Two years' experi- 
ence of teaching in the dissecting-room has taught me that such a book 
might be pre-eminently useful to students, by proving to them, when 
engaged in the earlier drudgery of dissecting, how useful the dry facts of 
anatomy will surely be hereafter; and later on by encouraging them, 
when busy in the wards, to keep up their knowledge of anatomy by apply- 
ing to their practice the thoughtful lessons with which these pages 
abound. 

I avail myself of this opportunity to thank Mr. Wesley for the trouble 
which he has taken, both in drawing the new and in altering some of the 
old woodcuts. More would have been done in this direction had it not 
been thought of more importance that the price of the book should be 
materially, diminished. 

81 FntSBUBT Squabb, 
September^ \^^ 




LECTURE I. 



Tbe Influence of Natural ThempeulicH— Hest the Chief Nntnral Tberapeutio— 
Object of Pftin — lUst tlie Fosterer of Eteiiair— Hest Nacesaary foe the Ileoltby 
Action of an; Orgim — Meaoii Adupt«il by Kuturc to Secure a State of Quiea- 
cenoe to the Various Viscera 

LECTURE II. 

Dietribntion of Che Dora Muter — Extenuil and Internal Arachnoid in the Cnuiium 
and Vertebral Caual— Phyaiology of the Oerebro-S-jjiniil Fluid — Relation of 
Spina Bifida to the Carcihro-Spiaal Flaid— Danger of Drawing off all the 
Fluid— Clot of Blood Giving a Cart of the Third and Fourth VentricleB and 
Intervening; Spooes— Case of Occlnsiou of the Cerebro- Spinal Opening Accom- 
piuying Inleriuil HjdroccphaluH. 13 

LECTURE in. 

Fnnction of the Cerebro- Spinal Fluid in the FoDtoI Brain — Cane of OcolaHlon of 
the Cerebro- Bpinal Aperture — The Bruin after Goncuaaion a Bruised Organ — 
Comparison between a Braise of the Drain and that o( other Oi^qb — Long 
RestEa&entioi after Coueusslonof tbe Brain—NeKleotof this a Fertile Cause of 
Pormanont Brain Dittense— Symptoms uf L'nncuasiou of the Spinal Cord, and 
Treatment by Rest — Most of tbe Graver Operations of Surgery Performed for 
the Purpo»a of Allowing Natnr& Rest to Rcatore Injured Porta. 

LECTURE IV. 

Coagiilable Lymph a means for Securing Best to Inflamed Serous and Muoooa 
Membranua — Pain with Increase of Temperature a sign of Inflammatioa in 
the Part where it is Felt — Diai-noatio Value of Sjmpathetio Pain — Diaeaaa of 
tbe Vartehna Indiuated bj Pain over the Lower Part of Uie Abdomen and 
Pubes — Knowledge of tbe Aouurate Distribution of the Various Nerves to the 
Head and Ear, Leading to a Dingnosis of the Distant Dineaseii Organs oausing 
Sympathetio Pain in tliose Parts— Pain between the Shoulders on Indication 
of Visceral Disease—Pain over the Stoinach in tbe Region of the Cutaneous Dis- 
tribution of the Sixth and Seventh Dorsal Nerves a Sign of Vertebral UiHCOsa. SS 

LECTDRE V. 

Sjmmetricol SaperScinl Pains Indicate a Central, or Bilateral and TTnilateTal 
PainH a Ona-Sided. Cau^e — Cases of Diseased Spine with Symmotcical Abdom- 
inal Paine— With Poin on the Back of the Head — Poiu over the Loft Shoul- 
der and in Left Arm— With Loss of Power and Sensation in tbe Limbs— With 
Impending Death from Pressure on Spinal Marrow fnred by Rest— Fatal 
Cases— PortJons i>[ Athw and Axis Expelled by Post- Pharyngeal Ahscess — 
Anohylosis of both Tempore- Maitillary Articulations — Patient Surviving Four- 
teen Years after Injury to the Cervicol Vertebno Producing Paralysis of Up- 
per and Lower Estremities 51 



X CONTENTS. 

LECTURE VI. 

PAOX 

Abscesses Opened to Secure Goaptatioii to their Internal Surfaces, and to Permit 
their Union by giving them Rest — Principle Exemplified in Sub-Mammary, 
Knee-joint, Axillary, Orbital, Cervical, Post-Pharyn^eal, Iliac, Sub-Gluteal, 
Sub- Fascial, and Sub-Muscular Abscesses, together with the best Method of 
Opening an Abscess — Sinuses Cured by Rest — Treatment of Sub-Occipital, 
Cervical, Carbunculor, Popliteal, and Facial Sinuses — Cause and Treatment 
of Irritable Ulcers 69 

LECTURE VII. 

Case Showing the Danger of Opening an Abscess in the Thigh by a Lancet — 
Case of Sloughing of the Scalp — Sinuses Cured by Application of a Truss — 
Irritable Extremities of a Nerve in a Wound Relieved by Division of the 
Nerve — Ileadache and Intolerance of Light Cured by Physiological I^est — De- 
sign Manifested by the Same* Nerves Being Distributed to a iFoint and to the 
Muscular Apparatus Used for the Motion of the Joint — Application of this to 
Explain the Involuntaiy Flexure of an Inflamed Joint 87 

LECTURE Vin. 

Cutaneous Branch of the Musculo Spiral Nerve — Precision of Nervous Supply to 
Muscles — Symptoms of Intiamed Joints and Treatment by Rest and Exter- 
nal Anajsthetics — Examples of Physiological Rest — Musculo-Cutaneous Nerve 
of Upper Extremity — Bent Arm after Venesection — Cases of Injury to Mus- 
culo-Cutaneous Nerve — Nerves of Fingers, Toes, and Thumb — Effect of 
Pressure upon Spinal Nerves— QiLngrene of Third and Fourth Fingers from 
Pressure on Ulnar Nerve 101 

LECTURE IX. 

Pressure on Ulnar Nerve Producing Gangrene of the Third and Fourth Fing- 
ers — Furred Tongue on one Side Depending on a Decayed Tooth, Disease 
within the Cranium, and Fractured Base of the Skull— Decayed Molar 
Tooth Producing Gray Hair on the Temple — Excoriation of Auditory Canal 
and Enlarged Lymphatic Gland — Nervous Supply of the Wrist and Lower 
^ Extremities — Caune of Ulcers on the Legs being Frequently jupt above the 
Ankle — Distribution of Obturator Nerve — Cutaneous Nerves of the Knee — 
Explanation of Ilysterical Pains in the Hip- or Knee- joint 115 

LECTURE X. 

Muscular and Cutaneous Distribution of the Nerves of the Knee — Dislocation and 
Contraction in Diseases of Knee-joint — Treatment — Muscular and Cutaneous 
Distribution of the Gluteal Nerves — Order of Supply in the Distribution of 
Nerves to Different Muscles — Pain on One Side of Penis Depending on Disease 
of the Perineal Branch of the Inferior Gluteal Nerve — Enlarged Bursa on 
Tuberosity of Ischium— Helation of the Peritoneum to Cutaneous and Mus- 
cular Distribution of Nerves — Application to Practice — Relation, by Nervous 
Distribution, of the Pericardium to the Diaphragm. 131 

LECTURE XL 

Cataneous and Muscular Nerve Distribution in Relation to the Pleura — Applica- 
tion to the Treatment of Inflamed Pleura— Mechanical and Physiological Rest 
as applied to the Treatment of Pericarditis — Analogy between the Effusion of 
Lymph by a Serous Membrane and the Production of Callus in a Fracture — 
Swollen Joint a Means Taken by Nature to Procure Rest for the Part — 
Rest Illustrated in the Treatment, Natural and Avtificial, of Injury to the 
Eye — Nerve Distribution of the Mucous Membranes — Practical Application- 
Chronic Cystitis Relieved by Opium Inducing Physiological Rest — Other Ex- 
amples — Cure for Onanism 147 



^^^^^H^ CONIBNTS. ^~ 

^™^^^ LECTURE Xn. 

Irritfttion of Hacoos MembiuiB oF Crethra uid Vagint, — Comparative Insenribil- 
iC; of Upper Portiou of the Mnaous Meoibrnne of the Rectum, Ulastnited by 
Cmes of Cnncer, Vascular Gcowtb. and Overloaded Colon— Great SensibUity, 
DiiBcnlt DilatatioQ. and Eaduring Power of (.'Dntntctioi). the (.'haracteristica of 
Lower Portion of Reclom — Ulcera of tbe Itectoia Cured by Uecbaiiioal and 
Physioloj^ical Reft — AoatomiciU Relatinsa of the Norres, Mnsctes, uud Ha- 
cooB Membrane of Anus —Arterial Siipptv of the Reutiim — Arterial ABSooiation 
of vanoaa Parts of the Body— Eola^^ed Lympbatio Glands near the Eeo- 
tam — Sympathetic Paina Produced by An&l Ulceration — Dlviaion of Nerves 
and Haxualar Fibre in tJiese Cosea — Anal Ulcer Prodnciog Ret«nUoa of Urine 
and Symptoms of Pregnancy (.'ured by Dividing tbii Sphincter — Anal Uloera- 
taon Treat«d by Diviaon of Sphinoter— Inteet^n&lObHtruution Treated by Me- 
cdianical and Physiological Eeiit . 101 

LECTURE Sin. 
Many Diaeasea of Joints Attributed to Scrofnla tbe Besult of Accident— Case of 
IM^enao uf the Knee- and Hip-jointa on tha same Side— Knee Amputatod — 
Fyamia Joint* In flaromations after Fevers— Hip -joint Cured by Bent- Dis- 
eased Joints Keqnire a Long Time for Core — Joints Protected from Injury 
or Over-eierljon generally Free from DciieniiB — The Coeto- Vertebral Articnla- 
tioDB an Example of tbis — Pelvic Articulations — Diseased Joints more Fro- 
qnont in the Lower than the U])ptr Extremities — Diaoasdof Outer Side of Foot 
more Frequent than Innpr— Healthy Joints not Likely to Deteriorate from 
Rest — Foot of a (^inese L!tdy^DiaeB«ea of Joints MndiQed by Age — Orating 
Bannation in a Joint before Cure by Anchylosis- Peculiar Coarse Followed by 
Diseasea of the Joints in OMldren.. "ITT 

LECTURE XIV. 
Hip-joint Disease not Necessarny Scrofulous — ^Importance of Diagnodnr Hip- 
joint Disease in au Early ^tnge — Distribution of Nerves to the Hip-jo!nt — 
BarlieHt Symptoms of Hip-joint Disease — Disease of t^boulder- joint not Kept 
at Hest. Joint Destroyed ; Tlipjuint DisGaee in tbe Same Patient Cur^ by 
Best — Dwarfed Pelvis as a Iteaiilt of Hip-joint Disease- Diseased Hip-joint 
Cured by Five Months' Rest — Another Case of Twelve Months' Standing: Cured 
by Seven Months' Rest— Hip DiaeniK in a Scrofulons Patient Cnred by Rest — 
Drseawd Hip-joint, Limb Bent, Straighten vd Under Influence of Cbtoroform, 
and Cured by Rest— Dialocatiou on Dorsum Till from Disease Reduced, Ancliy- 
losi; Proceeding — Similar Cose, Dialocation Twice Reduced 491 

LECTURE XV. 
Dislocation of Rigfat Pemnr ; Hedncod Two Months aft^nvBrds ; Death from Py- 
emia — Hip Disease Bupposed to bo Korofulous cured by Anchjloeis after 
Heat ; Xo DiHtinot, Alwce^s-Hip nia- i.iq io a Phthinical Patient cured by An- 
chylosis ; Abaci^HH nlimirbBd -Di.i'.ni-iflion of the Propriety of opening Abscesses 
connected wilb Di>'Hii.'<':d Juintt — llip Dlieas'* ; Bony AncbylosiR; 0|iening 
of Abaeoss deferreJ ; Recovery — Chronic Abscess absorheii^Absoeas in Dor- 
Mkl H^on absorbed — Disease of Hip-joiut; Anchylosis and Lur)^ Absceea 
Kbaorbad- Diseased Hip-jmnt, with Snppuiation of the Left Bide cnred by 
Four Months' Rest; Abscess absorbed — Diseased Hip- joint, snppoaed to be 
OonoTrbmnl I Abscess opened by Nattire; Portions of Bone extruded by 
OiULulations ; Cured by Rest, with Permanent Anchylosis Sll 

LECTURE XVL 
Hip-Joint Disease; No known Anaident ; Seqnel to Scarlet Fever; cored by An- 
obyiosiH, after a few months of Rpst^Loeal Affcntions after snch Diseases 
as Scallatiua. Meaoles, etc., arise from Previously Unhealthy Structures Snf- 
fering Rapid DeterioraSon from the Effect o( the Conntittitional Disturb- 
ance—Two Cases in IllusCration- Disciued Hip-JoinC. with N'ecrosLfl of Aoe- 
tabnlam, Cured by Rent — Hip Joint Disease— Anchylosis, vrith Thigh some- 



^^^ teb 



XU CONTENTS. 

pAom 
what Bent— Oaaea Simnlating Hip-Joint Disease Dne to Deficient Nervous 
Influence; Treatment — Curved Sacrum, Causing Outlying Symptoms of Hip- 
Joint Disease — Congenital Malposition of both Hip-Joints — Congenital Defi- 
ciency of Delopment of one Lower Extremity Resulting in its being Shorter 
than its Fellow ; Effects of this — Diseases of Sacro-Iliac Joints — Disease of 
r the last Lumbar Vertebra Simulating that of the Hip- Joint — Severe Disease 
of Spine close to Pelvis Cured by Best — Disease between Sacrum and Ilium, 
with Intense Pain in the Leg of the same side 328 

LECTURE XVII. 

Saoro-Iliao Disease in a Boy aged Five, cured by Mechanical Rest — Sacro-Iliac 
Disease in a Man of Forty-two, cured by Rest — Sacro-Iliac Disease in the 
Left Side after Parturition ; Suppuration within the Pelvis, Abscess Ab- 
sorbed, cured by Rest — Disease of the Sacro-coocygcal Joint, from Injury, 
cured by Rest — Inflammation of the Coccygeal Joints, from Injury, cured 
by Rest — Pain in the Posterior Portion of tiie Coccyx in Hysteric^ Cases, 
IbEplanation of — Case of Non-Development of both Patellae up to the Age 
of Three and a Half Tears — Disease of Knee- Joint Scrofulous ?) Treated 
by Mechanical Rest, cured by Firm Bony Consolidation — Diseased Knee- 
Joint, from Injury, with Partial Caries or Necrosis of the Patella, cured 
by Rest — Traumatic Dislocation of the Tibia, treated by Rest and Applica- 
tion of Cold-^Wounds Penetrating the Knee-Joint treated by Cold and Best — 
Disease between the Shaft and Lower Epiphysis of the Femur — Disease of 
Knee-Joint ; Biceps Divided and Limb Straightened — Old Disease of Knee- 
joint; FlezoiB Divided — Treatment of Loose Cartilage in Knee-Joint by Rest, 248 

LECTURE XVIIL 

Strnmons Disease of both Elbow-joints ; Joints well Anchylosed, bnt in bad Posi- 
tions — Disease of the Wrist cured by Rest — Case of Rupture of the Ligamen- 
tum Patella; at the Junction of the Ligament with the Patella — Disease of 
the Cuboid and Os Calcis; Diseased Bone removed; New Bone formed; 
Cure aided by ^* Mechanical Rest^* — Disease of the Os Calcis; Bone re- 
moved; Bone renewed — Disease of the Epiphysis of the Os Calcis — Distri- 
bution of Third and Fourth Cervical and First Dorsal Nerves to Upper Por- 
tion of the Chest — Disease of Right Stemo-clavicular Joint, cured by Rest — 
Suppuration in Left Stemo-clavicular Joint, opened by Ulceration, cured 
by Rest — Disease of Right Stemo-clavicular Joint, produced by Forcible 
Traction ; Death from Pyasmia — Disease between First and Second Portions 
of the Sternum, cured by Rest — Effect of Muscular Exhaustion on the Joints 
of the Foot — Inflammation of Right Ankle-joint and Foot; Suppuration; 
Dislocation of the Foot ; Cured by Rest — Injury to Soft Structure uniting 
Shaft of the Tibia to its Lower Epiphysis; Ostitis; Sub-periosteal Suppura- 
tion ; Death in Twelve Days— Conclusion 269 

APPENDIX. 

Case of Dislocation of both Thigh-bones from Disease of the Hip-joints ; one Fe- 
mur being displaced on to the Dorsum Uii, near to the Ischiatio Notch ; the 
other dislocated downwards, below the level of the Acetabulum, and close to 
the Foramen Ovale 289 



COOrER MEDICAL COLLEGE. 

ShN FRANCISCO. OAU 

Ohfi ?.• not to fee rwiio'-'-ti /'■("«• '^ 
hh>-"r<i Re- A hi/ t'}<;i pmoii or 

'' ON nhi 

THERAPEUTIC INFLUENCE OE REST 



k 



DIAGNOSTIC VALUE OP PAIN 



ACCIDENTS AND SURGICAL DISEASEa 



LECTURE t 



L 



Thelnflnenceof NntnrftlTherapentioi— Rent the Chief NatarJ Therapentio— Obi«it 
of Pdin— Rest the Foslerar o( Repair — Beat NecesBary for Ihe MeaJtby Action of 
an; Orgnn— Means Adopted b; Nutore to Secure a State ot QoieBueuiw to the 
Various Viscera. 

Me. Prkbideut axd Gentlehes, — There are duties which are difficult of 
fulfilment pertaining to every position in life; and there are duties attached 
to public professional life, from whicli no man can assume to himself the 
right to shrink, with whatever diindence and feeling of incapacity they 
may be undertaken. In this duteous but self -mistrustful spirit I have 
ventured to accept, at the request of my colleagues in the Council of this 
College, this Professorial appointment — this, in my estimation, highly 
boiiorable appointment— the requirements of which I must now proceed 
to carry out as best I tan. To this end it is desirable to set out with a 
clear conception of its objects and intentions. I conceive that the insti- 
tution ot these lectures was based — firstly, on the wise recognition of the 
fact that there is much in surgery which cannot be systematized — t.e, 
which cannot be conveyed from mind to mind in books, in systematic 
treatises — I had almost said, which cannot be given clinically, because 
the necessary grouping of like cases rarely accompanies clinical opportu- 
nities; secondly, on a natural anticipation of the progressive stops which 
might bo foreseen in a scientiiic art cultivated with such intelligence, such 
laboriotia activity, and such an abundant supply of husbandmen as the 
present century has produced; and thirdly, on the opinion that amon^ 
those who hod been actively engaged for a long period in extensive hospi- 
tal practice would be found a fitting exponent of surgical progress. 

This, gentlemen, is the conception I have adopted of the original Inten- 
tion of this College in instituting the short course of Lectures on Anatomy 
and Surgery which I have undertaken to deliver. How far I must fall 



2 ON THE THERAPEUTIC 

short of responding to that intention I need not to be reminded. But I 
feel convinced that the attainment of even mediocrity is best secured by 
planting a high standard before the mind, with the determination of 
approaching as near to it as one has strength to do. Nor need I seriously 
appeal to your indulgence for the manner of expressing my views. I am 
sure that many of my listeners will readily appreciate the J'acilis de8ce?i8tis 
by which an habitual lecturer to students, whom he ca?i presume to in- 
struct, may be betrayed into treating an audience, whose high reputa- 
tion and whose professional knowledge far exceed his own, as if he 
presumed to instruct them also. Nor is it necessary that I crave your 
consideration for my embarrassment in the selection of words and phrases 
appropriate to the ideas which I intend to convey. 

** Nam neque chorda sonum reddit, quern vnlt, maniis, et mens, 
Poscentique gravem penuepe remittit acatam ; 
Nee Bempei feriet qaodcanqae minabitur arcua.** 

But, gentlemen, phraseology and diction have been to me minor con- 
siderations in comparison with the anxiety of choosing a subject which 
would be fitting for hearers so distinguished in their profession. From 
time to time, you have listened with admiration to my predecessors in this 
chair, as they expounded to you the more recent advances in the pathology 
and diagnosis of the most important surgical diseases. Histology, gen- 
eral anatomy, and physiology have been so perfectly elaborated here as 
to bring under your attomtion their most recent discoveries; and it appeared 
to me that my forerunners had left to me, for the present, but one unoccu- 
pied department — namely, that of Therapeutics. By Therapeutics, how- 
ever, I do not mean to imply the action of drugs, which more especially 
belongs to the department of the physician ; but rather the influence of 
what I may venture to call " Natural Therapeutics " in the cure of surgi- 
cal diseases. The chief of these is one so apparently simple as to make 
me almost apologize to you for selecting it. It is Rest — Physiological as 
well as Mechanical Rest — which I hope to prove in the course of these 
lectures to be so important as to demand the very serious attention of 
every practical surgeon. 

Regarding this subject of Rest in its highest, closest, and best relation 
to mankind, and looking at it by the aid of my feeble penetration, I would, 
in all humility, remind you that when God ordained that man should live 
by " the sweat of his face," as a punishment for his disobedience, it pleased 
liim, in the plenitude of His unspeakable benevolence, to permit man's 
fatigue and temporary exhaustion to be followed by his greatest earthly 
solace, — the blessing of rest and repose, by calm and peaceful sleep; a 
blessing which should be the immediate reward of his labor. Nature 
devoting her best efforts, during this period of rest and sleep, to repair 
those powers which may have suffered exhaustion, to renovate the bodily 
strength, and to restore the mental vigor, mitigates man's punishment by 
a source of real and refreshing enjoyment, enabling him to resume his 
labor in all the delighful vigor of a renewed existence. 

Entertaining, as I do, the most exalted admiration of Nature's powers 
of repair, the thought has not unfrcquently occurred to my mind, when 
watching cases of extensive local injury, " What would have been the con-"" 
dition of man on earth, had it pleased the Creator to withhold from him,, 
this power of repairing his injured tissues ? " 

In my reflections on the subject of rest as a curative age7ity my mind 
naturally reverted to that period of man's existence when it was the sole 



IHTtUEirCB OT BEBT. 



^.5r 



curative means of which he could avail himself. I could but picture to 
myself the timorous awe which must have been engendered in his mind by 
the first accident which happened to him. Let us imagine our first par- 
ents suddenly thrust out of the gajden of Eden, and doomed to toil for 
their daily bread ; with hands unused to labor, inexperienced in the sub- 
stituted for unnecessary exertion and in the avoidance of local injury, 
and exposed to all the accidents of a precarious existence- ' ' 
realise the awe-stricken dismay which must have oppressed 
the infliction of his first wound, his first experience of pain , 
of surfiice disclosing to his si^ht his blood flowing unceasingly, or leaping 
at sustained intervals, from its opened chambers, his sense of fainting, 
aud hia ultimately sinking on the earth under the foretaste of denlh ; 
this, too, with the recent denunciation, " Thou shalt surely die," still ring- 
ing in his ears. Can words depict the hopeless anguish which he must have 
endured? But what follows? See him awakening to life again, the 
stream of blood stayed, the chasm plug^d, his strength revived, and day 
by day that wound — which he regarded as the badge of death, the venge- 
ance of the Creator's wrath— narrowing and healing till it could hardly 

1 have made these observations for the purpose of sho^ring the original 
promptings of Nature to man, for the aJlcviation of what must have 
necessarily befallen him in his altered oondition. Pain was made the 
prime agent. Under injury, pain suggested the necessity of, and, indeed, 
compelled him to seek for, rest. Every deviation from this necessary 
state of rest brought with it, through pain, the admonition that he was 
straying from the condition essential to his restoration. He must have 
observed with astonishment the breaking asunder of the newly formed 
tissue or the steady development into normal structure, which occurred in 
exact accordance with the disturbance or rest to the parts which the 
sense of pain had enublcd him to regulate so accurately, and to employ 
so beneficially for his own personal relief And comfort. 

That the Lord of all should have implanted in man, beyond the en- 
dowments which enable him to sustain his existence under the punish- 
ment of labor and the vicissitudes of hia daily life, a recuperative power 
from the accidents and mischances of his precarious existence, appears to 
me to supply an evidence of His merciful and unspeakable love, too 
lightly cfnisidered. 

But I must not lose sight of the immediate object of my lecture. I 
will, therefore, now proceed to the subjects of growth and repair. 

Growth is the antitype of repair, prefiguring the physiological capabil- 
ities of existing structures to repair themselves. Without digression, I 
may say that so Intimate is the association between rest and growth as to 
make them appear, on a superficial view, to stand to each other in the 
TVilation of cause and effect. Accurate observation of the animal and 
vegetable world certainly reveals their perpetual coexistence ; and growth, 
as a, rule, seema to prtxiecd, pari pas^i, with physiological rest. 

Mr. Ward* says : " All plants require rest, and obtain it, in some 
countries, by the rigor of winter ; in others, by the scorching heat of 
mimmer. Cultivators often fail in their attempts to grow certain plants 
from want of attention to this essential point. Thus most Alpine plants, 
which enjoy an unbroken rest under the snow for several months, are 
very difficult of culture in our mild and varying winters. 

■ Oa the Qrowtb of Flouts in Closeiy-glaxed Cases, p. U. 



I 



4 OW THE THBR&PXVTIO V 

"The winter of 1850-51 was ushered in by some heavy falls of snow, 
with which I filled my Alpine case, giviiie the plants a perfeot rest of i 
thtee or four months, and with a most satisfactory result ; the J^midtt \ 
marginata, Linnixa horealit, and other species, flowering much finer than 
usual. Many of these beautiful plants would, 1 am convinced, succeed 
well, if kept for five or six months in an ice-house, , 

** Plants, in hot countries, hftve their periods of rest in the dry season. ' 
In E^ypt, the blue water-lily obtains rest in a curious way. This plant 
abounds in several of the canals at Alexandria, which, at certain seasons, 
become dry ; and the beds of these canals, which quickly become burnt i 
u hard as bricks by the action of the sun, are then used as carriage roads, i 
When the water is again admitted, the plant resumes its growth with J 
redoubled vigor." ' 

Our great master in physiology, John Hunter, has not left this field 
vneKplored, for we find, not only in his published works, hut in others 
which remain in manuscript, that the subject of rest occupied no incon- { 
Mderable portion of his attention. " Most plants," says he, " have their 
periods of growth and periods of rest. 

" Some plants close their leaves, others their flowers, at particular 
boura of the day or night ; and with such regularity does this period ot < 
rest take place, that more than one vegetable physiologist has proposed ^ 
to construct from them a floral clock." i 

We all know how eagerly rest is sought for hy the lower animals, I 
especially in periods of suffering from injury or disease — how they en- 
deavor to escape from the prying curiosity of man in order that the injury \ 
may be the more speedily repaired. 

The value of rest in fostering the production of that highly organized 
animal tissue which forms so large a portion of our staple food is well 
known to the stock-keeper and grazier. A homely illustration may he 
found in the fact that in infanoy the child who sleeps much mostly thrives. 
Miif(if!» mvtandia, the observation is equally true, that the wakeful, rest- 
less child seldom displays the evidence of active nutrition. Doubtless all i 
will admit that in infancy development is in its highest state of activity, f 
and that the healthy infant passes the greater portion of its life in a 
state of rest and sleep. Growth — the renewal of some parts, and the 
fresh development of others — seems thus to claim sleep and rest a 
helpmates. 

Thus far I have endeavored very briefly to point out the relation of 
rest to growth. I would now say a few words regarding the relation 
of rest to repair. 

Repair is but the repetition of growth. The same elements, the e 
kindred conditions, are necessary to the same results. Rest is the ne 
■ary antecedent to the healthy accomplishment of both repair and growth. 
This surely is the natural suggestion of a means towards an end which 
riioutd never be lost sight of by the phj-Kician or surgeon. For example, 
children who are ill and lose their rest waste very rapidly, more rapidly 
in proportion than older people; but as soon as the morbid condition sub- 
sides, and rest asserts its power, the recovery or repair becomes extremely 
active, accompanied by an increased tendency to sleep; sleep supplying 
the great desideratum previously required. 

Take, for example, the case of a child suffering greatly from the irrita- 
tion of stone in the" bladder, which prevents sleep, induces sometimes 
extreme emaciation, and urges the child even to the verge of death. How i 
marked, how almost immediate is the change on the removal of the stone 1 



INFLUENCE OF BEST. 5 

(hi giving rest to the bladder, and consequent constitutional rest to the 
generul Bystem, the child falls into a profound and prolonged sleep.* 

In principle, the same remarks atid the same reasons would apply to 
cases of extreme dyspiiiiea relieved by the operation of tracheotomy, of 
strangul&ted hernia after the reduction by taxis or the knife, or to the 
removal of an extranecrus body from the auditory canal. In these and 
in many other instances which might be adduced, the relief afforded by the 
surgeon is often followed in children by long and highly restorative ^eep. 

The interruption of rest by local disease, occurring to persons in the 
middle period of life, does not cause the same degree of exhaustion and 
wasting as in the young. They bear the loss of sleep better, because their 
constitution has to sustain the stress of repair only — not of both develop- 
ment and repair, as in the child. Their recovery is slower ; their subse- 
?uent sleep is not so profound nor so prolonged, nor their rest so complete, 
'he defective sleep and slow repair which manifest themselves in the old 
after injury of any kind are familiar to us all. 

What I have here endeavored to inculcate is, that growth and repair 
bear an exact relation to due physiological rest, local and general. 

Although it is, I believe, impossible to explaiji what are the delicate 
elaborations which are associated with repair and growth {those marvellous 
renewals of life and strength resulting from repose and rest), I need not 
insist upon their obviously beneficial and constant ministration to the exi- 
gencies, emergencies, &nA necessities of man's life on earth. Practically, 
the maximum of result is co-equal with the minimum of disturbance. 
Thus rest becomes the great fosterer of repair. 

Let me employ a familiar example to illustrate the effect on the brain 
of rest, by referring to any overworked member of our own profession at 
the end of the London season. Free from structural disease, but worn, 
and appearing prematurely old from exhaustion by mental labor, not phy- 
sical exertion, lie takes his holiday. His rest from professional duties 
consists in riding, walking, fishing, or shooting. It is physical exertion 
and corporeal work which he selects for his relaxation; but during the 
same period he carefully excludes all mental worry. Now, I apprehend 
that under these circumstances some parts of his brain are nearly at rest; 
others are occupied with their appropriate function of superintending and 
regulating muscular exertion. He is, in tact, calling into activity the 
latent or suspended function of the cerebral centres, leaving the higher, 
the intellectual part of the brain, to work out its own recovery from over- 
fatigue or exhaustion by rest — that is, by freedom from its own peculiar 
function or occupation. After a time he returns completely invigorated, 
improved in general appearance, active, and full of mental vigor, and equal 
to the resumption of almost any amount of renewed professional exer- 
tion, without fatigue to his brain. 

I may adduce this additional remark regarding the beneficial influence 
of rest, that those persons who drop off to sleep quickly, anyhow or any- 
where, and sleep soundly, undisturbed by active dreaming, are, cwleris 
paribtts, capable of sustaining a greater amount of mental and corpore^ 
exertion than those who find it difficult " to get off to sleep" — who sleep 
lightly, and, dreaming much, awake but little refreshed. 

* For some inteteatiu^ information (gathered cbieflyat the Childreu'i HOBpit«l) on 
lbs risks of opcraciodg in ohildboud, and more particalajlf, aa bearing upon the 
pre»eiit (loiut, for an account oF ivro coaea of litbotom.y in fcry exlisuated chil'lreti. 
~ reader sboiild refer to tbe BrHC note whicb Mr. Howard Marsli baa appended ta 
Clin. I.eot. ami EauyB by Sir J. Paget, ol which he is the e^wa.^^^A 



I 

I 

I 



■ Ua read 

Mm 



6 ON THE THEE APEtTTIO 

Bearing on this subject, I, like others of our profession, have had re- 
peatcd occasion to observe the effect of overwork on gentlemen who use 
their brains with an expenditure of energy inconceivable to the heedless 
or thoughtless multitude — men o{ widespread mercantile affairs — men 
occupied with important calculations, engaged in money transactions oa I 
a large and anxious scale. The condition of such patients attested th*^ 
applicability of these remarks by their mental and physical exhaustion, 9 
by their depression of spirits, and by their want of self-confidence. Yet, • 
with such men, the restoration to health has been made complete by men- 
tal leisure, by " going out of town," and taking plenty of exercise in the 
open air, but abstaining from the real disturbing cause, their business. 

In order to give some additional practical interest to this subject, in i 
reference to cases of more decided mental disturbance from overwork at't 
[nay be permitted to read this note from my friend. Dr. Hooc^.J 
a Hospital : — 



of Bethlebet 



"March 2a, ISeO. 

"Mt dear Sib, — In reply to your inquiries, I may state that I am 
frequently applied to for the admission of lunatics into this hospital, whose I 
insanity is caused by over-mental work, anxiety, or exertion, and for \ 
whose cases nothing is required to restore the mental equilibrium 
Therapeutical measures are not necessary; all the mind seems to 
entire repose. I do not by this meati to imply that the patient reduced 
to a stale of nervous hypochondriasis, or the depression of melancholia, is 
to lead an indolent life. Such a course would only aggravate the disease, 
and probably result in complete dementia; but that those faculties which 
have been overstretched should have an opportunity of regaining their ■ 
elasticity by rest and relaxation. For example, an accountant, whose^ 
whole day is spent in calculation and thought, becomes by overwork e 
mentally fatigued that he is incapable of working out with accuracy t 
most simple sum in arithmetic Sensible of his incapacity, which perhaps 1 
may result in the loss of his situation, and with poverty then staring him | 
in the face, he becomes melancholic, and medical advice is sought, 
physical functions are healthy; no medicine is required or taken, t 
holiday from the counting-house, freedom from all thought and anxiety, 
the substitution of amusement for labor, restores his mind to a healthy 
state, and he returns to business as competent as he ever was. I have ii 
under my care a man who for some years past has beeji subject to oc 
sional attacks of melancholia. He is occupied as a compositor, and, being 
both a clever and trustworthy man, is constantly employed. He works 
early and late for many consecutive hours, and for some months all goes 
on well; but the stretch on the mind ultimately causes a break-down, 
from which he cannot rally, unless he leaves his business for a month or 
six weeks, and takes a complete holiday. He tells me that the cause of 
his mental suffering is from concentration of thought, and that rest re- 
moves the weight and agony of melancholia. In a word, he takes a 
month's holiday, engages in no occupation requiring thought or bringing 
with it anxiety, and returns to his duties with the mind of a young man. 
Some people may reply, 'This is not rest; it is only a change of employ- 
ment.' I maintain it is perfect rest to the faculty which has been over- 
worked. Of course we do not propose that the whole mind should r 
fallow, but that the pressure should be removed from the particular part 
which is fatigued. 

"I could give you many illustrations from the wards of this hosiiita^ 



INFLt'ENCE OF REST. 

where we are called upon to treut mental tj) mptoms in 
esses, students, clerks and clergymen; and rest i; 
with tliaC the most aggravated eases are restored/' 

Having thus very briefly and very imperfectly reviewed the subject of 
rest in relation to the body generally, let us i]ic:|iiiro into some of the 
expedients which Nature adapts to the same end in its individual nrgans. 

AH viscera (as in the case of the brain, to which I have already alluded) 
require the alternate condition of activity and rest to keep them vigorous 
and in health. If this condition be not observed or attended to, struc- 
tural changes and deterioration of function are sure to follow. Indeed, in 
reference to the etiology of the disea^ses of individual organs, it iiiay be 
asserted that a large proportion of these diseases originates iu circuui- 
staiices which deprive the organ of that rest which Nature has rendered 
necessary for the performance of its healthy function. 

For example, the heart, overtasked by constant emotional influences, 
or excessive athletic eicerciaes, and thus deprived of its appropriate rest, 
becomes prone to the various alterations in its structures, which post-mor- 
tem examinations daily reveal. The liver, unduly stimulated by excessive 
potations, by an unnecessary amount of food, or by habitual irregularity 
of diet (its physiological harmony with the other organs of digestion being 
thus constantly disturbed), glides into disorganization for the same reason. 
The kidney, too, if its function be disturbed by the abuse of alcoholic 
Liid other fermented drinks, which entails an unnatural and continued 



stress either upon its Malpighian or tubular portions, obeys the same tend- 
ency to structural deterioration, as a consequence of its loss of ' 
How different is the effect of rest upon any machinery i 



I 

I state ot pnysioiogicoi excitement or orgasm Degins to aiininisii. ine ^^M 

1 *TheT 

I its prope 

■ structure 

■ in their i 



constructed by man! How utterly abandoned is the expectation of man's 
ever contriving any machinery that shall have the power to repair its own 
waste of structure, or to renovate, by its own power, any defect in its 
combination! However perfect it may appear to be, its "wear and tear" 
is simultaneous with its mechanical activity. Rest even exaggerates its 
imperfections, and induces decay. Its necessary renewal is tJie substitu- 
tion, by other hands, of a new and like material. 

It is, I believe, an admitted physiological axiom, that each structure 
or organ, whilst actively employed, is in a state of vascular excitement or 
tuivescence, and therefore enlarged during that time. 

So it is noticeable that each organ of the body, which is liable to the 
ntpid supervention of activity in its proper function, is so placed in rela- 
tion to surrounding structures as to permit of temporary enlargement 
during the persistence of its exalted function. When it returns to its 
state of rest, or period of self- reparation, it may be said to have resumed 
its normal or standard dimensions. 

Secreting organs, in some of which vascular turgescence is extreme 
and prolonged, are relieved of their excessive congestion by their tubular 
outlets. The elasticity of the enclosing capsule exerts its beneficial effect 
towards the same end by inducing centripetal pressure, and this tends 
' ) diminish the size of the organ as soon as, its function performed^ its 
"•"i of physiological excitement or orgasm begins to diminisli. The 
.ic capsule thus maintains the healthy quiescent size of the organ. 

The liver is enclosed within a strong elastic peritoneum, and it has also 
8 proper elastic but thin capsule; a*id I may add, as probable, that the 
structure found in GUsson's capsule, surrounding the portal vessels, &c., 
'i their distribution witbiu the Uver, may influence their coudition by its 



8 



ON THK THERAPEUTIC 



elasticity. These forces, aided by the coiitrm.-tJlo poivi-r of tiie blood- 
vessels themselves, bring the liver hack to und niaiiituiri it in its condition 
of restj thus allowing' the individual minute secreting parts to recover 
their ph^siologictil strength and their tone. 

Again, the liver is so placed as to have the additional advantage o£ 
pressure from without, by its subjection to the contractile power of tha i 
muscular walls of the abdouiinal pajietes and the diaphra^, espeoiaJly 1 
during exercise and active respiration. This no doubt cxplams the benefit 1 
of walking exercise, in eases of congested or torpid liver, at which tima j 
the liver is compressed between the diaphragm and tile respiratory part j 
or upper half of the abdominal parietea. 1 would here ask you to observe | 
the effect of forced rest, or the absence of this pressure upon the liver, in 
r&ses of accident which necessitate the recumbent position, and induoe j 
congestion of the liver and jaundice. For example; we see a patient i 
good health suddenly placed upon his back by the fracture of a leg, the I 
local injury being confined entirely^ to the leg. The fracture goes on well, ] 
but the patient in a few daj-s is jaundiced, without much constitutional j 
disturbance. A moderate diet and a few doses of blue-pill with saline J 
purgatives soon dispose of the jaundice, and thenceforvfard everythin^^ 
proceeds healthily. 1 believe the congested liver, which leads to tha 
jaundice, results from the forced rest to which the liver is subjected by 
the recumbent position : the circulation through the organ up to the period 
of the accident having been aided by active respiration and ordinary ex- 
^^reiBe. The withdrawal of these aids leads to congestion of the liver, and 
thence to jaundice. The same kind of congestion of the lungs at their 
bases and posterior obtuse margins may, and frequently does, take place 
under the influence of difficult and inefficient respiration, dependent upon 
the difficulty of moving the posterior porietea of the chest while the patient ' 
is in tlie horizontal posture. The circulation through those parts of the | 
lun^ is not completed; and as the quantity of blood circulating, up to the I 
period of the accident, was adapted to a free and complete respiration, this 
want of balance between the area of respiration and the quantity of blood 
circulating, causes pulmonary congestion ond pneumonia. We see this 
fact exemplified when the patient is compelled to lie on one side, which, 
by interfering with the mobility of the thoracic parietes of that side, 
causes congestive pneumonia on that side only. I have repeatedly ob- 
' served this one-sided pneumonia disclosed at the post-mortem table, asso- 
ciated with lateral posture of the patient during life. The duty of the 
surgeon is to reduce the quantity of the circulating fluid by purgatives 
and diaphoretics, if practicable, and to allow the patient to sit, so that tha 
chest may be as little as possible encumbered hy position. No doubt it 
was the fata! effects upon the lungs and liver, which local and remote ai 
dents seemed to produce, which induced our forefathers to " let blood " 
in almost everj- kind of accident which compelled the patient to keep quiet, 
or eonfined him to bed. 

The spleen has a strong elastic capsule, and also an internal network 
of highly elastic* tissue, so that the interior of the organ may, ^ 

* In addition to the elastia flbres epaken of above, tlio presenoe rif iavntniitsiy 
mUBCulnr fibies in the capsule of Ibia Dtg]Ui. which, from it>« dose relation to the i'' 
tive function, is coDstimtlf liable to coDsiderable variations in siie, Hhowa nti ck. 
pToviaion for providing the spleen with r^st. The eiiatenou of these iiUras. thoagh 
disputed in nmn (W. Sluller and Uuleu offirming, while otbera, as Gray and KoUiker, 
deny or doulit their iiresonc-e). has bpen deroonstmted ia the capaule and traheoulas of 
the cpteon ut uuu>y uf tiio unuumjiin, notably tha rumlniuiU wid cLu pig. Their 



^H INFLUENCE OF EK3T. f 

necessary, be compressed, and its gorged condition reduced to comparative 

The kidneys also possess a strong elastic capsule for the same purpose, 
&nd arc also subjected to pressure by the weight of the superimposed colon. 

The tunica albuginea, which surrounds the testicle, tends in like man- 
ner to empty that organ, and to give it rest. 

TJie lungs are extremely elastic: this elastic property aiding, without 
muscular force, the return of the lung to a state of rest or quietude after 
full inspirations which fill the lungs with air. I may here remark, that it 
is proved by the preparations before me, that the lungs have a very definite 
form, which adapts them, in their extremest healthy distention, to the sur- 
rounding structures, without encroaching upon any of them. Thus we find 
the lung especially grooved or hollowed out, to allow the cavse, descending 
aorta, artena iniiominata, and left subclavian artery to pursue their courses 
without hindrance. The following is the plan I adopted successfully, 
more than twenty years ago, for the purpose of injecting the human lungs 
so as to display the exact configuration of their surfaces: — 

Remove the lungs and trachea carefully from the body without any 
laceration of their structures. Suspend the lungs in a pail or small tub 
(large enough to allow of their full ex pansion) containing water sulfi^^iently 
not to maintain melted tallow in a fluid state. Introduce a large tube 
into the trachea, and pour warm fluid tallow slowly through the tube until 
the lungs appear full; then leave them for a short time submerged in tho 
water, hot enough to keep the tallow within the lungs in a state of duid- 
ity. The air in the cells of the lungs will gradually rise and find its way 
out through the tube in the trachea, thus making space for the introduc- 
tion of more melted tallow. This method of proceeding must be repeated 
at intervals in the same slow and gentle manner until the whole interior 
of the luri^ and trachea is filled with fluid tallow. The lungs are then to 
be immersed in tepid, and subsequently la cold, water, until the tallow 
becomes quite firm. Preparations naade in this manner can be preserved 
for many years. 

One of the largest and the most remarkable excavations noticeable on 
the right lung is found at the base of the middle lobe. This excavation 
corresponds with, or receives, the right side of the right auricle of the 
heart; but for this the right auricle, when distended with blood, as it 
frequently is, would be pressed upon by the base of the wedge-shaped 
mass of lung which is termed the third lobe. Another advantage of 
this arrangement In, that the right auricle, thus distended, exerts ita 
mechanical influence upon a small portion of lung, which yields, and 
permits its distention. It is probable that thia fact constitutes one o( 
the reasons for the existence of a third lobe in the right lung; and it ta 
worthy of thia additional remark, that this third lobe is wedge-shaped, a 
mechanical form seldom employed in the construction of the human body. 
This wedge-force is the most powerful mechanical force which can be era- 
ployed; and, being interposed between the upper and lower lobe, is com- 
petent to sejiarato them from each other, and from the middle mediasti- 
num containing the heart, &c. The preparution which I now present to 
you demonstrates the anatomical relation of the right auricle and the base 
of the middle lobe of the right lung which I have just described. 

•baadBiice in the apleen of these snimoU. msf . I think, be e 
anil BDililen iat«rruptions to which the digej^tivo funotiou mot 
mode of life, be iinbjeot iu tJiesa amuiiiU. — [So.] 



I 



Quitting this digreasion re^rdinjr the surFaoe anntomy of tlie lungs, 
1 would observe, that if the views which I have advanced in relation to 
Nature's expedients to procure mechanical rest be true in their anatoin,v 
and sound in their physiology, as applied to the thoracic and abdomtniil 
visoora, they must also bo true of the brain. This suggests the intention 
of the interstices between the convolutions and other sinuosities and 
spaces on the surface of the cerebrum, and assig^is a probable reason for 
the existence and position of the ventricles of the brain. 

One of the purposes of the lateral ventricles is to allow room for tlie 
accumulation of venous blood in the plexus choroides during a state of 
general cerebral congestion, as in s.ustained inspiration. The cerebro- 
spinal fluid within the ventricle supports the blood-vessels, and so prevents 
Ineir rupture. Mr. Quekett tells me that any attempt to inject the plexus 
choroides, except la a liquid medium, is sure to cause rupture of the 
blood-vessels. 

In order to point out the parallelism, in this respect, between the 
mechanical appliances made use of in the cerebral circulation, and the 
like influence in the capsular organs within the chest and abdomen, let 
UB consider the relation of some of tlic deep, enclosed, and internal parts 
of the brain. 

For instance, the corpus striatum and thalamus opticus are placed witJ)- 
in the cerebrum, and project into the lateral ventricles. These parts super- 
intend the movement and sensibility of the upper and lower extremities. 

The completed brain, being enclosed within a solid case with unyield- 




ing walls, admits of no possibility of eccentric enlargement. If parts or 
organs liable to sudden or prolonged calls upon their function were placed 
within and surrounded by solid brain, they could not enlarge, except by 
pressure or encroachment upon some other parts, without creating mis- 
chief; they could not, in fact, be obedient to that general principle in 
physiology which I have mentioned. 



INFLUBNOE OF BEST. 11 

This increase in dimension of the parts forming the floor of the lateral 
ventricles is permitted, however, towards the interior of the ventricles, 
by the cerebro-spinal fluid receding through the foramina of Monro, third 
ventricle, aqueduct of Sylvius, and fourth ventricle, and thence through 
the cerebro-spinal opening in the lower part of the fourth ventricle to 
the base of the brain or sub-cerebral spaces, and so into the vertebral 
canaL As the local hypersemia of the blood-vessels in the thalamus, 
corpus striatum, &c., subsides, the cerebro-spinal fluid rises into the ven- 
tricles, and makes a properly-adapted pressure upon the corpus striatum 
and thalamus, reducing them to their size of inactivity, and sustaining 
them in a state of rest ; the cerebro-spinal fluid in this respect serving 
the analogous purpose of the elastic capsule pt the liver, kidney, and 
spleen. 



ON THE TUEUAPEUTIC 



LECTURE II. 

Diitribatioii of the Dara MatCT— Extemnl and InterDo.! Arachnoid in the Craaium and 
Vertebral Canal — Physiology of the Cerehro- spinal Fluid^Relation of Spitm Bifida 
to the Cerobro- Spinal Flajd — Danger of Drawing off all the Fluid — Clot of 
Blood Giving a Caet of the Third and Fourth Ventricles and Intervening S]>aL'e8 — 
Case of OcclonoQ of the Ceiebro-SpimJ Openiii); Aocompiuiyiug Internal Hjdro- 

1n my last lecture I endeavored to illustr&te the mechanical means 
employed by Nature to reduce organs aiter tfaey have been in a state of 
physiological exdtement or turgeacence, white performing their appro 
priate functions, to the proportions natural to their state of rest. The 
examples to which I particularly referreti were selected from the liver, the 
Bj>le«n, the testicle, and other organs ; and 1 was on the point of showing 
that if this principle were true in anatomy and sound in physiology as 
applied to these organs, it must of necessity be true as regards the hrain 
itself. I purpose in this lecture to place before you the facts which seem 
to sustain that opinion. I shall endeavor to prove that the cerehro-spinal 
fiuid performs, in relation to the circulation of the brain, the same func- 
tions that the elastic capsules referred to perform in regard to their 
viscera. The diagram before you is a median section of the bones of the 
head and of the vertebral canal. Within them we find placed the brain, 
the spinal marrow, and the membranes which are described as investing 
the spinal marrow, i shall be compelled to detain you with some ana- 
tomical details with which you are familiar, but my so doing constitutes 
a oecessary step in my attempt to show how this action of the cerebro- 
spinal fluid is produced. 

The letter a indicates the dura mater, which, you will observe, lines 
the whole interior of the cranium, and, after forming the tentorium, pur- 
sues its course down to the lower part of the vertebral canal, terminating 
in a conical point nearly opposite the second bone of the sacrum. A con- 
siderable space exists between the vertebra and the dura matei*, so that 
this interval allows expansion or eccentrical dilatation. 1 must direct 
your attention to certain lines (letter h) which are introduced for the pur- 
pose of localizing a piece of anatomy which, I think, has not hitherto 
received its proper attention. These lines represent natural ligaments, 
which proceed from the anterior inferior part of the dura mater, become 
fixed to the bodies of the sacrum scriatum, and pass downwards nearly as 
far as the first bone of the coccyx. So much for the dura mater. You 
will notice that the letter b is intended to point to the external arachnoid, 
composed of two layers. If we trace the black intermediate space 
upwards from the vertebral canal into the interior of the skull, we find 
that it corresponds to the space between the interior of the cranial portion 
of the dura mater and the surface of the cerebrum. Now, the external 
arachnoid, which is a complete serous membrane in itself, is fonned of two 
Jaj'ers: one layer lines the internal portion of the dura mater, and gives 
it its smooth character, and in the cranium the other rests upon the pia 

L mater of the brain. 
Let us now trace the continuity of this external arachnoid downwards ^H 



14 



ON THE TnEEAPEtTTIO 



into the vertebral canal. Here you may notice its linear continuity lining 
the internal portion of the dura mat«r, and proceeding downwards to the 
lower part of the dura mater, whicb contains the spinal marrow. This 
external aruohnoid is here again seen to be composed of two layers: its 
externa! layer, which lines Uie internal portion of the dura mater; and 
the internal layer, whioh is blended with the external layer of what I 
should denominate the internal arachnoid, to which I will presently direct 
your attention. This externnl arachnoid in a normal state contains only 
a very small quantity of serous or albuminous fluid; and I suppose the 
function of this external arachnoid is simply to pour out a small quantity 
of fluid intended to lubricate the two surfaces of the external arachnoid 
during the movements of the brain. The ill effects of any undue friction 
are prevented by the small quantity of fluid which exists between the 
BurfaoeB of the external arachnoid. The letter c points to what I should 
t^-^^a.^wt denominate the internal 

I arachnoid. It is this in- 

ternal arachnoid which. 
contains the cerebro- 
spinal fluid, which pro- 
ceeds to the interior o£ 
the brain through the 
cerebro-spinal opening, 
and then lines all the 
ventricles of the brain, 
and their different inter- 
mediate passages — with 
the exception of the fifth 
ventricle. 

The existence of thia 
cerebro-spinal aperture 
underneath the cerebel- 
lum, and between the cer- 
'ki*w ebellum and the medulla 
, ^^ oblongata, is not perhaps 
universally admitted; but 
I believe, beyond all 
doubt, that it is the nor- 
K bo- mal arrangement of struc- 
.ji^ tare, that there should be 
such an aperture. Soma 
lU, 10. S mllu tlBoe to 7. years ago I took a great 

deal of trouble for the purpose of ascertaining this point in a very excct 
manner; and in no one instance, except where there were abnormal collec- 
tions of fluid in the interior of the brain, did I find this aperture wanting. 
In other words, in every brain which I examined, except in cases of dis- 
ease {Figs. 8 and 9), I found there Vfas such an aperture, freely allowing 
fluid to pass inwards and outwards from the interior of the brain. I shall 
hereafter have the opportunity of lajing before you some cases in wliich 
this aprrturo waa closed, producing, in fact, internal hydrocephalus. 

This diagram (Fig. 3) does not pretend to. explain the exact and 
minute distribution of the internal arachnoid membrane, but only the 
general arrangement which exists at the base of the brain. If we truce 
the outer layer of the internal arachnoid upwards and forwards, as tar 
as nearly opposite to the fissure of Sylvius, it there becomes reflected upon 




Id lonnlqg. a. c«ttt7 at nr 



S.2?? 



Hm^wxtolw 



of HplDB] ea 



T. 0, postorior i 






I 
J 




I 



lASK USDIC'L LIB™ 

STA.'jyo^J U-IVBRSIir 
300 PA2TK:-S I>?.1VE , 
INFLUENCE OF rW#. ^*^. CALUJ.5 i 

itself, and lines the under surface of the brain, crura cerebri, pons Varolii, 
medulla oblongata, &c. Tracing this membrane (the intemul arachnoid) 
posteriorly, its posterior layer passes underneath the cerobellum, joined 
to the internal layer of the external arachnoid; it then quits the external ' 
arachnoid, and follows the under surface of the cerebellum until it reaches ' 
the cerebro-spinal opening, which it enters. You notice, therefore, that \ 
this large space ((I), which I now 
term the internal arachnoid cavity, 
and which contains the cerebro- 
spinal fluid, not only passes down 
the whole length of the vertebral 
canal (the relative position is indi- 
cated in this diagram), but the 
fluid lies under and supports the 
cerebellum, as well as the most 
important parts of the base of the 
brain; and it further passes up- 
wards into the interior of the 
brain, and is the fluid which we 
generally find, after death, occu- 
pying more or less the various 
ventricles of the brain. In fact, 
the central parts of the base of 
the brain, instead of resting upon 
the bones of the skull at its base, 
rest upon this collection of cere- 
bro-spinal fluid, which forms for it 
a most beautiful, efficient, and 
perfectly adapted water-bed; the 
water-bed itself being sustained 
in its position by the force of the 
you presently — and also by the elasticity of the d 
oral canal.* 

For the purpose of pointing out the practical application of these ana- 
tomical facta regarding the function of the cerebro-spinal fluid in its rela- 
tion to the base of the brain, I might say that almost the only part of the 

* This pnssnge has been left as it was origmall; written b; Hr Hilton. Tbe reader 
will see at once that the space botween the twn Inyers oF the " external arachnoid" 
oorreBpondB to the oavity of the nrachnoid, and that the interval between the two 
layen of the " iutemal arachnoid " ia tbe nnh'smchnoid spiLce between the antohnoid 
and the pia mater. Ur. Hilton beticvea that the cerebro-spinal flnid ia cuntaiued 
between two epithelial surtaoeH. i e,. that one euch Barfai^ not only exists, OB aaoalij 
deaoritied. upon the anuthnoid, bnt also npoo tbe pia muter bh well, anil that thna the 
otherwise inevitable inHltration ot the pia materia prevented. With all due dGferenoe 
to Ur. Hilton, I csnnot quite accept thin view. In die flrst place, as far as I am able 
to make out mlcroacopicnll]' and witb the nse of each reagents as silrec nitrate, no 
layer ot epithelial cells exists upon the pia mater, I am further inclined to believe 
that aolight iaflltration of the superficial part of the pia mater does take place, na the 
oerebro-spinal fluid posseB baokwnrdB and forwards over its imrface. More than very 
■light inllltration is prevented, partly bv the fact that the ccrebrn spinal fluid is 
broken up into a number of little lakes nnri pnols by the very delica(« bands which are 
fennd in the Bub-arachnoid space (tbe tissue forming theae bonda being alno ioSltrated 
by the lluld), and paitly by the deeper Inyens being most closely united to the brain 
sabstauce by Che innumi rable vesai^ia entering It 

I am indebted to Mr DaviesCoUcy fur the knowledge of tbe fact that Henle 
applies to ■Jie sub-arochuoid Liasue the epithet " waiiaei£Ui:htig'," (edematous. — [En.J 




I 



1 




hase of tlie brain 'which fits in close coaptation with the bones of the xkaj 
is the inferior part of the anterior lube of the cerebru 
upon the orbital plates of the froittal bones. So accurate is this cc 
tioii, that if you were to make a cast of the interior of this portion o 
skull, and compare the model from it with the under surface of that pu 
of the brain which naturally occupies this poBition, you would find thf^r 



not th< 




ith the other portions of 
thesB two models t which 1 have 
placed before you, you will find 
that one of them is nn exact out- 
line and confipuration of the va- 
rious parts which form the bi 
of the brain; the other model 
simply a wax cast of the iiiterii 
of the same skull, deprived of 
brain. Now, if the buae of 
brain rested upon the bane of the 
skull, the wax model which is 
taken from the interior of the 
skull ought to g\\c a east exactljr 
corresponding' to the base of it ~ 
brain. But we see that thin 11 
so, and the great difference marl 
the extent of the interval occupif 
by the cerebro-spina] fluid. Wi 
have here a complete dentonsti 
tion that there is not a coaptation 
or exact fitting between the under 
surface, or base of the brain, and 
those bones which form the base 
of the skull. This sustains the 
opinion that the two middle thirds 
of the base of the brain do not 
rest upon the bones, indeed do not touch the bones at all, but rest upon 
this collection of cerebro-spinal fluid, which I have ventured to call the 
perfect water-bed of the brain. Htnco a person may fracture the base of 
the skull, and yet show no evidence of injury to the brain itself; a fact 
which every observing surgeon knows to be true. I well remember a 
man walking into Guy's Hospital, sitting upon his bedside, undressing' 
himself, and lying down composedly in his bed: this patient, on his ad- 
mission, had bleeding from both his cars, and subsequently died from the 
injury to his head, it being shown at the post-mortem examination that 
he had a very severe fracture of the base of the akull. Yet this tnaa 
walked into the hospital, and showed no manifestation of loss of power 
or sensation in his legs, and no evidence of any encroachment upon thoaft' 
parts of the brain which form its base. 

Some time since I whs requested to see a gentleman in the country, 
who, coming home from hunting, was thrown from his horse, and got 
his foot entangled in the stirrup. In his fall be struck the back part of 
his head. After a time his horse was stopped; he disentangled his foot 
from the stirrup, and expressing himself somewhat confused, mounted hia 



1 



i 



M rcpreaeDted in Fig. I 



I 



horse again, and rode several miles home. This gentleman occupied him- 
ee\f as usual during thirteen dajs, occasionally riding, sometimes walking, 
but more frequently driving about the country in the pursuit of his busi- 
ness, and attending one of the county markets. He then became the patient 
of the surgeon who requested me toseebim. At the time I saw him he was 
suffering from some indications of paralysis dependent on injury at the baaa 
of the skull, or high up in the cervical region. This patient subsequently 
died, and upon examining his skull it was found that he had been the sub- 
ject of a fracture of its base; yet he pursued his ordinary avocations for 
thirteen days without the slightest evidence of any cerebral or brain lesion, 
complaining only of headache and some febrile condition. Now this frac- 
ture traversed that portion of the skull where the cerebro-spinal fluid is in- 
terposed between the bones of the skull and the brain structure. This is a 
good illustration, demonstrating that the brain is not actually in contact 
with the bones at that particular spot. And it shows us also that a man 
may have a fracture at the base of the skull without, at that time, mani- 
festing any evidence of serious lesion. Supposing a patient to receive a 
severe blow at the back of the skull: which part of the brain is most 
likely to suffer local lesion ? Certainly not that part of the brain which 
lies immediately under the point which was struck; but experience points 
distinctly to the anterior inferior part of the brain as most prone to local 
injury. In the anatomical fact to which I just now alluded, wo shall see 
the explanation of that circumstance. This is the part of the brain which 
rests accurately upon, and in complete surface coaptation with, the bonea 
of the skull, M hen the blow is received at the posterior part of the 
skull, the whole mass of the brain being driven forwards from the momen- 
tum given to it by the blow upon the bonea of the skull, the under sur- 
face of the anterior part of the brain rubs over the depressed and elevated 
surfaces which constitute the anatomical features of the anterior fossa 
of the internal base of the skull. I have seen a case where the blow 
which led to the fatal injury was received at the back of the skull; no 
injury was inflicted upon the subjacent part of the brain, the whole effect 
was propagated to its anterior part — that part which fits accurately upon 
the bones of the skull — here the under and anterior part of the brain 
was very much lacerated. These circumstances taken together will show, 
I think, the practical advantage of distinguishing the parts of the brain 
which fit accurately upon the skull from those parts which are separated 
from it by the interposition of the cerebro-spinal fluid. 

The cerebro-spinal fluid has a specilic gravity of about 1007. It con- 
tains scarcely any albumen, and is, therefore, very different from the 
serum of the blood. The function of this cerebro-spinal fluid is chiefly 
mechanical — that is, first to protect the more important parts of the brain 
from vibratory communications from the bones of the skull which might 
otherwise reach them;* the brain, therefore, at its base does not rest 
upon the bones, but upon the fluid ; secondly, this fluid isolates the 
various nerves passing near each other towards the same foramina; and, 
lastly, supported by the cerebral circulation, it tends to bring back the in- 
ternal organs of the brain to a state of comparative emptiness or quies- 



* Mr. niltnn has shown elsewhere (Lectarei tm the CniniDm) that tamij of the 
riilgeH on the innec surface of the bans of the akall serve to conduot vibrations f> the 
clmoid processeB vihiuh lie Hurrouoded bj cerebro-Hpinai Quid, and that the vibrnCioDs 
nrreiiiecl nnd lost in tbia fluid are thoB preveated from damaging ths base of tha 
brua.— [Ed,] 
■i 



18 OS THE THEEAPEUTIC 

cence after tlielr state of activity. In this latter respect the cerebroiTI 
jspinat fluid may be said to perform for the parts in toe interior of the 
brain a function analogous to that capsular apparatus to which I have 
already referred as investing; some of the thoracic and abdominal viscera. 

I will now elucidate the olGce of this cerebro-spinal fluid as a mechan- 
ical support to the internal parts of the brain, when they have ceased 
to be in the condition of pnyBiological encitement or turgescence. I 
have already said that the thalamus nervi optici and the coipus striatum, 
which occupy the base of the lateral ventricles, superintend the movements 
and sensibility of the upper and lower extremities. I presume that when 
these functions are actively employed, these two parts especially are in a 
state of turgescence, and tnat if they were imbedded in the solid brain it 
■would be impossible for them to enlarge without encroaching upon some of 
the adjoining structures, and thus inflicting, at any rate, temporary injuty. 
But the corpus striatum and thalamus nervi optici have a large extent of 
surface, which projects towards the interior of the lateral ventricles, and 
in proportion as they become enlarged by congeation they displace the 
cerebro-spinal fluid through the foramina of Monro, through the third ven- 
tricle, iter a tertio ad quartum ventriculum, into the fourth ventricle, and 
thence through the cerebro-spinal opening, and thus provision is made 
for the hyperemia of the thalamus and corpus striatum. When the 
physiological excitation ceases in the corpus striatum and thalamus nervi 
optici, then the cerebro-spinal fluid, supported by the venous circulation 
of the brain and the elasticity of the dura mater in the vertebral canal, 
rises up again through the same channels, and thus gives a mechanical 
support to the thalamus and corpus striatum in their state of repose. It 
is worthy of notice that these collections of fluid in what we term "the 
ventricles of the brain " communicate with each other through the medium 
of very narrow passages; and I must not omit to call your attention to 
the point, that wherever these passages are narrowed, the brain structure 
itself, or some structure added to that particular part, makes these nar- 
rowed parts very dense and strong for the purpose of resistance. At the 
margins of the foramina of Monro the structure of the brain is very 
dense, and the whole length of the iter a tortio ad quartum ventriculum is 
surrounded by a comparatively very dense material. I suppose the 
reason for the existence of these narrowed openings is for the purpose of 
preventing a very sudden and rapid enlargement of the internal parts 
of the brain, in order that their turgescence may be slowly and steadily 
brought about. In fact, as the turgescence slowly and steadily increases, 
the cerebro-spinal fluid recedes in an equal degree through these various 
ventricles and contracted passages, 

I must now place before you a few facts which show the exact rela- 
tion between the venous circulation and the cerebro-spinal fluid, in order 
to prove that they equipoise each other. At an ordinary post-mortem 
examination, with the body lying upon its back, place a ligature tightly - 
round the neck, so as to compress the jugular veins and prevent the 
venous blood running out of them. Then remove the thoracic and ab- 
dominal viscera, and divide transversely and neatly the various veins 
which escape from the vertebral canal, through the intervertebral fora- 
mina, and lie upon the sides of the bodies of the vertebra;, taking care to 
leave these veins full of blood. Then take away the bodies of the third 
and fourth lumbar vertebnc, so as to expose the vertebral canal, with the 
dura mater, containing the spinal marrow, arachnoid membranes, and the 
cerebro-spinal fluid. With a body so prepared, if the blood uiihin the 



INFLUENCE OF REST. 19 

veins ot the neck be pressed upwards through the internal jugulars 
towards the interior of the head, it will be seen that, just in proportion 
as you press the venous blood in that direction, so you will observe the 
dura mater rise into the place from which you have removed the lumbar 
Tertebne ; thus showing that as you push the venous blood into the inte- 
rior ot the unyielding cnmium, you displace the cerebro-spinal fluid; the 
evidence of that displacement being this, that you see the dura mater 
lifted up by the fluid at the part where you have removed the two lumbar 
vertebne. So again, confining your attention to those veins which are 
in section on the side of the spine, and filled with blood coming from 
veins in the interior of the vertebral canal — if you place your fingers upon 
the dura mater exposed by the removal of the bodies of the vertebne, and 
make pressure upon it so as to displace the cerebro-spinal fluid, you will 
observe that just in proportion as you displace the cerebro-spinal fluid will 
the blood rise within and then overflow the various divided veins to which 
I have alluded; thus showing that as you make pressure upon the ccrcbro- 
apinal fluid you displace blood from the veins which occupy the vertebral 

And hero let me introduce an experiment bearing upon this subject, 
made upon a living body. I would not, however, advise a repetition of 
the experiment, because, probably, it involves a slight degree of risk to 
the patient. Some years ago I had in Guy's Hospital a patient suffering 
from fracture of the base of the skull, and from one of his ears a thin 
watery fluid was pretty constantly running. It occurred to me that if 1 
could make this patient's head more full of venous blood, I might succeed 
in displacing the cerebro-spinal fluid, and that, if the fracture had estab- 
lished an easy communication between the auditory canal and the cerebro- 
spinal fluid in the interior of the skull, I should be able to force out of 
the ear some of the cerebro-spinal fluid. I accordingly went to his bed- 
side, and told him to take a very fuU breath; I then held his nose and 
lip, and put my fingers so as to compress his jugular veins on each side 
of his neck. His face became exceedingly congested and discolored, and 
he commenced struggling to get rid of the pressure of my hajids upon 
Ilia nose and mouth. This had scarcely taken place before a quantity of 
thin fluid came running out of the auditory canal, and I succeeded in 
collecting neariy half an ounce of it. The experiment was now com- 
pleted; J removed my hands from the nose and mouth of the patient, and 
ho quickly recovered his condition of repose. Thus, then, I had suc- 
ceeded in displacing from the interior of the cranium a quantity of cere- 
bro-spinal fluid (for so it was afterwards proved to be by microscopic and 
chemical examination) by propeUing to the interior of the skull an in- 
creased quantity of venous blood. 

1 think I have now proved a very close relation between the cerebro- 
spiniil fluid and the venous circulation within the cranium and vertebral 
column, and that, in truth, under ordinary circumstances, this cerebro- 
spinal fluid is supported by the venous circulation of the brain and verte- 
bral canal. I have also explained to you how this 6uid communicates 
with the interior of the lateral ventricles, and I believe that when the 
torgescence of these internal parts of the brain (corpus striatum and 
thalamus) subsides, the cerebro-spinal fluid rises within the ventricles to 
jccupy the space thus left by their subsidence. 

It may be a little wide of my proper subject, but while your attention 
B directed to the relation of this cerebro-spinal fluid to the interior of the 
brain, I think it may not be altogether out of place to remind you of thu 



20 N T ir E T It E H X P E U T I C 

utatomical rplation of the disease termed spina bifida to the int« 
arachnoid. This will enuble me to express the fact that the fluid oem- 
tained iii the interior of the cavity of a spina bifida is cerebro-spinal 
fluid.* 

The spina bifida is essentially the projection backwards, through the 
imperfect vertebral canal, of the membranes of the brain, and the thin 
fluid which occupies the spina bifida ts in truth the cerebro-spinal fluid 
(see Fig. 3, /). Thus the interior of the spina bifida actually commu- 
ntcates with the interior of the brain through the medium of the cerebro- 
spinal opening between the medulla oblongata and the cerebellum. I 
have no intention of dwelling on the subject of spina bifida beyond avail- 
ing myself of the freshness of this illustration for the purpose of pointing 
out the danger that is associated with operations upon this disease, espe- 
cially those of injecting it with any irritating fluid. It is obv-ious that if 
any irritating fluid be injected into the cavity of the spina bifida, we are 
injecting a fluid into a cavity extending the whole length of the spine, 
and communicating directly with the interior of the brain. Hence, al- 
though we may wish to linut the influence of the stimulating fluid to 
the spina bifida, it is impossible to prevent the extension of the mischief 
towards the interior of the brain. Illustrations of the fatal effects of this 
method of proceeding I have myself witnessed. Again, in the operation 
of ligature upon the spina bifida as a means of cure: if the patient dies of 
inflammation of the membrane of the spinal msrrow, that inflammation is 
manifested almost exclusively in the internal arachnoid, which contains 
the cerebro-spinal fluid; and if the mischief extends far enough, and the 
patient lives long enough, this mischief is actually traceable along the 
continuity of this internal arachnoid to the interior of the brain. I have 
seen this effect of the ligature several times. I might also point out that 
the anatomy of this part, as exetuplified by the diagram (Fig, 3), suggests 
the impropriety of at any one time drawing off the whole of the fluid from 
the spina bifida. Surgeons know very well that it has happened that 
when the fluid has been drawn o3 from the spina bifida as long as it 
would flow, it ceased only by the patient having a fit — a sort of general 
epileptic fit — and of that fit perhaps the patient has died. That occur- 
rence rec«ives an explanation when we trace a communication between 
tiie interior of the brain and skull and the spina bifida, for it is plain 
that as you draw off the fluid from the spina bifida, so you withdraw the 
whole of the cerebro-spinal fluid from the interior of the brain, and from 
the base of the brain. All the veins become congested and distended 
with blood, the interior part^ of the brain encroach and make pressure 
upon each other, the various nerves at the base of the brain, including the 
pnenmogastric, are compressed, and the patient dies from defective respi- 
lation, or from a struggling or epileptic fit. This is the direct effect of 
the withdrawal of all the fluid, which is sometimes done in the operation 
upon spina bifida. Now the safest and best method of proceeding, no 
doubt, is to take away only ao much fluid as will relieve tJie spina bifida 
of its state of tension ; the patient then runs no immediate risk from the 
operation. The removal of extreme tension from the walls of the spina 

* ThoDgh this is the uBDal unuigeraeDt in spina bifida, thnt the saa comrDDnioatsa 
with the sii^-niacliDOid Hpaoc, and contaioa oeiebro- spinal lluid, there is nn donbt thkt 
in A small Dumber of ciues the commtiTiicnUou is with the caiity of the nrochDoid. 
See Prescott Hewett. Med. Gm., yoL imiT., p. 4G1, aod the SorBical Tteatmeotg* 
CbUdreo's Diwasea, by T. Holmes, p. 78-81. — |Ed.] -^~ 






INFLVENCB OF BEST. 21 

bifida enables those walls to recover themselves, and to produce in time 
good and healthy skin, which forms the beat natural defence of this im- 
natnral projection of the membranes backwards through the defective 
vertebral canal. After this tapping operation, the skin ought to be sap- 
ported by the local application of a thick layer of coUodion ajid by a 
bandage. 

The diagram (Fig. 7) to which I am now directing your attention is 
made from a drawing represent- 
ing a dot of blood which I found 
in a patient's brain, in the year 
1842. You know that sudden 
deaths used to be most fre- 
quently attributed, erroneously 
no doubt, to apoplexy, but it 
has rarely occurred to any per- 
son to have the opportunity of 
seeing a case of apoplexy, 
where the death was so sudden 
as in the patient from whom 
this clot of blood was taken. 
This patient dropped down dead p.^. ,,_ci<.t rt bi»d ooropTinft »d d>i>MidinR th. 
public-house in which she had ^'"^'""■"^'^'^'•^'^'•"•"■^■"'•v^- ' 
been drinking, and I subse- 
quently examined the body, when I found that the cause of the sudden 
death was the clot of blood, the outline of which is given in the diagram, 
the clot itself being upon the table. I avail myself of this clot of blood 
to indicate two circumstances — first, the continuity of the spaces through 
which the cerebro-spinal fluid recedes during the increasing size of the cor- 
pus striatum and the thalamus; and secondly, to show that the pressure 
which led to this patient's death was made upon the fourth ventricle, 
which contains the origins of the pneumogastrio nerves. Running the 
eye along the upper part of the clot, from before backwards, we notioe a 
semicircular notch (e), which corresponded exactly with the anterior com- 
missure of the cerebrum in the third ventricle. A little further back is 
a peculiarly configurated depression (rf), which is the impression of the 
commissura mollis. And at the anterior and inferior part is a nipple-like 
projection downwards {/), which fitted into the tuber cinereum of the 
third ventricle. Behind this (a) corresponds to the interval between the 
two optic thalami. The narrow prolongation backwards (i) is a cast of 
the iter a terlio ad quartum ventriculum passing under the corpora qua- 
drigemina; and joined to this is a lozenge-shaped mass (c), having a pro- 
longation downwards, which passed through the cerebro-spinal opening 
and two lateral wing-like expansions, which were adapted to the laterw 
recesses of the fourth ventricle, where the trunks of the pneumogastrio 
nerves are placed; it is, in truth, a perfect cast of the fourth ventricle. 
There must therefore have been, in this case, great pressure upon the 
floor of the fourth ventricle at the orig'ins of the pneumogoatric nerves, 
which superintend the process of respiration. The sudden death was pro- 
duced by the blood which had been extravasated into the lateral ven- 
tricles haring pursued the course of the cerebro-spinal fluid, and rested 
in the fourth ventricle, and there mad« so much pressure upon the roots 
of the pneumogastric nerves as to completely paralyze them; and if the 
process of respiration could not be continued, as it certainly could not 



22 



ON THE TUEKAPBUTIC 



during the time the pneumogaetrics were thus pressed upon by the clot 
of blood, the patient would necessarily die quicklv. This then, I appre- 
hend, is the explanation of the sudden death of the patient. The clot of 
blood, which waa quite entire, will also establish the fact of the continnity 
of these various parts, through which, as I have undertaken to suggest to 
you, the cerebro-spinal fluid passes to and fro, according to the state of 
Oongestion of the interior of the brain. 

I might here remark, that it appears to me impossible that any patient 
can live with what is called a diffused external hydrocephalus, assuming 
that the external hydrocephalic fluid ia placed within the external arach- 
noid. As the brain is of a greater specific gravity than the hydroceph- 
alic fluid, it would of necessity sink upon the internal base of the skull, 
or if it did not sink from its own weight, it would be compelled to do 
so by the hydrocephalic fluid swimming over the top of the brain, and 
thuB pressing the brain upon the base of the skull. You will rememl>er 
that the arteries of the brain contain the blood, through the medium of 
which the brain is nourished and manifests its functions; that those arte- 
ries lie between the under surface of the brain and the bones of the skull, 
and if this hydrocephalic fluid press the brain downwards, it must oom- 
preas the blood-vessels between itself and the bones of the skull, and in 
that way the supply of blood to the brain would be cut off. So again, 
if the base of the lirain were thus pressed downwards, the pneuinogas- 
tric nerves would also be compressed, and the respiration would cease. . 
Now it has never fallen to my lot to see a case of diffused — mark, I 
say diffused — external hydro- 
cephalus, and, therefore, I pre- 
sume the cases must be rare. 
I apprehend that the examples 
recorded must have resulted 
from rupture of the internal 
arachnoid membrane, which al- 
lowed the cerebro-spinal fluid 
to escape from it, and flow over 
the top of the brain, thus leading 
to sudden death. 

Before quitting this subject 
of the cerebro-spinal fluid and 
the cerebro-spinal aperture, 1 
must call your attention to the 
drawing. Fig. 8, which repre- 
sents a specimen of the closure 
of this cerebro-spinal opening. 
In such instances the cerebro- 
spinal fluid could not escape 
from the interior of the bruin; 
and thus the collection of fluid within the brain would constitute internal 
hydrocephalus. And here I may add that the drawings from which the 
diagrams were copied represent specimens of morbid anatomy which 1 
removed from little children who had been the subjects of internal hydro- 
cephalus; and the occlusion of the opening was the only cause of the 
internal hydrocephalus that 1 could discover. 

The other drawing, V'l^. fl, is taken from the same preparation, 
but represents a longitudinal section of it, which enables us to see 
lely dilated state of the commuriioutlon belw.:>i'ii ihe third 




re bro -spinal 



INFLCENCIC OF REST 

&nil fourth ventncies, and the point ot closure o( the 
opening. 

These drawings have been in my possession a. long t'ui 
1844. At that period of my professional life I was examining the diseasea 
of the brain in i;hilclren. In almost every case of Internal hydrocephalus 
which I examined after death, I found that this cerebro-spinal aperture 
was so completely closed that no cerebro-spinal fluid could escape from the 
interior of the brain; 
a'ld as the fluid was 
being constantly se- 
creted, it necessarily 
^cumulated 



md the 



=cli.f 




formed, to my mind, 
the essential patholo- 
gical element of in- 
ternal hydrocephalus. 

Internal hydroce- 
phalus is not an un- 
frequent companion 
of spina bifida. In 
many of the cases of 
that disease that I 
have examined after 
death, the cerebro- wnaeJ nj hjdrocphaiio omW. 
spinal opening was 

closed, thus explaining how it happened that although the spina bifida 
had been tapped during life, and no limit put to the flow of the fluid at 
the operation, yet the little patient did not suSer from cerebral conges- 
tion. Indeed, it was a case of this kind which first made me acquainted 
with the pathological fact of closure of the cerebro-spinal opening in the 
fourth ventricle. 

1 will now detail to you the short particulars of a case of internal hy- 
drocephalus in which the cerebro-spinal canal was closed at the iter a tei^ 
tio ad quartum ventriculum. This case of internal hydrocephalus I saw 
in the year 1847, with Mr. Otway, a surgeon at Kensington: — 

A. II was a child of unhealthy parents, very thin, feeble, and 

sickly from birth, uttering constantly a peculiarly distressing cry, and 
having a remarkable rotary movement of the head. When four months 
old, the head began to enlarge rapidly; and after this had been noticed a 
week, the infant became comatose, lying perfectly quiet, almnst paralytic, 
with strabismus and dilated pupils; ner skin was of a dingy yellow tint; 
pulse scarcely to be felt; respiration extremely imperfect, both as regards 
frequency and extent. After the coma had continued twenty-four hours, 
as death appeared imminent, the anterior fontanelle was punctured by a 
trocar and canula, and eight ounces of colorless fluid escaped. While 
the fluid was being drawn off, the infant began to kick vigorously, the 
evelida opened, the strabismus ceased, and the pupils contracted. So that 
tne withdrawal of the cerebro-spinal fluid removed the pressure from the 
third nerve, which had produced strabismus and dilatation of the pu- 
pils; it removed the pressure also from the thalamus and corpus striatum: 
and this freedom from pressure was manifested by the child moving its 
limbs vignronsly. The lips began to move constantly, especially the low- 
er lip, which had been drawn inwards between the gums. When the fin- 



u 



OS THE TIIEBAPEUTIC 



ger was introdiiocd into the mouth of the infant, an attempt to suck 
made, und a little wiimi milk and water was swallowed without difficulty. 
The pulse was aViout 140, very small and feeble; respiration very iiregu- 
lar; the surface was cold and clammy, but wann applications soon re- 
stored its temperature. Moderate pressure was applied to the head, A 
week after the first operation, after some alight fits, the child became 
comatose again, and unable to swallow. Kignt ounces of turbid fluid 
were again drawn off, with the same result as before. And three weeks 
later, the same quantity of fluid, highly coagulable by heat {inflammatory 
effusion, not cerebro-spinal fluid), was again evacuated under simil&r 
cumstances. During the next two months, the child took mercury 
chalk, in small doses, with some benefit. The bones of the bead 1 
gradually becoming approximated, and the anterior fontanelle was dimi 
ished. Yhe child was emaciated, although it took the breast freely. 
thumbs were turned in upon the palms of the hands, and the peculi 
movement of the lips continued. The child died on the 30th of OctobejJ 
having had convulsions of increasing severity during four days; but it 
continued to suck, and took notice of surrounding objects, tiU the daj 
before its death. The child lived nearly three months after the first tap- 
ping. 1 did not see this patient alive, but 1 suspected, from Mr. Otway^ 
description of the case to myself, that we should find closure of the cere- 
bro-spinal opening. 

F^Mt-iiiortem ttamination. — Body much emaciated. The bones of the 
head overlapped each other considerably; the anterior fontanelle wa« 
imperfectly felt. There were cellular adhesions between the two layers erf 
the external arachnoid; this membrane was much thickened, and in some 
places opnque. There was no appearance of cicatrices in the position of 
the trocar punctures, but some firm adhesions existed at that spot, T" — 
veins on the surface of the brain were distended, and a dirty brownish-i 
discoloration, from altered blood, was noticed between the lobes of ' 
cerebrum. Within the right lateral ventricle three distinct cicatrii _ 
were clearly seen, correspotiding with the punctures made during life with 
the trocar. Each lateral ventricle was divided in an exactly similar man- 
ner by an opaque structure (resembling its lining membrane), in which 
there was on each side an aperture of about a quarter of an inch in diam- 
eter. This was either a new false membrane developed within thi 
triculor cavity, or the lining of the roof of the ventricle, thickened ai 
subsequently ruptured, so as to allow the fluid to make its way betwi 
it and the ventriiular wall; most probably the former of these conjeotu 
is the correct one. The lateral ventricles were distended, and eontaini 
four ounces of fluid. The plexus choroides was not to be recognizi 
The septum lueidum was elongated, its ventricle was enlarged, and 
tained fluid. The cavity of the tuber cinereum was dilated, and thu 
pressed the optic commissure, explaining the impairment of vision, 
iter a tenio ad quartutn veiitriculuin was dilated nearly as far as tne en- 
trance into the fourth ventricle, where it was closed by old and firm adhe- 
sion. This occlusion necessarily preserved the fourth ventricle from dila- 
tation, aud it was uceordingly natural in form. The olfactory nerves, as 
far as their bulbs, were hollow, and communicated vrith the anterior cor- 
nua of the lateral ventricles — (his persistence of a condition norms! to 
about the fourth month of intra-uterine life suggested that the hydro- 
ce[>halus, with its pathological oause, bad coiomeQced during the period 
a-uterine life. 



n ol 

rioc^H 



ITje 



INFLUENOB Oil' BEST. 

This hook is the projierty of 

COOPER MEDICAL COLLEGE. 

SAN FRANCISCO. CAt^ 
and i.t not to hi; rfinorrd from ike 
ZAbrni-t/ {}•'<■) h,/ f;iit pfi-non Of 

Pniictioii of the Cerebro-Spmal Fluid in the Fcetal Briuii— Caae of Oaclnsion of tfae 
Cercbro-EpiDol Aporturc — The Brain after ConouaaioQ a Bruisod Organ— Compari- 
•on between n Bruise of the Brain nod that of other Oi^i^ana — Long Iteat EBBential 
after ConcassiOD of the Brain — ^Neglect of this a Fertile Caaae of Permuneut Brain 
Disease— Symptoms of (.'oncugaion of tbe Spinal Cord, and Treatment bj Rest — 
Uott of tbe Ornver Operations of Surfer; Perfunuctl fur tlie Purpoite of Allow- 
iDf Nature Beat to Restore Injured Porta. 

A DIFFERENCE of opinion exists among anatomists as to the presence 
of a. well-defined membrane within the lateral and other ventricloa of the 
human bruin. I do not wish to express an authoritative opinion, but I will 
adduce this model of the fcctal brain in support of the fact that there 
must be a firm and compact membrane lining the interior of the ventri- 
cles during the early period of intra-uterine life, when the brain Itself is 
in a semi-liquid at diffluent state. This diagram, Fig. ID, was made from 
a model of the brain of a fcetus at about the fourth month ; it shows the 
relative position and size of the lateral ven- 
tricles and their walls accurately. The difllu- 
©nt rudimentary brain-atructure is placed 
between the pia mater entemaljy, and the 
epcndjmacontainingthc cerebro-spinal fluid 
in the ventricles internally. It appears to 
me that if a well-defined membranous wall 
did not exist on each side of the semi-fluid 
brain-matter, it would be impossible for the 
brain to grow and to austani itself in any- 
thing like a definite form. The cerel>ro-spi- 
nal fluid contained within the ependyma 
seema to perform the very important office 
of supporting the membrane, and thus con- 
stitutes a scaffolding or internal arcb upon 
which rests the diffluent brain matter, which 
la ultimately formed into firm braiii-struc- 

1 will not dwell longer on this subject, 
but I felt it necessary to advance these facts 
in confirmation of the belief of the existence 
of a lining membrane to the ventricles, even 
st a very early period of fcetal life. 

I said previously that I should be pre- 
pared to detail another case of occlusion of 
the cerebro-spinal aperture of considerable 
case will be more instructive, and it£ vali 




3.LUaBl tentrldeaarnii 



«j inlcrnuUy. 






L 



read the post-mortem * 
observed during life. 
The gentleman who n 



interest. I think that the 
better exemplified, if 1 first 



imination, and then allude to tbe symptoms 
i the subject of this disease died at the age of. 



2G ON THE THEEAPEUTIO 

tliirty-four. On the Hay of liia death he had visited the Crystal Palace. 
He had been seized with vomiting' in the morning-, and again about two 
liours before he reached home. He walked from the Crystal Palace (a 
mile or so), and when he entered the house he staggered, and said he felt 

Siddy and oppressed. lie was placed on a bed, and cold was applied 
is forehead, but he died in a very short time, with stertorous breathings — «j 
remaining sensible, however, almost to the last moment. 
body, assisted by Dr. Wilks, and this is the report of the post-morteidu 
examination : — 

" Cadaveric decomposition was advanced, except within the brail 
which presented in this respect a remarkable contrast to the other , 
of the body. The convolutions of the cerebrum were large, and Uii 
surfaces flattened by pressure from within." 

And these convolutions were few, suggesting, perhaps, that the ot 
dition of the brain was a persistent state of a very early development 
the convolutions ; for although the person was full grown, and thirty-fot 
years of age, the convolutions were large and few. 

"The brain -structure was healthy, neither it nor the 
taSnlng any tubercular deposit. On carefully opening the lateral venti 
cles, tncy were found to contain at least four ounces of clear cerebr 
spinal lluid." 

Regarding the character of this fluid there can be no doubt. It w 
carefully examined. Its specific gravity was 1008, and it 
the microscopic and chemical characters of cerebro-spinal fluid. 

" The ventricles were greatly enlarged, and all the receding and pr 
jecting angles of the boundaries and cornua were lost or subdued. D 
foramina of Monro were rounded, and capable of admitting a large qui .. 
not quite a third of an inch in diameter. The lining membrane of the 
ventricle and the choroid plexus were healthy. The septum lucidum and 
the fornix were softened, but the microscope showed no trace of infli 
tory deposit or softening. The fourth ventricle was greatly dilated in all 
its directions, showing well its lateral cornua which support the pneumo* . 
gastric, auditory, and other accompanying nerves. The cereliro-spiiMU 
opening between the under surface of the cerebellum and the upper su 
face of the medulla oblongata was completely closed by a tolerably deni 
membranous structure, which formed a kind of pouch projecting down 
wards, and showed the direction of the fluid tension upon it to have ber 
from above to below. 

"This was clearly seen when looked at either from the ventricular 
aspect or below from the spinal aspect. The arachnoid in the neighbor- 
hood, at the base of the brain, was somewhat opaque and thicker than 
natural. The large trunks of the cerebral arteries presented a few minute 
spots of opaque deposit. The veins of Galen and their tributaries were 
healthy. The lieart was healthy, both as regards its muscular tissue aud 
its valves. There was a slight deposit beneath the lining membrane of 
the aorta. There was no recent disease of the lungs." 

The pathological condition of the closure of the cerebro-spinal open- 
ing found in this gentleman's brairj is well represented by Fig. 8, c, but 
that drawing was made in 1844, from a preparation which I then obtained 
from the head of a child who had died of internal hydrocephalus. 

The details of the history during life present an apparently perfect 
fitting-in of the symptoms to the pathological anatomy, llut I wish it to 
be understood that this account has not been " cooked," as it is termed. 
It was not made up for the purpose of agreeing with the facts previously 



™i 

J 



INFLUENCE OF HEST. 27 

stated, but was drawn up by the brotlier of the gentleman liimself, who 
is not a professional man. I asked him to obl!^ me with a detail of the 
symptoms which his brother presented during life, and this is bis aocount 
of theio; — 

"This gentleman always had cfelicate health. The nails of his fingers 
were peculiar In form, the last phalanges being very short, and the uails 
inserted like two seeds into the cuticle."* 

I stop at this point to remark that here apparently we have evidence 
of a congenital error in the development of the ends of the fingers; and 
this inclines me to the conclusion that probably the cerebral error, the 
occlusion of the cerebro-spinal aperture, was also congenital. 

"As a child, he was active and wiry, but very irascible in temper. 
As a man, he was very spare and delicate looking. [All indications of a 
something which impeded healthy development.] He had always some 
color in his cheeks, which he retained until a year of his death. He had 
a fondness for intellectual pursuits; also for turning light fancy work, 
and gardening; and a great dislike to the excitement, and especially the 
noise, of London, Indeed, at the age of sixteen he had a severe nervous 
illness, with great depression, brought on by application to business in the 
City; it ought, however, to be mentioned that his occupation was not at 
all intense, and nothing would have been thought of it by ordinary men." 

Kow this is worthy of note, because in this instance there was no pos- 
sibility of the cerebrospinal fluid escaping from the interior of the brain. 
Whatever pressure might be made, by mental occuptitlon or physical ex- 
ertion, upon the internal parts of the braiu or the medulla oblongata, 
would be morbidly manifested, in consequence of there being no possibil- 
ity of escape for the cerebro-spinal fluid. Or to put it in another way: 
Suppose over-esertion or any moral influence to produce an excessive 
accumulation of blood in the head, there waa no possibility, in this in- 
stance, of insuring a proportionate escape of cerebro-spinal fluid, because 
there waa no aperture to allow of it. 

' " Uis food was always of the simplest kind. Even tea, coffee, and 
cocoa seemed to afTcct his head and derange his stomach; and he had an 
instinctive dislike to alcoholic stimulants of every kind. Though subject 
to coldness of the extremities, he could not bear a warm room, as it made 
him feel faint. Both winter and cold always affected him injuriously. 
He said himself he only half lived in the winter; he seemed torpid, and 
would drop into a deep sleep after a meal, from which it was often di£S- 
cult to rouse him at bed-time, when he seemed scarcely to know where he 
was. Excitement frequently brought on an impediment in hia speech. 
For many years he was subject to headache, derangement of stomach, and 
CKcasiona] deafness." 

We have here, if we may so term it, a most important and valuable liv- 
ing experiment. Here is a man who cannot bear any accumulation of 
blood in his braiu, because there is no possibility for the compensatory 
fluid to escape from the pressure or state of congestion of the organs in 
the interior of the skull. I conclude that we find the cause of the stom- 
ach affection and the deafness in the great distention of the fourth ventri- 

' Tbe fltd'jeiit will romember tbkt the two BtniotursB which in this case presented 
ftbnonaalitJEa, vii,. thebrnin and the &ppeQ<] ages of the cuticle, ue developed Irom one 
and the aame blurtodermic Inyet, i.e. the epililaat. So alwo in Bome oaBea of spina 
biQd», not onl; U there an abuonnal condition of the spinal cord, biit the Hkiii over the 
toiaor in goinetimes congenitally deGcienl or Bntirel; Hbeent, the spinal duia mater or 
iraohnoid taking ita plaoe, — [Eo.J 



28 ON TUE THERAPEUTIC 

c]e, And thi? consequent pressure upon the pneutnogastric and auditory 
nerves on itw floor. If the fourth veiitriele be filled with fluid, it must for 
the time oxcrt. some pressure upon the auditory nerve, thus explaining the 
tompiirary deafness. 

" Hia pulse was usually extremely weak, irregular, and slow, from 50 
to 60 boats por minute. He was thuught to be suffering from heart dis- 
PBBO. A peculiar restless, uneasy look of the eyes and stare, with dilated 
pupilii, and a muddiness of the conjunctiva, afforded a ready indication 
of any temporury derangement of his health. For the last year of his 
life ho was ffradually losing flesh; he became more feeble, too, and ac- 
quired a slight stoop in his gait. He also carried his head peculiarly, aa 
if affected with slight stiffness of the neck." [This is the way in which 
hydrocephalic patients carry their heads.] 

" A few months before his death, while in the country, he had a severe 
attack of vomiting, with great prostration, without any apparent cause. 
The .last month or two were marked by a morbid activity and restlessness. 
Amongst other things, he became greatly excited about the preparation 
for a scientific meeting; and this was followed by great prostration and 
collapse. On the day of his death he had been to the Crystal Palace. 
Ho had had some vomiting in the morning, and again about two hours 
Imfiire he reached home. He walked from the Crystal Palace, and when 
h« entered the room he staggered, and said he felt giddy and oppressed. 
He was placed on a bed, and cold was applied to his forehead; but he 
died in a short time with stertorous breathing [indicating pressure upon 
the medulla oblongata], hut was sensible almost to the last moment." 

If I were to select this opportunity to enlarge upon the apposite cir- 
cumstances of this case, pcrhops I might do so at too great length. I will 
morcly observe that I think it an important and interesting experiment 
in reference to the circulation through the brain, the administration of 
food and stimulants, and various other matters. His brain could bear no 
fulness of blood, no increase of size, because the cerebro-spinal fluid could 
not oMcape from the interior of the brain. He could not take wine, beer, 
or spirits; and could bear no muscular exertion. The congestion of the 
brain produced vomiting by pressure upon the medulla oblongata, exert-' 
ing its influence upon the pneumogastric nerve. He died from pressure 
upon the medulla oblongata, with stertorous breathing — that pressure 
which c«tdd not be obviated. I shall dwell no longer cither upon this 
case or this kind of case, but T think that occlusion of the cerebro-spinal 
opening is a pathological condition 'which bos not received due attention 
from the profession. 

Before quitting the subject of tte circulation through the brain, let 
me say that I think it is generally supposed that during sleep the brain is 
in a state of congestion, or, rather, overcharged with blood; and that it is 
the pressure of that blood which in some measure induces or sustains the 
stale of rejjose or cerebral quietude. Mr, Durham, one of our demonstra- 
tors at Guy's Hospital, has put into my hand this paper, containing the 
result of some experiments which tend to show that the brain is not in 
that condition during sleep; that it loses its congested character in order 
that it may assume what we should call its state of quiescence, or rest. 
The facts are very few, and they shall be allowed to speak for them- 
selves. 

" A dog having been chloroformed, a portion of bone, about as large 
as n six|jenpc, was removed from tbe parietal region of the skull by means 
<if ihu trephine; the subjacent dura mater was cut away, and the surface 



I 



INFLCBNOB OF BEST. 29 

of the brain exposed. Aa long as the animal continued nnncr tno influ- 
ence of the chloroform, the smaller vessels of the pia mater were turgid 
with dark -colored blood, and the larger veins were considerably distended.* 
No difference in color between the arteries and veins could be recognized. 
The exposed portion of the brain manifested a tendency to rise into the 
opening through the skull. By-aiid-by the immediate effects of the chlo- 
roform passed off, and the animal sank into a comparatively natural and 
healthy sleep, A very marked change in the appearance of the brain 
accompanied this change in the state of the animal. Aa sleep supervened, 
the vessels gradually emptied themselves; the veins ceased to attract no- 
tice by their distention; the exposed surface of the brain sank down to, 
or below, the level of the opening, and became pale in color. In the 
course of a short time the animal was roused, and irritated. A blush 
seemed to start on the surface of the brain; the vessels of the pia 
mater became fuller and fuller, and of a bright arterial hue. The con- 
trast between the appearance of the brain during this state of functional 
excitement and the previous state of quiescence was most striking. The 
more the animal was excited, the fuller of blood did its brain appear to 
become, and the higher did the exposed portion rise above the general 
level. When the animal was allowed to return to its state of repose, the 
brain again sank down, and reassumed its pale aspect." f 

I have dwelt thus far upon the subject of rest considered as a physio- 
logical agent almost exclusively, and attempted to show how important a 
feature its production appears to occupy in Nature's plan of development 
and for sustaining health. This X have felt to be necessary as ati intro- 
duction to the consideration of rest as a therapeutic agent. 

Mr. Prescott Uewett, who preceded me here, has dwelt so largely and 
BO comprehensively on injuries to the head, that I am almost ashamed 
even to approach the subject, except as an admirer of the monument 
which he has raised to himself. I would, however, solicit the attention of 
the profession to what observation has taught me — that recognised lesioTis 
of the brain and its membranes, associated with blows upon the head 
(whether the cranium be fractured or not), do not generally, or as a prin- 
ciple of treatment, obtain that extent of mechanical rest which is consist- 
ent with the expectation of perfect and comiilete structural repair. This 
error in the treatment of such cases is one of the chief sources of the dis- 
eases of the brain and its membranes which we meet with in practice. I 
must also claim your indulgence to employ a very short time in reference 
to the subject of what we term concussion of the brain or spinal marrow, 
for the purpose of indicating the value of rest with respect to injuries of 
those parts when they have been in a state of concussion. 

If a man receives a severe blow upon his head which produces symp- 
toms of compression of the brain, we at once admit that the cause is suffi- 

* Farther experiments of Mr. Ducbom ahowed that this fnlness of the veins was 
oansed bj the teinparary interfercnoe with respiration due to the admiDHtralionot the 
ohloToForni ; as soon aa the dog was perfeotlf under the inflaeace ol the lUUDsthetio, 
the brain became palo, veiy much as during^ sleep. — [En.] 

i A fall occounC of these and other oon&rmrktaiy eiperinents and ofascrvntioni was 
read at the British Associatiaa Moetiog at Ostord in I8IJ0, and was BnUwqnently pub- 
lished in the Guy's Hospital Roporte, 3d Her. vol. vi. p. U9. As Mr. Power has re- 
marked in the Pnnoiplea of Human Fhysiologj, of which he is tile editor. 8th edit. p. 
75J, Mr. Durham's factn have been corrohoratpd by some observations mudo by Dr. 
Ha^hlinftg JoRksoo, Royal Lond. Ophth. Ho.-3p. Rep., on the ophthnJmosoopia oundition 
of the retina daring sleep. In these the optic diso was fonnd to be whiter, and the 
aelghboriog part of the retina more anaemic, than in the waking stite. — [Ijii.] 



30 ON THE THERAPEUTIC 

oient to produce tbe aymptoms; and as long as tliese symptoma rt 
' we are disposed to think that the cause or its effects continue. I 

I *PP'y t''*' same kind of reasoning to the subject of concussion of the 

II There are one or two cases to which I have before alluded, showing clear]; 

1 that a patient may die with symptoms only of concussion of the brain;' 

while the real cause of death may bo laceration of the brain. Another 
cause of death with sj-mptoms of concussion will occasionally be found. 

I For instance, a patient has had a severe blow upon the top of the head, 

and dies; and yet no structural lesion or cause of death is found at tt 
post-mortem examination. But I suspect that, if in such cases the I 
,' of the brain be carefully examined, the cause of death may be diaoort 

Ij in injury to the (ilamenta of the pneumogastric nerve, near their oriciitsl 

from the medulla oblongata. Some years ago, I clearly made out Hiia 

! lesion in a case of concussion which caused the patient's death; the onljr 

indication of local mischief which I could discover was the laceration of 
Bome of the filaments of the pneumogastnc nerve. 

In concussion of the brain, as soon as the blow which strikes the sknll 
has caused the symptoms of concussion, the physical disturbance of the 
l' brain, whatever it may be, has been produced. The continuance of the 

|l symptoms must depend on the continuance of the structural or molecular 

disturbance. But the actual condition of the brain is not known, and, as 
I, far as 1 am aware, has received no clear explanation. Experience shows 

C that the symptoms mav last a long or a short time, varying from days to 

weeks, if you ask wiiat is the pathological condition of the brain in a 
state of concussion, I believe there is no satisfactory answer to be given; 
. but the generally received opinion is that it results from disturbance of 

the vascular system of the brain. I cannot conceive it possible that & 
y long continuance of the Bymptoms of concussion can depend upon ai 

' temporary error of this kind; 1 think it must depend upon sometMi 

',[ more intimately associated with the structure of the brain itself. One 

!'; the most iniportant results of concussion of the brain is " collapse," 

•'shock," employing that term as we employ it in cases of local injury 
I the exterior of the body in which the structures are not destroyed, bi 

' bruised or concussed. That the function of the part is rendered very tn 

perfect, is evidenced by the insensibility of the bruised skin, and its cott 
ness or diminished temperature. These conditions of the Jntegumei ' 

, may continue for some time, but ultimately, without loss of structure 

' function, the recovery is completed, although it maybe deferred to a c< 

siderable period after the accident. In the latter case of external braise, 
before and until the recovery is complete, the sui^;eon secures as much 
rest as possible for the injured parts, not allowing them to be moved or 

i; stretched. Relying chiefly upon Xature's own efforts to repair the injury, 

he employs but slight means to prevent the total death of the part — to 
help, if need be, the reaction or return of function, and to anticipate the 

I occurrence, or resist the effects, of inflammation. 

I Now, with aU due deference, I venture to think that the considera- 

tions applicable to external injury ought to indicate the principles of 
treatment to be adopted in c-ases of concussion of the brain. No doubt 
our duty should lie in this: to give the brain absolute rest: to rely on 
natural reaction, or Nature's power to repair the injury or disturbance; 
to nvoi<l stimulants, which excite quick reaction, and have a great tendency 
to do mischief, as much as possible. I suppose that a more serious error 
can scarcely be committed by any surgeon who is attending a 

I of the brain than to hurry on reaction by excessive stimulation. Wha^- 



oonensBion , 
0. What^H 



L 



INFLUENCE OF REST. 31 

ever llie ilerangement of structure may be which coexists with this con- 
dition of concussion of the brain, the structure itself is undoubtedly de- 
teriorated. If that be over- stimulated through the medium of excitants, 
such as brandy and ammonia (sometimes given in unmeasured quantities), 
the whole tendency must be to do harm at the period of reaction. Should 
we employ stimulants in that reckless way in the case of external bruises? 
If not, then I see every reason why we should not adopt such a plan in 
the case of the more delicate and highly vascular structure of the brain. 
Let us keep down any excessive temperature by the local application of 
ice, avoiding animal food, except milk in a delinite quantity. 

I make no pretensions to anything new in this statement. It is only 
a simple mode of considering such cases, and is, I believe, the true inter- 
pretation of what may be required to guide us in our principles of treat- 
ment of concussion of the brain. Sucli a disturbed brain is defective, if 
not in structure, certainly in its vital endowments, and is therefore 
unequal to even its ordinary duties. It recovers itself slowly; it then 
soon becomes fatigued from use; and if claims are made upon it too soon 
after the injury — that is, before the structural and physiological integrity 
is reacquired — the patient is very likely to suffer from serious disease of 
the brain. Cerebral exercise or mental occupation should always in such 
cases be short of fatigue. The brain requires absence from occupation, or 
fv-rf, for its complete recovery, and this should be in proportion to the 
severity and duration of the symptoms of concussion; in fact, the length 
of time which has been required by Nature for the repair of the injury 
must be in proportion to the severity of the local injury. 

The intention of these remarks is to secure due and continued rest to 
a brain which has suffered concussion, and to avoid the too early return 
to occupation, which leads, or may lead, to more obvious and serious 
chroniclesions, such as failure of mental powers, softening, chronic in- 
flammation, extravasation of blood, &c. All 1 have stated is analogous 
to what is observed in collapsed or bruised parts upon the exterior of the 
body. Thus, when those external parts have apparently recovered from 
the immediate effect of local injury, they are likely, if too early or too 
much used, to become painful — suggestive of need of rest — and to assume 
a chronic inflammatory condition, resulting in local thickening or ulcera- 
tion. The surgeon ought most circumspectly to guard the brain in this 
state of concussion, keepitig it most carefully under his professional sur- 
veillance and protection during its prolonged convalescence. 

Every experienced surgeon will support the opinion that a great many 
of the chronic brain affections which he meets with in practice are the 
result of local injury. A transient shake of the brain, slight or severe 
blows, a full upon the head, the immediate effects of which having passed 
off quickly, may have been almost forgotten ; or a sudden rebound or 
recoil of ihe brain, as in railway collisions, produce a condition of confu- 
sion for a short time, and are then thought of no more. Again we often 
hear of sudden deaths occurring a lonj^ time after concussion of the brain. 
I would suggest, then, that we ought to consider a brain which has been 
subjected to concussion as a bruised brain, not necessarily accompanied 
by laceration of substance or extravasation of blood, but as having suf- 
fered molecular disturbance in its exquisitely delicate structure. In cases 
of injury of what may be called the coarser structures with more simple 
functions attached to them, we see that without perfect restoration of 
the structures, their functions are not elBcIently performed. Such soft 
Darts hsvlnti; simple functions require weeks or moiiLhs, or longer, for 



'eierenc* 
ingfiOH 

bablyclH 
laseof 

: hud 



32 ON THE THEEAPEUTIC 

tlieir complete repair; surely, then, we ought not to deny the I 
and proportionately much longer time for the repair of the more deltcttt^ 
brain tissues: a repair, be it remembered, which cannot be acconipliEhed 
by any direct aid from the surgeon, but only by Nature herself employiiij; 
her chief agent— Rest. 1 believe that if this principle be adopted by Hur- 
goons generally, and the plan carried out, we shall not witness so tnftny 
ehronic diseases of the brain. 

I have thought it right to make these brief obsen'ations io referenc* 
to concussion of the brain. I will now add a few words respectittg O 
cussion of the spinal marrow, in which a patient may experience (" 
and temporary numbness, or inability to control his legs and am 

condition, I think, more frequently met with than formerl}-, probably C! 

account of the prevailing kind of railway accident. I will state a ca90 of 
concussion of the spinal marrow thus: — 

A gentleman falls, without violence, with his bock upon the hanl 

S'ound oreoft turf. There is no mcntul confusion, no cerebral disturbau^ 
e feels a transient, peculiar sensation — " pins-and-needles "■ 
and feet; he gets up; walks or rides home; feels little or noii 
makes arrangements for the morrow; but in the morning is unable to g_ 
up, because, iie says, he is in pain all over; he feels sore and stiff, juat i 
if he had been bruised, making it painful for him to move his limbs. 

What has happened in this case ? It is possible that the spinal 
marrow, obeying the law of gravitation, may, as the body falls, precipitate 
itself in the same direction, fall back towards the arches of the ver< 
tebrfe, and be itself concussed in tiiat way. Or the little filaments of the 
sensitive and motor nerves, which are delicately attached to the spinal 
marrow, may, for a moment, be put in a state of extreme tension, because, 
as they pass through the intervertebral foramina, they are fixed there by 
the dura mater; and if the spinal marrow be dragged from them, the 
intermediate parts must nei-essarily be put upon the stretch, producing at 
the time the " pins-and-needles sensation," and also explaining the symp- 
toms felt oil the following day. He has not caught cold; he has do 
rheumatism; nor has he been bruised. The stifTness which he feels is not 
the result of the local injury. He has received no blow where the pain is 
experienced. No such explanation will apply. These symptoms must 
all depend upon something which occurred wheu he fell. Has he stretched 
the trunks of the nerves, or the little fdamenta forming the roots of the 
nerves? or has the spinal marrow itself suffered molecular disturbance? 
No doubt that sensitiveness of th« surface, which creates paii 
touched, and the stiffness which he experiences, are the result of soi 
thing which has disturbed the sensitive or motor nerves conjointly 
individually, according as the function of one and not the other has be 
disturbed; or the mischief may have occurred in the interior of the spi; 
marrow. It is impossible that these symptoms could be the result of any- 
thing but some such structural disturbance; and they are, to my mind, 
the evidence of decided injury to the nerves or marrow, althougn what 
that injury may be is not ascertainable. It is the same when the spinal 
marrow has been impaired by a blow, or direct force; by a shake or a to- 
and-fro motion, such as occurs in railway collisions, in which the marrow 
is least efficiently defended from external injury by the mechanical con- 
trivance employed in the construction of the vertebral column. The de- 
terioration of function which follows such accidents must be the effect of 
some kind of structural disturbance, for it occurs immediately after the 
blovf. It is a shock to the spinal marrow. At least, that ' ' 



spinal 



I 



reasonable light in which to consider it, especially with reference to the 
proper treatment'. 

The object here should be to give the marrow rest from occupation by 
not allowing the patient to take walking exercise at all; or if at all, the 
exercise should be short of fatigue; certainly he should not be advised to 
endeavor to " walk oS " his condition. There seems to be an impression 
in the minds of the n on -professional public that if a man receives a con- 
cussion of his brain or spinal marrow, or has a fall which gives him the 
same sensations, the best plan is to " run it off." A little while ago I 
had occasion to see a gentleman in the country, who had a fall upon his 
back at Epsom a few years since. The accident occurred from some scaf- 
folding giving way. When he fell, he experienced the sensation of pins- 
and-needles in his legs. He was a most energetic man, and he set off 
and ran six miles. When a boy he had been told that if he ever had an 
accident of that kind he should run it off as quickly as possible. With- 
in a very short time he began to have Bninal-marrow symptoms, which 
have resulted in complete and irremediable paraplegia. 1 firmly believe 
that if, upun receiving the injury, he had gone home, and kept himself 
quiet and not used the spinal marrow for a considerable period, he 
would have been well at this time. It is this misdirection, this misuse 
of early exercise after a shock to the spinal marrow, that leads to more 
serious mischief — to a chronic inflammation or softening of the 
which probably remains incurable. 

I have seen many such cases of concussion of the spinal man 
some of the patients have been thought to be malingerers. A patient who 
baa suffered such a concussion perhaps continues his active exercise, takes 
no rest at all, or, after two or three weeks of rest, he may begin to resume 
his ordinary duties, but with some little difficulty in walking. In a few 
days, or a week or two, it is observed that the legs become feeble; there 
is a little jumping of the legs at night on going off to sleep, some sense 
of coldness in the limbs, slight dulness of sensation in the surface of one 
or both limbs, or of parts of one or boll limbs. Then, perhaps, he is or- 
dered by his surgeon to increase his exercise, so as to overcome the 
effect of disuse, especially if he is thought to be a malingerer. This in- 
creases the exhaustion of the spinal marrow, and the plan, if persevered 
in, most probably leads to paraplegia. 

The confirmation of the accuracy and applicability of these views is, 
I think, made apparent when it is added, that all these morbid effects of 
concussion of the spinal marrow are to be prevented, relieved, or cured 
by due and long-continued rest, 

The experiment to which I shall now allude proves our capability of 
exhausting the excito-motory functions of the spinal cord. A person re- 
ceives a fracture of the spine, which produces the destruction of contin- 
uity of the spinal marrow in the dorsal region, leaving a portion of the 
spinal marrow perfect below the line of severance. If you tickle his feet, 
you excite involuntary movements in the lower extremities, through that 
exoito-motory function which is apparently dependent upon the gray mat- 
ter in the centre of the spinal marrow. You continue to excite by this 
means the movements in the muscles of the toe, foot, or leg, for some 
lime, and you mention the patient's case to some other person, and ask 
him to go and see a specimen of excito-motory function. He goes imme- 
diately to the patient, tries the experiment, but fails; he cannot excite 
motion. You see the patient again ir a few hours, or on the following 

^apd perform the experiment successfully. The movemeuts are visi- 



OK THE THEBAPEUTtO 

ble, continue for a short time, and then cease; on the next day, perhi 
they reappear. Here, then, we have evidence that by over-excitation^' 
which is equivalent to fatigue, we exhaust or destroy for a time the true 
function of the spinal marrow; and I accept the result of the eiiperiineDt 
as an indication that by over-exertion, after concussion of the spinal mar- 
row, we may injure it by requiring it to do more than it is competent to 
accomplish without fatigue. 

The obvious intention of these remarks is to suggest that 
concussion of the spinal marrow by accident, it should have 
than is usually allotted to it, in order that it may not suffer physiologit 
exhaustion by premature and too vigorous exertion before its structi"' 

e repaired themselves. Experience distinctly points to tbi' 
' ■ nth: 



e observe that after 









: in cases ot 
e more ^^^ 
ihysiologio^^H 
:s structm^^H 
recomroend^l 

ir t.wn. «n(*^^ 



;1 



patients may recover perfectly. On the other hand, recovery is some- 
times rendered incomplete by the persistent loss of sensation or wasting 
of some part. This persistent loss, I apprehend, has reference to some 
distinct defect of structure in some minute filaments either of the spin&l 
marrow or the nerves themselves. 

I thought I could hardly pass over the subject of concussion of the 
spinal marrow without adducing these few observations, which I think 
have an important bearing on the function of the spinal morrow, 
manifest the necessity for keeping it in a state of rest after accident. 
trust also that these remarks will have a tendency to promote tmproi 
treatment of such forms of concussion. 

A few weeks ago a surgeon from the country came to my house witli 
Y* patient. He said, " I want to consult you about a young lady who has 
'•« diseased toe." With her was a relative, an elderly gentleman, a very 
kind-hearted man, who thinks himself a good surgeon, and goes i ' 
doctoring people, sometimes doing harm, and sometimes perhaps a 
deal of good. He is very fond of animals, and has a number of pets, 
ter I had examined, with the surgeon, the lady's toe, the elderly gentll 
man said, " Well, Mr. Hilton, what are you going to do to cure this youi 
friend of mine ? " I said, " 1 think we shall put a splint on the foot a; 
keep the toe very quiet, attend to her general health, and Nature, in i 
probability, will do the rest," 1 then said to him, " What led you to 
adopt the occupation of a philanthropic surgeon In addition to your c"' 
occupations?" " Well, -Mr. Hilton,*' he replied, " I wil! tell you. 
know I am very fond of animals. Some years ago I caught a live m 
in a trap. ! took it in my hand, and I said to myself, ' Poor thing! 
muat have suffered a good deal. You have had a severe laceration of your 
cheek; one of your eyes has been torn out; your skull has been broken, 
and, instead of ha\ing bone covering your brain, you have now only a 
thick dense membrane defending it.' Then I thought to myself, * 
mouse must have hud difficulties in the treatment of its injuries; and 
interrupting the relation of his story, he said, " I hop*" vou won't he 
fended at what I am going to say ? " " No," said I, " not in the least, 
" ^Veli," he continued, " I said to myself, ' Surely this mouse, although 
is cured, never had a physician or a surgeon! ' I quite agree with y( 
Mr. Hilton, that Nature is a very valuable surgeon." 

It would be well, 1 think, if 'the surgeon would fix upon his m 
as the first profesBional thought which should accompany him 
course of his daily occupation, this physiological truth — that Nature has 
a constant tendency to repair the injuries to which she may have been 
subjected, whether those mjuries be the result of fatigue or exbaustioa^ 



1 to 



35 

of inflaTnmation Or accident. Also tha.t this reparative power Iieoomea at 
oiice most conspicuous whpti the disturbing cause has been removed: thus 
presenting to the consideration of the physician and surgeon a constantly 
recurring and sound principle for his guidance in his professional prac- 

As illustrations of this truth take the following: — An extraneous body 
falls upon the conjunctiva; it is immediately pushed, by repeated involun- 
tary closure of the eyelids, towards the angle of the eye, close to the 
fiuncta lachrymalia; thence the lachrymal fluid floats it upon the caruncula 
achrymalis, where it becomes entangled by the hairs with which this 
structure is provided. So long as the Ritraneous body remains upon the 
conjunctiva, the redness, pain, &c., continue; but after its removal by the 
surgeon or N^ature, the whole of the inflammatory appearance vanishes, 
showing that it was only necessary to remove the disturbing cause. If 
there be a thorn in the finger, you have but to take it out, and the local 
irritation subsides. Suppose you have a fish-bone in the throat, exciting 
constant involuntary efforts of deglutition — as soon as it is removed all 
the disturbance in the throat ceases. An in-growing toe-nail produces 
g-reat pain and local inflammation: if you take off tlie edge of the nail, 
all these symptoms quickly vanish. Corns get well if pressure be taken 
from them. I admit that this is all very simple surgery, but it illustrates 
a principle — that if the local disturbing cause, whatever it be, is removed, 
Nature has an immediate tendency to repair the injury which has been 
inflicted, because she is enabled to adopt her own remedy. Rest. 

This subject at First sight may appear to have but a small application 
ID practice, especially when looked at through the biassed vision of those 
who think that in the treatment of disease or accident everything is to ba 
done by medical or surgical aid. But I feel convinced that, under the 
mast favorable circumstances, all that any of us can accomplish is to give 
rest to the parts, and enable Nature, through her own efforts, steadily to 
play her part, whilst we, as Nature's willing servants, act in the hope i 
that, by the use of appropriate niechanical applications, aided, if necea- 
aary, by soothing medicines, and by the use of properly adapted diet, we 
may facilitate her efforts to repair the injury she may have suiitaincd. In 
fact, nearly all our best-considered operations are done for the purpose 
of making it possible to keep the structures at rest, or freeing Nature 
from the disturbing cause which was exhausting her powers, or making 
her repeated attempts at repair unavailing. The operation does not cure; 
it only makes recovery possible, where, without the aid of the hand or 
head of the surgeon. Nature would have ceased her competition with the 
results of the injury, or succumbed to the exhausting influence of dis- 
ease. In aneurism — 1 think I am not iu error when I say that aneurism 
is cured by rest, and not by the surgeon — the surgeon takes care to stop 
the blood, or to moderate its flow; Nature herself actually cures the dis- 
ease by rest. So in all operations for hernia, the object is to give the 
intestine rest and freedom from pressure, both immediately after, and for 
a long time subsequent to the operation. Most of us now act upon this 
principle. We take care not otdy not to disturb the intestine by purga- 
tives, but we give opium to arrest peristaltic action. We know that Die 
gut has been damaged in its function and structure, and will not bear ejt- 
ciloment; that it requires re.st and quiet to enable it to repair itself. 
Sometimes we carry this so far at Guy's Hospital, that one of my col- 
leagues, Mr. Birkett, mentioned to me that in a case of operation for 
■Irangulated hernia, the bowels had not been opened up to t' b twenty- 



86 OW THE THERAPErTIO 



lai 



Bret day, and the question was asked, ^^ What shall I do ? Shall I give 
anything to the patient?" The reply was, "I think not; "and in the 
afternoon of the same day the bowels were well relieved. In chronic laryn- 
tis, cured by tracheotomy, the cure is not effected by opening the 
arynx, but by giving the larynx rest. The operation is performed in 
reference to these two circumstances — in reference first, no doubt, to 
securing the continuance of life by allowing the patient to breathe 
through the tracheal tube; secondly and ulteriorly, the object is to give 
rest to the diseased part. In the performance of tracheotomy for disease 
of the larynx, the surgeon never touches the disease at all; he merely 
enables the patient to breathe through the tracheal tube, and diverts the 
stream of air away from the larynx, thus giving the larynx the oppor- 
tunity of recovering itself. It is marvellous to see what happens in a few 
houra after the trachea has been freely opened in cases of traumatic in- 
jury to the top of the larynx, such as occurs from the accidental local 
application of scalding water. 

And hero I might remark upon the striking difference in the success- 
ful results of tracheotomy in CAses of traumatic injury to the upper part 
of the larvnx, as compared with the want of success of the operation in 
oases of dtnhtlioria or croup. In the latter cases the patient may have a 
tube introduced into the trachea, and may breathe through it for a con- 
sidorablo time, yot tlie diseased condition of the larynx remains, and is 
often fatal. It is not like tlio simple effect of a local injury: the seat of 
tlio local injury being kept quiet, tlie inflammation subsides, and the 
larynx rapidly roinwers; winlst in the other case, of diphtheria, whatever 
may be its cause, it still persists. Hence tracheotomy has not been suc- 
cessful as a curative operation in such cases. 

I may mention the case of a patient u}>on whom I performed the 
o}H»ration of tracheotomy twelve or thirteen years ago, to prevent suffoca- 
tion fn>m syphilitic numeration of the larynx. She has lived by breathing 
through the tube ever since, soarooly any respiration going on through 
the upiH'^r part of the larynx, the air wlno)i jvasses through this not being 
sufficient to bend the flame of a candle. 1 nee<i scarcely add, the voice is 
totally li>st, but slie is not dis[H>seii to have any further operation per- 
fonutnl in rt^fereniH^ to clearing the upjx^r part of the larj-nx, and the tube 
IS still worn in the trachea,* 

8i\ again, if a iH^^rtion of l>one he pressoii in u^^on the skull, you have 
only to rtMuovo it and give the brain rest, and the brain will repair itself. 
It is not the owration that cures the injury to the organ, but, by remov- 
ing the disturoing oaust\ the brain reemvrs itself. 1 might allude also, 
in the same spirit, to the o|v>ration of lithotomy. Stone is not the dis- 
ease, although it is the eaust^ of the symptoms. The jvitient does not 
ci^mplain of stone, but of the ^viin and irritation which the calculus in- 
duvvs within the bladder. If a }vitient has a stone in his bladder, it does 



* I bav^ Uurl^r \ April. lS7i$> «iM»n th\« itati^^V SIh» i» now idxty tmucb oi ag«, it 
t vtoiVT-oiirbi vx>Ar» nitKyk trftoh^^om^' w;m )vrf\\rm<si fv^r iW relief of Iftnmgitia, 
piv^Kikb^T «'^ a ^phiUlto natuiA Sh^" h*» >rom a f xitv ^v'^UnQv'vus^ ; ber txnoe as soch 
i« qiiit<» p.VA^ but br a b«.vinie wbi»|vr axvl mv>T^ni^nli« wf ber Up« »b^ mmk«a boa^ 
iaii^U|nbh<t. .V* Mr. HU;«>n ba» obMsrcKK)^ it i» t^^ b<»T xm?' snukll siae. and tberefore 
tnuUI mtpirM^M^ iMxsljk tbal b^^r baxit>^ Uv<>l ««> K^n^ w !<» hi^ aiiribvv^i. On recently 
cbjoxpi^r b^'r luWk ttM" ^YtrnMl opening and b^'x vmt jomaU tx^ob^^a only admitted a 
tub«i\f a cbikr« «i»K and vj^bowinj* ib^ ra^n^ of ^v>d »av<fr tttNv' ibe patient infonned 
sne tbat the lube I ^^moTy^t ba.) «a«t<fvt MX r^Mun^ Tbe la|^e-bx>K<>a w«i>r alnciaa won 
t>Tvvx|:^. bni the r«M< ef tbe tube •»pw)j' at^N^M.- ;Klvl 



INFLUENCE OF REST. 37 

not necessarily follow that an operation should be performed. The same 
symptoms are sometimes produced when there is no stone at all. Perhaps 
you have a little ulceration of the bladder or prostrate, with all the indi- 
cations of stone. No surgeon can tell whether it is stone or not till he 
has explored the bladder. Those are the symptoms complained of, and 
by removing the stone you simply make it possible for these symptoms to 
be subdued by giving the parts rest. I have a gentleman under my ob- 
servation who has had stone in the bladder during many years, probably 
for more than twelve. I discovered the stone ten years since. He is now 
seventy-four, and the only inconvenience he experiences is occasional and 
slight hemorrhage from the bladder. He is always relieved by maintain- 
ing the recumbent posture. Having recently treated him for nasal polypi, 
I asked him, " How is the other affair ? " " Oh," said he, " I have nothing 
the matter there, as far as I know; I am quite welL" Stone, then, is a 
disease requiring operation, because it induces a derangement of the 
structure which produces certain painful symptoms, and by removing the 
cause the part gets well — first, through the assistance of the surgeon, but 
ultimately through the medium of Nature. 



38 OK TRS TUEBAPEUTIO 

This hook IS fit* projir,'^^ i*f 

OOPER M2DICAL CGLL;:GEf 

SAN FRANCISCO. CAU 

ud i* ^'"^ ^" f^ fv>//»»#'. ^/ h'Otii the 
iby*i"^'' '^ ' •' ''•/ '' •/' pr»*si»,i or 

LECTURE IV. 

Ooacfiilmble I^ymph a memoB for Seeming Best to Inflamed Serooa and Muooob Mem« 
bianes — Pain with Increase of Tempeiatore a sign of Inflammation in the Part 
where it is Felt — Dia^oetic Value of Sympathetic Pain — Disesae of the YertehnB 
Indicated hj Pain over the Lower Part of the Ahdomoi and Pnhes — Knowledge of 
the Aocnrate Distrihation of the Various Nerres to the Head and Ear, Leading to 
a Diagnosis of the Distant Diseased Oigans causing Sjmpathetic F^un in thoae 
Parte — Pain between the Shoulders an Indication of Visceral Disease — Pain OTer 
the St<Mnach in the Begion of the Cutaneous Dirtiibution of the Sixth and Seyenth 
Donal Nenres a Sign of Vertehnd disfaae 

In mv last lecture I said that I thought it would be well if every sur- 
geon would fix this upon his memory, as his first daily professional 
thought, that Nature when undisturbed has a constant tendency to repair 
her own injuries, whether those injuries be the result of fatigue, of acci- 
denty or of inflammation. 1 had proposed to extend these observations to 
the consideration of the means adopted by Nature to obtain a proper 
d^ree of rest in her affections of serous and mucous membranes after 
they have been the subjects of an inflammation. Although time will not 
allow me to do justice to the subject, I cannot pass it over without a few 



Serous membranes are secreting and absorbing organs. If a serous 
membrane be wounded, coagulable lymph is poured out, and it forms a 
temporary splint untU the original structures repair themselves; in this 
way the inflammatory effusion produces a certain degree of rest to the 
original structures, and thus contributes to the work of reparation. The 
inflammatory effusion forms no necessary part of the ultimate bond of 
union: it merely holds the parts firmly in close apposition, and keeps them 
so until the union is perfected; and when the union in the original tis- 
sues is rendered complete, this temporary medium^ or splint, employed bv 
Nature completely disappears^ Thus we find that when a serous mem- 
brane is infiamed/the lymph which is poured out (as the result of a wound 
at least) keef« the parts in an accurate position and maintains them so 
until Nature has healed up the wound in the original tissues, when the 
Ivmph is absorbed. This is analogous to what we see in the case of frac- 
tured bones. ^Mlen a fracture is not nicely adjusted, or much disturbance 
has taken place. Nature throws out a large quantity of new material, 
termed callus, which keeps the fractured bones accurately in position for 
a considerable lensrth of time, until they have re|MLired' themselves, and 
when they have achieved that object, the callus entirely disappears^ 

This subject, perhaps, receive* its best and most practical illustratioD 
In cases of wounds to the viscera, an»i, no doubt, when locked at in this 
Kcht, it suggests to every surarecn the great impn>priety of doin^ anv- 
tninsT whidTat all tends to disf^rb the parts, in wounds of sercus mem- 
fanaes. This subject, however, I canr.ot enlarge upon at the present 
time. I would ask yoa to suppose a serous membrane intUmed. What 
happens when this takes place * When it is not traumatic, but depend- 



ent upon some internal cause (quite irrespective of any direct local lesion), 
almost immediately a considerable quantity of lymph is effused, and this, 
after a time, coagulates spontaneously upon the free surfaces of the serous 
membrane, and thus at once prevents the ill effects of further friction. 
If inflamed serous membranes are allowed constantly and freely to rub 
upon each other, it is impossible but that the irritation must be consid- 
erably increased; but by the coagulation of the lymph upon the free sur- 
faces, they are protected against direct friction — suoh is the case in the op- 
posed surfaces of the abdominal viscera and their parietes, or in the heart 
and the opposed surfaces of the pericardium. As soon as the lymph is 
poured out, the serous membrane, as far as it can be, is put in a state of rest, 
or freedoTn from friction. When the origiual disturbing cause has become 
exhausted or removed, then I apprehend that, in consequence of the rest 
whicli the serous membrane has experienced through the effused lymph, it 
is able to recover or resume its normal function of rapid absorption. Thus 
we Bee the effusion apparently performing two purposes — preventing the 
friotion between the two inflamed surfaces, and, that being accomplished, 
giving Nature a fair chance of removing the original disturbing cause. 
Here the rest has ho far contributed to the restored integrity of the serous 
membrane, that it has enabled it to recover its natural function — that of 
rapid absorption, and the lirst act of its renewed health and vigor is to 
absorb that effusion which wus the primary result, whatever the disturb- 
ing cause might have been. Thus, then, the lymph prevents friction, and 
ftids absorption. Lu this way, 1 apprehend, Nature does her best to repair 
injuries, wliether they be the result dimply of accident or other excitants 
of the inflammatory condition. 

I would ask you to bring to your recollection, for the moment, what 
happens when a mucous membrane ia Inflatned. When a mucous mem- 
brane is very much inflamed, coagulable lymph is poured out upou its free 
surface, and from that moment the menibrane is defended from the influ- 
ence of external agents. In the case of the lamyx and trachea, it pre- 
vents the contact of the irritating external air passing over the inflamed 
surface, and in that way gives the mucous membrane rest. And when the 
disturbing cause, whatever it may have been, has disappeared, the mucous 
membrane having had this advantage of rest, the secreting glands and 
follicles recover themselves, and pour out a. fluid between the mucous 
membrane and the effused lymph; tho latter is thus separated, pushed off 
from the internal surface, and becomes expectorated. This is seen in the 
little preparation before me. Here ia a portion of lymph partially sepa- 
rated by Nature, as the result of the rest which the mucous membrane 
aeema to have obtained by the effusion of the lymph. These glands and 
follicles, when inflamed, do not secrete their fluid normally, either in 
quality or quantity. By means of rest, however, they have the opportu- 
nity of recovering themselves, and when they have done so, their abun- 
dant and natural secretion is interposed between the mucous membrane 
and the lymph. The Ivmph is thus pushed oS, and becomes expectorated 
■^r swallowed. Sometimes, in the case of acute inflammation attackin— 



the mucous membrane of the intestines, you may see long tubular por- 
tions of solid lymph discharged from the bowels, having at first sight the 
appearance of the intestine itself; but, upon post-mortem examination, it 
will be found that the originally inflamed pordon of intestine has per- 
fectly recovered itself, and has pushed off the lymph from the interior, 
precisely in the same way that the glands secrete their fluids and push off 
the lymph from the interior of the larnyx and trachea. I cannot pursue 



40 ON THE THERAPEUTIC 

the subject further, but 1 thought it riglit to mention these circiimstanoes 
to sliow that & right interpretation of Nature's efforts demonstrates that 
when serous membranes and mucous membranes have suffered from a se- 
vere tnHummatory condition, tliere are indicationa of attempts on her part 
to secure rest to these membranes, and thus contribute to a favorable 

Aa a preliminary to my observations on the beneficial influence of reist 
in the treatment of diseases of the spine, it will be instructive to remem- 
ber that accurate diagnosis and early recognition of disease constitute two 
important steps towards successful treatment. It will be advisable, tliere- 
fore, that I should preface the subject of spinal aifections with some few 
clinical remarks on pain as a symptom of disease. 

When a patient is suffering from pain in any part, he is instinctarely 
inclined to believe that he must also be suffering from inRammation in 
that part. Fain, as we all know, is not by itself an indication of an 
inflammatory state, nor is redness, nor is swelling; for any or all of tbeoe 
may coexist without local inflammation. Increase of temperature or heat 
is the true sign indicative of a local inflammatory condition; and taking 
that as a single symptom, it is a most striking and valuable one in refer- 
ence to the diagnosis as to whether a part is actually in an inflammatory 
condition or not. For example, if we apply the hand to the surface of 
an ulcer, nothing is easier than to determine whether it is inflamed or 
not; its true character may be recognized at once. In the minds of some 
surgeons there may be considerable difficulty in distinguishing what is 
termed an inflamed ulcer from an irritable ulcer; both look red and con- 
gested, and both are painful: but by placing the hand upon the surface 
of the ulcer, and feeling the increase of temperature in it and its immedial 
neighborhood, the inflammatory nature of the looal malady is render 
evident. The real and essential pathological condition of an irrital 
ulcer I hope to prove to you before I have finished these lectures. V 
must also admit that the employment of the hand for the purpose 
recognizing increased or diminished or normal temperature is a matter of 
great importance in determining the stale of a diseased joint. It often 
happens that although a whole joint may be apparently unsound, yet 
there are certain parts of it which may manifest inflammatory symptoms 
more distinctly than others. These localities can be ascertained by the 
hand. This is useful knowledge, and clearly indicates the precise points 

where leeches, blisters, or counter- irritant a should be applied. Again, I 

would submit to you that if, in very young children, this little (oftentiin^^H 
repudiated) symptom of heat or increase of temperature had more cre^^H 
given to it, and was more frequently observed, its diaguostic value wotj^^^ 
soon be appreciated. Suppose a little child to be lame; it may be ve^^H 
difficult for the surgeon to tell with precisian the exact seat of tne cause; 
but if, with his mind intent upon what he is doing, he passes his hand 
carefully, slowly, and gently over the whole surface of the limb, he will 
detect, by the increase of temperature, whether or not there be an infiam- 
matory condition in any particular spot. It was in anticipation of what 
1 am about to state with regard to the true value of pain as a symptom of 
disease, that I have not deemed it out of place to make such elementkty 
observations. 

Pain in any part, when not associated with increase of temperature 
(the local symptom of local inUnmination) must be looked upon as eympk- 
thetic pain, caused by an exalted sensitiveness of the nerves of the p^i 
and it is to be regarded as a pain depending upon u cai 



m 



ite!^ 



INFLUENCE OF EEST. 41 

remotely from the part where it is felt. In availing ouraelves of these 
8o-calIeJ aynipathetio pains (and no doubt they are in a certain sense 
sympathetic pains), 1 should Uke to displace, to throw aside, the term 
"sympathy" as something too ideal, and would ask vou to consider such 
pains in their obvious, intelligible, and more natural relation. I would 
ask you to regard them aa resulting from some direct nervous communi- 
cation passing between the pari, where the pains are expressed and the 
real and remotely situated cause of the pain. 
' I admit that I formerly estimated this subject too lightly, so that if a 

patient complained of pain between his shoulders, or anywhere else, I 
never asked myself, What association of nerves will explain this pain ? 
But, beyond doubt, this is the proper way of regarding this question. 
If the hidden canse of pain be in any one particular spot, it is only bv 
tracing the nerves of and from that spot that we can hope to arrive logi- 
natly at the real cause of the symptoms, and so divest the case of ita 
obscurity. Applying this method to practice, it is through the medium 
of the distribution of the cerebro-spinal nerves of sensutionYthe tlftli nerve 
being the true cranial sensitive nerve) that we are enabled to explain 
those pains which are called sympathetic, but which result from a, con- 
tiimity of nerves between the cause and the effect, the disease and the 
symptoms. It is impossible, I believe, to overrate the practical significance, 
or over-estimate the value, of this simple statement regarding the relation 
of pain as a symptom of disease in forming the diagnosis of the kind of 
case in which pain forms a prominent symptom. 

When a patient complaining of pain applies to a surgeon, the surgeon 
ought to seek for the real cause. He ought not to be satisfied, as is too 
frequently the case, with saying, " Oh, it is rheumatism" {the favorite 
phantom). " You have caught a cold;" "you have been standing in a 
draught of air;" "it is the easterly wind, which has been lasting so long 
— wait till the wind changes." "It is gout." The patient says, " It 
cannot be; I live so carefully." "But," says the surgeon, "you have in- 
herited it from your father or your great -grand mot her; or you must have 
had a blow upon the part some time ago, which you do not recollect 
— that is all" 

Now external pain, or pain upon the surface of the body, if properly 
appreciated, may be considered as an external sign of some distant de- 
rangement. If the pain pei-sists — if it does not depend on any transient 
cause — it becomes necessary to seek the precise position of the pain; and 
as soon as wo recognize the precise position of the pain, we are enabled, 
by a knowledge of the distribution of the nerve or nerves of that part, 
to arrive at once at the only rational suggestion as to what nerve is the 
exponent of the symptom. By following centripetally the course of 
that nerve, and bearing in mind its relation to surrounding structures, we 
shall, in all probability — indeed, most likcly^ — be able to reach the origi- 
nal — the producing cause of pain, and, consequently, to adopt the correct 
diagnosis. 

Patients judge of the position of their own disease, most frequently, 
by the situation of the most prominent painful symptoms, or those most 
palpable to their senses; whilst we surgeons, relying upon our knowledge 
of the true cause of the symptoms, judge of the seat of the disease by a 
just interpretation of the symptoms through the medium of normal anat- 
omy. We know by experience that such symptoms may exhibit them- 
selves at a spot far removed from the actual seat of the disease. This lat- 
ter remark is peculiarly applicable and pertinent to diseasuB of the s^itis.. 






43 ON THE TUEltAPEUTIC 

In illustration of tliis, I may mention an instance that occurred to i 
some ye.Bsa ago in Guy's Ilospital. A patient was admitted, under mjr 
care, with disease of the spine. He had lost the [lowor of motion in his 
lower extremities, and his sensation was very much diminished below tha 
pelvis; but he complained of excessive pain over the lower part of the 
abdomeu and pubes. It waa there ho believed his complaint to be; and I 
failed to convince him that there was no disease at that spot. 

In this case 1 might incidentally remark on the close proximity of tlie 
two distinct nervous conditions of diminished sensibility and pain. Below 
the pelvis sensibility was verymucli diminished, but just above that point 
he suffered excessive pain. This is in strict accordance with what is ob- 
served in injuries of the spinal marrow, where a person may be coropletd] 
paralyKcd both as to sensation and motion; but a little higher up ~' ~ 
the original seat of injury, there may be exquisite sensitiveness, ca: 
the patient extreme pain. Let me illustrate the case in this way. 
pose a fracture of the spine, with complete loss of sensation, below i 
tain spot. A little higher than that spot the sensibility is not very dis- 
tinct, and, a little higher still, the skin is exquisitely sensitive. If the 
patient dies, we shall probablv find that the nerves that supply the slua 
where the pain was experienced are attached to the upper portion of the 
injured spinal marrow, near the seat of injury, which is in an inflamed 
tMsndition. This ia the reason of the exalted excitability of that part iin* 
mediately above the seat of the loss of sensation.* 

I tried repeatedly to assure the man that there was no disease where 
he felt the pain — that that was not the seat of his disease; but 1 failed to 
convince him. I ordered tartar-emetic ointment to be rubbed over the 
diseased portion of the spine ; but tlie patient would have it that the oint- 
ment ought to be applied where he felt the pain. He accordingly rubbed 
it in thoroughly over the lower part of the abdomen, amongst the hair of 
the pubes, and upon the penis and scrotum; and, I need not tell you, he 
suffered considerably for his scepticism and his obstinacy. Of course the 
pain was not in the slightest degree relieved. The pain in this case wsA 
situated at the lower part of the abdomen, over the pubes; but the re^ 
cause was the disease of the vertebne. After a time the man got per- 
fectly well, although he had been paralyzed, and nearly lost sensation 
the lower extremities, the treatment having been simply rest — nothi 
else — -and attention to his general health whilst lying in bed. 

When this patient was first seen by a surgeon, he was thought to 
laboring under some disease of the bladder and kidneys; for he had severe 
lumbago, pain over the bladder, and offensive urine. There had beeit no 

■ Ab ttuB area of hTpenesthesia may eiist very ahortly after the accident, when 
there has beon no tune fur infiammatiaD to have Boperveaed, there must be some 
other eipUnadoii for thig Hymptom. I tuumot da better thaa quote in Mc. Hilton's 
own woi^ another «iplanatioD given by himnelf in a cliutcixl leottu« (Oay'H Hoap. Bop. 
186S) OD a case of froctored spine, where thia hypenesllleaia was found to exist on 
admisfion immediately after the accident. 

" This sympl^im may, I think, be explained thus. Ton know that the lower yon 
get in the spinal canal, Uie long-or is the diBtanoe traversed by the ncrvcB which have 
cnme off from the iipinal cord before they enter the iDtiervertebral foramina Each 
pail of nerves is placed more otiliquely than the pair above It, and. to speak more pre- 
cieety with regard to the site of injury in thia cai^, the lower dor^ ncrv^a, after hav- 
ing' kft the cord, travel donnwardB an inch and a half or on inch and tbree-quarteta 
before leaving the spinal canal. Now. if a nerve in leaving the cnnal be prosed upon, 
an alteration in tlie perlormonoe of itt functioilB will, of coorBe. take place ; and this 
nlteratioa ia manifested by pain or increased aeiuiibility, which ia lotemd to the p«n- 
pberal diiUibalion of the nerve on the akin. "—[£d.] 



in^H 



J 



INFLUENCE OF REST. 



43 



) regards the spine. He was a maater 
id was monstrously conceited, thinking 
wrong'. When 1 explained to him, after 
ine was the cause of the symptoms, he 
I, and, without my knowledge, consulted 
■d him that liis spine was diseased. 



J y>in( 
Totl 



suspicion of anything wrong i 
painter and house decorator, a 
himself right and everybody els( 
careful examination, tnat the s 
was not saliaiied with my opinio 
Sir Benjamin Brodie, who also 

and told him that he must rest it by lying down. To this he then a 
sented. As he could not be controlled in his own house, I persuaded him 
to go to Guy's Hospital, where he got nearly well; but he wsa very impa- 
tient, and would not remain long enough under my care to be quite cured. 
He returned home, gradually iinprovetl, and was getting quite well, when 
aome pseudo-friend advised hydropathy and horactopathy — it did not 
matter which of the two — as "the thing" to cure him. After a few 
months he was perfectly restored, not by either hydropathy or homceopa- 
thy, but, no doubt, by Nature. The man, however, feels convinced that 
hydropathy and homoeopathy cured hun. 
It BO happens, gentlemen, sometimes that 
we do not get the degree of credit which 
perhaps belongs to us. Only the other 
day, I had a handsome present sent to 
me from a young lady of a pair of crutches 
which I had lent to her some four or five 
years ago. She had then severe disease 
of the hip-joint. 1 gave myself a great 
deal of trouble about her, and I believe 
I placed her joint in a comparatively 
healthy condition. Her note to me was 
— 4>er compliments, and she sent back the 
cmtchea, having got well after five 
months' treatment under a distinguished 
rabber at Drighton. She had been under 
my care for a considerable period, and 
no doubt she completely recovered by 
five months' further rest and quiet at 
Brighton. 

Id elucidation of my conviction of the 
value of pain as a diagnostic symptom, let 
me put the subject in a plain and practical 
way. Vou know that the upper and anteri 

the auditory canal derive their sensibility from the fifth cerebral nerve, 
which has its direct nervous associations with the interior of the head, the 
forehead anteriorly, the temple, face, eyes, nose, teeth, and tongue; whilst 
the posterior part and the anterior part of the pendulous portion of the 
external car derive their sensitive nervous supply from the spinal nerves 
issuing from the spine between the second and thu'd cervical vertebrte. It 
may appear to some of my anatomical friends rather remarkable that I 
should have depicted (Fig. 11) the precise distribution of the two sensitive 
nerves supplying the exterior auditory apparatus. A curious ciroum- 
stsncQ enabled me to do so. Some time ago I was anxious to depict this 
piece oi anatomy from my own dissections, but I did not feel quite satis- 
fied as to the exact line of demarcation separating the part where the 
cervical nerve aupplied the akin of the ear from that where the fifth nerve 
wasi distributed. A short time since, a man, who is now undergoing the 
punishment of penal servitude, attonjpted to cut his wife's throat. 




r part of the external ear and 



When a patient, then, tella i 
his ear, we ouglit to ascertuin 
of the ear, or whether it is iti 



ON THE THEBAPEtTTlC 

drawing tlie razor across her neck, he divided the auricular branch of t 
second oervical nerve, and gave me the opportunity of aseertaiuing t 
distribution of that nerve. My dresser, as well as myself, pricked wid 
needle over the whole of the auricular surfaise, and ascertained minaUj 
'Gcise position of the loss of sensation (Consequent upon the divifi$ 
) cervical nerve; whilst the skin which retained its sensation iH 
iited with equal precision the distribution of the fifth cerebral i 
n the external ear, 

9 that he has earache, or pain 1 
whether it is pain upon the back part 
the auditory canal, or upon the anterior 
and lower portion of the ear; because it 
is obvious that the real cause Rii(st be 
wddely different in the two cases. If 
the patient has pain in the auditory 
canal, or the upper portion of the ante- 
rior part of the external ear, the p«in 
must be, without question (I hope 1 
shall not be considered oa putting tliia 
too dogmatically), the result of some 
irritation or diseased condition associ- 
ated with the fifth cerebral nerve, and 
this giies precision to further inquiry. 

Nou, we know very well that there 
IS ofttn a eimultaneous occurrence o( 
toothai lie and earache. The some nen-e 
supplying the auditory canal and the 
anterior portion of the ear supplies also 
the teeth; hence, in all probability, this 
associated pain. 1 think you may take 
a further step in the other direction, 
and say that earache is often accom- 
panied with a stiffness of the jaws, the 
fifth nerve supplying the maslicatoi^ 
muscles which fix the jaw and also ih%- 
articulation. So we know perfectly well that disease affecting any p 
of the anterior third of the tongue is a very common cause of pain m t 
auditory canal, the tongue and the auditory canal being sup]>Iied by li 
fifth nerve. These auricular pains are pretty constant in cases of nial% 
naut disease attacking the side of the tongue or the part towards t 
apex. Local morbid conditions are sometimes induced by irritating sea 
tions which result from the free nervous communication between the d 
ferent parts which derive their sensibility from the fifth nerve. 

A professional friend had an enlarged gland below the external ( 
The real cause of this was not quite apparent, and so he requested mc 
look at it. There was a slight discharge of morbid secretion in the iUT 
tory canal. We argued the question together, and I said: *' Very likfl| 
it may be the result of a decayed tooth. Irritation from it may De o 
veyed to the auditory canal, and induce this morbid secretion; that i 
bid secretion may produce slight excoriation; and that excoriati 
by lymphatic absorption, may explain the existence of the _ 

gland." The tooth was extracted, all the other local morbid oonditioil 
disappeared, and there was no recurrence of the local symptoms, 

In order to show the practical application of the views I have j 




temponL 



ON THE THEEAPBUTIO 

advanced, I may mention a case that occurred last year. A gentleman, 
a^d sixt y-three, came to consult me about an ulcer situated upon the left 
Bide of his ton^e. On examination, 1 found op elongated, very ugly- 
looking ulcer, nearly as large as a bitter almond, and of much the samo 
shape. The surrounding parts were swollen, hard, red, and much in- 
flamed, and a lymphatic gland was enlarged below the horizontal ramus 
of the lower jaw on the same side. I saw in the mouth a. rugged tooth, 
with several projecting points upon It, opposite the ulcer. I'his gentle- 
man observed to me, " Having suffered a good deal from earache on the 
left side for a long time, without experiencing any relief from medical 
treatment, it was thought that I must be gouty, and I went to a surgeon 
who treats gouty affections of the ear. This surgeon paid great attention 
to my ear, but certainly did not do it the slightest degree of good. I 
accidentally mentioned to him that I had for some time past something 
the matter with my tongue. On aeeingf it, he immediately began to apply 
caustic vigorously; moreover, not aatisfied with applying it himself, be 
gave it to my wife, that she might apply it at home. I have gone on in 
this way from day to day until the pa.iii in my ear is very considerably 
increased, and the ulcer on my tongue is enlarging: so I have come to 
you for your opinion regarding my state; for, to toll you the truth, I am 
afraid of a cancer in my tongue." I thought I saw the explanation of 
this patient's symptoms. The pain in the ear was expressed by the 
fifth nerve, and there was a rugged tooth with little projections upon It, 
some of which touched a small filament of the lingual-gustatorv branch 
of the fifth nerve in the surface of the ulcer. I detected ttiis little 
filament by placing upon it the end of a blunt probe. It was situated 
near the centre of the ulcer, and was by far its most exquisitely painful 
part. This exposed nerve oauseil the p&in in the auditory carial which led 
nim to go to the aurist, and the aurist, instead of confining himself to his 
own department, seized the tongue, put nitrate of silver upon the whole 
of the ulcer, and increased the mischief. I simply desired that the ulcer 
should he left at rest; that the patient, to avoid touching the tooth, 
should neither talic nor move his tong-ue more than necessary; that he 
should wash his mouth with some poppy fomentation, and take a little 
soda and saraaparilla twice a day. In three days about one-third of the 
uloer was healed up, actually cicatrized, the enlarged gland nearly gone, 
and the earache much diminished. 

This rapid improvement might appear something like exaggeration, 
bat bU surgeons know that the tongue has those elements within it which 
contribute to the most rapid repair of injury. T do not know any tissue 
that repairs itself more rapidly. It is abundantly supplied with capilla- 
ries filled with arterial blood, and has an enormous distribution of nerves, 
and these are the two elements that contribute to rapid reparation. It 
was quite clear that the treatment was in the right direction — vie., that of 
giving rest to the tongue and ulcer. After a few more daya 1 requested 
nim to consult a dental surgeon with respect to the propnety of taking 
oft the points of the tooth. This was afterwards done, and the patient 
soon lost his anxiety about cancer, his earache, and all his other sovcre 
symptoms. 

I mention this case to point out the value and importance of recng- 
niring the precise distribution of the nerves of any part where a patient 
ia suffering pain, I thought I might take the surface of the external ear 
SB a pretty accurate illustration of what I intended to convey. I^st July 
a patient came to me with earache. The pain was on the lower part of 



J^J 



46 



ITTFLtTEITCK OF EFST. 






the ear — not the upper part, nor In the auditory o&nal. Looking ftt i 
neck, I saw a little swelling there, and the patient said, " Oh, that U 
a kernel which cornea down sometimes. I liave been under mj 
care for some time for the ear, but am no better." It struck n 
kernel or gland, lying close to the second cervical nerre, was tj 
the pain. Hemlock poultices were applied over the gland, and 
or so the gland suppurated^ it was opened, and the painful symptoms ais- 
appeared. The patient had earache, and the symptoms were precisely 
expressed. There was no pain in the auditory canal supplied by the "'" 
nerve; the part of the ear implicated was that connected with the au: 
lar branch of the second cervical nerve. It was the recognition of t 
distribution of the nerves to the ear which gave me the opportunity^ 
detecting the real cause of the painfu] symptoms. 

These cases support the opinion that accurate information n 
the exact seat of pain is a very important step towards obtaining a o 
rect diagnosis. 

Again, with respect to pain upon the head. Suppose a person to o 
plain of pain upon the scalp, is it not very essential to know whether tl 
pain is expressed by the fifth nerve, or by the great or small occipital ? 
It be expressed by the fifth nerve, it must be placed somewhere in front H 
the head, for all the anterior and lateral part of the head is supplied by 
the fifth nerve. Thus pain in the anterior part of the head would sug- 
gest that the cause must be somewhere in the area of the distribution ( ' 
the other portions of the fifth nerve. So if the pain be expressed behiiu 
the cause must as assuredly be connected with the great or small ( 
tal nerve, and in all probability depends on disease of the spine 1 
the first and second cervical vertefcree. 

I add these illustrations in order again to fix in your minos tne impof^ 
tance of ascertaining the exact seat of the pain of which a patient may 
be complaining. It is not enough to say that he has pain upon his scalp; 
we must know precisely on what part of the scalp. It is not enough to 
say that he has pain in his car, but upon what part of the ear; becaoi 
onnected with these two different parts. < 
s to indicate the proper method of expkx 
n whatever part o( the body they may oooi 
re especially applied to the surface of the body. 
1 the surface of the body, connected with de- 
nscera, are of great and pressing interest to 
situated upon the surface of the body, i 
' an internal viscus, must be lool 
upon as a beneficent provision, enabling us by external pain to n 



behiiid|^_ 
I ocKnc^^H 
between 

ent may 

ough to 
becaoB^H 

expka4^| 
Y ooon^H 



there are two distinct 
advance these local illustrati 
tion of the causes of pain, : 
although my remarks are ht 

"Sympathetic" pains o 
rangements of the internal 
us. I conceive that pains 

ted with some abnormal 
s a beneficent provision, „ . 

information and to appreciate slight organic changes or derangements 4 
function of the internal viscera. Otherwise, and without some such n' 
erenee, it seems difficult to understand why there should be struotui 
nervous communication, and thence pain, upon any part of the surface 
the body, consequent upon the pathological state of internal vis 
internal parts of the body. 

Perhaps one of the most frequent of the " sympathetic " painf 
which occurs between the shoulders, or over the inferior angles 
scapulie. This pain must be connected with the distribution of some c 
the spinal nerves, because no other structures could express the pain, and 
no other nerves occupy that position, except the fourth, fifth, and 
sixth dorsal nerves, which are distributed over the inferior angles of the 
' scapuhe and interscapular space. Hence we must conclude that these,^ 



1 

L 



INFttrBirOB or REST. 47 

nerves are the immediate Beat of the pain. If we trace intornally tlio 
^jeat splanchnic nerve from within the thorax tlownwards, and Hiid it 
connected at its abdominal end with the solar plexus, thence trace its dis- 
tnbution to the stomach, duodenum, liver, aud pancreas; and if we follow 
the other or upper end of the same ^reat splanchnic upwards to the 
fourth, lifth, and sixth dorsal nerves, which give peripheral sensitive tila- 
ments to the interments, over the angles of the scapulie, to the inter- 
scapular spaces and the adjoining skin, one can well imagine (without go- 
ing into the question of how the transmission is made) that these nerves 
carrying the influence upwards and backwards may explain the occurrenco 
of the pains sometimes experienced in those external parts associated 
with abdominal visceral disturbance. 1 think it likely, then, that the 
pain which persons experience in disease of these viscera may be explained 
hy tire relative position of the great splanchnio nerve, communicating, on 
the one hand, with the solar plexus, and thence with these digestive or- 
gans, and, on the other, distributing its branches to the fourth, iifth, and 
sixth dorsal nerves. 

I have detained you with these general, but I hope pertinent, remarks 
on the subject of pain in anticipation of their more exact application to 
cases of well-delined disease of the spine. As in accidental injuries to 
joints, so in accidental injuries to the spine — as in diseases of the joints, 
so in diseases of the spine — mechanical rest is an essential part of the 
treatment, and on this account it is to be steadily pursued. And here I 
must state my belief that the niajority of the cases of primary disease of 
the spine in children, and almost all those in adults, are the results of 
exercise persevered in after fatigue — that is, after muscular exhaustion, 
or of accident, unacknowledf^ed or overlooked. This, I think, is opposed 
to general opinion, which affixes tubercular disease or scrofula to disease 
of the spine in children as its almost invariable cause. The earlier the 
detection of spinal disease the more successful will be its treatment by 
appropriate rest. 1 trust I shall not be thought too sanguine when I 
assert it to be my firm conviction that if diseases of the spine were recog- 
nixeA sooner than they usually are (and 1 am confident they may be), 
most of the cases would be cured by properly applied rest. If the dis- 
order is allowed to proceed until deformity is manifest, as in hip-joint 
disease, then assuredly the difficulties of the case are much increased, and 
the prospect of a favorable result much diminished, though not by any 
means destroyed. 

In the cases of inflamed joint, wc can discover its actual condition 
through the existence of a single local symptom — viz. increase of tempera- 
ture in the parts. So, in disease of the spine, there is one symptom which 
almost always stands out most prominently, 1 would almost say solicits 
our right appreciation of it, and that is, local and fixed pain upon the sur- 
face of the body, with or without exacerbations, local increase of temper- 
ature being absent at this spot. I feel quite certain that through the 
medium of this symptom, properly employed, me may be led to the recog- 
nition of morbid conditions of the spine long before there is any evidence 
tt disease by palpable deformity. 

Diseases of the spine may begin in the vertebne or in the interverte- 
bral substance — -I think, upon the whole, most frequently in the inter- 
vertebral substance, or where this is joined to the vertebra. This rather 
supports the view that diseases of the spine are very often the result of 
accident, because we know that in accidents, at least so far as I have been 
able to discover, the must frequent lesion in injury to the spine is a par' 



OTT THE THEEAPETJTIC 

! of the vertebra from the intervertebral subatanoej and T 
suspect the eame thing obtains ■with respect to disease of the spine.* 
The pain associated with diseased spine to which I now refer is found 
upon the skin supplied by the nervea which escape from the vertebral 
canal through the intervertebral foramina, close to the bones or interver- 
tebral substances, either of which, as I have said, may be the seat of the 
disease. It is upon the recognition and right interpretation of the cause 
of this pain upon the surface of th« body that we ought to place the best 
jjrospect of early and correct diagnosis in spinal disease. 

In disease of the lower cervical, dorsal, and lumbar regions of the 
tebral column, the pain is usually expressed symmetrically — that is, on 
' sides alike. It is often, however, not so when the disease lies between 
ciput and atlas, or between the first and second cervical vertebrae 
In all cases of symmetrical pains tfce cause is central or double, both sides 
being in a like morbid condition, whatever the disease may be. I have 
had this sketch (Fig. 13) made for the purpose of reminding you of tha 
method of proceeding in analyzing the cause of sj-mmetrioal pains. Sm 
will select two of the dorsal nervefc for the purpose of illustration. ^^ 

The positions of the sixth and seventh dorsal ner%-e3 are here indioatafl| 
as they are distributed to the skin just oT^9 
the pit of the stomach. If pain be felt at that 
part alike on both sides of the median line, 
these nerves become the only possible expres- 
sion of that cause, for there is no other struc- 
ture there situated which could manifest the 
pain By, then, tracing the nerves producing 
these surface -pains backwards to the posterior 
median line, and noting accurately the healthy 
i>r unhealthy condition of the various structures 
ni ar which these intercostal nerves would pass 
— such as the ribs, pleurte, aorta, ccsophagus, 
and other structures in the posterior mediastt- 
nutn,~we arrive at t)ie vertebra and spinal 
marron , and in that way, proceeding by the 
law of exclusion, we arrive at the diseased 
spine as the real cause of the pains experienced 
at the pit of the stomach. (See Fig. 13.) 

I w ould now point to the application of 
this method in practice, as illustrated by i 
case which I saw in 1851. On the 18th «' 
March of that year, Mr. Ray, of Dnlwidj 
brought me a boy, eight years of age, who Ii 
been suffering from severe pain during Janiu 
and February, 1851, just above the pit of ti 
stomach, and who used to walk about with b ^ 
8 placed over that region, with the body a little inclined forwards, ti 

*Th{B view, tbtt disease of tha spine ccimmeQccB at the junction of the Tertubll 
with the intervertebral iubslaoceg more freqnentl.v tliao in the intervertebral «l1^ 
stances or the vertebne themnelves, receives support from the fnct tliat the junntiov 
of a mora to a leas elaetio body ia the woaiteat spot, and therefore reoeivoli 
effect of a sunin. In a eomewhuC nimil^r moimer, niieniiBmB bo caiamonly ot 
at the Junction of an atheromaMus nitb the healthy part o[ aii artery ; snoh a spot, 
with it« sudden diminution of elaatlcitj, being DUtutall; unfitted to meet either a 

ii iuoreuied blood-pressure. — LED.] .^ 




INFLUENCE OF 



49 



if suffering from some irritation or pain of the abdominal organs, in which 
direction the treatment had hitherto been chiefly applied, but without 
much benefit. It was noticed that the pain increased during the maiiita- 
nancc of the erect posture, and that it was relieved by the recumbent 
position. The child was old enouffh to express a little of what he felt, . 
and when asked where the pain was, he put both hia hands over the 
stomach, where he had previously complained ot pain, and we observed 
that the pain was expressed on both sides alike. Mr. Ray and myself 
agreed that it was over the peripheral distribution of the sixth or seventh 
dorsal nerves. I requested that he should be undressed, so that we might 
be able to examine his spine. We then found that there was disease, with 
slight displacement, between the sixth and seventh dorsal vertebrae, and 
pressure upon these vertebne produced the pain in front. The child could 
give us no explanation of the symptoms. No known accident had oc- 
curred; but the seat of the pain was strongly marked by his placing both 
his bands in the position which I have described. The real cause of this 
patient's symptoms was now apparent, and by putting the boy upon a 
hair mattress on hia back— that is, by giving the spine rest — during four 
or five months, he got quite well, without any local application to the 
spine. The improvement began immediately on his lyin^ down, and it 
was steady and permanent. He only took some cod-liver oil. Since then 
he has had no return of his symptoms, and is now grown up a healthy lad. 

In this case, when we traced the dorsal spinal nerves backwards, or 
centripetally, we immediately arrived at the cause, and having recognised 
it, there was no difficulty about the treatment. In March, 18G0, Mr. Ra,y 
reported to me: He is now seventeen years old, is strong, in good health, 
has not any deformity, and has not tad any recurrence of his former 
Bymploms. 

1 mention this case for the purpose of showing that lapse of time, and 
the accidental casualties of life have not induced the reappearanoe of the 
disease, and of displaying how much useful information we may obtain 
in practice by a precise examination of the exact seat of pain under these 
circumsta nces. 

About two years ago Dr. Addison was requested to sec a gentleman's 
son, who was tnen at the Westminster School, and who, it was thought, 
had been suffering from something wrong in his abdomen, for he had pain 
at the pit of the stomach and occasional vomiting. Observing that the 
toi^ue and other circumstances did not indicate much serious disturbance 
in tneneighborhqodof the liver, stomach, duodenum, and other parts in that 
locality, ho suggested that there might be something amiss with the spine, 
I was therefore requested to see the lad with Dr. Addison. 1 found that 
he bad precisely the same pains {as those observed in Mr. Ray's case to 
which 1 have been referring) over the pit of the stomach, and taat he was 
«aaj/ when li/inff in bed. We believed wo recognized disease of the spine 
exactly between the sixth and seventh dorsal vertebrae. All the stomach 
me<licmes were entirely put aside. Ho was made to He down on a bed, 
Bofa, or couch in the drawing-room for two or three months nearly unin- 
terruptedly, and from that time he got perfectly Wflll. ' No cVJse could 
be made outfor the disease.of the epiirt;,exGept^tinit«Khe'Wife"a fall, grow- 
ing lad, it might have been induced 'by sitlifiy dally loo long, without any 
support to his back, upon aiform at the "Westminster School. The source 
of the mischief was here accurately diagnosed by obsen'ing the precise 
position of the pain. There was no evidence of a local inflammatory con- 
dition where, the pain was expressed. It was clearly a pain dependent 



50 ON TUB THERAPEUTIC 

upon a cause situated remotely from the point of manifestation. Tracing 
the pains backwards, we came to the seat of the disease, and then, by 
adopting rest as an agent, the boy was ultimately cured. 

oome time since I saw a gentleman, who was brought to me by a sur- 
geon, complaining of something wrong in his back. I was not told what 
it was, but was requested to examine him. I asked the patient whether 
he felt any pain. He said, " Yes, I have pain hereabouts," pointing to 
the distribution of the fourth and fifth dorsal nerves on the chest. The 
pain was on one side only, not symmetrical, which led me to conclude that 
the cause was one-sided. Upon tracing the posterior course of the fourth 
dorsal nerve towards the spine, I recognized a distinct aneurismal bruit. 
This led me to conclude, as a physician had done before, that the patient 
was the subject of aneurism. I mention this case, not for the purpose of 
prolonging, or parading unduly, the subject, but merely to show what pre- 
cision this method of examination gives. 

If a patient complains of pain on the surface of the body, it must be 
expressed by the nerve which resides there; there is no other structure 
that can express it, and somewhere in the course of its distribution be- 
tween its peripheral termination and its central spinal or cerebral oriein 
the precise cause of the pain expressed on the surface must be situatecL 



• 






•' : ^^l ': -.: /: 



* 



ISFLUEJSCE OP BEST. 



LECTURE V. 

gTBunetrioal SnperficitJ Paina Indicate a. Ceutml, or Bilatoral and Unilateral Paios a 
OnC'Sided, Cauae — Ca^ea of Diseased t^pln-e with KjmineCricikl Abdontinal Piuns — 
Witb Pain on the Back of the Ht;ad -Puiu over the Left Shoulder and in Left 
Ann — With Lobs o( Power lui'l Sunoatioii in the LimbH—With Impending Death 
from PresHure oa Spinal Hirrow (^red hy Best — Filial Cases — PoitiooB of Atlaa 
and Axis Expelled bj PoHt-Pbaryn^ceal Abscess — Aiiohjlosin of both Temporo- 
M^dllarr Articulationa— Patient Surviving Fourtcuu Yeara after Injury to the 
Cenioal Vertebne Produeing Paralf sis of tipper and Lower Extiemilies. 

Whks referring to the subject of pain, in my previous lecture, I en- 
deavored to show its value as a means of diagnosis, with especial refer- 
ence to the detection of disease situated remotely from the part where 
the pain is expressed. I have little doubt that my observations seemed 
to be rather wide of the ultimate object which I had in view — viz. the 
consideration of pain in its relation to the diseases of the spine. But I 
mast claim your indulgence when I remind you that part of the object of 
these lectures is to consider the influence of physiological as well as me- 
chanical rest; therefore, the point which t brought before you, in relation 
to the fifth nerve, was, I think, within the area of my intention, as an 
evidence of physiological disturbance leading to remotely situated struo- 
tural disturbance. I will now, however, confine my observations to the 
subject ot pain as a local symptom in its relation to diseases of the spine. 
In order to carry your attention with me, I will, for the sake of brevity, 
endeavor to reduce my views to the Foiro of a proposition — a proposition 
admitting of qualification, it is true, but it may assist your apprehension 
of niy meaning. I would state, then, — 

'l%at sup^tdal paitut on both »i<lea of the body, which are symmetri- 
cat, imply an origin or cause the seat of which ia central or oilateral,' 
iutfi thai unilateral pain implies a seat of origin which ia one-aided, and, 
at a rtde, exi«ts on the same side of the body as the pain. 

This is an important stand to take in endeavoring to unravel any ob- 
scure case through the medium of local pain. I must therefore repeat, 
that in cases of symmetrical pains on the surface of the body, without the 
looat manifestation of inflammation by an increased temperature of the 
parts, the cause must be centnkl ; that if the pain be felt on one side only, 
tbe cause is only on one side, and it is on the same side of the body as 
the pain. 

Associated with disease in the lower cervical, or the lumbar or dorsal 
vertebne, the pains are almost always symmetrical, whilst in diseases be- 
tween the occiput and atlas, or between the atlas and the second verte- 
bra, it often happens that the pains are unilateral, or one-sided. The 
probable ground of this peculiarity is, that the disease of the spine which 
oocnra between the occiput and first vertebra, or between the first and 
second vertebra?, may attack and confine itself to one of the joints be- 
tween these bones; whilst a disease of the lower cervical and dorsal and 



L 



52 ON THE THERAPEUTIC 

lumbar vertebnc, generally involves the whole of the body of the vertebne, 
or the whole of the intervertebral substance. 

I detailed in my last lecture two or three cases showing that, notwith- 
standing the strikingly marked symmetry of these spinal pains on the 
surface of the body, especially over the abdomen, they were not properly 
interpreted, and consequently that such cases were often treated errone- 
ously by being thought to depend upon some abdominal disturbance. I will 
now mention two or three other cases of a similar description. One is 
very characteristic, and I have the notes of it from the gentleman in at- 
tendance. I purposely abstain from mentioning the name or the locality. 

Case of Diseased SpinCy with Symmetrical Abdominal Pains. 

E. A , aged four years and a half, a moderately robust girl, with a 

rather strumous diathesis, always enjoyed good health until about a year 
ago, when she began to lose flesh ; her face became anxious, she stooped 
a little in walking, complained of symmetrical pains in her belly, and soon 
became fatigued. She was under medical treatment for some time for the 
abdominal affection without benefit. In consequence of the continuance 
of these symptoms, she was sent to the sea-side. The surgeon there in 
attendance assured the parents that she was suffering from a slight stom- 
ach derangement, and physicked her accordingly. One month subse- 
quently to this period the child returned home much reduced in strength 
and flesh, and unable to walk about, from spasmodic pinching pain in the 
abdomen, which "doubled her up." In a short time, however, having 
been kept quiet in bed, she recovered her flesh and strength, so as to be 
enabled to walk about a little without pain. Quickly again all the unto- 
ward symptoms supervened; the abdomen became large and tumid, bow- 
els irregular, with pain in the belly, as if a cord were tied round the abdo- 
men. (This sensation of a cord around the abdomen is very significant, 
and is usually suggestive of spinal mischief. A gentleman whom I saw 
from the neighborhood of Norwich, with a disease of the spine, in detail- 
ing his case to me, said: " Did you ever see any of those Italian fellows, 
with monkeys on boards, dancing to music, with a cord or piece of leather 
strapped tight around the belly and loins? That is just how 1 felt" — 
giving one an idea of the pinching and contracted condition of the abdo- 
men which he had experienced.) The advice of another surgeon was 
obtained, who assured the parents that the mesenteric glands were af- 
fected. The urine was at that time phosphatic and ammonical. She was 
allowed to go about as usual. In a short time the alteration and un- 
steadiness of gait became more marked, and the other symptoms continu- 
ing, she was taken to London to see a surgeon (not myself), who told the 
parents that the child was suffering from angular curvature of the spine. 
The child was placed in a recumbent position, and I was consulted. I saw 
this patient on the 19th of March, 1860, when there was evidence of dis- 
ease of the eighth and ninth dorsal vertebne, with slight projection back- 
wards. The urine was now healthy. Uninterrupted rest in the recum- 
bent position was ordered, with no medicine at all. It had recently been 
remembered (this is one of the important points) that the child, aoout a 
year ago, fell out of bed upon her back — a distance of about two feet^ — 
and that her abdominal symptoms began about three months afterwards. 
This I take as another illustration of what I have generally found, that 
almost all these diseases of the spine are the result of slight accidents 
overlooked. On the 15th of May the child was lying down, and was re- 



IKFLUENOB OF BB8T. 



53 



ported to be in excellent health and spirits, having no outward symptoms. 
It was then intended that the child should lie down two or three months 
longer, and we assumed that, if on resuming exercise it was gradual and 
steady, she would be cured, ar\d cured by rest. 

It ■!< apparent that in this case the real cause was altogether over- 
looked: that the abdominal symptoms were treated as depending on some 
error in the abdominal viscera, when they merely depended on the spine, 
and the spinal condition was for a time altogether ignored. I do not 
mention this case by way of casting imputation on any one. We all im- 
prove oiir professional knowledge by observation and experience, and this 
IS a point of experience. 

A little while ago, Mr. Sewell, a surgeon in Lambeth, reminded me of 
a like case that I had seen with him nine years ago. It was the case of 
a little girt, six years of age, with symptoms as nearly as possible tike 
those I have just detailed. There was disease in tlie lower dorsal verte- 
hrae, with slight projection backwards, and psoas abscess fluctuating just 
below Poupart's ligament. She got perfectly well by six months' rest, 
and the abscess has never shown itself since. It gradually receded; I 
presume it has been absorbed. She is now at school, perfectly well in 
every respect, except a siigjit vertebral deformity. 

I direct your attention to these two or three cases, especially, because 
in childhood there is oftentimes very great difficulty in detecting the real 
position of the pain of which such young children complain. When we 
see an adult, or a person advanced in life, he is able to express the precise 
position of the pain which he feels, and may, perhaps, be able to indicate 
the depth of the pain, so as to enable us to get at the real cause. 

No cases of diseased spine are so immediately dangerous to life as 
those in the upper part of the cervical region, especially if situated be- 
tween the first and second cervical vertebra?. I believe if surgeons will 
examine carefully the pains of which such patients complain, and use 
theni as a means towards the right interpretation of the probable seat of 
the real disease, and then adopt, in a most positive and determined man- 
ner, tlie unjper treatment by rest, the majority of these cases will do welL 

1 shall now endeavor to sustain this opinion by dstailiiig some casea. 

J>iaeaM of the f!ptne, mth Pains on the Back of the Head. 

About fourteen years ago I saw, in consultation with the late Dr. 
Bright, a gentleman, aged twenty-eight, who had been suffering for some 
time from pain at the back part of his head, which was thought to be 
rheumatic, and had been treated medically without any benefit. The 
cause of the pain was the question to be decided. Dr. Bright entertained 
an opinion that pain at the back of the head resulted sometimes from the 
close proximity of the vertebral artery to the sub-occipital nerve between 
the occiput and the atlas, or to the great occipital nerve, between the 
atlas and axis, and that the pressure of the artery upon one of these 
nerves produced the pain at the back of the head. This is the chief 
reason for my mentioning this individual case, because I believe the 
explanation will not hold good as regards the sub-occipital nerve, for that 
nerve normally ra^e^? sends any filaments to the skin beyond the muscles ; 
indeed, it is chiefly a mptor nerve. The great occipital nerve supplied the 
dun where the pain was felt by this gentleman (rt(& Fig. 12, a ), and on 
[ tnoing this nerve towards the spine, we came to the cause — -viz. disease 
W k.tw. — .u^ c_* .„.i ij cervical -vertebros. The patient was ulti- 



between the first and s 



pah^^ 



L 



54 ON THE TnERAPEUTIC 

mately cured by nnntinucd rest in the nearly horizontal positior 
however, consisted in complete anchylosis of the bonea, and a lixeil neck, 
with the head turned somewhat downwards and towards the left side. 
This patient died from pulmonary consumption twelve years after his 
reco'-ery from his disease of the spine. 

Diwaae of the Spine, with Pain at the Saek of the Head and over the 
i^ Shmdder and in Left Arm. 

In the autumn of 185T I wa.s consulted by a lady from one of the 
Uidland Counties, respecting a pain she experienced on the back of her 
bead and ear, and upon the shoulder of the left side, accompanied by losi 
of power, and pain in her left arm. I was told that these s)*mptoins had 
oome on about Christmas-time of the past year, without any known 
cause. She had from the first submitted to constant medical treatment, 
and not improving, had been then sent to Cromer, on the Norfolk 
to improve her general health, and with the hope of getting rid of 
supposed hystencal or rheumatic symptoms. She remained at the 
side during the whole of the summer without any benefit. When I 
this lady in the autumn of 1857, her ape was about thirty; she had f 
on the left side, at the back of tbe head, and at the posterior part of the 
external ear; pain over the clavicle and shoulder (alt on the left side); 
pain, with loss of power, in the left arm; pain deep in the neck on press- 
ing the head direetly downwards upon the spine, and on rotating tli« 
head; some fulness and tenderness on pressure about the first, second, 
and third cervical vertebra, especialty on the left side. She could not 
take walking exercise in consequence of the increasing severity of all the 
symptoms. She had almost sleepless nights, and her appetite was very 
bad. Expecting to learn that she had had some accident, I was particu- 
lar in my inquiries on that head, but nothing of the kind was admitted 
by the patient. It was obvious that there existed some disease or iniuiy 
of the spine affecting the occipital nerves (see Fig. 12, a', b\ the third 
cervical nen-ea, and the nerves forming the left axillary plexus. As far 
t& I could interpret the case, rest appeared to be the proper remedy. 
The patient maintained almost uninterruptedly the recumbent position 
during nearly three months, two sand-baga being placed one on each side 
of the head. You will excuse triy bringing forward these sand-bags, but 
they are not sufficiently used. They are useful iu cases of fracture, for 
the purpose of sustaining the fractured parts in a right position. They 
are also extremely useful in the kind of case which I am now detailing, 
and eminently serviceable in cases of disease of the spine in children, 
when situated high in the neck. Every practical surgeon knows how 
difficult it is to keep the neck and head of a child quiet and in the recum- 
bent position, when suffering from disease of the cervical portion of the 
■pine. I know of no simple mechanical means answering this purposeso 
well aa sand-bags, made of bed-tick, and about three-fourths filled with 
dry sand. One is to bo placed on each side, close to the head and neck, 
■o as to be moulded to them, in order to keep the head straight, and to 
render lateral or rotatory movements impossible. As I have said, two 
heavy sand-bags were placet], one on each side, upon the pillow, support- 
ing the head of this lady. The oidy medicine cmpjoyed was one-sixteenth 
of a grain of bichloride of mercury twice a day, during about two months- 
At the expiration of three montfas the patient had lost all pain and ten- 
derness, and had regained the use of the arm, neither did pressure ■ 



ISFLUENCH OF BEST. 55 

rotation oF the head induce pain. The fulness in the neck had also dis- 
appeared. 

1 might here refer to what I have already alluded to, when speaking 
ot inflammatory effusions, and endeavoring to show that the effusion of 
lymph, associated with local disease, really acts as a splint to secure local 
rest to diseased parts, and so aids recovery. In the case now under con- , 
sideration this is the interpretation of the fulness of the neok during the I 
persistence of the disease, and its disappearance when the original disease 
was removed. It is the same with disease of the larger joints of the bodyj 
when a cure is effected with or without anchylosis; all the surrounding! 
lymph that has been poured out for a. great length of time, and which 
seemed to promise to be very enduring, entirely disappears. Its object 
was to act as a temporary splint, to keep the parts quiet; that duty hav- 
ing been performed, the splint of lymph is no longer required, and it is 
absorbed, just like the temporary effusion, or callus, in tiie case of frac- 
ture. To conclude the case before us: this lady left town, and afterwards 
rttported herself quite well. 

I may here add, that this patient was accompanied by a lady who was 
very anxious to know whether her friend would get well. There was an 
intensity in her anxiety which I could not understand; for she really 
shook with fear when she looked forward to the possibility of dcatn 
occurring to the patient. The real cause ot the patient's aj-mptoma, and 
of this anxiety, was afterwards explained to me. The disease in the neok 
was produced by a blow playfully given by this other lady, with a bolster 
or cushion, upon the left side of the head of the patient, which forcibly 
displaced it laterally. These two ladies had been reading with each other 
something about the intestine wars of the houses of York and Lancaster. 
One seized a red and the other a white rose, and thev had a battle of the 
holsters instead of the battle of the roses. My patient (the white rose) 
was struck down, and so Vork fell — upon the carpet, and was unconscious 
for some little time. She had, as reported to herself, a sort of stru^ling 
fit. On recovery she was put to bed, and in a day or two nothing re- 
mained of the accident except some tenderness in the upper part of the 
neck; but soon afterwards the symptoms already described came on. 

This patient had been under treatment nine months, getting worse the 
whole time. At first I experienced great difficulty in persuading her as 
to the necessity or advantage of her lying down; but having felt consid- 
erable relief to all her painful symptoms in about a fortnight, she then 
made no further opposition to the adoption of rest to the spine and head 
by lying down. This patient was certainly perfectly cured, and rfist, so 
far as I could interpret it, was the sol© important element employed to 
aid and secure her recovery. 

The next ease is that of a surgeon, who was in the yacht of another 
gentleman. Running along from one part of the ship to another (I do 
not attempt to mention the names of the parts, lest I should make some 
very ridiculous mistake), he struck his head against the top of a door, and 
was thrown backwards with great force. Very shortly afterwards he had 
pain in the distribution of the occipital nerves at the back part of the 
head and the back of the neck [nide Fig-. 12 a', b'). Six weeks from that 
time (he still continued in the yacht), having experienced some increasing 
pain, and heard and felt a grating sensation in his neck, he was some- 
what alarmed, and came to me, suffering from pains indicating disease of 
the second or third cervical vertebra. He was ultimately cured by lying 
—that is, by rest. On the 8th of February last he came to me per- 




i 



56 ON THE TIIEKAPEUTIC 

fectly well, and he says he was quite cured by rest. Time will not per- 
mit me to dwell upon the details of this surgeon's case, although I have 
his permission to use his own notes of his symptoms. 

The anatomical diagrams (Figs. 14 and 15) were taken from dissec- 
tions made by myself many years ago, and I merely refer to them as they 
point out the relation of the occipital bone, the atlas, and the vertebra 
dcntata, and the various ligaments associated with the upper cervical 
vertebnp. These arc the strong means employed by Nature to support 
the head and neck, and at the same time to permit flexion, extension, and 
rotation of the head. 

Disease of the Spiney Pain at the Back of the JTead, with loss of Power 

aiid iSemation in the Limbs, 

On the 28th of February, 1858, I was requested to see Mrs. S | 
aged forty-five. I found her sitting in a large, high-backed arm-chair^ 
supported by pillows, with her head resting upon the side of the chair, 
unable to rise from her seat. I ascertained the following facts from her 
husband, and partly from herself. Her voice was very feeble, and her 
breath extremely short. During several months back, she had been suf- 
fering from pains in both arms and weakness of both legs, accompained bj 
pains in the neck and shoulders. She had been under medical treatment 
during the whole time, and had consulted a physician and an hospital 
surgeon. Both, according to the patient's report, considered the case as 
one of rheumatism or neuralgia, and ordered her to take walking exercise 
daily: one of them said two hours daily; the other, as much as possible. 
Iodide of potassium, colchicum, and opium to relieve the pains, had been 
freely administered. The pains were really terrific (that was her own 
description) in the arms at night, generally commencing about twelve, 
and continuing until four in the morning, when she usually dropped off 
into a short sleep. The dropping olT to sleep at any time induced jump- 
ings and start ings of the limbs. This is a pretty constant concomitant 
symptom when the central portion of the spinal marrow is involved in the 
mischief, that being the very seat of the excito-motory function, as regards 
the spinal marrow. All her sufferings were increasing in severity and in 
danger up to the day I saw her sitting in the chair, when she presented 
the following symptoms: Loss of sensation in both arms, so that the prick 
of a pin was not felt (this I examined carefully myself). Both arms were 
nearly paralyzed. She could move her fingers slightly, but could not lift 
either hand or arm, and was obliged to be fed by lier daughter; this con- 
dition had been coming on nearly four months. In both legs sensation 
was much diminished, and they were imperfectly paralyzed. She could 
neither walk nor stand, and was therefore carried from place to place. 
Both the uj)pcr and lower extremities were swollen from venous conges- 
tion, but not cedematous; this seemed to depend upon the difficulty expe- 
rienced in her respiration, which interfered with the transmission of the blood 
from the right to the left side of the heart, and so caused venous congestion 
in the veins tributary to the veUiOe cavje. This, I believe, explained the 
accumulation of blood observable in the arms and legs, and on the surface 
of the face, for the latter was swollen and the veins full. The voice had 
become gradutilly more and more feeble, and deglutition was difficult — in- 
deed, sometimes so difficult that she was afraid of being choked. She could 
not move her tongue freely, nor protrude it; hence her articulation was 
very imperfect. (I think we may fairly infer, from the difficult move- 






'iNFLDEMCEOFEEST. 57 

ments of the tongue, that the hypoglossal nerve, which is attached to the 
medulla oblongata, must have been implicated in the fniechief.) There 
was DO paralysis of the face, do loss of power, no pain, no loss of sensa- 
tion in the distribution of the fifth nerve. The movementfi of the eyes 
were normal. There was exqui- 
site pain and some tenderness 
at the back of the head, extend- 
ing to the vertex on both sides 
of the median 'line posteriorly 
(Cfrftf Fig. 13, a'). (This, you 
see, marks pretty accurately the 
distribution of the great occi- 
pital nerves; therefore, if any 
pains be expressed in that neigh- 
borhood, it must be referred to 
the great occipital nerves.) 
There were pains at the back of 
both ears (within the distribu- 
tion of ihe small occipital nerve), 
but more especially upon the 
right ear (eide Fig. 12, fi'). 
There was no pain in front of 
the ears, or in the external au- 
ditory canals. (This is in accor- 
dance with the fifth nerve being 
free from implication.) The 
head was inclined to fall for- 
wards, and, indeed, she found 
it impossible to keep it up with- 
out artificial support of some 
kind. On pressing the head 
directly downwards upon the 
spine, and attempting to rotate 
the head upon the spine, she 
could not bear it. She became 
nesrly pulseksa and fainted, and 
the umba tremulous and agita- 
ted. We immediately placi 
her upon the floor of the rooi 
1 thought she was dead, but si 
very slowly recovered. The 
neck, from immediately below 
the occiput to opposite the first, 
second, and third cervical verte- 
bra;, wns a little swollen and 
^iiifal on direct pressure. 
Bowels veiy much constipated; 
micturition very difficult and 
tedious, the urine of a strong, 
pungent, ammoniacal odor. The 
patient could not recollect any 
mischief having occurred to the 
■ .'IftP^' '''"' ^'"' remembered she had fretjuentty experienced pain in the 
KdS^vid head in trying to take any weighty things from high shelves. 







to be 



Oir THB rHSBAPEUTIG 

t dotftin you with the full details of the case. It is a in 
nrtKnt Olio, iiDt only in regard to its aotuul character, but as havir^ 
irerlookcd by the physictun and surgeon who were first coneulted. 
L Ilelidvinif tho dispose in this case to be seated about the first and sec- 
ond oervieal vert«>br)r, that all the symptoms were explicabie upon such « 
lUppovitioii, and that the only possible remedy was absolute and lon{^- 
JKiniinufd rest to the spine, I directed her to be placed in bed flat upon 
Ifhtr back immediately; and 1 did not leave the house until it was done. A 
* ■mall, firm pillow was put under the neck, and, in the evening of the same 
d^y, two large, hnlf-filled bags of sand were placed, one on each side of 
the ht<ad ami ntiolc, to prevent any lateral movement of the head. She 
WHH not to be diiiturbed from the horizontal position for any purpose 
whalnvor; the bowels were to. be relieved by enemata, and the urine to be_ 
drawn oft if noocssary. As the eitact and methodioal arrangement 
patient suSering from disease of the upper cervical vertebra; is a tnatl 
of great importance, I 
placed before you a drai 
(Fig. U) of a vertioal 
nearly median section of the 
head, brain, spine, and spinal 
marrow, for the purpose of 
enabling me to explain and 
illustrate the necessity of pla- 
cing the patient in a properly 
sustained position in bed. Th^ 
drawing is copied from ft 
cent dissection made for " 
object. 

Tho patient was pli 
with her back flat on her 
This position brought on 
trerae difficulty in her breath- 
ing. Whilst she was still 
the recumbent position, and 
breathing with ditEculty, I 
placed my hand underaeal 
the neck, and lifted upwi 
and forwards that part of 
spine. Tho sense of 8uff< 
tion became at once much di- 
minished (I had observed the 
same circumstance before, in 
another patient who had dis- 
ease of the highest part of 
the spine), and I had there- 
fore a small, firm pillow put 
underneath the neck, which 
supported it very perfectly. 
This is a very important fact, 
because I think I have known 
in consequence of this littls 



'•I 

leatb^H 



I K>ut two porBons who were destroyed 
liui lull havmg been attended to. 

If ihu li^incnts between tho first and second vertebra? and the occip^] 
• bo destroyed, and you have nothing to support the great poatf 



:tls^ 

] 



INFLTJEITOE OP REST. 59 

rior concave or noUow of the neck, this part of tbe spine gravitates; the 
odontoid process sinks or falls, and presses upon the lower part of the 
medulla oblongata. (See Figs. 14 and 15.) By putting Bomething(say a 
small firm pillow) nndemeath the neck, we lift up the body to the second 
vertebra, and remove the odontoid process from the lower part of the 
medulla oblongata, and thus prevent the fatal results of pressure upon it. 

Ihavehereanothersketch, taken from the same dissection as Fig. 14; 
but in this instance the ligaments between the second vertebra, the atlas, 
and the occipital bone have been purposely divided, and I believe it 
fairly represents the condition of the parts which caused the death of one 
of the patients to whose ca^e I shall presently allude. In the sketch before 
you all the before-mentioned ligaments have been cut away. If a dead 
body, thus prepared, be placed in the recumbent ponition, without mechan- 
ical support to the hollow of the neck, the second vertebra, with its odontoid 
process, falls towards the medulla oblongata, and makes presaure upon it; or 
if a dead body, so prepared, be placed m the sitting or erect posture, the 
head has an immediate tendency to fall forwards, and to impale the medulla 
oblongata upon the odontoid process, which, as you may see, strikes ex- 
actly upon the medulla oblongata. This is the mortal part of the cerebro- 
apinal axis, because it superintends the respiratory process; aud thus it 
happens that patients so circumstanced are killed immediately. 

In the patient's case, to the details of which I have been directing 
your attention, a small pillow was placed under the cervical portion of the 
spine, by which we were enabled to lift up the odontoid process away 
from the medulla oblongata, and maintain the latter in & state of compar- 
ative security from pressure, I repeat that when this patient was lying 
flat upon the bed, she could scarcely breathe, but as soon as I put my 
hand behind the neck and lifted up the odontoid process, she was nearly 
free from dyspnoea. It was obvious that her condition necessitated her 
iyii^ down upon her back for some considerable time. 

This patient was ordered one-sixteeiith of a grain of bichloride of mer- 
cury, and one drachm of tincture of bark, to be taken twice or thrice daily 
in a wineglassful of water, and sul^cient laudanum, when required, to 
procure sleep. At the expiration of a month she had regained her voice 
and her power of articulation and deglutition; her pains were lessened, 
she could sleep more, and all the other symptoms, with her general health, 
were slightly improved, but not much so. She had found the sand-bags 
very comfortable; their lateral support to the head and neck appeared to 
pve her confidence, especially in going to sleep. She remained lying 
down, and in the same position, almost without stirring, during seventeen 
weeks, uninterruptedly. At the expiration of that time, all her symp- 
toms were so much relieved, that it was thought safe to allow her to be 
raised a little in bed, more and more, but by slow degrees, every two or 
three days for about ten minutes, with the head supported. About two 
months afterwards, she was permitted to sit for a short time in a chair, 
but still with the head supported. She had now regained her power over 
her limbs, was nearly free from numbness, and had little or no pain on 
moving the head. Walking exercise, to be carefully and gradually in- 
creased, was therefore allowed. After some little time, gaining strength 
and nonfidence in herself, she extended her walk into her garden, and re- 
mained in it until she became so fatigued and exhausted that she lost all 
muscular power, and was obliged to be carried in-doors. The pain in the 
neck and back of the head, and the other old symptoms, again manifested 
themselves slightly. She then determined that she would not go out of 



GO ON THE THERAPEUTIC 

doors during the next five months. I did not advise it, but she said she 
would lie down more or less during the whole winter, and get up with the 
spring of the year. During the winter she was loosely and warmly 
dressed, got up daily, but spent most of her time recumbent upon the bed 
or sofa, with her quiet, comforting companions, the sand-bags, relying on 
the influence of rest for her recovery, which was slowly but progressively 
accomplished. 

I saw this patient myself on the 2d of March, 1860. She told me she 
had been well during many months, and occupied, as usual, in her house- 
hold duties. She rides in omnibuses, walks well, and has nothing to com- 
plain of except some little weakness and stiffness in her neck, for which 
she is to wear an iron collar. 

Here is a case which puts rest in a very triumphant position. I think 
we may say that the life of this patient was saved by opportune rest. 
Her early painful symptoms at the back part of the head were not appre- 
ciated or regarded in their proper diagnostic light. Had these pains 
been recognized, and rightly interpreted, by those whom she consulted at 
an earlier period of her disease, the imminent danger to the life of this 
patient might have been averted, and much of the delay, associated with 
her continued lying down, avoided. 

And here I am reminded of a contrivance adopted by a patient of 
mine living in the country, and suffering from disease of the spine, which 
compelled him to be on his back during many months. He ultimately 
got well, and is now fully occupied in business. The ceiling of his capa- 
cious and comfortable room was, as usual, white. 1 had occasion to see 
him in a few weeks after his first lying down, and on entering his room I 
was surprised to observe the ceding covered with green gauze. I asked 
what was the matter, and he said, " The fact is, lying on my back, and 
looking at the white ceiling all day long, became so distressing and irk- 
some to my eyes and brain, that I could bear it no longer. I knew, from 
exj)orience, that 1 could look upon a green field all day long without tir- 
ing, and therefore 1 have had the ceilinp covered with green gauze, and 
since then I have had no difficulty at all." This was a slight practical 
hint which 1 thought worth recording. 

Case of Diseased Spine^ trifh severe Pa hi vpon the Back of the Head; 
imjxndiny Death from Pressure upon the tSpinal Marroio ; cured, 

I must now briefly refer to the particulars of another case somewhat 
like the foregoing. In 1850 I was requested by Dr. Addison to see with 
him one of his hospital patients, a young woman suffering from injury to 
the upper part of the spine, the result probably of accident. This was 
subsequently ascertained to be the fact. I found her almost pulseless, 
witli great distress in breathing, loss of voice, an inability to swallow, and 
nearly oom]>lote paralysis of the anns and legs. She had had from the 
early part of her illness severe pains spread over the back of her head and 
neck, increased on j^ressing the head downwanis upon the spine, and on 
rotating it ujH>n the spine. Iler symptoms had gradually arrived at this 
stage of dangler without benefit frt>m medical trv\HUnont. I might here 
say, that tho diflioulty of breathing and doglulitiou had so greatly in- 
creased of late, that it was thought ntvossarv, or to hor aiivantage, to lift 
her up m<>n» and more in the bed; but the oluu^jje of |H^stu^o seemed only 
to add to hor distn*ss in bn^athing and swallowing. These were the diffi- 
cult ios for whioh my assistance was rtHjuostod. Sl»o was then pn'^pped up 



INFLUBNOEOFBEaT. 61 

in bed by pillows at her back, with h&r head inclined somewhat forward, 
or dropping upon the chest. As the impediment to swallowiiie was 
almost au insurmountable difficulty, I was desired to examine the throat, 
but I could not discover anything wrong in it. It was our opinion that 
her life was in imminent or perhaps inatant danger: she was paralyzed, 
and could not swallow; her voice waa excessively feeble, and the pulse 
uot very perceptible; she scarcely breathed at all, and waa not quite con- 
scious. It was evident that something must be done without delay. 
Believing that her symptoms resulted from the odontoid process of the 
second vertebra pressing upon the spinal marrow, close to the medulla 
oblongata, I advised that she should be made to lie down immediately. 
On saying to her, " You must lie down in bed," she replied, in the small- 
est possible voice, "Then I shall certuiidy be hilled; I can't get my 
breath," Seeing there was no time for contention, 1 told her our opinion 
waa, that if not placed horizontally in bed she would in all probability 
die in a very few minutes. Being ijaralyKcd, or nearly so, she could offer 
no resistance to my purpose; and I shall never forget the weight of the 
responsibility when I took hold of her, desired the pillows to be removed 
from her back, and, supporting her head and shoulders in my anns, slowly 
placed her upon her ba^K, nearly flat upon the bed, with her head upon a 
thin pillow, some additional support to the hollow of the neck, and two 
sand-bags, one on each side of the head, to prevent lateral or rolling 

Here was a patient in the greatest possible danger, and T do not hesi- 
tate to express the opinion, that if the head had fallen forward, say half 
n inch, she would have died in an instant. Her sense of suffoc ' ' 



soon relieved by the horizontal position, and she remained lying down 
during six months uninterruptedly, at the end of which time all the serioua 
symptoms had disappeared. She was then allowed to move about the 
ward with caution, and a few months afterwards left the hospital, well, 
with the exception of a stiff neck, most probably depending on anchylosis 
or bony union between the atlas and the axis. In this case nothing but 
complete rest was employed as a remedy ; rest waa the only element of suc- 
cess in the treatment, and I think it is a very striking example of its power 
to prolong life, oy enabling Nature to repair her injuries undisturbed. 

Ciue of Diseased ^pine, with atoere Pain tepott the Back of the Ifeail ; 
iudtlen Death of the Patient. 

1 will now direct your attention to another case of diseased cervical 
vertebne, which terminated in sudden death. It is that of a little child, 
five yeara and five months old, seen by me in 1841. She was a small, 
delicate, unhealthy girl. She had been accustomed to ride a good deal 
in the country with her mother in an open carriage, and was thought in 
that way to have caught a cold in the back of the neck, which became 
ctwlualiy stiff and swollen, accompanied by pains in the head and nock. 
These pains were believed to be rheumatic, and the treatment employed 
had reference only to that impression, which was supposed to be supported 
by some pain experienced in the limbs, with cramps and stiffness in walk- 
ing. Shu frequently suffered from fever and loss of appetite, and had 
been under medical treatment during many weeks, the symptoms slowly 
increasing in severity. The mother told me afterwards that she had 
Ihonght her an obstinate child, and that she sometimes threatened to 
;i or to shake her well, because she would not take her food. I have 



UtOnght 



ON THE TIIEBAPEUTIO 

doubt if she had done so she would have killed the child. Upon 
ful examination, 1 thoug'ht I made out the case to be one of diseasa 
between the first and second cervical vertebne, or theroabouta. 
thereabouts, because the parts were too much swollen and too painful to 
admit of a more accurate local investigation. There- was pain at the bade 
part of the head, in the course of the great occipital nerve ; pain behind 
the ear, in the course of the great auricular, and of the small occipital, 
pain in the higher part of the neck, on rotation of the vertebrte upon*eaclt 
other; and pain in the same vertebrs, probably the first, second, snd> 
third, by pressing the bones upon each other. Sne had some difficulty ia 
deglutition, and the voice had lately changed Its character and becomi 
more feeble, indicating that the pneumogaslric nerves, and possibly th« 
spinal accessory, were involved in the mischief. Thus having, in commof 
with the surgeon in attendance, recognized the real nature of the uaae, 
directions were given that the child should be placed upon her back, with 
her head resting upon a thin pillow, and some additional support to ■ ' 
nape of the neck, each side of the head to be supported by sand-bags, 
as to prevent any lateral or rotary movement in the neck. It was plaia, 
that if the life of the child was to be prolonged or saved, it could only bft 
accomplished by long-continued rest to the spine : and for the purpose e 
securing easy rest to the little patient, a water-bed was sent from Londoi 
and the child was safely placed upon it, with the sand-bags extending; froi 
the shoulders to beyond the head. In about a fortnight, tne nurse speciaJt 
appointed to attend the child, finding that her rest at night was now i 
calm and quiet, that she was so free from pain and fever, that her appetit 
and power of swallowing were so much improved, as well as her temp 
and thinking she was altogether so much better, and willing no doubt 
mark her own penetration, as well as to please the mother by tellinc 
the morning what had been done by her little charge — this meddlmg 



, instead of 



givi 



IF the child her breakfast, i 



I usual, witb 



sit up to 

dead. The post-mortem examination proved that disease existed 
articulations between the first and second cervii'al vertebra, that the bonei 
were loose, and that when the head with the atlas fell forward, pressure 
had been made upon the spinal marrow close to and below the medulla 
oblongata, at the point of decussation, so that the child was killed almost 
instantly, as in pithing animals. This was a case in which both the sur- 
geon and Nature were oompletely thwarted. The local di 
sidered at the time to be dependent upon a constitutional or scrofulous 
cause, but I have since understood that it was the result of a blow given 
to the little girl by her brother, who struck her with something he had' 
picked up in the room. It was not constitutional; there was no viscert!' 
disease of any kind. 

I thought I might detail this as another case in evidence of 
severe condition of disease, the real character of which had been over- 
looked, and which in all probability would have been improved and cured 
by proper and long-continued rest. But, as I observed before, Natupa 
and the surgeon were both thwarted. 




INFLDENCE OF HE8T, 




Put. 16, — Dnwing of a wet (qvpurotlan o 
diHl vnU'biw In <I ny'B HnplUl U lueum. tS 
iC Ibt utlcn^Bi isrtllifc QpoD Ilia aq<.-i|ilul 



Caae of Diseased Spine; sudden Death of the Patient. 

I have bere a preparati 
history attached to it, 
fatal aoaident which hnp- 
pf^ned in the previous 
case. There is disease 
between the occiput and 
the atlas, and also bi.'- 
tween the atlas and tin.' 

ament has been forcibly 
ruptured, or has given 
way by structural dis- 
integration, so that the 
odontoid process waa 
free and able to make 
pressure upon the me- 
dnlla oblongata, and 
thus to kill the patient. 
The late Mr. Mackmur- 
do informed me, that 

when attending the SUr- cn«ly uin v*"erinT nurtam o! thrSoriiiid pTOOm.nl'lhcMil,'""", «, 

pieal lectures of Sir Aat- SS'S'glll^TJtU" ^'iX.ttSi'^^S!!?;:^^ ^^ 

ley Cooper, he well re- ^"^ cnaava-e lltdnucol. illowlng the atUu «ilh Itm ti€id u movo 
' _ ■ ' . IsTVtrd IiDm Ibo ujil d, Nnml arcU of mtJu. (. Sulaoui pmooB 

members seeing a prep- oi nit. . r r^ 

aration exactly like this, 

to which Sir Astley appended the facts, that the man to whom it had be- 
longed had been long the subject of syphilis, had suffered great pain in the 
necK, and that, after eating his dinner, his head fell forwards upon the 
table, and he died instantly. He added that the cause of death was pres- 
sure made by the odontoid process of the axis upou the spinal marrow. 

Com of Diseased ^ine, with Poet-pharyngeal Abscess, from which were 
e^^Ued portions of the Atlas and Axis. 

Here (Fig, 17) is another interesting preparation, consisting of two 
portions of bone: the larger one appears to be the articular surface of the 
anterior part of the atlas, which articulates with the anterior surface of 
the odontoid process of the axis; the other portion, a part of the articular 
surface probably of the odontoid process. I will now read to you a abort 
record of this caae from the Guy's Museum Book: — 

" Mrs. G-- — , a patient of Mr. Babington in 1834, a, married woman, 
who had worked hard at washing, end been much exposed to cold. Five 
years before, she had an attack of pleurisy, but waa not aware of having 
taken mercury, at least not to salivation, and she never had syphilis. 
Four months previously to her seeking advice, she began to find her neck 
stiff, with a pain at the back of her head. These symptoms increased, 
until one day, on coughing, she brought from her mouth a piece of bone, 
and aubscquently some smaller fragments, and a portion of the atlas, or 
first vertebra, seen in the specimen. She was visited for some months af- 
terwards, when the head was nearh" fixed, and there was a discharging 
uleer at the back of the pharynx. The patient was last seen in Ootobct, 



ON TUE THEEAl'EUTIC 



tolerable licaJth, and scrvuig at the bar of a publl^ 






JJ1838, when sht 
louse." 

There are in the anatomical tmiseunis of this metropolis Tnany patb 
Igical specimens of complete bony anchylosis of the occipital hofie, mt' 
knd axis. Such preparations show cleiirly ihat very important and d 
eoroua ctiseaae of the art' 
lations between these b 
must have existed, aiid t 
the patients must barelifl 
some long time after r 
disease had been so Ear rei ^ 
died by anchylosis. I htn 
here npon the table before 
me several preparations il- 
lustrative of perfect recov- 
ery from disease of tiiis uppf 
part of the spine by boi 
anchylosis, but I aeleet I 
your attention this exarafl 
partly because the 1 
pair of the spine was { 
in progress at the time | 
death, but eBj>eciaUy : 
its displaying also a rared 

thologica] fact — viz., perfect union between the inferior maxilla and t 

poral bones on botfi sides. 




of both Temporo-maxil 



i 



laae of Diseetaed ^ine ; Death; Anchyloai 
ArticulalioTt*. 

This head and spine belonged to Charles Davis, a black from Janiitifsf' 
was admitted into Guy's Hospital, October 12th, 182.1, under Dr. 
Bright. Three years previously he slipped down three or four steps into 
the cabin of a sloop, and in the full a fork penetrated to a very small 
depth into the back of his neck. He felt no inconvenience aftenrardn 
Sixteen months before admission he complained of pain in rarious paral 
of his limbs, and frequent inability to move his arms and legs froolW 
"The head is always bent forwards, so that the chin approaches the t^ 
of the sternum. He can nod his head a little, but cannot turn it. De- 
cember 6th. — More pain in the shoulder and neck. 22d. — Was seiaed 
with stiffness and pain in his feet. 29th. — Pain in his neck increases; he 
is unable to walk, and almost to use his arms. He has oecesional cramp 
in his Icffs; says he fails in everv part of his body. January 2d. — Speaks 
less distinctly; has pain about tihe muscles of the neck and shouldei-s, and 
is acarcejy able to walk. (!th. — Complains of pain in the hips on motion. 
20th. — Tenderness about the neck and shoulders, increased on pressui 
no loss of sensation in any part; bowels regular; urine natural; pulse If 
rather weak, March 4th. — Only very slight motion in the jaw, 7th. 
Increasing fixity of the lower jaw. His Inability to move the Ji 
tinued to increase, until it became totally locked, so that he could tatcl 
no nourishment but what he sucked in between his teeth, or through 
the space produced by [he removal of hia first molar tooth." lie grad- 
ually sank, and died March 'I'M, 182C, about three years after the piino- 
tured wound in the neek, which might or iiiig'ht nut have been the start^n 



ion. 

1 



I 



The membraiiea adiiered 



INFLUENCE OF BEST. 

ing point of the disease in the cervical vertebrae. The post-morteiD ex- 
aininutiou was as follows: "Body emaciated and rigid; neck immov- 
able; the jaws iuaeparably locked; cninitim remarkably thick; arachnoid 
opatjue and thickened; a more than na.tural quantity of Huid external to 
the brain, which was generally firm and of healthy appearance. The 
medulla oblongata was less tough than usual, and broke otf short v 
the brain was being removed from 
to this part with re- 
markable firmness. 
There was no motion 
between the occipital 
bone and the atlas; 
the articulating sur- 
faces had ulcerated, 
and bony union had 
commenced. The ar- 
ticular siirtaees be- 

processea of the atlas 
and axis did not ap- 
pear to be diseased, 
but there was a. con- 
siderable quantity of 
bony matter thrown 
out on the dentiform 
process of the sec 
end vertebra, not me- 
rely impeding the 
motion of the joint, 
but encroaching on 
the spinal canal. An- 
chylosis bad also 
taken place between some of the succeeding cervical vertebrte. A very 
compact and hard bony deposit was formed immediately under the ante- 
rior ligament of the spine, upon the bodies of the upper cervical vertebrae, 
and at that part concealed the intervertebral substance. On cutting the 
muscles of the temporo-m axillary articulation, it became obvious that 
bony union or anchylosis of the joint had occurred to a considerable ex- 
tent on both sides; the soft parts did not appear to be at all diseased in 
the neighborhood of any of the affected joints." 

Case of Injury tojiflh, sixth, and seventh Ceroical Vertebrw; Parulynig 
UTui Luan of Semation in t/ie Upper and Lower Extremities ; the 
Patxent lined fourteen years, and then died from another accident. 

Id two or three respects the following case is one of great interest. 
John Carter, aged twenty-one, had an mjury to the fifth, sixth, and 
seventh cervical vertebnc, producing paralysis oE both legs and both 
arms. He lived fourteen years, and then died from the effects of another 
accident. The particulars of this case, bo far as 1 know them, are theset 
The accident occurred in May, 1830. The man's age was tweniy-one. 
He fell from a tree, forty feet, upon his back, or probably his head. He 
was senseless, unconscious, and paraU'7<id below his neck. Being carried 
home upon a hurdle, the late Mr. Whitniore, of Uoggeshall, Essex, saw 




uUoiililioR, oui TntimUj i 



I •go:- 



ON THS THXBAFZCIIO 



after the accident, and wrote me this 



"It™ 



I May, l&Jfi, that I waa called up, on a Sunday moniiog, 
»nd five o'clock, to John Carter, who had fallen from a tree. 




between four and 

when in the pursuit of young rooks. When I saw him he was perfectly 
insensible and motionless; cold, and breathing imperfectly; with a pulw 
weak in the extreme; and he appeared to have sustained some fatal injury 
to the brain or spinal column, from which there waa scarcely a hope of 
his recovery. The accident had then occurred about two hours, I beliere. 
I ordered hot flannels and other means to be used, to restore wanuth 
the body and to bring about reaction. In the course of the day re*oti 
was established, and there were signs of returning conBciouaness, el 
danced by a groan when aroused. Towards evening the pulse was ao i _ 
re-established as to warrant venesection. In the course of the ntght b« 
became more conscious, and was sufficiently sensible nest day to enable 
me to ascertain that the serious injury was high up in the spine. There was 
a perfect absence of muscular power, and of sensibility of the skin throagti-. 
out the body, except in the head and upper part of the neck. The mv 
cular power of the neck was lost also for several days; but after cuppii 
the back of the neck, and using proper remedies, a capability of movo 
the head gradually returned. The bladder was paralyzed and the catbet 
required. 

" There was no appearance externally to indicate the precise situal 
of the injury as to the vertebra? — not the slightest irregularity; but ^ 
general symptoms and circumstances rendered it pretty certain that serioui 
damage had been sustained by the fifth or sixth cervical vertebra. After 
some weeks, a certain amount of motion was restored to the head and 
neck, and sensibility to the same extent; but the rest of the body (u 
long as I attended the case) remained perfectly paralyzed and insensib' 

" I left Coggeshail to go on the Continent, and after five years' absei 
on my return I was surprised to find the patient Carter still living, 
in much the same condition as when 1 left England." 

This patient used to amuse himself or earn his living by making copies 
of engravings with his mouth. I have one in my possession, taken from 
a line engraving of Hewson, in the Sydenham Society's works, which is 
certainly a most extraordinary example of the man's wonderful artistie 
capabilities. He employed a camel's-hair brush, three or four inches il 
length; with which every line was made with the greatest accuracy 
precision. 

1 saw this man several times during the latter period of his life, 

ik these few notes of his case: — 

Perfect loss of sensation in the lower and upper extremities, excel 
idistinct sensibility on the left side as far as the elbow. Muscles of 
left shoulder more developed than the right. Feels distinctly on the 
shoulder, and indistinctly on the right shoulder. The left forearm is now 
flexed; the thumb is turned into the paim of the hand, and the fingers are 
bent over it. Right arm nearly straight; the little and fourth fingen 
flexed. The hands remained open until about six months after the acoi; 
dent, when contraction commenced. No contraction in the feet, 
that the right foot is a little flexed. Legs jump a little during the effoi 
at defecation, and sometimes suddenly without obvious cause. Arms 
jump, especially the right, during micturition. Bowels not open without 
medicine (senna). On some days has peculiar sensations of chilliness, 
becomes pale, and then feels hot and flushed during defecation and mictU' 



i 



INFLUENCE OF REST. 67 

rilion. The more constipated the bowels, the more these peculiar sensa- 
tions are experienced. Urine very offensive when he has caught cold; 
at other times not so offensive, but always a little so. Urine acid. Feels 
a distinct pain in the bowels occasionalfj-, and now and then an aching in 
the loins. When sick, vomits with great difficulty. Krections of penis 
are frequent, and last a quarter of an hour, with slight escape of seminal 
fluid occasionally. Spine: nothing abnormal to be felt. No costaJ move- 
ments during respiration; no hiccough. One good meal of meat daily." 

This case forms a great encourage- 
ment togiveeverypossiblecare and atten- 
tion to the treatment of injuries of the 
spine, with the hope of obtaining the 
same happy result as occurred in this in- 
stance. According to statistics and the 
text-books, he ought to have died within 
a few days after the accident; but, repa- 
diating any such duty, he lived during 
fourteen years, and then his death oc- 
curred from accident. Whilst being 
dragged about in a little four-wheel cart 
by a boy, he was upset, and, as he could 
not put out his hands to save himself, he 
fell with great violence upon the ground; 
this led to some chest affection, which 
occasioned his death in a few days. His 
friends would not allow his surgeon, Mr. 
Nott, of Coggeshall, to examine the 
body, and only upon a very special appli- 
cation, just before the removal of the 
body from the house for the purpose of 
immediate interment, was he permitted to 
take out the portion of spine of which 
a drawing is given in Fig. 19, otherwise 
we should never have known what kind 
of accident this patient had experienced. 

In the drawing, which waa made from 
the preparation itself, the bodies and 
arches of the fifth, sixth, and seventh 
cervical vertebne are seen blended to- 
gether by bone. The body of the sixth 
vertebra is displaced, and projects back- 
wards into the vertebral canal, and no 
doubt was the cause of the paralysis. 
It is worthy of notice that the inter- 
vertebral substances have disappeared, 
but their outlines are still marked, and 
their places occupied by bone. The thin 
articular laminie of bone usually interposed between the intervertebral 
substances and the bodies of the vertebra are still visible, although the 
intervertebral substance itself is gone. Every one must admire the per- 
fect and level union by new bone which has taken place at the fore-part 
of the spine; and if Nature could have been as effective with the spinal 
cord, this patient might have perfectly recovered. I will conclude my 
reference to this case by reading an extract from a short memoir of this 



68 ON THB THEBAPEUTIC 

man, publisHed by John Parker, in the Strand. I may add that the whole 
memoir is of great interest, and will amply repay the reader for the time 
he may employ in its perusal; — 

" The way in which John Carter executed his works must be stated. 
The posture in which he drew was, lying a little on the side, with the 
head a little raised by pillows. A small, light desk of deal, made under 
his own direct ions,* was adjusted for him. On this desk his drawing-paper 
was fastened in the usual way. The drawing to be copied, if of moder- 
ate size, was set up between the drawing-paper and the desk ; or, if too 
large for this, was suspended by tapes from the top of the bed. He 
never drew but in bed. He first sketched his subject with a lead pencil, 
sometimes as little as four inches in length, which he held between lus 
teeth. This done, a little saucer of Indian ink was prepared, and the 
brush was moistened by his attendant, and placed in his mouth. He held 
it fast between his teeth, and by the motion of the head produced 
most accurate and delicate strokes." 

I must apologize for detaining you so long with the details of these 
cases of disease of the cervical portion of the spine, but they appeared to 
me of great interest in demonstrating the value of rest as a remedial 
agent in such diseases. The last case, in which the injury was not situ- 
ated in the immediate neighborhood of the atlas and occiput, had intrin- 
sic and rare merits of its own, which must be my excuse for devoting so 
much time to it. 



INFLUBNCB 



LECTURE VI. 

Abscuse* Openei] to Seonro OoapUtion to their Internal aurfacoa, and to Permit their 
XJaioD by giviitg them Itent— Principle ExempliSed in Sub-Mnmmiuy, Knee-joint, 
Aiillv;, Orbital, Cenicol, PoHt-Pburyiigea], Iliac, Knh-Olateal. Sab-FaBOia], 
and Sub-JMuBcuIar Abscesseii, together with the beet Method ot Opening no Ab- 
BCGMi — Sinuses Cured by Rest — Treatment) of Sub-OccipidiJ. Oervicul. Caibonati- 
lu. Popliteal, and Facial Sinusea — Caiuo and Treatment ol Irritable Ulcen. 

Belibvino that even in public lecturea some little varietr may add a 
slig4it degree of charm, 1 have taken the liberty to break in upon the 
order of my subject, and to ask you for the present to divert your atten- 
tion from the consideration of pain, as associated with disease of the spine. 

As I contemplate the subject of rest in its curative aspects, its applica- 
tion appears to me so widely estensive, and the variety of conditions in 
irltich we may derive important assistance from its use so great, that I 
«m inclined to say there are few surfrical diseases to which it may not be 
made to contribute relief. My present object, however, is to remind you 
ot its beneficial influence in some of those familiar coses of diseases which 
the surgeon nieets with so frequently in practice. I have therefore selected 
for our consideration in this lecture its ugency in the cure of abscesses, 
sinuses, and certain forms of ulcer. 

I wouJd now put the question — Why do surgeons open abscesses ? 
Various answers may be gii'en: to relieve patients from pain and consti- 
tutional disturbance; to prevent the abscess enlarging, or to limit the 
deatniction of tissues; to prevent further encroachment upon important 
<H^ns; to remove the accumulated extraneous fluid, &c. This is alt 
true; but still the question presents itself — What is the ulterior object 
in opening an abscess ? The ulterior -object is to permit and to secure 
(coaptation of the internal surfaces of the abscess — to give its internal 
surfaces rest, so as to permit of their union, and further rest, for the pur- 
pose of consolidating the medium of union. This ulterior object has, or 
ou^t to have, an important bearing upon the surgeon's proceedings in 
opening an abscess. In order to empty an abscess of its pus, we must 
make the opening into it at its lowest part, just as if we desired to empty 
a pail of its water, without disturbing the pail, we sliould make a hole at 
iho bottom of it; or as if we desired to remove the whole of the fluid con- 
tents of a soft bladder, and induce collapse of its pliant walls, the aper- 
ture of exit must be made at the lowest part of the bladder. In the treat- 
ment of abscess, it must be borne in mind, that it is only by the evacua- 
tion of the whole of the Huid of an abscess that we can render coaptation 
of the two surfaces of its walls possible. 

It ia worthy of remark, that an abscess, under many ciroumstanoea, 
experiences a great difficulty in getting rid of its purulent contents. We 
»ee what a great length of time an absoess requires to push out any solid 
extraneous body, such as a portion of wood or clothing, or of necrosed 
bone; or a wound to rid itself of a portion of linen thrust into it. A con- 



It ill 



k 



OW -THK THERAPITTTIO 

mder&ble time may elapse before the granulations can ejttntde these solid 
bodies. But in the case of a. simple abscess the oollection of fluid natn- 
rally sinks to the bottom, and compels the abscess so to fill up its floor by 
the tardy process of new growth or slow adhesion, as to eject the fluid 
against gravitation. The granulations, or newly organized lymph, may 
ultimately succeed in forcing the fluid contents oat of the abscess, but fl 
is a long time before the two surfaces can be brought into accurate appo- 
sition, and in general the abscess is a very long time healing. Abscesses, 
then, ought to be opened at their moat depending or lowest part, 
the only way to promote surface coaptation; and it is the flrst step 
wards cure. It is also the best preventive against the necessity for di 
squeesing an abscess for the purpose of emptying it. This continui 
interference with Nature by the surgeon or patient might fairly be call 
rery "meddlesome surgery." There cannot be a doubt that by rubbing 
the two surfaces of an abscess together once or twice a day, we are not 
only likely to disturb the natural process of adhesion or granulation, but 
almost sure by such friction to induce an inflammatory condition 
tures which, for the purpose of repair, ought to be in a oomparati 
healthy state, and quietly taking their own steps towards filling up 
whole interior of the abscess in a sound manner. 

The lowest part of the abscess necesHarily depends on the position 
the patient. Thus, in the case of a patient in bed having a sub-fi 
abscess of the thigh, the lowest port of the abscess may be the upper 
of the thigh. 

I may remind you that, in a case of suppuration under the teni] 
aponeurosis, we sometimes experience great difficulty in curing it. 
difficulty arises partly from the necessary movement of the surrou 
structures {temporal muscles especially), and from our inability to 
the floor of the abscess. We know that if we open this abscess above the 
zygomatic arch, whilst the floor of it extends much lower down, the ab- 
scess is extremely tedious in closing, and the surgeon fails in his object. 
By-and-by, Nature herself makes a. hole by ulceration into the Tnouth, at 
the lowest point of the abscess, near the coronoid process of the lower 
jaw, and then the abscess or sinus closes. Such a cose clearly marks the 
difficulty in which the surgeon is placed. Under these circumstances, 
and in such a ease, it is better for the surgeon (instead of allowing Nature 
to be the sole agent in accomplishing the object in view) to pass his probe 
downwards, through the aperture made above the zygomatic arch, towards 
the mouth, to feel the end of the probe through the walls of the mouth, 
and then make a smalt aperture opposite the point of the probe, and iu 
that way obtain an outlet at the bottom of the abscess. Surfac« cnapta- 
tion, equivalent to rest, then quickly takes place, and the abscess, instead 
of being tedious, is brought by "rest" to a rather speedy termination. 



Siib-Miimmajy Abscess, ■ 

In marked illustration of the advantage of this principle, I may men- 
tion a case detailed to me by Mr. Luke. It was that of a very large ab- 
scess, which lie was called upon some years ago to treat, and cured speed- 
ily by acting upou these views of opening the abscess at its lowest part, 
and securing subsequent surface coaptation of its walls. 

ISie patient had a very large abscess, extending under both r 
across the front of the cheat, from which Mr. Luke let out the whole a 



g DJntB of pus. He took 




INFLUENCE OF BEST. 71 

(owest port of this abscess, and to coapt the dome and floor of the abscess 
by pressure with pads of lint, plaster, aud bandages. The result of this 
accurate coaptation waa that the abscess was completely cured in a few 
days. 

This patient was thus cured by giving "rest" to the nails of the ab- 
scess, and enabling them to become united and consolidated by adhesion. 
This case expresses an important fact, for there can hardly be a doubt 
that, if this large abscess had been opened at the upper part, and the pus 
inoompletely evacuated, it would have required a very long time on the 
part of Nature to extrude the fluid. We have here, then, a good exam- 

{)le, showing on a large scale thu advantage of opening an abscess at its 
owest point, — the interpretation of the successful result being that of 
accurata coaptation and rust." * 

Abscess over ths Knee-joint. 
I have had this diagram (Fig. 20) made for the purpose of illustrating 
the position of one kind of abscess which occurs in the neighborhood of 
the patella. I have seen two or three such cases, where an abscess upon 
the exterior of the knee-joint has ultimately found its way into the inte- 
rior of the articulation. In this sketch from nature I have endeavored to 
indicate the position of an abscess underneath a layer of fascia lata which 
is prolonged over the patella. Such an abscess may be the result of an 



* To show the value of the treatment of absoesseB by rest, the two followingf caites 
ha<ra b«eti added, Uie one treated b; meohamcal. the other b; phjsiological, rest. 
Tbo fiiat, tor wbioh I am indebted to the kimlueBS of Mr. Cooper Forator, is of espe- 
cial intereBt on aocount of the previous prolonged and ineffective treatment. The uotea 
of this cose are from the report of the warl-cJeik. Mr. Pluinmer. 

W. a, Et. 30, waa admitted Into Luko waj.l under the oareot Mr C. Foreter, Deo. 
A, 1875. About eighteen months ago be noticed a alight awelliog on the upper part at 
the rig'hb chest. This proved to be a subpectoral abscess, wbioh " came to a head and 
broke'*Nov., 1874. As the place oontianed to discharge occasionally, he was under 
the oare of his alab doctor till June, I8TS, when he went to University Colle^re Hospi- 
tal Here the sweilin;; was " Inuced " three times, aud poulticed. He left in Septem- 
ber, aad attended aa an oat-patient foe a month longer, and then was under his dab 
doebOT again ti!) his admissioa into Gay'a io December, 1875. On odmisHJoa there was 
an ahecess over tha second right rib. No dead bone could be detected after laying the 
abwwra freely open. Deo. 13. — The arm wqh fixed with bruidoges, so as to keep the 
peotoralea quiet. Jan. -'SI.— The arm has been kept fixed ; the place is almoBt entirely 
healed, diach.irge very slight, the skin aroand the wound is now Grm aud healthy. 
Har. S. — No discharge. Har '£i. — The patioat went out cured. 

The details of the second ooae, in irhich physiological rest was succesefally used, 
have been given me by Mr. nilCoo, iu whose practice the caae occurred. 

Id 1804 Mr. Hilton was coosalted by a lo^y who had a large absceiui in her right 
breartsoon after a confinement. The nb^ioea^ hiid continued to discharge from several 
idnnses daring many weekit. not withstand in;; the applioatlon of well-adjiisted presHure 
and many other local means. All along since her confinement the patient had eon- 
tinned to saokle the child from the left breast, the supply from which seemed suffl- 
cient for it. Mr, Hilton, fiudin^ on inquiry of the patient that the breasts sympa- 
thiiod physioit^cally both before and during the feeding of the child, advised that this 
functional and aasooiated sympathy shonld be destroyed by weaning the child, in order 
to seonre physiologlonl rest to the right breaet. The ordinary means were adopted, 
and within a day or two Che right breast leHsened both in site and hardness, and the 
diacbaige from the sinuses quickly cessed. In a tew days the local absoess symptoms 
disappeared, and secretion of milk iu the left breast soou ceased after the withdrawal 
of the child. Since the nbove date this lady hns had several childreo, and has experi- 
enced no arrest of fnpclion in the right breast. In April, ISIti. Mr. Hilton had an 
iqiportanicy of eiamining the right breast, and found it presenting the condition nor- 
mal to this organ in pregnancy. — [Ed.] 



OS" THJ! THBRAPIitrTt* 

ifiammtvtion hpginning within the bursa upon the patella, or snpervi 
' ilpon any accidnnta) inflammation at that part. This abscess ext«n< 
laterally on both sides, spreading over the joint, so that if prcasuro, with 
the linger bo made on one side, lluctuution will be felt on the other side, 

I leading to the suspicion that the abscess or collection of fluid is really 
within the knee-joint, and fluctuating through the interior of It. Under 
f the supposition that it 





my oMiaigao 



\ which this 



nilammatory efltuion, 
it may create a great 
of unnecessary ' 
Upon cjareful t 
tion, however, it 
found that a thin li 
of fluid is conveyed 
the patella from odi 
to the other, thus 
ing the ex-articulai 
tion of the abscess. 
would not place such a 
rudimentary case before 
you, escept to controvert 
an error which not nnfre- 
(juently occurs, and which 
1 know has led to the, 
death of two persons 
giving time and ojn 
tunity tor the absoeas 
find its way into the ini 
rior of the knee-joint. 
In caacB of this kind ot 
abscess, whether they 
originate in a burs* or 
some other structure, it is 
of little use to open the 
abscess at its top — thiit 
is, over the patella, 1 
have seen many examples, 
and it has been almost in- 
variably necessary ulti- 
mately to open its lower 
not done early enough, 



the 
int^B 



^^Pir- 



each side. In on , „ 

abaceAS found its escape under the fascia of the thigh, and became & 

large sub-faseial abscess. This might have l)een obviated if t 
ifture on each side had been made, so as to prevent extension upwai 
It is true of this kind of abscess, that after opening the top of it, | 
16 knee-joint can be carefully strapped on each side, so as to secu*^ 
accurate coaptation of the walls of the abscess, we may now and then 
succeed in closing it. But in this proceeding there ia some little risk of 
the whole of the matter not being evaeuated. Pressure also may lead to 
ulceration towards the interior of the joint; for abscesses follow in their 
course the direction of the least resistance, and the interval between the 
abscess and the interior of the joint may be very slight. It has fallen to my 
lot to see one case (it occurred in the practice of a surgeon in Finsbury 
.Circus who is now dead) in whicli too long delay in opening such mn 



INFLUENCE OE RES 



abscess allowed it to i 
death of the patient. 



ake its way into the knee-joint, and caused the 



AriHary A^acesge*. 

A large abscess extending; hi^h into the axilla, under the pectoral 
muscles, should be opt-ned from the axilla, through the floor of the 
abscess. If you open the ahseess at the upper and anterior part of the 
axilla, you open the top of the abscess, and the tedinusness of the case 
annOYB both patient and surgeon. Many years ago, 1 saw, with Mr. 
Blenkarne, a case of this kind, in which this difficulty and annoyance 
occurred to us. I stupidly opened the aTjsiwss at its upper and anterior 
part; the man was relieved, but it was many weeks before he got well. 
My error was, that I had opened the top instead of the floor of the 
abscess; we could not keep its walls qi.iiet, and Nature had to fill it up 
from the bottom, under the disadvantage of frequent disturbance by the 
movements of the shoulder. 

To make the opening into an abscess st its most depending part is 
not always a very easy and safe proceeding; hence it becomes important 
to ascertain, as far as we can, what is the safest and best method of open- 
ing a deep abscess. Here 1 must take the opportunity of mentioning to 
you a method that 1 have employed for this purpose during a great many 
years, and I have never seen a single inconvenience arising from it. 
Persons have died, and many lives have been endangered, by hemorrhage 
consequent upon opening a deep abscess by the lancet or bistoury. 
Within the last twelve months I have known two lives placed in great 
jeopardy by the use of the lancet in opening deep abscesses. These cir- 
cumstances alone will, I hope, be a sufficient excuse for my bringing this 
subject before your notice. My own long experience of its value justifies 
the high opinion 1 entertain o( the method of opening a deep abscess 
which 1 am about to recommend to your notice as safest and best. It is 
safest, because it is scarcely possible to inflict by it any injury on blood- 
vessels or nerves. I think, too, it is th« best plan; for if the deep open- 
ing into an abscess be lacerated and bniised, it is not at all likely to close 
hj adhesion; and undoubtedly, when we have opened a deep abscess, we 
are desirous that the deep opening should not close immediately. Id 
principle, all will admit that if a lacerated opening be made instead of an 
incised one, it will be under circumstances adverse to its quickly reuniting. 
Nay, more: supposing a lacerated wound, for example, to be made deep 
in the thigh, and a btood-vessel divided by being torn asunder, it would 
be a lacerated wound of the blood-vessel, and therefore not so likely to 
bleed as an incised wound. 

Some surgeons, when speaking of deep abscesses, say with rash con- 
fidence, " Plunge in a knife." It is a grand term — " Plunge a knife into 
a deep abscess," It is not a courageous plunge for the surgeon; for it is 
without danger to himself, while perhaps it is a fatal stab to the patient. 
Some more careful surgeons say, " Wait until the abscess comes nearer 
to the surface, so that it can be opened without danger;" but the patient 
may die in the meantime. Now the plan I have been in the habit of 
adopting and recommending is this — in the case, for example, of opening 
a deep abscess in the axilla — cut with a lancet through the skin and cellu- 
lartisaue and fascia of the axilla about half or three-quarters of an inch 
behind the axillary edge of the great pectoral muscle. At that part we 
can meet with no large blood-vesse!. There ia only a small branch of one 



I 



Orr TIIK THEKAPKITTTC 



Jiof tlie external thoracic arteries, which Bometimes runs alr>ng the P<5fr^ o( 
xilta; excluding that, which if wounded can be easily ligatured 






^^^^^0 introi 



other risk. Then push a grooved 
grooved director upwards into the 
awelUiig in the axilla; and it you will watch 
the groove in the probe or director as it i» 
being passed up through the comparatively 
healthy tissues into the axilla, a little stream 
of opaque serum or pus will show itself. 
Take a hlunt (not a sharp) instrument, anch 
as a pair of " dressing forceps," and run the 
closed blades along the groove in the probe or 
director into the swelling. Now opening the 
handles, you at the same time open the blades 
situated within the abscess, and so tear open 
the abscess. Lastly, by keeping the blades 
of the forceps open during the withdrawal of 
the instrument, you leave a lacerated track 
or canal, communicating with the collection 
of pus, which will not readily unite, and will 
permit the easy exit of the matter. In this 
way you may open an abscess deep in the 
axilla, or in other important parts of the 
body, without fear of inflicting any injury 
upon the patient. Having been connected 
many years with a large hospital, 1 have 
necessarily had good opportunities of trj-tng 
this method. During that time I have not 
opened a deep abscess in any other way, and 
T can say, honestly and truly, that it has 
never failed, and that I have never observed 
any inconvenience from it. 
With respect to this method of proceeding, a curious circumBtance hap- 
pened to me. I was requested some years ago to see a surgeon in London, 
who was suffering from a large inflammatory swelling in the armpit, 
resulting from a wound made at a poat-mortem examination. When I 
saw him, he had a dry, brown tongue, and was delirious. His pulse was 
very feeble, and there were other circumstances indicating that fatal mis- 
chief was impending. I opened the abscess in the axilla in the way which 
I have pointed out, passing the grooved director between two and three 
inches up into the axilla, and opening the abscess by a pair of dressing 
forceps. The patient got well, the Btarting-point of his recovery being 
the opening of the abscess. About ten years afterwards, this same sur- 
geon came to me one morning, in a great hurry, to request me to go with 
him immediately to see a patient who was dying. He then told me that 
on the previous afternoon he had opened an abscess in the armpit. " I 
did it," he said, " as well as possible, without any difficulty, for I used 
Liston'a knife" (blaming the knife for what had happened). "I opened 
the abscess yesterday, and let out the matter, and this morning I find the 
armpit fuller than before it was opened, and blood is coming out of the 
hole 1 made. The man is nearly dead, and his arm is as big as two." We 
went directly, and found the man nearly at the point of death from loss 
of blood. I had to enlarge the aperture in the axilla, so as to enable me 
:o introduce my hand, scoop out the whole of the blood, atid expose thj 




INFLUENCE OP EEaT. 75 

y to the external air. No further hjpmorrhage occurred, but the patient 
was very nearly killed. Now, this was the very same surgeon whose 
axillary abscess I had opened with the dressing forceps high up {two or 
three inches from the surface), without doing him any mischief ; while he 
himself wounded a blood-vessel in the armpit with " Listoii'a knife," and 
nearly killed his patient. 

Orbital Abscess. 

Some years ago I had a case in Guy*s Hospital of a fractured base of 
the skull, the fracture extending across the posterior part of the orbit. 
After some little time the parts within the orbit began to swell, and the 
eye to be protruded. The patient was amaurotic on that same aide, and 
was suffering very severely locally as well as constitutionally. With the 
hope and probability of finding a collection of blood or pus at the deeper 
part of the orbit, I made, with a common lancet, a small cut horizontally 
through the fibres of the orbicularis palpebrarum of the upper eyelid, and 
passed through it a grooved probe or director along the roof, towards the 
apex of the orbit. A little purulent fluid was visible in the groove of the 
director. I then introduced along the groove the blades of a small pair 
ot dressing forceps, and opened an abscess by separating the handles of 
the forceps ; the matter escaped freely, the patient was relieved of his 
distreaa, the pressure upon the optic nerve was removed, the amaurosis 
disappeared, and he ultimately recovered without need of further aid. 

JDeep Cervical Abscess, 

About four or five years ago I was sent for by a surgeon in my neigh- 
borhood to see his wife, tjho was a delicate woman, in about the middle 
period of pregnancy, and it was feared that she would miscarry in con- 
sequence of her having a large inflaranaatory swelling deep in the right 
mde of the neck. There was an obvious fluctuation in the swelling, and 
it was thought to be an abscess. She was suffering greatly, and the ques- 
tion was, how to reach the seat ot the disease. I should not have dared 
to pat a knife in, because, with all the anatomical accuracy which a 
surgeon may possess, it must be admitted that movable parts get very 
much displaced by the enlargement of an abscess, so that it is not possible 
for the best anatomists to lell with accuracy the exact position of those 
blood-vesseis and nerves which it is important to avoid. I cut through 
the cervical fascia with a lancet, thrust into the swelling a grooved probe, 
and used the dressing forceps. In this way the abscess was opened, and 
the patient did perfectly welL The patient in this case was the wife of a 
surgeon, who saw the diflieulty of opening the abscess, and who appre- 
ciated the advantages of this safe method of proceeding. 

Post-pharyngeiil Abscess. 

A short time ago, while going round my ward at Guy's Hospital, a 
little child was brought in; and the circumstances of the case were shortly 
these: — She was an unhealthy child, twelve months old, and had a post- 
pharyngeal abscess, with disease of the cervical vertebnc. She had a 
lai^ deep swelling in the upper part of the neck, on the left side, ex- 
tending to the angle of the jaw. The carotid artery was pulsating upon 
the anterior surface of the swelling, close to the anterior edge of th» 



Oft THE THKBAPKUTIC 

,^ "no-oleido- must Old. TIio trachea waa pushed forward and to the rigl 
' side, and the tongue was protruded. My finger detected in the pharyi 
a swelling, which prevented deglutition. Respiration was extremely dil 
cull, and the spine and neck were curved forward. Large superfii 
veini were crossing the left sterno-cleido-masloid, and oceupving 
Kimoo between it and the trapezius muscle. Examination of tfie th 
through the mouth brought on extreme dyspntea, so that the child 
iii-'arly suffocated, the face becoming quite livid. On the previous e 
iiig a surgeon was called to the case, for the purpose of jjcrforming ti- 
oheotoniv, but it was thought better to send the child to the hospital. 
Whew the patient was sent up into my ward she could not swuJIow any- 
thiTig, and it was expected that th« child would die of suffoi'aiion if tra- 
chcMtomy were not immediately performed. The post -pharyngeal cioll) 
lion of puB was the cause of all the urgent symptoms, but how to get at 
without danger to the little pati«nt was the question. In this 
wicmed to mc that if I made an aperture through the mouth, thi 
might bo liable to suffocation by a large quantity of matter escaping into' 
the larynx, i determined, therefore, to adopt the following expedient: — 
1 carefully made an incision, about half an inch in length, with a lancet, 
through the stent o-cleido-mastoid, thus exposing the faB<L'ia underneath it; 
I then thrust a grooved probe or director through the fascia, towards the 
back part of the pharynx, when a Utile stream of opaque fluid eaine trick- 
ling down the director. I then ran the dressing forceps along the 
grooved director, made an opening into the deep abscess, and let out 
throo or four ounces of pus. The exit of the pus was aided by passing 
my finger into the child's mouth, and pressing upon the posterior wall of 
hpr pharynx. Tho carotid artery subsided to its proper position, the 
breathing was immediately relieved, the patient lost all sense of suflDc»>^ 
tioii, and some wine and water was quickly i " 
th« hospital after six or seven weeks in a cc 

1 bplievo it would have been unsafe to ha 
nliaci>ss in tho neck, and close upon the spine 
ing instrument, 

Oct.. 18(i0. — This patient was seen three 
rcgartls tbe abscess, and the spii 






The child 

nparatively healthy oc 



ave attemjited to open this 
by any cutting or perforat- 



3 



((mte 



inths arterwards; she w«« 

was consolidating. 



liiaa Abscess. 






A man oarao under my care at Guy's Hospital, having received a kif 
from 11 hnrse over the left hip, which broke the os innominatum, 
ilmve a large piece of it inwards towards the abdomen. Subsequently 
ahnrtestt occurred under tho iliacus intcrnns, and thence it descended into 
the lliigh, behind the femoral blood-vessels in front of the hip-joint, 
towards the inner side of the thigh. He was suffering great constitutional 
iliiitn^N.'), and it became necessary to open the deep and obscure abscess. 
Itdieving that it could not be safely reached by a knife or bistoury, I 
nindi' an aperture on the inner side of the upper part of the thigh by 
culling through the skin and fascia lata, and exposed the gracilis muscle. 
1 ihmi ran the grooved director through the gracilis into the deep and 
painful swelling, and opened the abscess with the dressing forceps. 
The patient was relieved at once, and there was tbeaceforward neitfaw 
ilifllcully nor danger associated with the case. 






INFLUENCE OF BEST 



Sub-t/hUtal Ah^ce»3. 
A few ^ears ago I saw, wHIi a. ptiysicjan and a surgeon, a young gen- 
tleman, in St. John's Wood, who hud acute disease of the hip-Joint, with 
deep fluctuation (abscess) under the gluteal muscles. TJie lad wus verv 
feeble, and dangerously ill, and it became necessary to relieve him. 1 
made a small cut down to the gluteus maximus, not through it. I then 
run a director through the gluteal muscles, and opened the abscess with 
the forceps without the slightest dilliculty to myself, and without any im- 
portant bleeding or danger to the patient. 

Stib-fascial and Sub-musailar Absctases. 

I have over and over again pursued this same safe plan in sub-tasciol 
or sub-muscular absoeas or abscesses formed upon or under the periosteum 
in the thigh. It has occurred to me many times in such cases, after 
dividing the fascia lata, to see the healthy muscles project boldly and 
dearly in the wound; and, instead of cutting through them, I have 
reached the abscess by running n. director right through the musclea into 
the collection of fluid, and tlien introduced the dressing forceps in the 
way I have described. It is, I believe, impossible that any surgeon can 
foretell the exact position of the branches of the circumflex arteries, or 
perforating arteries of the profunda, in a case of deep abscess of the 
thigh; so that when he plunges his knife into the deep swelling he can 
feel no certainty as to his being able to avoid blood-vessels or nerves. 
But it the plan which I have recommended be pursued, it is hardly possi- 
ble that any such mischief or accident can occui ; and I can add this satis- 
factory assurance, that 1 hare not yet had a single case in which this 
method of opening deep abscesses has been followed by important h:em- 
orrhaee. 

1 nave recently (October, 1860) seen a young patient, who a short 
time since had a deep abscess in the thigh, just above the knee-joint. 
The surgeon in attendance opened the abscess by some cutting instru- 
ment. Pas and arterial blood escaped from tlie opening, but the bleeding 
was stopped for a time by plugging the wound. A recurrence of sudden 
and profuse arterial hemorrhage took place in a few days, which nearly 
destroyed the patient. It was then thought right to ligature the femoral 
artery at the upper third of the thigh, and the bleeding ceased from that 

In the case of a patient having an abscess close upon the interosseous 
ligament in the forearm, if the attempt to reach it be made by cutting 
down upon it, it is extremely difficult, next to impossible, to ascertain 
previously the exact position and direction of displaced nerves, veins, or 
arteries; so it must be equally impossible to avoid, with certainty, wound- 
ing some of these important parts. But if you simply cut through the 
fascia so as to expose tne muscle at the most prominent point of the swell- 
ing (taking care to avoid the course of the larger blood-vessels, which may 
be felt with the finger), and then thrust the grooved director through 
them down to the interosseous ligament, the matter wilt show itself by 
welling up the groove of the director, and the introduction of a dressing 
forceps will then complete the operation with safety. 

I think I have now said enough of this operation. I have not brought 
it forward from any egotistical feeling, but simply for the purpose of 



Olsr TJIK THEEAPETTTIO 

deep abscesses may be opened with the grentest 






I 



Sitmaes enred hi/ Jtegt. 
Tf a sinus remains a long time after an abscess, we are very apt i 
think that it depends on the bad health of the patient, and the custom 
to send him to the sea-side, away^ from liis ordinary occupation, and t 
leave the sinus alone ; and certainly the sinus gets well. The reault ' 
perhaps, not so much the consequence of improved health as o[ re»t 
the sea-side. 

I will now place before you a short series of cases where abscesses 
sinuses after abscesses, are moved by muscles, and are, therefore, vi 
difficult to heal. With regard to many such abscesses or sinuses, if 1 
surgeon will only take the trouble to ascertain whether the atiatomici 
associations are such that muscular disturbance of the walls of the abscei 
can take place, and will adopt the right means to secure rest to the bi 
of the abscess, or track of the sinus, 1 think ho wilt discover that this ki 
of abscess or sinus, which seems to defy almost every kind 
agent, wiL be found amenable to a very simple method of treatment, 
rest. Walls of abscesses, influenced by muscular force, are t 
,ted by rest — that is, by preventing motion, and by the use of genii 
sure; or, when necessary, by the division of the muscle or fascia, H 
la may be considered as a portion of the insertion of muscle; for 
apprehend there is no fascia in the body which is not iiiQueuced by mu 
cle. Physiologically and surgically considered, fascia is one of thi 
lions of muscle — a point to which I may have occasion to refer in mot 
detail at some future time, 

I Sub-occipital Abscesses. 

An abscess under the occi pit o- frontal is muscle is sometimes very lanp 
and resists surgical treatment for a very long period. Why is this? Li 
me remind vou that the areolar tissue in which this abscess exists is abui 
dant, and that the whole superficies or dome of the abscess is under t) 
influence of the occl pit o-fron talis muscle. Hence there is no rest to tl 
abscess: it never has a chance of quiet, or of accurate and persiaten 
coaptation of its surfaces, from the disturbance produced by tlie t 
ments of this mifecle. That such abscesses are difficult to heal w 
admitted when I mention the particulars uf some cases; and I wi 
endeavor to demonstrate to you that in the sui^ical treatment of sue 
cases the great object should be to keep the occi pito- frontalis perfeoti 
quiet. I would say, then, that cJironio abscesses or sinuses under t) 
acatp may be cured by keeping the occi pi to- frontalis quiet and at rest h 
Etrappin^r- 

lu illustration I may mention this case. I-ast spring I was reques 
to see a stout gentleman aged fifty, who had fallen down the hold o 
ship. He had been taken to the T.ondon Hospital, where his wound waft 
well dressed. The anterior half of the scalp was injured; it had been 
turned forwards and downwards, quite over his face by the accident. 
This Hap was repliteed in accurate position, Imndaged, strapped, and the 
"itient was sent home. No primary adhesion took place in the woun^ 
a few days his sui^geon thought it right to take oS the dreasinj 
ten it was found that the sa»ip its<'lf was much swollen, and that t 
rhole of it was lifted up ur raised from the bones by sub-occipital supp^j 



>uii^^ 



IlfFLCENOEOFBEST. 79 

ration. The patient subsequently h&d two attacks of severe lisemorrhag^, 
from sloughinK and ulceration of the temporal arteries, vrliich required 
ligatures. It la worthy of remark that the bones of the cranium were 
denuded of pericranium to the extent of several inches, and were daily 
exposed in this condition during nearly a fortnight. Yet the bones did 
not die, their nutrition being mainly derived from the blood supplied by 
the arteries of the dura mater. The wouud was dressed daily with lint 
and warm water, and the pus squeezed out from under the whole of the 
occipito-fron talis; but the abscess would not heal, and the question was, 
how to get the pus from under the posterior part of the scalp — tor there 
was no outlet for it in that direction^and how to secure rest to the 
movable dome of the abscess. The hair upon his scalp was shaved off, 
and long strips of plaster were so arranj^ed across and around the head as 
to empty the abscess, to keep the occipito- frontalis quiet, and to press it 
downwards upon the pericranium and bones: this was done simply for the 
purpose of giving rest to the parts. The rapidity with which the abBoess 
then healed was very remarkably in contrast with the tardy results of the 
previous daily dressing and emptying of the abacesr. He got qulukly 
well, without any necrosis of bone. 



Sab-orcipitat Abscess and Sinuses. 

The nejct instance I have to mention is of a patient who had suffered 
during a whole year from sub-occipital abscess and sinuses — sequelie to 
suppuration — and who was cured by rest and pressure in from three, to 
four weeks. It was the case of a girl, sixteen years old. Her general 
health had become exceedingly impaired, and her frame much wasted by 
the discharge from the sinuses under the occipito-fron talis and the swollen 
scalp. This abscess and the sinuses were originally the result of a blow, 
and slie had been more than a year uTider surffical treatment. Sinuses 
had burrowed under the swollen cedematous scalp, traversing it in differ- 
ent directions, and communicating with each other. The cranial bones 
-ware found denuded of pericranium at two or three points, and profuse 
suppuration took place from the openings of the sinuses. (Here I may 
incideii tally remark that profuse suppuration ia tantamount to daily vene- 
section — and this is the way in which I think a surgeon should regard 
excessive suppuration. The drain must necessarily keep the person in a 
reduced condition of health.) Poultices and stimulating injections had 
been osed, with ointments to the scalp, and these had been assiduously 
employed during a twelvemonth. The head was now shaved, and numer- 
ous long strips of plaster, from half an inch to an inch wide, were 
ammged around and across the scalp, so as to keep the niuscles perfectly 
quiet, while allowing the a[)ertures of the sinuses to remain uncovered, 
thus permitting the escape of any discharge. Fresh strips of plaster 
were applied as soon as the others becauie loose from the gradual diminu- 
tion of the size of the scalp, and the patient was well in three weeks. 

Now this patient had suffered from abscesses and subsequent sinuses 
during a whole twelvemonth, the sinuses freely communicating with each 
other, with here and there denuded bone. Perfect rest was given to the 
walls of the abscess, by accurate adaptation with plaster, and the patient 
was well in three weeks. There was no exfoliation of bone, the chief 
nutrition to the bones of the head being derived, as I before remarked, 
from the dura mater, and not from the pericranium. 

Some years ago, I saw, with the late Dr. Marshall Hall, a young gen- 



80 ON THE THERAPEUTIC 

tlcman in Weslboume Ternnie, who had eTysipeias of the Bc.a\p, followwl 
by Bub-o'!cipital abscess. We could not succeed in healing it until tha 
head had been shaved and plasters applied, eo as to keep the occipito- 
frontalia at rest, when he got perfently and quickly well, 

I may mention another case of th e same kind. H. U , a^d twenty, 

general health good. Ten weeks before niy visit he had roceivetl a blow 
□pou the top of his head, which was followed by an abscess of considoi^ 
able size under the tendon of the o<x;ip it o- frontalis. It was opened by ft 
surgeon, and had been discharging freely ever since; but when I saw him 
the dischaive had ceased for a day, from temporary closure of the artificirf 
opening. On passing a probe into this closed opening, between two and! 
three ounces of thin aero-purulent 0uid, tinged with blood, es(?«ped fro* 
under the occipito-frontalis, leaving a targe loose wall of scalp covertn* 
the seat of the abscess. The head was shaved, a pad of lint was placal' 
upon the loose portion of the scalp, and there strapped down with mo' 
erate pressure, leaving the opening free so as to allow of the escape i 
any dischaive of pus or serum. On July 14th, eighteen days from the h 
^lining of the treatment by rest, this was the state of the patient:- 
Walls of abscess have almost entirely united: little or no diachargoj 
strapping applied to-day for the third time. On the 2l6t of July 
patient was quite well, having been cured by local rest. 

Sub-occipital Abscess, with Ulcer on the Fhrehead. 

About the end of September, 1848, Edward L , aged twenty-sevea^ 

applied to me with a large, deep ulceration of the integuments of tiis fore- 
head, and Bub-occipital suppuration two inches above the ulceration. H* 
had been under the treatment of an hospital surgeon, uninterrupt«dl]il|ii 
during seven months, without benefit, the meana used having been poiik 
tices, stimulating injections, ointments, and various medicines. Tfaiii 
ulceration, influenced by the corrugatores and occi pi to-fron talis, was R 
ated near the middle of the forehead, chiefly over the left frontal mt 
the ulcer and the walla of the abscess or sinus weTe freely movable by b 
these muscles. Two long strips of adhesive plaster were applied tivnl^ 
versely across the forehead, extending laterally to each temple; and o 
long piece was applied vertically, extending upwards from just above t 
nose, and near the median line, along and over the vertex of the head tQ 
the occiput, a path having been previously made by cutting the hu 
the intended course of the plaster; a bandage was then passed severs 
times firmly around the heath AJl this adjustment was made for the put^ 
pose of opposing the disturbance of the parts influenced directly by the 
muscle-s to which I have alluded. Nothing else was done. The ulceratioii 
began to improve; and on November Uth, 1848, my notes report him weQj 
so that in four or five weeks it was bealed ; but as the cicatricial structurtC 
were yet feeble, one transverse slip of plaster was worn, so as to Btea<^ 
the base of the ulcer, until February, 1849, I saw this patient during 
the summer of 1849: he continued j>erfectty well. He was cured by giv* 
ing rest to the base of the ulcer, the muscles being kept quiet by piaster^, 
I happen to know that this patient had had the advantage of very good 
professional advice; but 1 think that his professional adviser did not r — 
ogniie the simple cause which interfered with Nature's healing procc 
It was only by the recognition of the fact that the abscess was so pla< 
as to be under the direct intlnenee of various antngonizing muscles whicdl 
contending against each other, and making traction upon and d 






iirFi.trEiTCE 



abscesa in various directions, never allow- 
i'e any rest, that the method of cure was 
pointed out. 

Cervical Abscess under the Platystna Myoidft. 
Abscesses in the neck, under the platyama myoides, are weU worthy of 
your attention. When these abscesses are opened either by the surgeon 
or by Nature, they are sometimes very difficult to heal. I believe the 
great difficulty depends upon the fact that thev are under the influence of 
the ptatysma myoides. Some time ago, my fnend, fJr. Daldy, brought to 
me the son of a cleiOTman, who was suffenng from a large ulceration, tha 
sequel of an abscess, lying deep in the neck. He had had the advantage 
of good professional attendance and general treatment ; but the ulceration 
not only did not heal, but was slowly extending. We determined to see 
the effect of rest to the ulcer. Stnps of plaster were placed across the 
neck, and a layer of cotton wool over the plaster and the ulcer, upon the 
side of the neck ; these means, aided by gentle bandaging', kept the 
platysma myoides quiet. The ulceration had existed a considerable period 
before I saw the patient, going on from bad to worse ; but immediately 
on this plan being carried out, the surf&ce of the ulceration began to im- 
prove in appearance and to diminish in size, and in a very short time was 
perfectly well, although the child was not, upon the whole, a very healthy 

Deep Cervical Abscess^ foUovttd by a Smtts. 

1 have here the notes of another case, where a sinus existed in the 
neck, which was cured by rest. This case was of two years' duration, and 
was cured in three weeks. I am almost afraid you may be induced lo 
fancy I am using the language of exaggeration in this statement ; but 1 
really am not. 

In 1849, Elizabeth H , aged twenty, living at Lambeth, had had a 

l&r^ abscess eitending deeply under the platysma myoides and the stemo- 
cleido-mastoid. This had continued as a long sinus, discharging freely 
during many months. She had been an hospital out-patient for two 
years. Iodine, &c., had been injected into the sinus, and a seton passed 
through it, and retained within it for some time without any benefit. 
Strips of adhesive plaster were drawn tightly over and across the muscles 
covering the sinus, and the head was steadied by a pasteboard splint, cut 
rudely into a form which could be adapted to the body, along the back of 
the shoulders to the back of the head, and then laterally on each side, so 
Bs to embrace the whole of the head in a circle of pasteboard. This splint 
was made ofT-hand with wet, soft, thick pasteboard, covered by linen, 
pressed upon the surface of the body, so as to become moulded to it, 
and then allowed by the bandaging to dry firmly in its position. A 
lig^re-of-8 bandage was then applied over this apparatus around the head 
and under the axilla, crossing in front of the chest, so as to fix the head 
and neck forward and a little downwards firmly upon the shoulders, and to 
relax the muscles. At the end of a fortnight the sinus ceased to discharge ; 
but she continued to wear the apparatus tor a short time — about three or 
four weeks — longer, as & further security. 

This patient was thus quickly cured by rest. 



ON THX THBBAPSnTIO 

AnoA Superficial Cervical Abtceas. 
We are often troubled how to deal eatisfactorily with the resoltB 
small superficial abscesses in the neck. Such open ahsc«asea under ths 
skin are mostlv said to be scrofulous ; but I suspeet their peisiateniMi 
depends not unfrequently upon their close relation to the platysma myoidec 
I believe — and I am speaking here from experience — that by placing & p«-*" 
of cotton wool, twice as large aa the area of the disease, over the part, an 
by fixing it there so as to keep the platysma myoides and all the sarroutM 
ing parts at rest, many of those cases that seem to defy almost every kin 
of treatment may be successfully dealt with. I have hud opportunitit 
in very many such cases of observing the success of this treatment. 

Caeeg of Carbuncle, foUowed by Sloughing. 

We all know that it is not easy to manage successfully the treatment 
of a patient who has had a lai^ carbuncle on the back of the neck near tbl 
scalp, which, by destroying the subcutaneous areolar and fascial structure 
has left large portions of loose overlapping skin, bine, dark-colored, t 
congested, showing a very feeble power, and, in addition to this, expoi 
the trajiezii muscles to view. Now I wish to show the therapeutical valai 
of local rest in the treatment of such a. case. 

Two years ago I saw the wife of a physician, whose condition i 
rately resembled that which I have just delineated. She had t>een pra 
viously attended by a very eminent London surireon. The case was n 
proceeding satisfactorily; there was no local evidence of repair; and t 
wound had remained stationary some time before my visit. On looking 
at the patient's neck, it appeared to me that there were two additioni 
requisites la the treatment which might help the cure: one was to arrangi 
some simple mechanism which would keep the trapezii muscles quiet; anl 
the other, to support iu their proper positions, and to maintain in a state of 
perfect rest, the loose feeble flaps of skin. 1 hoped by such means U 
facilitate adhesion of the two granulating surfaces. The loose flaps od 
skin were laid neatly upon the subjacent trapezii, and then a large thiob 
pad of cotton wool was firmly fixed upon the surface of tlio flaps of skiat 
and surrounding parts. A bandage was applied around the head, and' 
extended as a figure-of-8 bandage, crossing behind the neck and undef? 
the armpits, in order to fix the head, neck, and shoulders, and control thli 
trapezii. In twenty-four hours the healing commenced, and proceedei^ 
under the same local treatment, to the most satisfactory and speedy teci' 
mination. 

Not long after that time I saw a patient in the CTapham Road, wiilj 
Mr. Wright, where just the same circumstances occurred, with exactly 
similar treatment, and precisely the same result. Here the parts weil| 
kept at rest partly by a thick pad of cotton woo] pressing upon the flapo^ 
and by means of a bandage to keep the head and the trapezii muscles ill 
a state of rest. Cases of a like kind, with the same result from similai 
treatment, have lately occurred to me in Guy's Hospital. 

Popliteal Abiciss and Sitnites. 
Sinuses in the popliteal region, in unhealthy subjects, are very diffi- 
cult to cure, except by local rest; and here I will take the liberty of read- 
ing part of a note which I received from a surgeon in Essex, who baft; 
sinuses at the back of his knee-joint : — 



"Jan. 9th, 1853. — My sinuses oecurrad after an abscess in the popliteal 
space, which left a very irritable, unhealthy ulcer, the size of a walnut, 
aud several long and deep sinuses extending from it, amongst the tendons 
of the hamstrine muscles. Not being able myself to improve this ulcer, 
1 consalted the Tate Sir A. Cooper, who stated that it was owing to a 
defective state of my general health, and ordered me steel and quinine, to 
inject nitric acid lotion, to take exercise, and to wear a high-heeled shoe. 
At the end of many weeks the ulcer and sinuses remained as they were. | 
You then saw me, and ordered my leg to be flexed, and placed upon a 
resting splint upon a wooden leg, with moderate pressure upon the si- 
nuBCB by soap plaster. I continued this plan. In two months I was quite 
well, have been so ever since, and am in active occupation in my proc- 

Small Fiieial Abscess. 

In some small abscesses sometimes occurring in the face, cheek, or 
□eck, which have opened by a minute ulceration through the skin, the 
aperture communicating with the sac of the absceae, I have found the 
happiest results from carrying out this principle of rest to the part, I 
have merely passed a small probe into the aperture in the skin for the 
purpose of keeping it open whilst collodion was being applied upon the 
dome of the abscess, so as to press the dome ujjon the floor of the abscess. 
In this way pressure and rest are aecured, and by coaptation the parts 
are kept undisturbed. The process of healing then commences, and I 
think the patient gets well more quickly by this than by any other local 
method of treatment. 

Sinuses, then, are cured by the adoption of local rest; and I think 
that if surgeons, instead of affixing to every sinus the opprobrium of bad 
general health, would take into consideration the possibility of there 
Vreing some special local disturbing cause associated with it, such as mus- 
cular or other movements, more success would result from the very simple 
plan of treatment by rest. 

Painfal and Irritahle Ulcera. 
I promised, before concluding these lectures, to refer to some surgical 
cases which show the good effect of " physiological rest." As yet I have 
SfMKiely had an opportunity of alluding to the subject. The only exam- 
ple of the principle of " physiological rest " as a curative agent which time 
will admit of my using is that of the painful irritable ulcer. An irritable 
ulcer is to be distinguislied, no doubt, from an inllamed ulcer, by the 
quantity of lymph which is poured out upon the inflamed ulcer, and the 
high degree of its temperature. Irritable ulcers, as we know, are exceed- 
ingly painful, and sometimes very difficult to cure. As far as I have been 
able to detect their real essential pathological character, it depends upon 
the exposure of a nerve on the surface of the ulcer. Of course it is quite 
clear tnat eTery ulcer must have nerves more or less exposed on th< 



rerr ul. 
face; bat in the case of an irritable ulcer, it seems probable that the 
sheath of the nerve is destroyed, atid that the end of the true nerve-fibre 
or tubule remains denuded, and so causes the exquisitely sensitive and 
painful character of the ulcer. Upon this exposure of nerve depends, I 
believe, the chief feature of what we term an irritable ulcer, and the 
method of detecting the precise seat of the exposed nerve is very simple. 
V Ou must understand that my remarks on this subject are founded on a 



M 



OW THB THEBAPBITTIO 




twelve or fourteen years' experience of such eaa 
fill uninflamed ulcer before you, you apply the 
probe upon the sore, and, as you move it about, the patieot preaentlr 
exclaims, "Oh! there you hurt me dreadfully." You then go a little 
further on with the same method of examination, and scarcely any pain 
u felt; but on eoming back to the same spot, the patient is again " dread- 
folly hurt." At that painful spot some small nerve is exposed on the 
surface of the ulcer. The first time I observed this fact, and arrived it 
what I believed to be the right interpretation of it, was in the case of a 
patient who had a thecal bursa extending from the palm of the hand 
under the annular ligament to above the wrist. 1 made an aperture into 
the bursa above the wriat large enough to let out all the fluid and solid 
contents. The bursal swelling gave me no special trouble, and was speedily 
cured; but at the seat of the opening a very irritable painful ulcer re- 
mained which 1 could not heal by any local application. On examining 
the ulcer with a probe, I discovered a point of exquisite tenderness. The 
normal position of the small palmar branch of the median nerve corre- 
aponded with the site of the local sensitiveness, and seemed to explain the 
pain. I then passed a small pointed bistoury under the track of the nerve 
kbove the tender spot, so as to divide the nerve between the spinal n 
row and the irritable point of the ulcer; from that time the pain cei 
and the ulcer rapidly healed. It was cured by the " physiological i 
resulting from the division of that little nerve. 

Painfid Granulations foUowinff Injury, 
Some long time after the occurrence of this case, I had a patienfcl 
Guy's Hospital suEfering greatly from an ulcer at the end of the finger,, 
which, as the original injury was* a cut from breaking a window, it ii 
supposed there was a piece of broken glass. She had been under t 
observation of a surgeon, who hod tried repeatedly to get out the t 

pected piece of glass, and had severely but unintentionafly punished hll 

She came into the hospital, and I thought the case would give me a good 
opportunity of making a demonstration of what I had long deemed and 
taught to be correct. On placing the broad end of my finger upon the 
ulcer, it gave her exquisite pain; the broad surface of my finger, however, 
was not a sufficiently accurate localizer of the pain. I then employed the 
rounded end of a probe, and with great care examined the whole surface 
of the ulcer by pressure, until I came upon a spot that was exquisitely 
tender, and produced dreadful pain to the patient. With a pair of scis- 
sors I cut out the painful granulations. Explaining to Dr. Habershon, 
then Demonstrator of Anatomy at Guy's Hospital, the views I entertained 
regarding the cause of the painful granulations, 1 requested him to exam- 
ine them by the aid of the microscope, and he found in them, and near 
the surface, as 1 had expected, looped ^laments of nerves, thus completing 
the demonstration of the cause of the pain. From the time of my cutting 
By those sensitive granulations the pain ceased, and the sore began to 
heal; there was no more trouble or difficulty as regards the treatment ^H 
the ulcer: it got well by giving it "physiological rest." ^H 

Exquisitdy painful Ulcer after Injury. ^ 



Doachman, who, on getting off 

the lower bar and the seat, and thi 



and a half ago, I was requested to see a gentleman': 
getting off his b 



, slipped his fingers betweeu 
had two of his fingers broken off St 



INFLUENCE OF BEST. 85 

«BCOT)d ph&Ianges. One of them went on rapidly towards healing, 
\Md so very well. The other remained ewoHen, irntable, very painful 
^^ touch or on exposure to the air, preventing sleep, and producing 
constitutional disturbance. Wo failed to relieve these symptoms 
B local and internal employment of opium. This unhealthy condi- 
tion could not be from any constitutional defect, because one finger did 
well; nor oould it be from the result of any dissimilarity of the original 
injury, for they were precisely alike. With the surgeon in attendance, I 
made a careful examination of the part; and when 1 placed the end of a 
probe towards the edge of the ulcer upon the finger, it detected a spot 
which was exquisitely tender, and the patient screamed out — "Oh, pray, 
for God's sake, cover it over! I can't stand it." The position of this pain 
was in the course of one of the lacerated digital nerves. I passed a 
pointed bistoury under the nerve, about one-fourth of an inch above its 
exposed portion upon the wound, and so divided it. The pain in the 
ulcer ceased immediately, and the touch of the probe caused no uneasi- 
ness. From that time all the local symptoms rapidly improved, and the 
case gave no further trouble, being quickly cured by " physiological rest." 
These cases prove distinctly that an ulcer may be very much modified 
in ita character from the exposure of a nerve in the wound. 

1 mentioned this subject to my colleague, Mr. Cock, some time ago, 
and shortly afterwards he had an opportunity of testing the value of the 
observation. He recognized the condition of such an ulcer as that 1 have 
referred to, and divided the exfiosed nerve; the patient lost the pain, and 
the ulcer quickly assumed a healthy character and got well. 

J'ain/ul Irritablf JTicer of the Leg. 

I have here short notes of two other cases that have lately occurred, 
under my care, at Guy's Hospital, to which I will, with your permission, 
now allude. 

John J , aged twenty-seven, a sailor; admitted on the 9th of No- 
vember, 1859, surtering from a syphilitic sore on the fncnum and penis, 
with secondary eruption and a very painful ulcer on the inner malleolus 
of his left leg. The syphilis was treated and cured by Plummer's pill, 
five grains, twice a day; but the painful ulcer remained nninllueuced by 
the mercury. 

This is the history of the ulcer recorded by my dresser: — 

" When leaping, about four years ago, he sprained his ankle, and an 
uloer formed on the inner malleolus of the left leg. It had made frequent 
efforts at healing, but never cicatrized completely. It now looked irrita- 
ble, with no inclination to heal, and was very painful, with intense ner- 
vous sensibility localized at its upper margin, which was ascertained by 
examining it with a probe. 

"Jan. 24th, 1860. — Mr. Hilton passed a pointed bistoury a little dis- 
tance above the tender spot, under, and then through, the granulations, 
thereby severing the filaments of the nerves supplying the morbidly sensi- 
tive granulations; and although the patient made much ado about the 
operation, yet he immediately acknowledged himself relieved by it. The 
uloer readily assumed a healing aspect, sensation over the other parts of 
the ulcer was not more acute than normal, the surface became covered by 
healthy purulent exudation, cicatrization daily advanced, and the uloer 
waa closed in a fortnight, and remained so until he left the hospital, on 
the 8th of .March, ItifJO." 



86 ON THB THEBAPBUTIO 

THis wa45 a case of irritable ulcer, cured by division of the nerve. 

The other case may be put before you in a few words: — 

Jan. 11th, 1860. — The painful spot of an old irritable ulcer was exam- 
ined by a probe; the nerve supplying the tender granulations was divided; 
marked relief was the immediate consequence. This division of the nerve 
was done on the 11th of January, and on the 16th this is the dresser's 
report: — 

'* The ulcer above mentioned is free from pain, and has assumed a 
healthy character; its edges are throwing new skin over the granulations." 
From this time the painful ulcer required no special attention, and in ten 
days all was healed. 

These are cases that appear to me to display very accurately the thera^ 
peutic value of what we may fairly term " physiological rest,^ by remov- 
ing the abnormal sensibility of the surface of the sore. The division of 
the nerve had its effect upon the neighborhood phyaiologicaUy^ and the 
ulcer began to heal.* 

I trust I may have succeeded in thus briefly pointing out the tme 
pathological feature of what is termed a '^ painful irritable ulcer." 

* Mr. Hilton has furnished me with the following notes, which show that *' pKt|a- 
iologioai rest " is in this class of case of as much importanoe in private as in boqpital 
practice : — 

** Soon after the delivery of these lectures, Mr. Quain, who was at that time called 
away from London, placed under my care a patient who had for many moatha been 
suffering extremely from a most painful irritable ulcer on the lower third of one dt 
her legs. This ulcer had resisted well-directed treatment of the usual kind. When 
Mr. Quain and I saw the uloer it was circular in shape, about an inch and a half in 
diameter, and so sensitive tiiat my blowing a breath of air upon it caused tiie patienfe 
exquisite pain. We then examined the surface of the ulcer by the aid of a bhmt 
probe, so as to indicate the exact position of the most sensitive points, of which there 
were several. Opposite to each of them, and about one-eighth of an inch from the 
edge of the ulcer, I passed a sharp-pointed bistoury through the skin, and divided in 
eadi case the subcutaneous Ussue containing the branch of the nerve, the end of widfdi 
was exposed upon the uloer. This division of the nerves rendered the uloer almoti 
painless, and the patient expressed herself as much relieved. No special treatment 
was required ; the patient, £reed from tiie pain by which her health had been mnoh 
impaired, was enabled to take her food and enjoy plenty of sleep. Healthy pns soon 
appeared upon the surface of the ulcer, the healix^ proceos was quidUy establishfld, 
and the lady returned to her home cured," — [Ed.] 



IWFLUESCB OF REST. 



LECTURE Vn. 

Cue Showing the Dangor of Opening »n Absoeas in the Thigh by a Lasoct — Case of 
SloQghing of the Scalp — SinuxeH Cured bj AppUcation of a Tnua — Iiritabla Ee- 
tremities of a Necve in a Wound Relieved bj DiviFtion of the Nerve— Headache 
and Intolerance of Light Cured by Physiological Rest—Demgn Manifefltcd by the 
Some Nerven Buing DiBtributed to a Joint and to tbe Muscular Apparatus Used 
foT the Motion of the Joint — Apptloation of thiii to Explain the Involuntary Flex- 
ure of an InSamed Joint. 

WiiiLB I endeavor to iJlustrate atill further the principles on which I 
have insisted in my previous lectures, it seems to me but right tha.t I 
eboutd briefly recapitulate the leading features of the subject with which 
our attention has been occupied. 

It may be remembered, then, that we first hastily glanced at the im- 
portance which Nature seemed to have attached to tbe attainment of 
" physiological rest," as exemplified in the marvellous provisions which 
she had made for it in the vegetable and animal kingdoms. After a some- 
what miimte review of the equally wondrous and efficient, yet simple, ex- 
pedients adapted to the same end, with which each of the several organs 
of our own highly complex system is endowed, I proposed to myself, and 
scrutinized as well as I was able, the application of these primary prhici- 
ples to the treatment of various forma of disease. I remarked that tbe 
subject grew with contemplation; that, narrow as it appeared when 
adopted as a mere platitude, or in its axiomatic fonn — " Rest is an impor- 
tant agent in the cure of disease," nhen employed in relation to the 
countless forms of disease presented to tbe observation of tbe surgeon — it 
expanded aod enlarged in its proportions, like tbe series of circles extend- 
ing from a pebble thrown into the water. I feel my subject is by no 
means exhausted, and I pursue it in the hope that I may thereby excite 
in others, more capable than myself, a spirit of research into those deeper 
recesses of the existence of which I am convinced. 

This is no new subject of inquiry. Perhaps there are few thoughtful 
members of our profession to whom it has not suggested itself; and my 
reason for discoursing upon it is rather for the purpose of gathering 
leather in a connected form notions which had long been floating 
vaguely id the minds of others as well as my own, and which required to 
be collected that they might produce precise results. Asfarasmv knowl- 
edge extends, this has not been done, even in the meagre degree ni which 
1 now present it to you. But as an evidence that it has long been present 
to the reflective minds of our profession, I may mention that since my 
last lecture I have met with a prize essay on the subject of " Rest," by a 
French surgeon, M. Uavid, presented to tile Royal Academy of Surgery 
of Paris so long since as 1778. The subject proposed by the Academy 
for the prire essay of that year was "to explain the effects of motion and 
rest, and the indications according to which either should be prescribed 
I in su rgical diseases," M. David, the successful competitor, in accordance 
^^*^tbe phraseology of his day, speaks of man as the epitome of the 



^^^^ tion. 
" facli 



ON THE THBBAPBtTTIO 

Universe, and of firo as the great moving principle; and proceeds to \aj 
down the following converse propositions; " If it be required to resist M 
prevent the inspissation of the fluids in the cure of these disorders, it will 
be neceasarj' to call in the assistance of motion, provided there be no par- 
ticular ciroumstance that renders the use of it improper. If, on the con- 
trary, the plan of cure require to ffive a better consistence to the fluids, 
and if the effects of motion should counteract this plan, we must have 
recourse to rest." Pursuing these propositions, he dilates freely on the 
subject of motion as apptiea to rheumatism, gout, anchylosis, and so forth; 
rather as if for the purpose of creating a marked antithesis to the use of 
rest, than of especially treating of rest itself as a curative agent. On the 
latter point, however, after relating some cases of chronic vertebral dis- 
ease which had been benefited by rest, and dwelling upon such obvioi 
necessitous cases for its adoption as dislocations, rupture of tendons 
muscles, contusions of joints, &c., he suggests its application to the 
ment of sinuses and fistula of the anus. 

Hence I believe I am only arraTiging, in an approach to a systematio 
form, the fragmentary atoms of a great principle, which haa occurred to 
the minds of very many surgeons. Fortunately, from my position, I am 
enabled to illustrate that principle by cases deduced from my individual 

arience, and thus, I trust, to impress it on the minds of others, wl 

extend its application. At any rate, I can say. 



iral dis- 
ivioudfH 
dons^H 
e tie«|^H 



I he 

m 

^^^^ fcav( 



^^bei 



Before proceeding to a further and wider examination of the thei 
lutic value of Kest, I would solicit your attention to three or four adi 
tional cases, illustrative of some of the points which I have had the satift^ 
faction of previously placing before you. These few cases are good 
examples, perhaps, but form only a small portion of the nunterooa 
instances which I could adduce; yet they will serve to show that the 
subject has an important bearing on practice. It will be remembered, 
that the series of facts which I brought forward, for the purpose of exem- 
plifying the value of Rest as a curative acrent, consisted partly of cases of 
diseased spine, taking my examples of disease from the highest portion 
of the vertebral column. These were selected specially on account 
the danger which so frequently attends their professional mismanagemei 
I hope now to place in detail before you more cases of diseased spii 
situated lower down, and cured by Rest. 

I also endeavored to call your attention to what I deemed to be th« 

^fest and best method of opening deep abscesses; namely, by a lancet, 

■ooved director, and ordinary dressing forceps. As 1 have had a caae 

ifore me, full of point with respeot to this subject, 1 will detain you by 

iting one or two facts regarding it; — 

A young lady, aged thirteen, had a deep abscess in the lower third 
left thigh. As far as I can judge of the case by the history which 
tiave received, the abscess was associated with periosteal or sub-periosi 
inflammation, for the abscess was deep under the muscles. It was opei 
at the lower and inner part of the thigh with a lancet or bistoury, by oi 
puncture or clean incision, which reached the abscess. Pus escape 
mixed with a considerable quantity of arterial blood; and after all t1 
purulent fluid had been evacuated, arterial blood still flowed from t1 
aperture. The aperture was then plugged. On the third day, the pli 
being removed, a little hiemorrhage took place, and it was plugged agai 



1 



ion 



INFLUENCB OF BEST. 89 

On the seventh day after the openin;^ of the abscess, a most profuse &nd 
sudden itrterial hemorrhage occurred, bringing the patient really to the 
very brink of the grave. At that time a consultation of Burgeons took 
phice, when it was determined to tie the femoral artery. This was well 
done, just ahove the middle of the thi^h, and there was no subsequent 
bKCDorrhage. I saw this young lady in London last October. She was 
then in an extremely emaciated and depressed oondition, with a slough 
upon the back. The aperture made by the lancet was still there, and 
pouring out daily a small quantity of sero-purulent fluid. I need not 
trouble von with any further particulars of this case, except to express 
my opinion, not in opposition to the gentlemen to whom the case occurred, 
but as bearing upon the facts which I have brought before you. Had 
this abscess been opened in the way I have suggested, I think the 
extreme danger to which this patient was subjected might have been 
avoided. My plan would have been to cut down to the fascia lata, divid- 
ing the faseia lata only, and then (instead of allowing the lancet to pass 
into the deeper-seated parts, where it was impossible to predetermine the 
precise position of the subjacent arteries) to thrust the grooved director 
through the vastus intemus muscle, and open the abscess by the dressing 
forceps, guided into it by the groove in the director. 

I look occasion also to refer to the treatment of abscesses by "rest," 
and ! brought beforfe yournotice some cases of abscess under the occipito- 
frontaiis muscle — abscesses most difficult to manage, except upon one 
principle, the use of mechanical means to keep the parts in a state of qui- 
etude or " rest." 

Since then a most curious and remarkablo case has been brought 
under my notice at Guy's Hospital;* it is here depicted (Fig. 22): — A man 

(W. D ), aged sixty-three, in January, 1860, fell from the rigging of 

a ship, his head coming in contact with a bar of Iron in a barge, produc- 
ing extensive laceration of his sjalp. 
He was professionally attended to imme- 
diately, adhesive plasters were applied, 
and tne edges of the wound were ad- 
justed; but, from what cause T do not 
Icnow, these plasters were allowed to re- 
main on the man's head eleven days un- 
disturbed. He was not, I think, under 
professional care during that time. The 
plasters were then pulled off by him- 
self, and subsequently he had several 
attaoks of erysipelas and sloughing of 
the scalp. In May, four months from 
the time of the accident, he and his sur- 

Son began to notice that the scalp was 
ling, like a land-slip, gradually slid- 
ing down the side of the head till it 

ultimately attained the displaced position which you see in this por- 
trait (Fig, i2). The apace between the fallen scalp and the edge of 

* I bare espeinaUy guarded mfself agiunsti introducing into these leotures any a 
from Gny's Hospital, except those which hava been entirely under ray own oara and 
treatment. I mention this because 1 shonld be very sorry to lie nodec the aeriouB im- 
patatioa of cjuoting or mHiog the unpubliahud cases of mj' hospital colleagues, fur the 
purpose of illuBtratifm, witbont their pcrmisBion, and u full ucknowfledginent of the 
■ourue Ctom which they have been derived. 






BAPXUTIO 

i[»ed by newly formed skin, free 
o( the parietal and adjoining bones 
l*» Wp «f ihe head, so as to expose tbe pul- 
W a«Mi« of the l&rge and massive gjanu- 
I I id- <ira,-Kixif(. I adduce this ease for the pur- 
iiii litMt the whole of this mischief might hare 
i.i f>t»n paid to what 1 have alluded to in my 
-, -hi ose of some meehanical means, suoh «s 
•iuuttd mnd. over the scalp, to maintain tbe ooctp- 
ito-froti talis in its pfnpcr 
position. lo this case the 
euhjiLcent areolar tissue 
sloughed; there was noth- 
ing to bold the occiptlo- 
frontalis, and it slid off tba 
siHe of the skull. I might 
add another practical re- 
mark. I think it is probft- 
ble that if the scalp hul 
been carefully retained in 
situ on the top of tbe head, 
the loss of bone would not 
bavo been so extensive. The 
portions of detached bone, 
when put together, make a 
large piece, somewhat circu- 
lar in form, with a diamt 
of about four inches, 
exfoliation is confined to 
external plate of the 
and diploe, ei 
le parietal foramina, 
where a piece of the inter- 
nal plate or table is viaibia 
on its concave aspect, and it 
is at the corresponding part 
of tbe exposed duT& mater 
that the distinct pulaationa 
^ ivare that the chief nutrition 

1 is obtained from the dura mater, yet no doubt 
I is derived from the periosteum or periuranium. 
Lit'T&ne wus destroyed by its exposure, and henoe tbe 
Litrod. ■ This picture (Fig- 23) represents the patiaDt 
"hioh 1 fwrformed upon him. It is perhaps rather too 
\wM, and a little too complimentary to the success of 
V tint [ would ask you to remark one other point la 
I'litv to the influence of rest. The granulations in tbiiii' 
iii>t artistically well depicted, do exhibit a healthy, 
, ,.M i.t much diminished, aud is still diminishing. Thil 
., 1 since the removal of the hanging mass of the 
M. IS making constant traction upon the healing 
. . Ii Nature's curative efforts. By taking away 
■.:;ilp, I gave " mechanical rest " to the margins 
itA ih'" •'nableil Nature to concentrate her attenti< 



irou- , 
letfB^ 

M 



Although I a 



i 



ioorB 



INPLtTENOK OP BEST. 



91 



V the condition is 



t that I brought for- 
r two bearing upon 



mora upon the healing of the exposed surface; and r 
that which is here represented. 

The cure of sinuses by " rest " was anotiier subjee 
ward, and I may )iere menliun an additional case o 
tliis point which have since occurred. 

On November the lilat, IStiO, a g-entleman, aged twenty-three, con- 
sulted me with regard to a sinus in his rfght groin, whieh was the sequel 
to an extensive suppuration which toolc place in a glandular swelling be- 
low Pouparl's ligament, three or four months previously. The abscess 
had been first punctured, arid subsequently freely cut along its whole 
length, near its lower boundary. The sinus did not heal, and the gentle- 
nun was sent to Rauisgate, where he remained three months, during 
which time he wore a pad of lint bandaged over the parts, with the idea 
of making pressure upon them. Upon his return to town, there being 
Msorcely any improvement in the condition of the ulcer and sinus, he was 
ordered by his surgeon to return to the sea-side for the winter, for the 
further improvement of his health. It was at this time that 1 was con- 
sulted. The gentleman explained to me that he had made great sacrifices 
from the commencement of his illness, several months bacb, to the present 
time, by absenting himself from business, without any benefit to tlip Bore, 
had that ho could not aSord to lose more time, except as a matter of ne- 
ceseitj. On examination, 1 found a short sinus, 
about an inch in length, running parallel with 
Poupart's ligament, on the right side, and then 
(Mmiaunicating with a cavity having granulat- 
ing walls. One granulating surface passed un- 
derneath an overlapping piece of skin, about 
two inches long and three-quarters of an inch 
wide, which rested in part upon a long slip of 
exposed granulation, extending below the mar- 
fpa of overlapping skin. Both surfaces were 
oovered with granulations, and the two were 
moving freely upon each other. It appeared to me that this gentleman's 
health was pretty good, and all that was required would be to aj>ply some- 
thing to make a steady pressure upon the flap of skin, so that these gran- 
ulating surfaces might be brought in contact, and maintained in that 
state, for the purpose of aiding secondary adhesion. Just as when pri- 
mary adhesion fails in the operation for hare-tip, by bringing the granula- 
tions together they unite, and the reparation is tolerably perfect. For 
the purpose of securing this necessary adaptation of the grnnulating sur- 
face in this patient's case, I reoommendod him to wear a truss of this kind 
(Fig. 24), which was well adapted to relieve his condition. Towards the 
large end of the truss is introduced a ratchet wheel, regulated by a key. 
Thjs is capable of turning the pad inwards upon the sinus almost to any 
extent; and if the patient finds the pressure too great, he can himself re- 
duce it with facility and precision. This truss was apjilied, and I advised 
the patient not to sacrifice more time, but to attend to his business, and 
not go into the country. In a fortnight the sinus had nearly healed. On 
the 8th of January, 18fil, it had completely healed, and the discharge had 
entirely ceased. The skin over the wound being then thin and delicate, I 




* Tbin truBK is well adapted (or the tTentment of some troublGsome cases of hernia 
requiring aitx\j adjusted preasa^e, and exoctdtude as to the direction ot the force to 
be eniplored. 



J 



92 OTTTHlSTHKKAPBtlTrO 1 

requested him to wear the tniBs a few ureeks longer, which he did, and I 
then everything was perfectly well. In the springi he went out banting, I 
and the friction of the truss led to a little excoriation, which requiral j 
some temporary attention. J 

Thus we see that the simple treatment by Rest — that is, by bringing I 
the granuSating surfaces together, and keeping them quietly in contact ttoM 
a short time — did away with the necessity of this gentleman's quitting hM| 
business and making large personal and pecuniary sacrifices, for the por^ 
pose of doing what would not ultimately have led to much, if any, intV 
provement in his sinus and concealed ulcer. V 

In the summer of 1859, my opinion was requested regarding a gentlft-^ 
man, aged forty-two, who had just then sought advice in reference itf^ 
some sinuses in his groin, which had remained after glandular enlaree- 
ment and suppuration, associated with n on -syphilitic ulceration upon tlw 
prepuce. The patient had been, during the three previous months, un- 
interruptedly under the care of an hospital surgeon, who had used majiy 
different local applications to the sinuses, and had given him mercury iB*J 
temally, with rest at his home, but all without any benefit. His si 
had told him that nothing remained to be done but to " lay the i 
open, and make them heal from the bottom." This gentleman, wl 
in good health, refused to bo cut, and sought the advice of Dr. Daldy, ^ 
suggested that my opinion might be taken as to what had best be doiM 
i found five external openings of sinuses, margined by granulations, a 
communicating with each other deeply under a surface of about tw^ 
inches. The discharge from the sinuses was purulent, but thin, and tb^ 
immediate neighborhood of the sinuses was massive and thicker 
appeared to me that a truss applied upon the skin overlying these dec 
sinuses, so as to force the granulating walls into contact, and to keepr 
them in that state during a few weeks, might close these s 
obviate the suggested " laving thetn open." Such a truss as that I have 
shown you was then applied, and the patient permitted to walk about. 
The truss was worn day and night, and in a fortnight all the sinui 
firmly closed. After that time, tbo patient wore the truss dui 
daytime only for several weeks longer, until all the thickening and nard 
ening of the soft parts had entirely disappeared. 

The merits of "mechanical rest" are sufficiently obvious in this o 
I may add that this patient had, s. few months afterwards, a most se" 
and dangerous attack of double pneumonia, which invalided him for a loiy 
time, but the sinuses did not reopen. 

The next case to which I will refer is that of a sinus under the tcndonl 
of the extensor muscles on the dorsum of the foot. This was the case a 
a young gentleman aged thirteen, who was brought to my house on I 
11th of July. I860. The sinus ocourred after an abscess suspected to fa 
associated with disease of the tarsal bones; it had existed off and < 
during four years, and he had been under the surgical treatment of ■ 
hospital surgeon irregularly during the whole time. Sometimes the sini 
"scharging; then it would heal up; soon again liecome swollen; thea 
ind discharge for a time, and so on. A probe passed easily along 
the snnis under the tendons of the long extensor for about two inches, the 
course of the sinus being indicated by considerable thickening of the 
areolar tissue. I could detect no disease of the tarsal bones by examina- 
tion with the probe, or by pressing upon the heads of the metatarsal 
bones towards the 
ucertain with pi 






f pressii 
This 1 



latter method enables the surgeon to 
which of the tarsal bones or articulations, if any, 



i 



INFLUENCE 0FEE8T. 93 

are diseased. The patient's mother told me that on walking far the back 
of the foot became swollen and painful. I placed a thick pad of lint over 
the track of the sinus, leaving its opening free, and then applied a band- 
age over the whole of the foot, so as to coapt the sides of the sinus, a 
small aperture beinf left for the escape of discharge. Now it will appear 
almost ridiculous when I add that in four days the sinus was healed; but 
around the sinus there was a thick mass of consolidated structures adher- 
ing partly to the tendons and partly to the subjacent tissues. Here, I 
suspect, was the starting-point of defect in the treatment by the surgeon 
who preceded me. The new tissues filling up the sinus, or uniting the 
opposed granulations, were not strong enough and healthy enough to 
resist the traction of the tendons of tne extensors or the movements of 
the foot. Looking: on the case with this interpretation of the previous 
failure, I desired him to continue wearing the pad of lint and bandage for 
three or four months. The last time I saw hira was on December lOlh, 
1860. The skin and subjacent tissues in the course of the old sinus were 
soft, and the areolar tissue was pliant and movable, allowing of the move- 
ments of the extensors, and apparently competent to the performance of 
its yielding and elastic duties. So the sinus remained perfectly well. 
Anxious that I might state nothing but the truth relating to this case, I 
wrote a note to this patient's father, who thus replied to me. May 7th, 
1801: — "1 have much pleasure in saying that my son's foot continues 
•ound." 

This is a good case, because the sinus was cured by " rest," as you may 
term it, in four days, after four years of unequal results. I think it also 
illuBtratea this wide but frequently disregarded principle, that new tissues 
are not competent to the same emergencies as those which are more 
thoroughly organized or advanced in life. The uniting medium of this 
fresMy closed sinus was young at first, and I have no doubt, if I had 
allowed it to continue under the influence of these extensor tendons, it 
irould have given way, and I should have had a repetition of the condi- 
tions which occurred to the other surgeons who had attended the case 
previously. 

I shall be excused if I mention one more case, and then proceed to the 
other part of my subject. I adduced in my previous lecture some 
instances of ulcers and wounds which were very painful in consequence 
of the exposure of the ends of the nerves in the wounds — cases in which 
the pain was stopped by division of the nerve just below the surface of 
the wound. Two or three cases of that kind have since occurred at 
Guy's Hospital under my care, in which I have pursued the plan of 
dividing the nerve exposed in the wound. One case, that of a man aged 
twenty-eight, who had his finger cniahed by accident, presented itself 
veiy recently. Ho was admitted last March, with a severely contused 
anci lacerated index finger. An attempt was made to save the finger, but 
it was ultimately thought right to amputate it, just above the head of 
the first phalanx, by two lateral flaps o£ soft parts. The flaps assumed an 
unhealthy character, and the man was brought into the hospital. The 
sutures were removed, and the flaps fell widely apart. They were 
extremely painful, the agony of the nnan's feelings being expressed by 
his features in the clearest manner. He was scarcely ever free from pain, 
except under the narcotizing influence of large doses of opium. Upon 
the exposure of the Haps I detected the precise position of the exquisitely 
sensitive points in the granulations, and I passed a pointed bistoury under 
the course of the nerve within the flap and divided it, and my dresser 



9^ OK THE THEBAPEUTIO 

divided the other nerve in the same way in the other flap. It is not too 
inucli to say that the man was immediately freed from pain. From that 
time he suftered no pain and required no opium. The flaps became less 
swollen and inflamed, and in ten days, the granulations beins- then 
healthy, they were nicely adjusted, and the man got perfectly and 
quickly well. 

I cannot avoid encroaching upon your time for a moment in order to 
relate another case, which comes from a professional friend, Mr. May, of 
Reading, who wrote to me on the 12th of December, 1860, as follows: — 

^^ My dear Sib, — I cannot resist the temptation to tell you a case 
which offers a striking illustration of the principle so admirably explained 
and enforced in your lectures at the College of Surgeons, and for which 
our profession is deeply indebted. 

" Nearly twenty years since, I attended a lady, who, for eight or nine 
years, had been afflicted with intense headache and intolerance of lisht^ 
commencing on flrst awaking in the morning, and persisting more or ten 
all day, totally disabling her, and, during many months, confining her 
entirely to her house. 

" I learned that she had consulted several medical gentlemen, both in 
London and the provinces. Under an impression of inflammatory mis- 
chief in the brain, Dr. Marshall Hall ordered her a scalp issue with twenty 
peas, which was prolonged for some weeks; she underwent a long course 
of mercury, was cupped many times, blistered, &c., &c. Under other 
advice, she took tonic medicines of various kinds, and made a journey 
on the Rhine, &c. All seemed useless, and she had resigned herself to 
despair. 

" At my flrst examination of the case, I learned that a severe frown 
was caused by the flrst influx of light in the morning; then followed 
h(*adache, &c. My impression was, that if I could arrest this spasmodic 
ncliop (by physiological rest ?), and break the habit of return by mechan- 
i(!al means, I should prevent the other symptoms; and so it happened. I 
ninrcly covered one eye with a card, about the size of a crown piece, and 
attached an elastic tape to it, so that it passed around the head, across 
ilio forehead, and over one eye, sliffhtly compressing the occipito-frontalis 
and corrugators. This simple device effectually prevented the frown, and 
I lM*n' was at once an end to the mischief. 

" The only further treatment required was to gradually accustom the 
nyt'N to light and action; and this was readily done by using one at a 
lliiin for two hours, and then changing the card to the other eye, regula- 
ting till' admission of light. In other, but still more expressive words, I 
^Hvn * n;Ht to parts' morbidly excited; and so this most terrible maladj 
vnninlird as a charm. 

" Tlin patient continued free from the complaint during the remainder 
I if hiT life, and died about two years ago." 

" Believe me, dear Sir, yours most faithfully, 

"Georgk Mat. 

Ilnrn was an important recognition of the principle of "Physiological 
liivit/* which seems to have been applied very delicately and neatly to 
ilm irlirf of the persistent and painful symptoms experienced by this 
lilt I y. 

i nhall now venture to direct your attention to an arrangement of 
nurvuutt distribution, which has supplied, to my mind, during more than a 



INFLUENCE OF REST. 

quarter of a century, and still supplies, a noticeable instance of design, 
which has not been, so far as I Itiiow, generally recognized or properly 
appreciated. 

It is my purpose to devote a part of these lectures to the considera- 
tion of the influence of Rest in the treatment of diseased joints. In an- 
tit^ipatioii of those facts which will make manifest the importance of rest 
in treating diseased joints, and for the purpose of showing the physio- 
logical and fundamental principles on which it is based, I am dt^sirous of 
placing before you some details of healthy human anatomy, regarding 
the general distribution of the nerves to the joints, and the associated 
muscular apparatus moving those joints, which bespealc special design. 

I believe we can scarcely attach too much importance to the study of 
the simple, but exact, anatomy of this nervous distribution, which I hope 
to render intelligible and practically useful. I know that it is not only 
capable of accounting for morbid sympathies and pathological conditions 
requiring close and deep attention for their elucidation, but that, if prop- 
erly applied, it will suggest and point out the true principle of treating such 
morbid states, based, as that treatment should be, on the anatomical and 
physiological considerations which will enlarge and enhance our apprecia- 
tion of the beneficial influence of mechanical and physiological rest. 

If surgeons will keep this monitory principle of Nature foremost in 
their professional thoughts, they will, under its guidance, become not 
only more convinced of its truth, but will make it more frequently the 
groundwork of legitimate treatment in cases of accident or disease. 

I may now remind you that wheu a joint becomes inflamed, il is pain- 
ful and dilBoult of movement; it becomes involuntarily fixed by Nature's 
own process, thus securing comparative rest to the interior of the joint. 
Indeed, we may lay it down as an axiom, that Nature instinctively 
renders an inflamed joint comparatively fixed and flexed. Now, what la 
the key to the explanation of the flexed position and rigid state of an in- 
flamed joint ? Some might say, " Because the patient finds it the easiest 
position for himself, and the easiest position must, of course, be the best." 
But this is no answer to the question, How is this position induced ? It 
is DOt voluntary. The patient cannot either prevent it or change it when 
it exists; nay, more, it is not true that the flexed position is the easiest; 
for every day's experience declares the contrary. I shall hope to have 
the opportunity of showing you distinctly that, when the hip-joint is dis- 
eased, it is flexed, and is often in a very painful state; but that when the 
femur is put straight, so that the flexed condition is destroyed, the pa- 
tient from that time is free from pafn. Here is an instance in direct con- 
tradiotion to the idea that the flexed condition is the easiest for the patient, 
When the joint is made straight, the patient experiences, almost imme- 
diately, a diminution of pain. It is true, however, that, in the case of 
the knee-joint, it is sometimes otherwise. It is plain that when the femur, 
tibia, and patella are in the position caused by the leg being in a state of 
extension, there must be a much larger extent of articular surface coap- 
tation than in any other position of the joint. This surface coaptation 
becomes more and more reduced, or lessened in extent, as the tibia is car- 
ried backwards away from the femur. Probably, it is this diminution in 
the extent of the articular surface contact, as well as the diminished pres- 
sure, which explains the feeling of comfort that patients sometimes expe- 
rience when the inHamed knee-joint is allowed to become flexed. 

Still the question comes back to us. Why is an inflamed joint fixed 
and flexed? It appears to me to result from the circumstances to which 



i 



OH THK THBBAPItTTIO 

I shall presently ftllade more in detail — viz.: tbat the irritated or inflamed 
condition of the interior of the joint (say the knee-joint), iavolving the 
whole of the articular tierve», excites a correspionding condition of inita- 
tion in the same nervous trunks which supply both sets of muscles, exten- 
■ors and flexors; but that the flexors, by virtue of their superior strength, 
Gonipel the limb to obey them, and so force the joint into its Jlexed con- 
dition. The joint then becomes rigid and flexed, because the same 
nerves which supply the interior of the joint supply the muscles also 
which move the jjoint. 

This anatomical arrangement, physiologically considered and righttv 
interpreted, may be made the means of explaining some of the most promi- 
nent symptoms of joint diseases, and of constituting a foundation for the 
required treatment of diseased joints by rest, which E propose to advance 
and to recommend. 

In order to bring in a comprehensive and definite form before you this 
fact, which is so important on anatomical, physiological, and pathological 
grounds, I will state it thus: " The same trtmJca ofnervea whoae brancha 
aupptjf the groupe of nntsdea moving a Joint JvmisA also a distrHnUion 
Oj ntnea to t/ie akin over the ituertiong of the same nuiacles ; and — lohat 
at this tnotn^U more eapeciaUy fTterita our attention — the interior of tht 
joint receives it* nerve* from the same souTVe." This implies an accurate 
and consentaneous physiological harmony in these various co-operating 
straotures. 

For instance, the circumflex nerve supplies the teres minor and the 
deltoid muscles, the skin over the deltoid, and also the skin over the fascia 
of the upper arm, into which the deltoid muscle is partly inserted. It also 
gives an articular branch to the shoulder- joint. Other nerves go to that joint, 
such as a branch from the subscapular trunk, which is derived from almost 
precisely the same part of the axillary plexus as the circumflex nerve. The 
suprascapular nerve, after supplying the supraspinatus and infraspinatus 
musoles, sends little filaments to the interior of the same joint. Thus the 
same circumflex nerve supplies these museles, the joint which the muscles 
move, and the skin over the muscles, as well as the skin over the fascia, 
which is a part of the insertion of the deltoid muscle. But here 1 touch 
Upon a point, by which I am reminded to state that every fascia of the 
body has a muscle attached to it, and that every fascia throughout the 
body must be partly considered as the insertion of a muscle. I shall be 
able hereafter to trace nerves derived from the same trunk supplying the 
joint and muscle, and sometimes distributed over a large extent of fascia. 
That extent of nerve distribution, however, I shall show to have a very 
exact relation to the proportionate attachment of the muscles to the fascia, 
of which 1 shall be able to adduce some well-marked examules. 

The object of such a distribution of nerves to the muscular and articular 
■tructures of a joint in accurate association is to insure mechanical and 
I physiological consent between the external muscular or moving force, and 
the vital endurance of the parts moved, namely, of the joints, thus secur- 
ing in health the true balance of force and friction until deterioration 
occurs. If this point of balance or adjustment be overreached during 
exertion, pain. Nature's warning prompter, is induced within the joint, 
and suggests the necessity of diminishing or arresting exertion. This 
cessation or this reduction of exercise, or friction and pressure upon the 
articular structures, must be tffected hj the muscular apparatus of the 
joint, either through the will, or immediately by its own inatinctive efforts, 
called into play by means of the nervous association, The muscles, indi ' 



le«]^^ 



INFLUENOB OF BEST. 97 

appear to be told, through the medium of the nerves of the interior of the 
joint, that its articular structures are overtasked; and the antagonistic 
muscular forces of the joint being thus involuntarily excited, the joint is 
at once rendered rigid and stiff, for the purpose of keeping it at rest. Or 
it may be put in this way (only as confirmatory, however) — that the syno- 
vial membrane itself, under the influence of physiological exhaustion, con- 
tributes something towards the same end, by tailing to secrete the proper 
quantity of synovial fluid. The joint thus robbed of its lubricating medium 
demands of the exhausted muscles^ for its movement, a still greater effort 
than in its normal state; and their inability to respond to the extra de- 
mand necessitates the rest of the joint. Still, in this mode of viewing the 
subject, the necessity for limiting exertion, in order that the interior of the 
joint may obtain the rest requisite for the renewal of its physiological power 
and structural integrity, is intimated to the moving agents by the same 
nerve interpreters, and the moving agents, in obedience to the announce- 
ment, render the joint stiff and difficult of movement. 

Without this nervous association in the muscular and articular struc- 
tures, there could be no intimation, by the internal parts, of their exhausted 
function. There cannot be any doubt that it is when this period of func- 
tional exhaustion in the internal parts has been reached, and articular 
friction is nevertheless continued (notwithstanding the structural and 
functional prostration^, that the mischief to the articular structures com- 
mences, and disease oi the joints, as we term it, starts into existence. 

Again, through the medium of this muscular and cutaneous nervous 
association, great security is given to the joint itself by those muscles 
being made aware of the point of contact of any extraneous force or 
▼iolence. Their involuntary contraction instinctively makes the surround- 
ing structures tense and rigid, and thus brings about an improved defence 
for the subjacent joint structures. 

This same associated muscular and cutaneous nerve distribution is 
obriously of the highest importance in reference to the sense of touch. 
Thus in prehension, or grasping with the hand, the indication as to the 
amount of force to be employed must be the impression made upon the 
sensitive branches of the same nerve which supplies the muscles employed 
in the act of prehension or grasping. Hence the median nerves, with 
others, are employed in grasping, and also in the adaptation of the Angers 
to the palm of tne hand. Whether the body to be grasped be great or 
small, tnere must be an instinctive limit to the grasping effort. This can 
only be indicated to the muscular apparatus employed by the sensitive 
nerves. I say, therefore, in prehension, the indicator as to the completion 
of the necessary force to be employed must be the impression made upon 
the sensitive branches of the same nerve which supphes the muscles em- 
ployed in the act of prehension or grasping. 

In standing, walking, or jumping, the contact of the skin of the foot 
with the ground intimates, in health, not only the degree of muscular 
force, necessary to sustain the erect posture in standing, but gauges the use 
of the required energy in walking, and moderates the concussion of jump- 
ing. Without this normal, consentaneous muscular and sensitive func- 
tion, precision of action would be lost, and unmeasured exercise of muscu- 
lar force would be employed during the performance of any of these func- 
tions. The nice adjustment of muscular power must be an important 
tiling, for we know that unexpected muscular force breaks the patella. 

Let us now go to the bedside. Is it not indisputable that if we allow an 
inflamed knee-joint to lie upon a soft pillow, unconstrained by mechanical 
7 



means, the musoles of tlie joint, stimulatert to undue exertion, never nllpf 
the articular surfaces to be kept quietly in apposition with ewh 
other? This explains the fixed and flexed oondilion of the joint. Thus 
the flexors — as I have before remarked, the more powerful musdes — «rt 
unoeaainffly day and night, apparently without any rest, and e8pe<!i»lh 
declare their mischievous assiduity by the wakeful slumbers and disturbed 
sleep of the patient. This persistent action of the flexors slowly alieif 
the relation of the articular surfaces of the bones to each other — more 
alowly, indeed, but not less surely, than the hour-hand of the clock, 
which does not appear to move, but yet, if I compare its present position 
with that which it occupied some time since, 1 perceive tnat It has gone 
on marking the course of time. 

Let us take for example the case of the knee-joint. The surgeon sees 
an inflamed and swollen joint, lying on tu 
outer side, and desires that it may be kept 
quiet upon the bed, or on a soft pillow. 
Whether he sees it again in a few hours, ot 
days, or in a week, the first thing that 
strikes him with regret, and perhaps 
prise, is the changed position of the bon*»_ 
He sees that the knee-joint is coosidi 
more flexed than when he last saw it. 
inquiry, he ascertains that neither 
patient nor the nurse has disturbed it, 
then he recognizes that the stealthv 
mischievous flexors have secretly effe 
this change in position. It is merely Hexii 
under the influence of muscular enei^^ im 
untarily exerted; for as soon as muscular 
contraction is destroyed by chloroform, thfl 
fixed and flexed conditions of the joint are 
for the time entirely lost. And here I 
Etat«, that over and over again 1 have 
the mischievous and destructive effect 
this increasing state of flexion of the j< 
resulting, not seldom, I may say, from 
crastination, or inexcusable want of i 
age on the part of the surgeon to rectify 
or from his yielding too easily to the impf 
tunitiea of the patient or his friends, 
MdM^;;.r,ia™h'i';;^™'a«^gf^ °^^f to &void gi%nngpain to the palie 
tt« .ppUcMUon oi totoB ipritaitng liquid From the time when the limb besins 
i»iiiL ' "™ be flexed starts the mischief, which by- 

by cannot be controlled. 
I have here a drawing from nature (Fig. 25) to show to what exti 
flexion is sometimes involuntarily carried. You see the tibia flexed 
the femur at a very acute angle. This was originally a case of inflai 
tion beginning in the interior of the knee-joint, and the contraction 
the muscles was never resisted in the slightest degree, but was allowed 
take its own course, and you see the result. 

Fig. 2G represents another case of diseased knee-joint, in which 
tibia and fibula were carried backwards, so that the heel touched the tul 
osity of the ischium. 

lliese are extreme specimens of the results of the absence of mochi 




•onM. 

I 



INFLTJENCBOFBEST. 99 

cal constraint, and I feel convinced that the starting-point of the mischief 
which ultimately led to this condition, neceBsitating tLe amputation of 
these limbs, might hare been succeasfully combated by plaemg a splint 
behind the knee-joint, thus counteracting the influence of the powerful 
flexors. I may add, both patients did well after amputation. It seems 
to me that it is a great mistake on the part of profession ttl men, when 
they see an inflamed knee or other joint beginning to be contrncted or 
flexed, not to correct it at once, and so avert the condition whiub led to 
tlra necessity for amputation in these two cases, at all events. 

This explanation of the sole cause of fixed and flexed joints applies 
particularly to recently inflamed joints, before the deposition of new and 
comparatively solid material has taken place around and within the artic- 
ulation. In cases of long-continued or chronic inflammation of joints, 
the contraction and fixed condition depend partly, no doubt, on the in- 
cumbrance of the joints by the new material. Hence the deformity of the 
joint at that period cannot be entirely removed even under the influence 
of chloroform. 

Permit me just again to refer to this constantly flexed *itate of an 
inflamed joint. Take, for ex- 
ample, that of the hip: I ven- 
ture to say that no gentleman 
here ever saw an inflamed hip- 
joint with the leg exteuded. It 
la uniformlv bent, and also, as a 
rule, slightiy adducted, the cause 
of which I shall have occasion 
to refer to at another time. In 
the cose of the knee-joint, when 
inflamed it is always flexed. 
Curiously enough, tne malin- 
gerer, wishing to deceive and 
to impose, almost always en- 
deavors to indicate his long- 
continued and extreme suffer- 
ing by fully extending the leg. 
But this extended position dis- 
plays the imposition, for an in- 
flamed joint is never straight, 
but always flexed, the degree 
of that flexed condition depend- 
ing upon the intensity or the 
long duration of the mischief. 
Did any person ever see an in- 
flamed ankle-joint, permitted to 
pursue its own course, remain 

nearly at a right angle with the foot ? The heel is always raised bjr the 
gastrocnemii, and the toes pointed downward. An inflamed elbow-joint 
la always flexed, never extended. But when we come to the wrist-joint, 
we find that, although the muscular power associated with it is very great, 
yet in consequence of the extending and flexing forces being pretty 
equally balanced, we seldom have much flexion of the hand when the 
wrist-joint is inflamed. This is in strict accordance with the law which I 
hKve endeavored to place before you — the equality of muscular force not 

"' f much disturbance of the bones, but simply maintaining the joint 




100 ON THE THERAPEUTIC 

in a quiet but fixed condition. Again, with regard to the fingers. Who 
ever saw a finger with an inflamed joint of any duration in which the 
finger was perfectly straight ? Such a thing was never seen; the inflamed 
joint is always more or less bent under the influence of the flexors. I 
think that the degree of flexion associated with diseased joints in the 
hand is proportionate to the number of muscles and the nervous supply, 
on which I shall have occasion to dwell in my next lecture. The fore- 
finger, for example, when inflamed, is generally not so much flexed as the 
others, because it has an additional muscle, the extensor indicis, which 
counteracts the tendency to become flexed. With regard to the thumb, 
as a rule, I should say it is not proportionately so much flexed towards 
the palm when inflamed as the middle or ring finger. The explanation is: 
that there is a greater balance of power in the muscles of the thumb, the 
flexors and extensors, as compared with the corresponding muscles of the 
fingers. This will account for the extreme flexed condition of some of the 
fingers, the slight degree of flexion of the forefinger, and the nearly straight 
condition frequently observed in an inflamed joint of the thumb. 



INFLUENCE Oi" BEST. 



LECTURE Vin. 

a Branch of the Mnscnlo-Spinil Nerse— Precision of Nervous Supply to Mas- 
des — Symptoma of InHnmed Joints bciI Trentment by Rest and External Adkb- 
the ties— Exam plea of PhyBioIogieal Rest — Musoulo-CutaneouB Nerve nf Upper 
EitreiDity — Bent Ann after VeneBeotioQ — Casea of iDJury to Muatulo-CutaneouB 
Nerve — Nerrea of Fiugera, Toes, aud Thumb — Eifect of Pressure upon Spinal 
Nerves— Gangrene of Third and Fourth Fingers from Preasmo on Ulnar Nerve. 

Towards the conclusion of uiy last lecture, I made tlie statement, — 
that tbe same tmnka of ner7cs, the brandies of whieh supply the groups 
of muscles moving any joint, furnish also a distribution of nerves to the 
skin over tbe same muscles and their insertions, and (what at that time 
more especially merited our attention) that the interior of the joint re- 
ceives its nerves from the same source. Hence arises an accurate, con- 
BCDtaneous, and physiological harmony in these various co-operating struc- 
tures. I availed myself of this statement for the purpose of explaining 
how it happens that an inflamed joint is necessarily rigid and as necessa- 
rily flexed; and I explained, somewhat in detail, this method of tracing 
out the distribution of the nerves to the joints, to the skin, and to the 
muscles. I was in the habit of teaching this publicly at Guy's Hospital 
tor upwards of twenty-five years. I did not expect that I should have 
occasion to refer to this fact at all, because 1 apprehended that after 
teaching at least three thousand students in Guy's Hospital it would be 
pretty well known, as the result of my public teaching. But I find 
amongst the escellent books published by the New Sydennam Society a 
work by Schro?dcrVan der Kolk, in which he states: "After I had, in the 
year 18i7, detected a close connection between tbe peripheric distribution 
of the sensitive and motor nerves, by the discovery of a remarkable law of 
the course and distribution of sensitive nerves in the skin, — namely, that 
throughout the body tbe sensitive branches of a mixed nerve run to the 

Sart of the skin which is moved by the muscles receiving motor filaments 
'om the same nerve trunk; so that, the action of the muscle being known, 
we can, according to this law, even d priori, define the distribution of the 
sensitive nerves in the skin." 

Here you will observe is the same idea expressed by this gentleman in 
1847. Now it so happens that- one of my colleagues, Mr, Birkett, pub- 
lished a translation of a German book on Human Anatomv in the year 
1846, in which reference is made to this very subject by the translator. 
He added within brackets the fact of the associated supply of nerves to 
muscles and skin, but without further notice; introducing it i" '^" -"-"~ 



ray in which it had been habitually treated by myself in public lectures 
at Guy's Hospital during many previous years. He so introduced it no 
doubt for the purpose of marliing an advance of our knowledge in that 



respect beyond that of the German original. I have therefore no hesita- 
tion in claiming tbe anticipation, or priority if we may so term it, in tha 
observation and expression of the facts here alluded to by Schroeder Van 
der Kolk as a discovery of his own. I do not know that this is a matter 
of any very great importance, but I suppose it right, i 



103 ON THE THBBAPBUTIO 

any rate, to nmintftin one's own position. It is not necessary to 
the statements made by Van der Kolic, because what 1 liave done at Guy'» 
Hospital, long before they were published, has taken a much wider and 
more extended view of the subject than thatpresetited in hia book. 

To proceed with our subject, however. This articular, muscular, and 
cutaneous or peripheral distribution of the nerves is, in my opinion, a uni- 
form arrangement in every joint of the body. We may find numerous 
illustrations of the same method of distribution in other parts of the body 
which have the same definite relation to each other, and in this respect 
present the same physiological and mechanical arrangement observa- 
ble in ordinary joints, to which I s-hall hereafter refer. For instance, I 
shall endeavor to show that this same principle of arrangement, anatomi* 
cally, pi ly Biologically, and pathologically considered, is to be obBervedc 
with an equal degree of accuracy, iii the serous and in the mucous tneia* 
braiies. Thus considered, it manifests a wide principle, which, if it K 
any application in practice, must be one certainly of large extent. I shi 
endeavor to show tnat this is really its true position. 

1 may now, for a moment, refer to another diagram (Fig. 27), for tl 
purpose of confirming the proposition that the same nerves that suppljl 
the muscles supply the joints, and also the skin over the muscles. Thi 
mtmailti-iipintl tierve supplies certain muscles very definitely, and non 
others — these are the extensors of the elbow-joint, of the wrist, of til 
fingers and thumb, and the supinators of the radio-ulnar articulations. I 
also supplies the skin over all these muscles, and the joints wfaicb the 
move; and this is the whole of its distribution. Its cutaneous portion i 
accurately drawn in the diagram aa far as it is exposed. This diagni 






(Fig. 27) clearly gives expression to what I shall hereafter allude to 
So, detail with respect to this m 



respect to this musculo-apiral nerve — the precision of I 
supply to muscles. 

PrecUion of Nervous Siipphj to Muscles, 



The great precision with which muscles are supplied by their nen 
worthy of remark; and is such that if we have before ua a contri 
muscle, or a spasmodic condition of a muscle, we may be sure ol 
nerve which must be the medium, or the direct cause of it. Thus w 
the teres minor lying in contact with the infraspinatus, yet never, as fac 
as I know, receiving a branch from the suprascapular nerve. We maj 
notice the four muscles placed between the os nyoidea and the lower 
jaw ; all four are usually considered aa forming one group, but when yon 
consider them with reference to their nervous supply they are entirely 
separable. The mylo-hyoid and the anterior belly of the digastric receivq 
their nerves from the mylo-hyoid branch of the third division of the Wtld 
thus pointing aoouratefy to the strict association between these rausclcl 
and the process of mastication. But looking to the genio-hjoideus aiM 
the gonio-hyoglosBus, we see that tliey are supplied by the hypoglossal 
hcnco we must conclude that they are funetionnlly associated with tin 
movements ot the tongue. And here let me observe to the rising geB' 
pration of anatomists (who will, ! hope, excuse my referring to 8U<A 
points), that 1 have always found anatomical lectures very much increased 
in interest and utility by jrainting out the functional association and thfr 
physiological relation of niuscles by their nervous supply, rather than b^ 
their mechanical relation to the bones. 

Thtsn are some muscles that receive two nerves; thus, for oxamplaj 



iTrvzvzmos of rest. 



103 



the adductor inagnus of the thigh receives its nervous supply partly from 
the obturator and partly from the gjeat sciatic; clearly indicatine that 
the adductor magniis is aseociated in action partly wif"- '"i- -H'-'-r 
muscles and partly with the niuacles at the back of the ' ■- ' i i,; 

the idea of a double functional association. 

In studying the supply of nerves to muscles, over 
every part of the body, we find a great degree of preci- 
sion, which marks one difference between their distribu- 
tion and that of the arteries. Thus, if we look to the 
omo-hyoideus muscle, we find that it receives its nerves 
from three sources: it haa a branch from the hypoglossal, 
and if you trace that branch upwards, you find it re- 
ceives a filament from the pneumogastric nerve, and there 
are other filaments to the muscle from the cervical plexus. 
This clearly points out that this muscle has three dis- 
tinct functional associations — one in connection with 
the hypoglossal and the movements of the tongue, which 
it aids by fixing the hyoid bone; another connected with 
the pneumogastrio nerve, so as to bring it into associ- 
ation with the process of respiration; ana a third to asso- 
ciate it with the movement of the muscles of the neck. 

I make these remarks for the purpose of pointing out 
that there is a remarkable precision in the supply of 
nerves to the muscles. These examples are taken from 
small muscles, but they stand out distinctly, especially 
the omo-hyoid, not so much from their size as from the 
precision of the demonstration. This iriuscle arises from 
the superior edge of the scapula, dose to what we call 
the supruscapular notch, and in close proximity with 
the suprascapular nerve. If it had been a matter of no 
importance as to what nerve should supply the omo-hyoid, 
there is a nerve close at hand ready to do this; but I be- 
liere it was never seen, that the suprascapular nerve £ , 1 

sent a filament to the omo-hyoid. The facts hefore you f ' \ 
express clearly, that the muscles receive their appropri- ' ^ 

Kte nerves in a very decided and definite manner. p™ sr -c 

The precision and accuracy of the nervous supply to oin> bnmo'n o("^h« 
mosoles are shown not only by each muscle receiving a """""'V'rlil^tori 
definite nerve, but also by its receiving it in a definite oervo mippijine tha 
way. As a rule, nerves enter the muscles where they rt'Hp'jii''m''S^Jl|J 
would be most secure from pressure, and it is curious Wc^s. »nd tiio whoiB 
to observe how careful Nature has been in this respect um f onaSS. "'"'^ 
to guard one of the most important nerves of the body. 
The phrenic nerves (our lives hang on these threads), after passing 
through the chest, traverse the diaphragm, and distribute their branches 
Bpon the un(2cr surf aco of the muscle, and are so situated that they cannot 
be compressed during respiration. It they were distributed upon the 
upper surface of the diaphragm, where there is a constant and forced con- 
tact between the base of the lung and the superior aspect of the dia- 
phragm, and especially so during a retained inspiration, it is obvious that 
these filaments of the phrenic nerve would under such circumstances be 
exposed or subjected to compression, and the action of the diaphragm 
, ^ould be dangerously interfered with. The nerves, however, are dis- 
' '"'* ' ' Q the under or concave surface of the diaphragm; the whole ten- 



OK THE THEBAPETJTIO 



ver, ttie stomacli, and the spleen 
s to carry their influence to the 



yof gravitation oeing to r 
/ from them, so aa to enable the 
pSutphragm unmolested. 



qf Jt\fla})ied Joints^ and Treatment by Rest and External 
An*MtheCif». ^ 

I will remind you, that when the 

J apprehend that that condition ooour 

t[tAeJ6int « in a elate of injiamntation or oj" irritation, the ij^w 

WiOHdition is carried to Hit spinal ntarrow, and thwtce reeded to tK$ v 

mata mttscke of (As joint, through tlie medium of the aiuociated i 

fturvee, the muscles being sujyUiecl h<j the same nerves tfiat sttpply th« i 

r of the joint. A fixed position is thus produced; for undoubtedly^ I 

I remarked the other day, if you give such a patient chloroform, yf 

destroy the fixed condition, and the joint is perfectly movable by tl 

ABnd of the surj^ooii. Again, in the case of inflamed shoulder- joint, ll 

shoulder is very sensitive. Perhaps not immediately, bntfl 
^ Bhort time — in a day or two— there is pain over the cutaneous distritf 
a of the circumflex nerve, and not unfreijuently considerable pain 4 
the back of the shoulder. Vou 'will recollect that the same trunks ( 
nerves which form the circumflex nerve transmit some posterior filaments 
to the skin over the shoulder and the lower part of the neck; hence the 
pain experienced in this region by patients aulTering from disease in the 
I shoulder* joint. • 

~ Now, upon what principle should we treat the inflammation of a joint ? 
Win answer to this general inquiry, I would especially refer to the shoulder- 
joint, because it is so simple in its anatomical arrang'einent, that I can 
the more easily apply these practical remarks. 1 should say, in aid of 
other means, employ this cutaneous distribution of nerves as a road or 
means towards relieving pain and irritation within the joint. You thus 
quiet the muscles, prevent extreme friction, and reduce muscular pressure 
_ and spasm. Therapeutics may certainly reach the interior of this joint, 
I and its muscles, through the medium of the nerves upon the surface of 
» the skin, and so induce physiological rest to all the parts concerned in 
moving the joint. I mean to say that, these nerves upon the surfac* of 
the skin being in direct association with the Interior of the joint itself, 
we may reduce the muscular spasm as well as the sensibility of the interior 
portion of the joint, by applying our amesthotics with accuracy and with 
sufiicient intensity upon the exterior of the deltoid muscle, over the dis- 
tribution of these sensitive filaments. The thought will occur to you at 
once that there is nothing very r«markable in this opinion, and that is 
quite tnio. The embrocations, however, which would ordinarily be nag^- 
gested for this purpose are not of a character BiifBciently potent tgj 
alleviate the pain of the patient, and are, 1 believe, seldom employed v ' 
a definite idea in the jnind of the prescribcr, 1 would suggest that n 
should employ our fomentations strongly medicated with heliadonni 
opium, or with hemlock, instead of using mere fomentations of hot watn 
Some will say, " Oh, hot water is quite as good;" bnt I can assure ym 
practioallv it is not so. The advantage to be derived arises in this w»y>B 
the sensinility of the filaments supplying the skin being reduced, that'* 
infiuence is propagated through the sensitive nerves, to the interior of the 
joint, and to the muscles moving the joitit. This diminution of sensi- 
bility tends to give quietude or perfect rest to the interior of the joint, 



INFLUENCE OF KEST. 



which is one of the most important elements towards the successful LBsae 
of the treatment of cases of this kind. 



Examples of Physiological Rett. 

Suppose you have a patient who is the subject of iritis. You drop 
sulphate of atropia upon the conjunctiva, and you act upon the iris; 
you see its influence upon the condition of the iris. How is this brought 
about? It must be through the medium of the impression made by atro- 
pine upon the sensitive filaments of the ophthalmic branches of the fifth 
nerve, which are distributed upon the conjunctiva. I cannot believe it to 
be by its direct transmission through the various and dense tissues cover- 
ing and surrounding the iris; for we observe that exactty the same effect 
can be produced upon the iris by nibbing or smearing belladonna upon the 
eyebrows, forehead, and eyelids, which are supplied by the first division of 
the fifth nerve. If, then, admittedly, you influence the condition of the 
iris by dropping atropine upon the conjunctiva, which is supplied by the 
fifth nerve (the iria receiving its motor supply from the third and sympa- 
thetic nerves), why should you not succeed in relieving muscular spasm 
in the interior of a joint by narcotics, applied to the peripheral branches 
of the same nerve which supplies the muscles that move the joint ? I feel 
confident that quacks oftentimes succeed in giving relief where lefrjtimate 
surgery seems to fail; and they do it in this way: they employ the most 
patent means of counter-irritation in combination with ansesthetics, where 
we should use only an embrocation or infusion or a fomentation of com- 
paratively little aniBsthetic influence. These fellows employ potent reme- 
dies, Bod they succeed, without knowing how, where some of us, more 
legitimately circumstanceil, actually fail. 

Jjet ua take another illustration. If we can, by introducing opium 
into the auditory canal, relieve toothaclia and a stiff jaw, do we not come 
to the same principle as that which stands before us in respect to the cir- 
cumflex nerve and its cutaneous filaments ? Last winter, during that very 
cold weaiher with sharp easterly winds, a gentleman called on me, and 
told me that whilst riding on horseback that morning down Hlghgate- 
hill, he was suddenly seized with stiff jaw and intense pain in his left e^r, 
and he added, " 1 have been to my office, but in consequence of the pain 
in my ear 1 cannot do anything. I have endeavored to overcome the 
pain by sitting quietly in my warm office; but I cannot he^r myself, and 
now I have the most exquisite sensitiveness and pain in the left oar, and I 
can hardly move my jaw." In order tn relieve him, I employed the prin- 
ciple of physiological rest, which 1 have been advocating to-^ay. By mj- 
direction he introduced some cotton wool, soaked in the sedative solution 
of opium, into the auditory canal. As he had a good deal of throbbing 
pulsation in the head, and imaginary noises in the e^r, I thought it would 
be as well to give him a calomel pill at night, and a pur^e in the morning, 
and I requested him to let me see hitn on the following day. When I 
aaw him in the morning, he said, " 1 am much obliged to you for the 
medicine, but I have not taken it; for I had not put the opium into the 
passage of the ear a quarter of an hour before all my symptoms disap- 
peared, and the jaw became free from pain and stitTness." I think, then, 
we may fairly deduce from this and like cases, that if we can remove mus- 
cular spasm of the jaw by putting antesthetics upon a cutaneous branch 
of the fifth nerve which supplies those muscles, we may employ the same 
kind of remedies, with great advantage, in joint diseases, We may surely 



OK THX TSEBAFEtTTIO 

expect to ffire great relief to the joint, by acting upon the cutaneous 
nerves of tne same trunks which supply tnoBc muscles that are doing 
great harm by spaamodically moving it, or by pressing tlie iiitlunied articu- 
lar surfaces upon each other. 

Opium is injected into the rectum to relieve an irritable urinary blad- 
der, or spasniodic stricture of the urethra. Is not the same principle in- 
volved here? In like manner we apply an wsthetics to the skin of the 
Eerineum to relieve retention of urine. Again, we find some pntients with 
ip-joint disease suffering from pain in the knee. Now, although the dis- 
ease does not lie there, we know that the pain can be relieved by a bella- 
donna plaster, or strong hemlock poultices or fomentations applied over 
the knee-joint; thus acting upon the nerves of the hip-joint through the 
medium of those which are spread over the knee-joint. 

There are some circnmstances ia which the circumflex nerve beoomes 
injured and exceedingly painful, especially after dislocation of thd' 
humerus. In such cases, the patients experience a wasting of the deltoid) 
snd suffer a great deal of pain in and about the shoulder. This, in part>, 
(sometimes, at any rate), depends upon the temporary pressure of tlid'| 
head of the humerus upon the nerve, or the stretching or tearing of thft; 
nerve at the time of the accident. Although the patient is disabled for ft 
time, ultimately the pain disappears, the deltoid recovers its size, and th«,{ 
capability of the joint is restored. The same wasting of muscle and pain ' 
are manifested also, though not so satisfactorily explained, when the tendoa. 
of the biceps is ruptured; the deltoid becomes reduced in size, and thO' 
shoulder-jomt suffers a great deal of pain, relieved by strong aniesthetica . 
applied to the skin of the shoulder. 

These points I now place before you as associated with the circumflex 
nerve; and I might repeat them with respect to the other joints and their 
nerves, but, as 1 should only be reiterating the same suggestions, I hava i 
selected the relation of the circumflex nerve as representma' the type of' 
the arrangement in joints generally, and have appended to it these prao- . 
tical reflections which have a very general bearing and a wide significance. 
I speak strongly upon this subject, because I have long been in the habit 
of acting upon it and of seeing its advantages. Of this I feel assured, 
that if the profession will act upon the cutaneous distribution of the nerves 
with determination and definite ideas, for the purpose of conveying a calm- 
ing influence to the associated deep-seated muscular and articular or in- 
ternal nerves, they will find the treatment very successful. 

I now proceed to the examination of the distribution of the 

» External or Musmlo- Cutaneous Nerve of Che Upper SktremUy. 
The cutaneous portion of this nerve is very nicely shown in the dia- 
gram (Fig. 28). Yon see the nerve spreading its branches down the an- 
terior and outer part of the forearm, nearly as far as the base of the radius. 
Now what is the object of this nerve? It Is derived from the fifth, sixth, 
and seventh cervical nerves, and it has a well-defined distribution to tho 
muscles, fascia, and skin. It goes to tho coraco-brachiaJis, to the biceps, 
and then to the brachialis anticus, and thence sends a branch to the 
anterior part of the elbow-joint, thus displaying the articular association 
pointed out in the case of the circumflex nerve. The nerve now becomes 
subcutaneous, reflects a branch over the lower part of the biceps, and 
then prolongs numerous branches (at first sight apparently) far away 
from the muscles with which it Is associated. Vou may first observe the 



INFLUBNCH OF BEST, 



107 



recurrent branoh passing upwards to the akin over the lower part of 
the biceps. From the tendon of this muscle proceeds what is termed 
its fascia) insertion. Now the fascia of the forearm is part of the inser- 
tion of the biceps — it is an essential part of it. Instead, therefore, of this 
nuaculo-cutaneoua nerve departing from the arrange- 
ment to which I have referred, it substantiates it 
most completely, because it is distributed to the skin 
over the fascia which that muscle moves. And mark 
another association here: a part of the musciilo-spiral 
nerve, as it ought to do, comes over the supinator 
radii longus, because that muscle is supplied by the 
tnuxculo-spiral nen-e. On the inner side, a portion of 
the internal cutaneous branch * of the median nerve 
should be seen, because the fascia on the inner side 
g^ves attachment to the pronator radii teres, the flexor 
carpi radialis, and the flenor carpi ulnaris. These mus- 
cles are supplied by the median nerve, and they arise 
from the fascia. When they contract, they can exert 
some influence upon the fascia: so that this fascia is, 
as it were, the common property of three nerves. 
Here, then, we have an arrangement of nerves which 
shows very distinctly the muscular, articular, and cuta- 
neous branches all associated in one trunk. The at- 
tachment of the muscles to the fascia is no doubt the 
reason why we have sometimes such difficulty in treat- 
ing injuries to the fascia. If we have to treat a large 
■nb-fascial abscess, we all know the difEculty of healing 
it, in consequence of the fascia of the forearm being 
freely movable by muscles. Unless we can keep certain 
muscles quiet which at first sight might appear to have 
no relation to the abscess, we cannot succeed in our 
treatment. This is to be accomplished, however, by 
the employment of mechanical pressure by bandage^ 
BO as to coapt the internal surfaces of the abscess. 
We quiet the biceps and the muscles of the upper part 
of the arm by making pressure upon them, and so se- pia. Hi.-a. uukdIo- 
oure mechanical rest to the walls of the abscess. ih^hlSL'^thpiraTiuB 

I feel bound to place before you one or two facts iibnTcihi>boniiaf uissi- 
associatei with this nerve, bearing on the practice of !hrtl^d™o™ih^bi«[^ 
our profession, because, if I should take up your time md tiipniiiiitriiiutinBiw 
without showing you that some practical advantage thelown'putotUicnp- 
waa to be obtained, I should be asking you to make a '"',"'™'[|?H|i.'2'^*r^ 
Baorifice which would not be justifiable. We have here ^."srlnrh of thcmas- 
(Fig. 29) a drawing of a dissection made by myself I^*X"|,rr™oni'"[h« 
many yeara ago, showing the superficial nerves and ™t« rUm at the urm. 
Teins of the anterior part of the elbow-joint, and also ^" "" "''^°"'"' '°"' 
the brachial artery and its accompanying veins. You 
■ee a part only of the external cutaneous nerve. The inner cutaneous 



J ontaiieoas branoh of the medtan " U meant the internal cnta- 
a itself, wfaich takes orieiii from the eighth cervical and firat doisnl nerves, 
D with the inner head of the median, of which it may therefore be desoribed 
M a ontaneoos branch, Bappl7iug the akin over the fasoial origin of moHoles supplied 
bj ttMlnadlan nerve. — [Bd.J 



nlaments at 
Buperiicial v 



ON THE THKBAPKDTIO 



! traveling over and others under the diflcrcnt 



Cause of lient Arm ajter Venenection. 



Formerly, when bleediiiff was a 
rare one), patients used sometimes tc 
venesection, from wbat was termed a 



suffer 



operation (it is now (t very 
after, and as the result oi, 



i 



" bent arm." It was explaineil by 
Biipposiiig the fascia had been 
wounded during- venesection; 
this supposition was adopted, 
because tite fascia and ten- 
don of the biceps stood promi- 
nentty out, and forced them- 
selves upon tbeattention of 
the aur^on. It aecms clear 
to me that injury to the fas- 
cia is not the explanation. 
I would say, that in the vene- 
section one of these little fil- 
ameats of nerve was wound- 
ed. As the lancet is passing 
into the vein, the patient 
feels a very sharp, acute, 
electrifying pain running 
from the seat of injury into 
the upper arm, which then 
distributes itself upon the 
back of the neck or shoul- 
ders, indicatins that some- 
thing' unusnal has happened. 
Now, under these ciro— 
stances, what occurs ? 
most always the wound isiqg 
beahhy: it suppurates, g 
ulates, and becomes exoe 
ingly painful, and there J 
subsequently a ve _ 
cicatmation. How is it ti 
the arm becomes l)ent ? ' 

injured nerve is a branch j 

that trunk which 
the biceps and hrachialis anticus. The effect of the injury is carried t, 
wards to the spinal marrow, and reflected along the motor filaments 
supplying the biceps and brachialis anticus, and thus produces a spasmodic 
contraction in them. This is realty the cause of a " bent arm, which 1 
accept in preference to the other interpretation, of a wound in the fasci^ 

But this point may be carried a tittle further. It is nearly tn 
years ago since i saw a patient who for several years had had a beni 
after venesection. I cut away the old cicatrix, which was very tend«l 
small filaments of nerve were detected in the cicatrix, and from the tttT 
of the excision of the cicatrix tlie patient was free from "bent e 
This demonstrated to my mind, that the " bent arm " which foUoitt 
venesection was not the result of a wound of the fascia, but of a woill 




INFLUENCE OF REST. 



109 



of one of the nerves supplying the musclea which are capable of bending 
the Krm. Thus I have a right to say, that ne can attach to these nerves 
points of practice which do not at first sight appear, when it is eiinply 
Otated as a sort of axiom, that the same nerve that BuppHes the inusules 
sappiies the slciii over the bisertion of those muscles. 



Jifjury to the Musculo - Cutaneottt Nerve hy a Mullet. 
I had once an excellent opportunity of seeing a well-marked cose of 
injury to this musculo-cutaneous nerve. A lieutenant in tlie navy was at 
JjAgoa, fig-hting- with the natives. He jumped ashore with his award in 
bis right hand, and ran with his men up to a stockade. Although he was 
■track once or twice, he went forward; preaentiy bis sword-arm di-opped, 
he could grasp his sword in his hand witri great vigor, but could not bend 
or raise his forearm. This gentleman, before he returned to his boat, 
received seven balls, of which some went through the right side of his 
chest. When 1 saw him in London, I removed a bullet from his leg, and 
he then explained to me the nn.turo of the injury which he had received 
in his arm. This made one of the most precise experiments that you 
could possibly conceive upon the external cutaneous nerve. The bullet 
had bruised or severed tiie nerve, causing a paralysis of the biceps and 
br&chialis anticus; both muscles were wasted, whilst the other muscles 
of tbe arm were well developed; a curious- looking depression was thus 
produced in the arm over the wasted muscles. In order to bend his right 
forearm, he used to place his left hand behind his right hand, and forcibly 
jerk the forearm into the flexed position. The sensibility of the skin 
ovttT the oriliiiary distribution of the external cutaneous nerve was 
destroyed. He had consulted the late Mr. Guthrie as to giving up his 
appointment in tbe Service, and he subsequently came to me with the same 
objeot. I said I did not think the nerve had been divided. It mi^ht 
b»x'e been; there was no doubt it was seriously injured. I advised him, 
whether the nerve were divided or iiotj to retain his commission, as the 
probability was greatly in favor of its being ultimately repaired. He 
obtained leave of absence for two or three years, and wore his arm in a 
short sling, I met him three years afterwards in Piccadilly, when he 
flourished his stick in the air with his right arm, and said he was ready 
for anything. I asked him how long he had been getting well, and he 
told me, " About two years and a half." His arm was quite strong, and 
the wasted muscles had nearly regained their normal size. The power of 
grasping and moving the lingers which this irentieman retained after his 
injury, left no doubt that the median and ulnar nerves were uninjured. 
This was a well-delined injury, that marked very completely the distribution 
of the musculo-cutaneous nerve. This gentleman, as a captain in Her 
Majesty's Service, is now receiving his reward for bis courage and his 
wounds. 

Meostoais pretging upon the M'tiscido - Cutaneoua Nerve. 

I may mention another fact with regard to the same nerve. Four or 

five years ago a boy came to me at Guy's Hospital, with his arm con- 

trairted, and suffering a good deal of pnin in the course of the external 

cutaneous nerve. On careful examination, I found a simple exostosis 

t>ressing upon this nerve as it passed through the coraco-brachialis mus- 

[e had several other similar exostoses at different parts of his body, 

did not pain him. 1 cut down upon the exostosis to which 1 



OTT THI THBKAPBtrTIO 

specially referred, and renioi'ed it. He had no lunger any pain, anJ 
Boon able to move his arm freely, 
I think, then, we may assert that this external cutaiieoua nerve does 
I manifest the law or principle of nervous distribution which I have en- 
deavored to point out — that the same trunk of nerve which euppljee ihe 
muscles, supplies the joints which move those muscles and the akin over 
the lengthened insertion in the fascia. 

I am speaking in accordance with the experience of everybody when 
I say that an inflamed elhow-joint, permitted to take its own ceurae, 
always becomes flexed under the influence of the biceps and brachiaiis 
anticus muscles; and I think we can understand why it should be so, 
from the distribution of the same nerve to the joint and muscles moving 
it. I think we may find some advantage in remembering what I have 
now pointed out with respect to the cutaneous nerves of the arm. 1 
believe, also, that if strong arueathetics were applied over the course of 
these cutaneous nerves, we should be entering upon a line of treatment 
1 which would ultimately influence the same nerves as they proceetl to sup- 
Ljply the different flexor muscles. 



Distribution of Neroe^ to tJte Fingers. 

The other two large nerves of the upper extremity are, I 
and uhiar. I must not trouble you with much of the details of 1 

distribution, ex eejl 
to point out its gi 
precision. The 
nerves, together, 
ply all the flexors of 
the wrist -joint, fin- 
gers, and ihumb, all 
the pronators of the 
radio-ulnar joints, 
and all the joints that 
those muscles move. 
The separate distril 
tion of thi 
and the ulni 
need not refer to, 
yond reminding you 
of the fact. But 
when we come to look 
at this distribution 
closely, it is a little 
remarkable. We have 
here two middle fiji- 
gers, drawn from 
ture: one with its muscles and tendons shown, and the other with thi 
tribution of the nerves upon it. We see the tendons of the estei 
running along the back of the finger, but scarcely further than the 
o£ the second phalanx. Then by the side of the finger, and joined ti 
tendon of the extensors, we may see two small muscles — the lumbricalii 
and the interosseous. Their tendons pass on to the end of the finger, 
towards the dorsal aspect, Thus it might appear, at first sight, as if tli* 




B prowedtna ftlong the 



nove. 

r3B 






INFT. UENCE OF REST, 



111 



flexor (median) nerve came on to the grounii of nn extensor distribution; 
but it IS not reall; so, because the iiiterossoi and the lunibrioales, which 
form a part of the flexor apparatus, are supplied hv the median and ulnar 
nerves. We have here the tendons of these siiiall muscles (supplied by 
flexor nerves) passing along the dorsum of the finger, in accordance with 
the distribution of the flexor nerves. "We aUo ohaerve a distinct portion 
of the extensor nerve running along the dorsum of the linger, as far as 
the tendons of the extensors proceed distinctly, and then uniting with 
the branch of the median nerve. So accurately is this systematic 
arrangement carried out in the median nerve, that these little muscles — 
the interosseous and the lumbricalis — command, as it were, an associated 
cutaneous nervous distribution. Hence this median nerve, whilst passing 
along underneath a portion of the finger, sends a. large branch across the 
side of thfi second articulation, between the first and second bone of the 
finger, and distributes itself along the dorsum of the fitiger. Here again 
we have an instance of the same nerve supplying the muscles, and like- 
wise the skiu over the iusertion of the same muscles. 



Distribution of Nerves to the Toes. 

Now contrast that state with the middle toe. You will observe the 
extensor tendons 
and nerves Running 
along the dorsum of 
the toe. But here 
is a marked differ- 
ence, apparently, in 
the distribution of 
the plantar nerve. 
Instead of there be- 
ing a distinct dorsal 
branch from a plan- 
tar nerve, as you ob- 
serve from the me- 
dian or ulnar nerves 
in the hand, this 
plantar nerve (the 
aaalogae to the 
braoco of the median 
nerve) does not pass 
towards the dorsum 
of the toe, but con- 

fioe« itself to its under surface: and it seems, upon careful examination, 
tbat tbfl interossei and lumbricales do not extend themselves so completely 
along the domum of the toe as the corresponding muscles do upon the 
dorsum of the finger. Again we have, on a small scale, the same thing 
expressed with equal precision^ — that the same nerve that supplies the 
muscles supplies also the skin over the insertion of those muscles. 




Dielribidion of Nerves to the l^umb. 



In this dnwiug of the human thui 
I dtStrilKltioi) of the musculo- spiral nen 



lb (Fig. 33) you see a part of the 
! to which I have already alluded 



119 OS THE THERAPETTTIC 

as supplying all tlie extensors of tlie elbow, wrist, fingers, and thuniH 
without exception, and none others except the radio-ulnar supinati>rs. 
Now the thumb stands in this peculiar position, that instead of liavi 
the tendons of its n 

cles blended togetbc 

and merged into each 
other as in. the fingers, 
making a sort of cooi' 
mon ground for the 
distribution of two 

the separate and dis- 
tinct insertions of 
tendons of the 
second, and third 
tensors of the thi __ 
and the musculo-spiial' 
(extensor) nerve going 
lb. There is no branch 
thp dorsum of the thumb, but tJiere \* 
of the linger. Why this difFereno»' 
mscular association on the dorsui 
Be extensor tendons, al! of which 
:ulo-Kpiral or 




fir^S 
I BJ^M 

ipiial^^ 



exclusively to it on the dorsal aspect of thi 
of the median nerve proceeding t ' ' 
a branch of it going to the dorsi 
It is obvious that the whole of th 
the thumb is confined to these 
supplied exclusively by the mus 
B with this arrangement, thi 



o-spir: 



is the only one that supplies the skin over the dorsum of the thumb, thiq 
making a marked diSerence in the cutaneous distribution of the thua 
and the fingers. This arrangement is also subservient to the rule or ]*lf 
which I have mentioned, that the same nerve which supplies t 
supplies the skin over the insertion of those muscles; it is an examjde 
a small scale of the distribution, but it could scarcely be more exact. 

Even this little piece of anatomy may be occasionally of direct iinp< 
tance, I remember seeing an error completely checked by Its recognitia 
A patient was suffering from tetanus, having a wound upon the domi 
of the finger over the third phalanx. The surgeon proprtsod to divide t] 
'---'- luppliea that part, and intended to divide the muscnlo-ff 



* 



That would have been a 
ipply that part exclusively; it i. 
the median nerve. 



The inusculo-spirsi nerve doi 
supplied partly, if not chiefly, from 



Cases iUwutrat'ing the l^ect of JVessure upon Spinal Neret 



ow for a moment refer to illustrations of the effect of mechani- 
cal pressure or irritation upon the median nerve. We know that a frac- 
ture near the base of the radius, with displacement, is sometimes followed 
by a large amount of callus, that callus being always in proportion to the 
disturbance of the parts or severity of the fracture, and is occasionally due 
perhaps to the want of proper management. The swelling and displace- 
ment together lead to pressure upon the median nerve, and that pressure 
may produce destruction of the tissues at the peripheral distribution of 
the nerve. 

Some years ago a sailor came to Guy's Hospital, under the care of tlu 
late Mr. £ey, having had a bad fracture of the lower part of thi 
"here was no surgeon on board the ship; the fracture was not properh 



th^l 

iua^H 



ITTFUJEIIOB OP BBST. 



113 



set, and in conscqiipnoe the callus pressed severely upon the fnedian nervo 
above the wrist. The inun had ulceration of the skin upon the thumb, 
the forefinger, and the middle linger. The hand was purposely Hexed, 
and put in suoh a position that all the tension was taken oS the median 
nerve, and the ulceration got perfectly well ; but as soon as his hand was 
allowed to be freely used and extcniied again, and the pressure of the 
callus permitted to exerC its inllueiice upon the median nerve, the ulcera- 



tion reappea:«d i 
not pursue hia i 
mit him to any 
so he preferred 
hospital, subject, 
have alluded. T 
ducing deteriorati 



lupati 



Thi! 



thumb, forefinger, and middle linger. He could 
n as a sailor, Ijut it was not thought right to sub- 
operation, which might place his hand in danger, 
g as he was. He was allowed to depart from the 
doubt, to a recurrence of the ulceration to which I 
is a good iliustra-tion of pressure upon a nerve pro- 
of structure. 



I have placed this sketch (Fig. 34) before you for the purpose of illus- 
trating a faot someirhat like the preceding. It shows gangrene of the 
little and of part of the third linger of the left hand. I will give you in 

a few words the history connected with it. Elizabeth B , aged forty- 

aeven, oame under my care at Guy'a Hospi- 
tal in February, 1853. She was of healthy _-?^_ .. . 
aspect and regular habits. About a year 
before, she felt numbness in the extremities 
of the third and fourth fingera of tho left 
hand, with pain in the same parts, espc- 
oially increased during the night. Th« fin- 
gers gradually became enfeebled and i 
ened in size. In a short time the ends of 
the above-named fingers began to appear 
discolored, while the numbness and pain 
increased. She had no pitrlioiilar treatment 
for tins, and, as mortification was impend- 
ing, the surgeon advised her to come to the 
hospital. On admission, the thii-d and 
fourth lingers were found to be gangrenous, 
the extent of which is shown in the sketch, 
A healthy line of demarcation between the 
living and dead structures was then form- 
ing. No pulse was perceptible in the ra- 
dial, and only a very slight one in the viliiar 
artery. On examining the case v 
to ascertain the cause of all this, I found 
upon the first rib an exostosis pressing upon 
the subclavian artery so as to obliterate it, 
or prevent any blood from passing through 
it. The exostosis was pressing upon a 

ire also, which turned out to be the ulnar 

ire. I pressed my finger upon 1 
immediately the patient expressed ailditional pai 
ing fingers. The exostosis pressing upon the s 
every part of the upper extremity alike, aa far a: 




114 ON THE THEBAPEUTIC 

concerned; but the additional circumstance was, that it pressed upon the 
ulnar nerve, and so produced a peculiar effect upon the two fingers sup- 
plied exclusively by the ulnar nerve. The interference with the nervous 
power or nervous influence, or the irritation of the nerve,* whatever it 
may be, led to structural deterioration, and finally to gangrene, of the 
ends of those fingers. The case is quite analogous to that of the sailor 
who received a fracture of the radius, with a large amount of callus press- 
ing upon the median nerve, leading to ulceration of the forefinger, middle 
finger, and thumb; for the line of demarcation between ulceration and 
gangrene is but small: the one is molecular death — ^the other is local 
death, but on a larger scale. 

♦ See note, p. 117, ibigue c»to^.— [Bo.] 



INFLL'EJiCE OF KE 



LECTURE IX. 

Preaaure od tHnur Nerva ProJueiog Qangrene of tlio Thinl and Fourfi Fingora — 
Furred ToD^e on oni) Hide Depeadiiig on a Decayed Tooth. DiseaHe within the 
t.'raDmin, and Fractured Hiu-e of the Skoll—Decajed Molar Tooth FroduaJag 
Gray Hair on the 'I'emplo — Eirairiatioii of Audi?otj Canal and Eulaiged Lym- 
|ibatic Qland — Nerroua Supply of the Wrist and Lover Extremitiea — Cauae of 
Ulcers on the LegH being Frequently just, above the Ankle~~DiBtribntioD of 01)- 
tiuatOT Xeire—Catsaeoua Neives of the Knee — £xplaiiation of HyEteiical Faiiui 
in the Hip- or Knee-joint. 

At the concluaiou of my last lecture I was compelled abruptly to cut 
short the details of an interesting case of pressure upon the ulnar nerve, 
leading to g;angrene of the third and fourth fingers. Tliat, at least, was 
mv interpretation of the case. Another question arises with respect to 
this case — Whether the exostosis, which was the source of pressure upon 
the subclavian artery and upon the ulnar nerve, subsided under the influ- 
emie of the biuhloride of mercury V The exostosis did undoubtedly dimin- 
isli in aixe during the time the patient was in Ciuy's Hospital; but 1 have 
not Been her since that time. 

I might have said, with respect to the details and the treatment of this 
case, that there was s very swollen condition ot the left upper extremity, 
from pressure upon the artery, and, probably, the veins also. The arm 
was mottled in appearance, and its temperature much diminished, fore- 
hoding ffeneral gangrene ot the limb. By the recumbent position of the 
body, with slio'iit elevation of the arm, the return of the limb to a com- 
paratively healthy state was very much facilitated and hastened, whilst 
the pain upon the ulnar nerve became greatly reduced. A large and 
thick layer of cotton wool was placed around the whole limb, and ulti- 
mately portions of the two fingers, which were actually gangrenous, en- 
tirely separated. The wounds healed up, and cicatrized healthily, and 
the patient went out of Guy's HuspitnJ free from pain, and, as far as I 
know, perfectly well, except that the subclavian artery did not carry 
blood, nor waa any pulsation to be felt in the radial artery, and scarcely 
any, if any, in the ulnar artery; but the mobility and temperature of the 
limb were nearly re-established. I might add, that there existed a small 
exostosis on the first rib of the right side of the chest, not so large as 
that on the left. Certainly both exostoses appeared to move with the 
first rib. 1 say, appeared to move with the rib, because there may be some 
surgeons who would question whether lh« exostoses were connected with the 
firBl rib, or with the transverse process of the seventh cervical or first dor- 
sal vertebra. Aa far as I could tell, they appeared to be assoriateil with 
the first rib. This instance of local gangrene is, I apprehend, an illustra- 
tion of destruction of tissue from physiological disturbance and interfer- 
euce; that is, by pressure upon the ulnar nerve. If it could have been 
possible to remove that exostosis before the gangrenous ulceration took 
place, I believe that those fingers would not have been destroyed. This, 
then, will complete all I have to say on this case, which is one of great 



OH THB 3rHXBA.PXUTI0 



t; not BO much from its ow 
ieverity, it stands at tbe head of 
leavor to enlarge. They c 
»oks, though not unfrequi 



ndividuat value, as that, in point ol 
group of cases on which I shull Qn- 
a class not generally referred 
itly niet with In pmatice, wliioh have t 
of these lectures; I mean that of " ph; 



inths I was requested to s 

; painful symptoi 



: a young lady from 
o had in lier right 



tr\C 



relation to the subji 
logical rest." 

Within the last three r 
the country on acoount ol , _ 

hand, especially in tbe little finger and the ring finger. Associated with 
these symptoms there was the suspicion of an aneurism of the right 
ctavian artery. I wil! not trouble you with all the particulars uf this i 
but only those which bear upon the suggestions before us. Thi 
bad a slight, hard swelling upon the first rib, which her mothi ^ 

bad resulted front a fracture that occurred in her cliildbood, she being now 
about nineteeti years uf age. Th« swelling had lifted up the subcTavian 
artery very much, and gave it the appearance of unusual pulsation, and 
upon close examination a sort of aneurismal bruit could be heard, appar- 
I ently the result of some enlargement encroaching upon the subclavian 
artery. There was really no aneurism. 
This was a case in point, where some- 
thing had occurred to the first rib, 
possibly a fracture fof that I have my 
doubts, still it might have been sot, 
which led to the pressure upon this 
ulnar nerve, and had caused the loss 
of. sensation in the little and the ad- 
joining finger, the loss of temperature 
ill those two fingers especially, i ' 
very constant pain in them. 7" 
are, as far as I can see, the prelim 
conditions of the previous case, ' 
ultimately terminated in gangre 
the fingers. In the case of this young 
lady, wo have only the evidence of 
deterioration having gone so far as to 
diminish both the siee and the t 
perature of the fingers, and to | 
duce considerable pain in then 
has been the issue of the case I do not know. It was, before I a 
vested with a great degree of anxiety, on the part of both the patient I 
her friends, for they had received tfie impression that she had a subolavi 
sneurism, which would require a very serious, and no doubt to her 
very dangerous, operation. 

Hirr«? Tongue on otie aide caused by a Decayed Tooth on t/ie »mne a 

As I purpose making the case of gangrene of the fingers from pressutff" 
Upon the ubiar nerve the starting-point of a little group of cases bearing 
upon the subject of phyHlologicaf rest, or rather tbe evil resulting from 
the want of physiological rest to t he nerves, I must request yoiu- attention 
to this sketch (Fig. 35) of a tongue furred on one side, and comparatively 
clean on the other, 1 dare say some of you at first sight wondered what 
this represenlBtion could be intended to elucidate, beyond the bare fact 
e side being tolerably clean, and the other somewhat furred. Now, 




Pio. 5B. 

Jrit iMe, mnltlnv trmn b ilacftyed and ■■ 
L •Boond molu' tooUi In tbe uppw Jnw oo tin 



INFLUENOE OF REST. 117 

this furred condition of the toHHiie, let me say in anticipation of what I 
have to spe&k of more in detail, is frequently aBsociated with a diseased 
condition of the second and third divisions of the fifth nerve. It is, in 
fact, a functional and structural deterioration depending upon nervous 
influence,* in that respect very much resembling' what we have already 
seen in an extreme condition In the case of gangrene of the fingers, 

If\irred Tongue on one eiile, deperidinff on DleeoJie tuilhrn the Cranium. 

The first time I had an opportunity of clearing up such a case as this 
oocurred in 1843. On December 17th, 1843, I examined, with Mr. Blenk- 
arne, a surgeon in the City, the body of one of his patients, who had died 
with dJaease of the brain and spine. She had suffered from intense pain 
on the left side of the head. She had also, during her life, a tongue furred 
on the left, and scarcely at all on the right side. It became, therefore, 
an important point to clear up what was the probable cause of that con- 
dition of the tongue. We made a post-mortem examination, and found, 
as was anticipated, a diseased spine. Then, upon very careful examina- 
tion of the head, on turning up the dura mater from the anterior part of 
the petrous portion of the left temporal bone, for the especial purpose, we 
exposed the Gasseriau ganglion, or the ganglion of the fifth nene. We 
there found what might be called a scrofulous deposit upon the convex 
edge of this ganglion, involving the second division of the tilth nerve 
more than the third, but still invohnng all more or less. Here, then, 
appeared to us to be the probable explanation of the tongue furred on its 
left side. This observation was made in 1843; the disease was near the 
ganglion of the fifth nerve, and on the same side as the furred tongue. 
If I should not mention the fact again, it will be clearly understood that 
the diseased condition of the tooth, or of the fifth nerve, was always found 
on the same side as the furred tongue, and that the fur was confined to 
the anterior two-thirds of the upper surface of the tongue, over the dis- 
tribution of the lingual gustatory nerve — a portion of the third division 
of the fifth. 

* In other nords, this condition of the fur is one of the offeots which diatm-banoe 
of the nerve force maj produce on the nutrition of a, part. It is well known that it la 
not msrely defect, but diaturbsinue, of oerve force whioh iadaoeH inorbid nutrition. 
For a very clear aocounC of this and numerous inntauoeB of the influence of tlie nervous 
CfBtem ID nutrition, the render is referred to Sir J, Paget'fi Surgical Pathology, lent. iL 
He will find there, as iuBtanocB oE narve intlaenoe on other epithelial tiMuen. n case of 
the hail growing quickly and temporarily white after nervoua bendoohe (caaes In which 
the bail became permanently gray after mental anguish are well known), and a case 
quoted by the lata Dr. Anstie (fMncet, June Idth, 1808|, in which not only unilateral 
fnirfng of the tongue followed, but also temporary unilateral blanoUing of the eyebrow 
and fioilp, and also nlcers of the comeo. 

Qnite a different eKplonation baa been pnt forward of thin unilaterally furred oon- 
ditfon of the tongue — viz. that the half of the jaw in which the diaeiuied tooth ia sit- 
nated is but little nsed in luBatioation. and hence no removal of the epithelium of the 
bn^ue takes pliice by the friction of the food on that side. 

Mr. Hilton informs me that since the delivery of these lectnreB he hoahad numerous 
oUier opportunities of observing the association of a unilaterally furred tongne with 
diaeaaed mohire in the upper or lower jaw. In the inntanoes quoted above, the tongne 
was nniiaterally furred over the distribution of the lingual guatntorj to the anterior 
part of the tongue. I am able to state, on tke authority of Mr. Hilton, that the pos- 
terior part only of the tongue (which receives its nen'e supply from the glosso -pharyn- 
geal) may sometimes be Been to be furred in coses of inflamed ton^ (which also 
Teceivea branohes from the glosso-pharyngeol nerve). — [Kd.J 



J 



OH TfiB THERA-I*BtTTlS 

In 1844, when delivering some lectures upon the nerves at Guy's Hos' 
pitat, I mentioned tliis case, and one other that I had aeen before, the 
cause of which I had not distinctly proved. After the lecture one of the 
students said, " Look at my tongue; it is furred on one side, and I cannot 
get rid of it." This sketcn (Fig, 35) was taken from hia tongue in 1844. 
He had a decayed and painful tooth — the secotid molar in the upper jaw. 
That tooth was, by my advice, removed, and after a short time the fur on 
the tongue entirely ceased. Now, in this caac, as far as we could judge 
from these concurrent circumstances, we seemed to have a demonstration 
of the rehition of probable cause and effect. Here was a painful and dis- 
eased second molar tooth in the upper jaw, on the same side as that on 
which the tongue was furred. This was apparently the cause of that con- 
dition; for, as soon as the tooth was removed, the fur on the tongi 
ceased, and the two sides became quickly alike. 

Case of I^acttered Jiase of the SttitU, with Fiirred Tongue only on O 

Some time afterwards a case of fracture of the skuH was broaght 
Guy's Hospital, where the fracture ran across the foramen rotundum 
taining the second division of the fifth nerve. In that case the man 
a furred tongue on the same side, indicating a probable relation of cai 
and effect. 

When Mr. Bransby Cooper was alive, a gentleman was admitted 
Guy's Hospital, who was believed to have fractured the base of bis skott, 
and being anxious about the case, he requested Sir Benjamin Brodie to 
see him, Tliat patient had a furred tongue on one side, and he had also 
indications, from the loss of sensation about the face, that the line of fra 
ture interfered with the second division of the fifth nerve. He ha<I 
furred tongue on the same side as that which we supposed to be the 
of injury during the whole time he was in the hospitEil. 






Mtrred Tongiie on 07ie side ; iSeeond Molar Tooth of Upper Jaw 
tantd. 

Recently, a ladj, whom I have known for some years, consulted me" 
regarding some matters not of importance, and I, perhaps not for any very 
preciso purpose, said, " I^t me look at your tongue." She put out her 
tongue, and it was furred on one side. I said, " Vou have a bad tooth," 



ind she thought it was exceedingly clever on my part. " Vea 

(>lied, " and I am going to Mr. Bell to have it taken out." She went and 
lad it extracted; I saw her a fortnight afterwards, and all the fur liad 



tiihsided. This was a second molar tooth in the upper jaw of the sanit 
side as the furred tongue. 

Very recently my bootmaker had some little accident, and he rame 
my house to consult me. 1 found he had a furred tongue on the rig 
side, and I remarked to him, " You have a decayed tootn in your up] 
jaw." "No," he said, " ] have not; but I have had a bad tooth stopped, 
and it is very painful when I touch it in this way" (pressing his finger 
upon his cheek over the tooth); "almost ever since I had my tooth 
stopped my tongue has been like tliis." 

Now tliese cases, taken together, and considered as a series or small 
group, seem strongly to suggest the influence of irritation or of pressure 
upon what we may call common spinal nerves, regarding the fifth nerve as 



INFLUENCE OF REST. 119 

^Thon spinal nerve, although it has its relation only with the face and 
the head. 

Gray Hair on the Temple ilepending on a Decayed Molar Tooth in the 
L»icer Jaw on the same aide. 

A person was brought to me by a Hiirgeon suffering very great pain on 
the left side of his face. He was much exposed to the weather, and suf- 
fered a great deal in consequence. U.e had taken many things to cure 
the neuralgia, as it was termed, I observed that he wore a wig, and I 
asked lum the reason. He said, " Curiously enough, the hair on my left ' 
temple has all turned gray. I did not like to have black hair on one side 
and gray on the other, so 1 had my head shaved, and wear a wig." Upon 
examining his month, I found he had a decayed and painful molar tooth 
on the left side of the lower jaw— supplied by the third division ot the 
fifth nerve. The patch of gray hair appeared to me to be the effect of the 
nervous association of the auriculo-tomporal branch of this third division 
of the fifth nerve with the decayed tooth in the lower jaw. When this 
second molar tooth in the lower jaw was extracted the neuralgio puin 
very nearly ceased. I have not seen the patient since, and cannot 8av 
whether the hair has recovered its color, All I can say is, it was 
stated to me, that during the time he was suffering extreme pain on 
the left side the hair over the temporal region became nearly white: 
a difference in color suggesting to myself some stnictural deterioration, 
and to the patient the propriety o£ having bis head shaved and wearing 
a wig. 

IHaeased Mnlar Tooth of the Lweer Jnw producing Excoriation of the 
Auditory Canal on the name side, and an Mdnrged Li/mphatic 
Oland: itired by removal of th-c Tootft. 

In a previous lecture I mentioned that a professional friend of mine 
ha^l suffered from a condition which bears on the subject ot the influence 
of nerves upon the structures supplied by them, Tnat friend, unfortu- 
nately, is no more. It was Dr. Addison to whom this happened. The 
case IS one of some interest, and I will repeat it in a few words. Soma 
years ago Dr. Addison had a very offensive discharge from the auditory 
canal of one of his ears, which annoyed him very much; and below the 
i-xtemal ear was a small gland enlar^d in the upper part of the neck. 
He had tried various remedies for this discharge, and had gone, I believe, 
to some surgeons who attended Bpecially to the ear, but, as far as I could 
learn, no good resulted from any of their applications. Upon examining 
the ear from which the offensive discharge proceeded, I found a slight 
ulceration upon the floor of the auditory canal. On arpuing the question 
out between ns, we came to the conclusion that the ulceration probably 
depended upon a diseased molar tooth in the lower jaw on the same side. 
We had that tooth extracted, and in a very short time the ulcer healed, 
the discharge and morbid secretion disappeared from the auditory canal, 
and 88 soon as that uteeration was cured the enlarged gland subsided. 
Here the true cause of error was remotely situated from one of the moit 
prominent symptoms; namely, the enlarged gland in the upper part of the 
neck : in this respect the case is of great interest. This case adds another 
to the group of results of nervous disturbance which prove, as we have 



0!T THE TirERAPETTTrC I 

I, that irritation induced in a nerve, or pressure upon a nerve, is euSi- 
lent to lead to more or less change in function and structure, and that 
that morbid infiuence may after a time induce a deterioration resulting in, 
or BuHicient to produce, a furred tongue, ulceration of skin, or ganpvne 
of the fingers. In iJr, Addison's case there was an ulceration in the 
auditory canal, and the gland enlar^d as the 
consequence of the exposed lymphatics absorb- 
ing and carrying the morbid fluid of the uJcer 
down to the lymphatic glands. Fortunately for 
us, these glands are highly conservative in their 
tendency, and they slop the progress of the 
morbid fluid in its onward course towards the 
circulation of the blood, where its damaging 
influence might be more diffused, and lead very 
frecjuentl^ to the occurrence of the more sen- 
ous condition which we are in the habit of call- 
ing ^y the general term pyremia. 

I tliougnt I might be excused this dig 
sion, though I hardly think it requires an eiS 
cuse, since it has enabled me to bring befor 
you this very illustrative group o( cases, whiel 
as far as 1 know, have neither received due ■ 
t«ntion nor a right interpretation. 

Before (quitting the nerves of the upper e 
tremitv, I direct attention to thisdiaCTam (FIC 
3«), taken from Mr. Swan's book on the Nerv« 
It shows the fascia covering certain tendons ji 
above the wrist -joint, and you observe upou tl 
fascia thr«e nerves arising from three diSere 
sources. In truth, the fascia in this portioi 
the foreftrm may be said to be the eomn 
erty of the muscles supplied with n 
rived frcMU the median, the musoulo-cutanec 
and the musculo-spiral nerves. The Utter send 
its brauches over the tendons of the sujiin __ 
radii lon^^s, one of the muscles which this mus- 
ouio-sjiiral nerve supplies. This example ia a 
good illustration of the law that the same nerve 
'hich BU]iplies the muscle supplies the skin over the insertion ot th6_ 
LtlBcK Ilere {Fiff, 3G) arv three different muscular associations — th| 
I ne^^■e. suppTving the flexors in front; the musculo-cutaneous, sn 
th« fascia, which is part of the insertion of the biceps; and I 
nerve, coming down to th« out«r side ot ih« artn on its way ti 
aspect of the thumb, wtiich it supplies excJusively. 



JJIuitrati<m* fivut AWrw i^ Loffr Ertrfmity, 

In th« lowvr nstrrmilT we diBcoTi>r th« »m« law of nwre distrilM 
»■ in tba aitn. For ttxampte. the ani^rior crural n*rte supplies iMsrlf a _ 
ths mnsrles wUrb w^ rnipJoy in ihv first effort of propwa s ioa; ws Aex the 
thigh, wv extend the kiiev, and wo slightly evert tiM te«: Mkd iMtrtf sH 
the mnaelM empkiyro) for thosppurposM— Abe psoas. tb» uiiMW 
the two rmsti, tbs revtus, sad autorras a 






JfSLUENCE OF KES 



sapplied b^ the anterior omral nerve. Not only are nearly all those ii 
des supplied by the anterior crural neri'e, but Bo also ia the skin i 
their insertion, 




subjacent distri- '" " ' '"^ .'--■! . — . -^ • . i- 

botion of the 
anterior crural 

nerve to the various muscles. But from these various cutaneous nerves I 
mnst select the long saphenous, which pursues a peculiar course, and runs 
ahead (seemingly, at first siffht, without purpose) of all the other nerves 
downwards as far as the ankle-joint and the side o( the foot. I say, at 
6rBi it appears extraordinary that this long saphenous nerve should run 
away from its comrades, and apparently from its proper muscular and 
catAneous association, and proceed as far as the inner aide of the foot; 
but when we come to examine this drawing, the thing iseiplained. Hera 
IB a sketch (Fig. 37), taken from a dissection, of the inner side of the 
knee. The sartorius (ft) is seen to bo most intimately and largely at- 
tached to the fascia of the teg (A); in truth, the fascia of this portion of 
the liuib must be considered as part of the insertion of the sartorius, just 
as the fasuia of the forearm is to be considered as part of the insertion of 
the biceps muscle. Not only is the sartorius supplied by the anterior 
crural nerve, but, as you will observe, the fascial insertion, extending 
down the leg some considerable distance, even as far as the ankle-joint, 
where it is blended with the fascia over the foot on the inner side of the 
inner malleolus, receives its nervous supply from the same source. This 
explains why the long saphenous nerve, which is derived from the anterior 
crural, should thrust itself through the fascia of the thigh, become sub- 
cutaneous, and then follow the course of the skin as far as the inner side 
of the ankle-joint, and sometimes as far as the inner side of the dorsal as- 
pect of the foot, thus following the fascia. It appears a. deviation from 
the natural order to find this anterior crural sending down branches to the 
leg as far as the foot ; yet, when you come to examine this fascial asso- 
ciation, yon see that it is only carrying out the principle that the same 
nerve which supplies the muscle supplies the skin over the insertion of the 
muscle — -the sartorius having a long fascial insertion as far as the point I 
have already Indicated, and requiring an equally long nervous supply. 



122 ON THE THEJlAPBUTIC 

The anterior cmrai nerve sends breneliea also to tlie hip-joint. 1 have 
here a little sketch (Fig. 38) by Mr. Durlium, of the nerves of the liip-joint, 
whioh has been taken from hia notes of 
the vjirioua cases he met with in diSBect- 
injr the nerves going to the Cftpsulur 
ligament of the hip-joint. I wisli you to 
understand that these artioukr nor\-es 
a,re not copied directly from dissections, 
but arQ SKetches made from different 
nerves, and grouped together to convey 
to you the ide-a of the supply o( nprve* 
to the hip-joint, although not with that 
precision of anatomy nhich, no doub^ 
IS always desirable, and especially i 
within this college. We see filamen'' 
of the anterior crural nerve traced to ti 
anterior part of the capsular ligament^ 
the hip-joint; this nerve also send! 
branches to the muscles of the thigh,H 
to the capsular ligament of the I 

Thus we see that the ai 
nerve supplies the joints which i 
cles move, the anterior part of the I 
joint, and a portion of the knee-joi 
and it supplies the skin over the wha| 
of the muscles of the thigh, as well i 
the skin on the inner side of the leg, j 
low down as the limits of the fascia f 
'which is attached the sartorius mi 
It is important. In tracing the 
in this way, to hx upon them, 
as we can, some useful reference, so that we may not only bca, 
in mind, but see the practical application of the subject. Now, wc 
that the long saphenous nerve follows the course of the eaphena 
vein; and this is, no doubt, the explanation of patients expenenaing | 
much pain in this neighborhood 'nrhen these veins are dilated and yrtf 
upon portions of the nerve. So, again, ulcerations on the lower and iq[|| 
|Mrt of the leg, although small, are exquisitely painful — ii 
them; and on some occasions 1 have been under the necessity of diridiq| 
the n^rve in the ulcer, and that has led to its rapid healing — a point j 
respect of which I have addressed you two or three times before. Tt 
pfttn in the leg thus experienced is most manifest when the patient I^ 
standing, when all these veins are full of blood, and thereby encroaching 
upon the nerves; but if the leg be lifted up, and the blood-veaseU so 
emptied, the pain is quickly peliev*d. It is pressure upon the nerve thftt_ 
OBUSes the pain under those circumstances. I have very often r 
mended {with gr^at advantage to the patients) elderly persons suSeriu 
from large veins, with or witlioul sore legs, to raise the lower half of tr 
bed on which they sleep in such a manner as to place the legs a litfc 
higher than the pelvis: the veins arc thus empty nearly all the night.a 
the result is to remove the pressure; and if the patients are in bed al« 
half the rest of their lives. Nature has an opportunity of repairing the !■ 
juries that have been inflicted. I have known many persons by this a*^ 




INFLUENCE OF BEST. 



128 



'contrivance live in great comfort atid freedom from the repetition of 
these small ulcere. Ths lower halt at the bed being slightly elevated, 
whether the patient was asleep or awake, the legs were always lying on a 
slightly inclined plane; the venotis blood then runs down easily to the 
neighborhood of the thigh, where it enters freely into the general cireu- 

Cctuae of TTlcera on th-e I/egs heing m frequently aititated just above 
the Ankle. 



myself. 



I would here ask a question, which I will endeavor to 
Why is it that varieose ulcers occur so frequently at the 
part of the leg ? It might be said that they occur because the blood in 
the veins of the lower extremities has to run uphill, and gravitation inteiN 
ferea very much with the return of the blood; the valves become broken 
down, and the whole pressure, if wo may so term it, is retrograde. If 
th»t were the sole reason, ulcers should occur by preference on tlie feet or 
on the toes, because these are more remote from the central circuliition 
than the ordinary site of ulcers from varicose veins. Hence I suspect 
this cannot be the cause. The explanation has always — at least for some 
time past — appeared to me to be this: — The superficial and deep veins of 
the leg freely communicate with each other in the neighborhood of the 
ankle-joint. The Urst two inches above that point is the spot where the 
greatest stress is laid upon these superficial veins; below that point they 
freely communicate, and if tiie blood cannot return by tlie superficial 
veins, it can do ho by the deep veins, or mee versa. But when you reach 
the point where that brown patch of sltin ao often occurs in old persons, 
above the inner malleolus, the anastomoses are less free, and this appears 
to me to be the reason why ulcers from varii 
about that neighborhood. 

To return, however, to the subject of t 
the muscles of the knee-joint were groupei 
the knee-joint — four extensors and six flexors — and they may b 
Amongst the flexors were placed the sartorius, the gracilis, and the semi- 
teodinosus. Now 1 shall have occasion to show you presently that a bet- 
ter grouping of these muscles might be obtained ; for we shall find, upon 
examination, that they do not receive their nerves from the same source, 
but each from a different one. Thus, the sartorius receives its nerve from 
the anterior crural nerve, the gracilis from the obturator or adductor 
nerve, and the semi-tendinosus from the great sciatic ; thus clearly indi- 
cating the three different associations of those muscles. It is hardly fair, 
then, to group them as three of the Qexors of the knee-joint. It is, in my 
opinion, better to look at them in their functional association, and then I 
think you will perceive a distinct indication that the sartorius, receiving 
ita nerve exclusively from the anterior crural, is, in ordinary circumstances, 
associated with the other muscles supplied by the anterior crural. So 
with regard to the gracilis, it is supplied by the same nerve as that which 
supplies the adductor muscles ; hence the gracilis should be called an 
adductor rather than a flexor muscle. Again, the semi-tendinosus re- 
ceives its nerve exclusively from the great sciatic, which controls the flex- 
ors of the knee-joint, 1 shall have occasion almost Immediately to allude 
to this more in detail. 

Here is a beautiful diagram, or rather drawing (Fig. 39), of a recent 
dissection made for the purpose of displaying the course and distribu- 



8 occur so frequently 



) distribution. Formerly 
n this way ; ten muscles to 



( 



OS THE THEBAPEtJTIO 



tion of tlie obturator nerve. The trunk of this nerve is seen coming 
_ out as usual of the vertebral canal, between the third and fourth lumbar 



ertebrffi. 1 do not attach much 
importance to the point of exit, be- 
cause you will remember that tb^. 
spinal marrow ceases opposite C" 
second lumbar vertebra ; there 
no marrow below that point 
the adult, or long anterior to that 
period of life. But, keeping to the 
anatomy of the day. we say that the 
obturator nerve comes out between 
the third and fourth lumbar verte- 
bne, then passes down through tht 
pelvis, and you will observe it in the 
drawing passing over the aaero-iliac 
articulation. I am disposed to ihil 
it sends some filaments to that 
ticulation ; at any rate, it lies d< 
to it, and would be likely to b 
from its proximity to it when 
eased. 'Hie neT^'e then passes doi 
across the brim of the pelvis 
along its inner aspect, then 
the obturator intemus muscle 
through the obturator foram) 
(which in this drawing is e 
by cutting away part of the hi 
tal ramus of the pubic bone),'wliere 
it throws a branch into the obtura- 
tor externus muscle. The obturator^ 
nerve suppllesthis obturator i 
then gives a filament to the 
lar ligament ; branches downwai 
to the notch of the acetabulum, a 
one 61ament to the hip-joint to be 
inserted into the baseof Ine ligamen- 
tum teres. This explains those sym- 
pathetic pains associated with the 
hip-joint which manifest themselves 
at the knee-joint. Having sent 
branches to the capsular ligament 
and to the ligamentum teres, you see 
in the diagram the muscular distri- 
bution of this nerve ; you see it supplying the obturator externus, and 
here the adductor brevis — not the pectineus, which is turned back as 
having no branch generally from the obturator, its chief supply being 
from the anterior crural, with an occasional branch from the acceasoiy 
obturator when present. Here are filaments passing to the adductor 
longus and to the adductor magnus, and also to tlie gracilis. The mu 
lar supply of this obturator is very precise to the obturator externus, 
three adductors, and the gracilis. Then trace these two sensitive fil 
ments; one passes down to the inner side of the knee-joint, and the oth( 
(a part of the posterior division) proceeds through the adductor magi 




haf^ 



rator 



bnni^uii of thr 



tthsr bmnohet mpplylnjE tTi 



d& A, Adrtaclor 
ol the btji-juLnt^ 



etor 

] 



mSVLVXSOK OF BEST. 125 

into the popliteal region, and there enters the knoo-joint at its posterioi 
part. Tlie distribution of this nerve is another illustration of the same 
nerve supplying muscles and also the joints moved by them. 

Looking »t the long courso and wide distribution of this obturator 
ner%-e alone, it ia obvious that there are many different causes for pain 
felt along its branches to the inner side and interior of the knee-joint ; 
&nd here I would remmd you of the importance and value of precise ob- 
servation with regard to the locality of pain on the surface of tlie skin. 
Tracing the trunk of the obturator nerve, we find it associated with many 
internal and external parts. Assuming the obturator nerve to be the seat 
of pain on the inner side of the knee and within the knee-joint, it is plain 
that this may depend upon disease within the vertebral canal, or it may 
depend upon some diseased condition of a vertebra near which the nerve 
lies. You see it passes over the sacro-iliac articulation, and when that 
joint is inflamed and swollen, as sometimes happens, patients complain of 
pain within the knee and on the inner side. I have known patients com- 
plain of pain on the inner side of the knee when the disease was not in 
the hip-joint. I recollect a patient — a lady whom Mr, Solly knows very 
well — who had a diseased condition of t he articulation between the sacrum 
and the ilium, and suffered pain in the knee and other indications of hip- 
joint disease. As the obturator nerve protieeds downwards, it is obvious 
that a psoas abscess might produce the pain in the knee. It also runs on 
the left aide under the sigmoid flexure of the colon, and the colon, when 
distended by fteces or diseased by cancer or scirrhus, is quite capable of 
producing pain on the inner side of the knee. Oidy recently I saw a 
gentleman from South Wales, who was the subject of stricture of the rec- 
tum from malignant disease. He suffered pain in the knee-joint and. in 
the back part of the leg. This led me to suspect, what really turned out 
upon careful examination to be the case, that a large mass of cancer was 
involving the nerves on the anterior part of the sacrum, and also, no 
doubt, the obturator nerve. This was the explanation of the pain which 
he had experienced on the inner side of the kuee-joint, p'artly depending 
ujjon the obturator, and partly also upon the distribution of the great 
sciatic nerve. 

About two years since a surgeon brought a gentlemen to me under 
these circumstances. He said, " He is rather an irritable man, and has 
pains and distressed feelings all over his left leg. I want you to make 
out the cause." I examined the leg carefully, and it seemed to me that 
the mischief, whatever it was, had been impressed upon the obturator and 
stnatie nerves, 1 made some suggestions as to the cause of the symptoms, 
and he said, "Well now, let us go into the other room, and I will tell 
you what happened." 1 then learned that this gentleman some time ago 
was going officially down to Southampton by the express. Before he 
Btart«d he was anxious to have his bowels opened, as they were rather 
relaxed, but he had not time. He got into the carriage, and travelled 
with great rapidity, but in great pain, all the way to Southampton. I 
suppose he did not know the strength of his little sphincter am, but be 
had to rely upon it in his emergency. As I have said, he sat quietly, but 
in great distress, until ho got to Southampton, suffering great pain in his 
1^. That was the history and essence of bis case. It was pressure upon 
the sciatic and obturator nerves, which seemed to have been extreme in 
this neri'ous man, and led, I believe, to the painful symptoms respecting 
' ' lb I was consulted. 

Be know that hip-joint disease is capable of producing pain on the 




OK TBB TKEBAPZUTiO 



isa 

Inner side of the knoe. This diseftse, o 
more frequently in t)ie ligsinentuiii ter< 
haps of the articulation.* Seeing that 
goes to the hip-joint, a second to the 
the inner side of that joint, I think w 
t!ie interior of the hip-joint can prodi 
eido of the knee, and in the interior 



the whole, I suppose, commpnc.es 

than in any other portion per- 

ne branch of the obturator nerve 

uf the knee, and a third to 

oe sympathetic pain un the inner 
f tlie knee'joint. I da not know 



• Mr. Key, who originally (Mad. CJiir. Trii., vol x 
thia view of the aeixal oriciu of hip-joiut diseaae, did s 

" Tile beginning' of the affeotioa is often to be tcaced to a foil, by whidi tba 1>:|{m bi 
been foicibly aepBraCed. and ths llgaoieataai t«ieB streUAed. . . . The moti 

of the joint that giTe the patient moat pain are strongly indioatiTa of the seat ol U 

affection. In the earliest stage, before the eoft porta oould well be affected, if tlw 
duciLBR commenced in the cartilnge, everaicui of the thigh and abduction of the liinb 
prulucu the greatest degree of suffering- to the paljent, while he oun bear the j^nt to 
bo Hexed ana to be slightly Inverted without complaining." The aboia aigtunaati, 
depending as they do ou liie old belief that tlialiganientam teres was rendered tenaetr 
abduction, have lost much of their vidue now that more is known about this ligament. 
More importanoe U, 1 think, to be attached to two uthor argumenta of Ur. Key, tbs 
fint uf which must be admitted to strongly support bis theory of the origin of hip 
diseimo. when we remember that, in every oxaiuination that boa been recorded of early 
hip disease, inllamniatiaD of the ligamentuin teres was always present as the chief, it 
not the only, morbid appesfunoe. " A Eimilar indluution of the ligamentum teiei 
being indamed is the pain sonistimes expressed on pressing the head of the femur agaiott 
the occtahuliim. In itt healthy state, the ligament, being lodged in the hollow of the 
acetabulum, receives bot little pressure, bat when it, is swelled by inflammation tiia 
cavity of the joint alfonls it less protti<:tion, and when pressure is mode by forcing Out 
hend of the femur upwards the liijiiuicnt is compressed, and usually produces imma 
degree of pain. The oircumstance. too, of the ligamentui^ tereii being destroyed ig 
nloeration, when the head of the bono and aoetabulnm ate only panially ulcerated, 
may be uonsiderad ns preEuini>tive pcouf of its being very early engaged in the disease. 

It is well-nigh impossible to doeide whether this view of Sir. Key's is oonetA or 
not. If. In examining a case of early hip dLscase, the aargoou endeavors to make oat 
the condition of the ligamentum teres (rendering ic tense by flexing and addueting di* 
limb, or by rotating it outwards), he Gnds it iiupust^ilile^his patient being nanall; a 
ohild from five to twelve — to satisfy himself that saoh movements alone eitJiei pio- 
duoe pikin or increase it. Again, it ia tha rittesC thing i)OBsible for patients to die from 
the effects alone of this disease in tt,B early stage, and when death has taken plaoa 
from some other canse, either no examination is made, or the adrua! oanse of death is 
looked for, and the hip-joint left unnotioed. The fact, however, is of very great 
interest, that where opportunitiea have been afforded of examining hip disease in its 
early stage, the ligamentum teres has in every cose been found chiefly or solely impli- 
oated. Tbns, In Mr. Key's cose (in which the disease had, however, lusted six mimtlis. 
and bad been treated with partial success), the ligamentum teieswas found thickened _ 
and inflamed, and tbe drawing and preparation show little other change ssvo aspotoT' 
ulcerated cartilage st the root of the ligament In a oosa recardsd bj Ur, Sonth U 
his Chelins's Surgoiy, and in which the joint wus dissected by Mr. Adaias, the i 
once of the round ligament was precisely similar. In a third cose (the most viUuable at, 
oil, on aoconnt of the specimen which is iireserved in the niuseum of the Hoapiiol foa 
Siok Children), recorded by Mr. Holmes in his Snrgicol Diseases of Children, deata 
having token place a mon'tli after the fint symptoms were noticed, almost the sou 
morbid appesranoe was ulceration of ths ligamentum teres. So, too, in a case reoonti 
eil by MU, Martin and Collineau. and mentioned {Ivc. mipr. cit.)bj1ii. Hulms^ 
where death took place a few days after the Erst onset of the symptoms, the conditio) 
seems to have been identical. Other cnntjitioos of the head of the femur, wblob n 
be noticed after excision, point to tbe same origin of the disease, in that the| 
appear to show that the first stress of tlie ioflamuiiition fell open the ligan ^ 

ttires : thus ulceration of the cartilage is often ino't murlced just at the position of tlw^V 
ligamentum teres, and in a esse in which I recently excised the head of the femur 
(iind I have sean a second very similar case), a distinct sequestrum luy not quite de- 
t:it:hed just bi^low the centre of the head of the femur, immediately beneath the 
LiU3!:aned renu^ns of the iigomeutnm teres. — IKo.] 



^ 



INFLUENCE OF EEST. 127 

that it is important to insist upon this piece uf anatomy, because there 
are other explanations of the point. If we find that an iiillttmed tooth in 
the second division of the fifth nerve can produce irritatiun of the tongue, 
and cause it to be furred, Burely it is not forcing the jirinciples of nmt- 
omy and physiology to say that the ohturator nerve, being involved in 
nttMbief in the hip-joint, may, by continuity, convey irritution to the sur- 
tftce of the skin on the inner side of the knee, and also to the interior of 
the knee-joint. But whether that be physiologically the true explanation 
or not, we knows it frequently happens that patients have pain on the 
inner side of the knee, and even within the kneo, when Buffering from 
hip-joint disease. I think that if the distribution of the nerves were 
studied in this way, tryinjf to fix upon them some practical reference 
in relation to symptoms which are oftentimes very remotely situated from 
the real cause of the mischief, it might tend to make the study of thia 
p»rt of human anatomy more intensely interesting, and certainly more 
useful, than it at present appears to be in the consideration of many 
sumeons. 

Beverting, for a moment, to the distribution of nerves as a means 
towards diagnosis, let me remind you oE the ijisertion of these three mus- 
cles — the sartorius, the grai^ilis, and the semi -tend! nosus. The sartoriua 
receives its nerves from the anterior crural. The gracilis is supplied by 
the obturator nerve, and by it alone; it is inserted into the tibia, and 
attached, in part, to the fascia of the leg (Fig. 117). Then the semi-ten di- 
nomts b supplied by the great sciatic nerve, and this also is attached to 
the fascia of the leg. We have here three rouacles — the sartorius, the 
j^racilis, anti the semi-tendinusus — all inserted into the fascia. Now, if 
that be true, and it undoubtedly Is so, we ought to discover a particular dis- 
tribution of cuta- 
neous nerves at thia 
point; we ought to 
find part of tbe an- 
terior crural nerve 
coming to the inner 
side of the leg, and 
br&nobes of the ob- 
turator and the 
great sciatic pro- 
ceeding to the same 
point. And here 
they are depicted 



from nature 




iranch of Uuj cnMl iiHatlc oc 

40). Here ()<")■?■ "~""""' 

(he long saphenous nerve — part of the anterior crural; here also ff?) is a 
lilament of the ubturiitor — that nerve which supplies the gracilis; and 
here again (t) is a branch of the sciatic nerve, a cutaneous filament — that 

' Prom Buch experienoe an I have had during tbe two yean in which I have been 
one ot the awistaut Jeinonatraltira of anatomy at Ouy's Hos))ita], 1 do cot thiuk that 
thia bnnch is coustaiitl? prescut. as theoretioally it should be on Hr Hilton's expla- 
aatiou. Au " occaaiODiil cutaueoaa branch " of the obliurator which occupies thia posi- 
tiwi is tlina described In Quain'a Aunt., ed- Tth, p. 0(13: — "In some inHtanoeB the 
(flminncucating " (with long snpbeuouB and iutemal cutonooua nerrea) " bTanch is 
hujieiUtan □bhdJ. and dosceudB along the posterior border of Che mrtorius ta the inner 
"tot the knee, whore it pcrforaten tbe fascia . . ■ and extends down the inner side 
bujipljiug; Llieskin ee low bg the middle of the leg." — [Ed, J 



S8 



ON THB THEBAPEHTIO 



I Tery nerve which suppliea the sei 
EtiQrvea, then, supply the fuBciaai 



uosus muscle ilself. These three 

(in on the inner side of the luwvr 

f |»rt, und just below the knee-joint, and arc directly associated with the 

I three muscles, the sartorius, the gracilis, and the semi-tendinosus, which 

I receive their nervous supply from tliem. 

It is not unworthy of admiration to see the precise position of thest^ 

[ Siuacles. If you measure with accuracy the distance of the points of 

[ insertion of these muscles between the fulcrum (or tiie hip-joint) and 

r the foot), you will find that these muscles are inserted just 

beyond the mid-distance between the fulcrum and resistance. If you 

B the measurement from the hip-joint, for example, down to the point 

of insertion, and measure the whole length from the hip to the sole of the 

foot, you will find that the point of insertion is just beyond the halt-way 

. between the fulcrum and the resistance. Hence the jfracilis is a great 

I ielp to the adductors of the thigh ; it helps to adduct the leg; it goes far 

I ftnough to seiae the limb just beyond the midway between the fulcrum and 

J ,the resistance. Again, the semi-tendinosus, a powerful flexor, and the 

I 'MrtorJUB in like manner, are inserted just in the same way. The sartorius, 

Ithen, is a very powerful assistant to the muscles employed in the first 

effort of progression, slightly everting the leg, spreading out the foot, 

and widening the base of the column, so as to make it more easy for man 

to maintain the upright posture. 

In a former lecture J made use of two or three diagrams (Figs. 11 and 
13), to point out the importance and value of knowing precisely the dia- 
trilsution of the nen*ea to the skin of the head and face. If a patieri~ 
complain of pain at a certain part, supplied only by one sensitive nerve,* 
is certain that nerve must be the seat of the pain. 

Now let us apply the same method in examining the cause of pain i 
the inner side of the knee. Here are nerves from three different si 
— the obturator, the anterior crural, and the great sciatic. It i 
clear, then, that if the patient complain of pain on the inner side of 1 
knee-joint, we ought not to be satisfied without ascertaining which of fl, 
nerves produces that pain. We know that there are three possible lii^ 
of direction for this pain, and we are bound to examme tho'se three lineal 
direction for the purpose of ascertaining in the course of which nerve « 
real cause is situated. For this purpose we ought carefully to exam 
the anatomical relations of the obturator, the great sciatic, and the aitl 
rior crural nerves, in order to ascertain, if possible, the real cause I 
pain expressed on the inner side of the knee jonit, for it is obWousthas 
disturbing cause associated with the course of any of these might prodlil 
the pain. i 

I must not, however, continue the subject further, but Fig. 40 shoM 
I think, very accurately these points. The three muscles — the gracitt 
the sartorius, and the semi-tend inosus-^instead of being spoken of, r 
they usually are, as flexors of the knee-joint, ought rather more phyd 
logically to be regarded in reference to their association. Their nervoi 

t supply suggests that association to be in this way; the sartorius with 
ftntenor crural, the gracilis with the obturator, and the seini-tendin< 
with the great sciatic nerve. 
Let us fix another praotical and useful reference to this distributlo 
nerves. From it I would offer this suggestive esplanalion of what J 
termed hysterical hip- or kiiee-joint disease : — 



INFLUENCB OF KEST. 



Bj^anation of Ilyaterkal Paitia in the Sip- or Knee-Joint. 

The sacral ganglia and the lower lumbar ganglia of the sympathetic 
nerve are conneeted with the great sciatic nerve, and partly also with the 
ohiurator nerve. These same ganglia are connected likewise with the 
nerves proceeding through the broad ligament to the uterus and to the 
ovaries. 1 think we have here, then, an explanation of the frequent 
cxicurrence of what we call hysterical Mp-joint or hysterical knee-joint. 
If the nerves in the ovaries or the uterus be in a state of irritation, that 
irritation can be conducted to 
these sacral nerves or to the 
obturator, and then, in accord- 
ance with the generally re- 
ceived law of distribution of 
nervous influence, irritation or 
pain may be manifested at the 
other peripheral or articular 
end of the same nerve. Hence 
it mav be expressed within the 
knee-joint, on the Inner side of 
ihekiiee-joint, orit may be with- 
in the hip-joint because the hip- 
joint as weU as that of the kiiee 
ves from these 
The posterior 
part of the hip-joint, you will 
remember, has nerves coming to 
it from the sacral plexus. The 
sacral plexus receives some fila- 
ments from the sacral ganglia ; 
so do the uterine and ovarian 
nerves; and it is quite possible, 
nay, I think is very likely, that 
the irritation commencmg in 
tbe ovaries or the uterus might 
be conveyed to some of the fila- 
ments derived from the same 
ganglia in the sacrum, and irri- 
tation in the hip-joint be thus 
produced. You will observe 
that the two nerves, whic 
the pain in the joints, are the 

lieve this is a probable explanation of the fact, that of all the joints i 
human body affected hysterically as we term it, none are so frequently 
involved as those of the hip and the knee.* By tracing these two nerves, 




\ 






a distributed as to be capable of producing 
great sciatic and the obturator; and I be- 



' Sir J. Paget, to whose tot it bsa fallen to eee more of these coses thtiD to anj 
Other mrgeoD. save. perhapH. the late Sir B. Brnclio. speaks na follows in his Cliu, Leot. 
and EBsa.vs. edited hy Howard Marsh, p. Ii)7 ; — ■' Among all ths joints, the hip and Uib 
knee, which are the most frequent seats of renl diaeitae, are equally so of Che mlmicrj' 
— a toot not easy to aocoaot for. It ma; be due to mental SHsociation, perhaps un- 
oofucioual;, or to a minftled inheritance — tor instoaoe. to an inheritance of nervons 
emwtitatioD and of relative weaknoas in the joint or joints moat weak ii 
-IED.1 



L. 



J 



130 OK THE THEBAPBUTIO 

I think we may find a probable interpretation of that frequency. I have 
here constructed a diagram intended to represent what I have been allud- 
ing to. Suppose this {/) to represent the three ganglia of the sympathetic; 
we have then a spinal nerve {d ) attached to the spinal marrow, and taking 
its onward course to the muscles and the skin. We know that these spinal 
nerves communicate with the ganglia, and so, by the sympathetic branches 
travelling along the arteries (oj, reach the intestine {eV uterus, and ovaries. 
Let us assume, then, that a patient may have irritation from any cause in 
the intestine, in the uterus or ovaries, or in the broad ligaments. On this 
map we may trace the course of that intestinal, uterine, or ovarian irrita- 
tion through the ganglia, through the spinal nerve and spinal marrow, 
thence to be reflected to any part of the peripheral or articular distribution 
of that same spinal nerve. This condition, 1 apprehend, is sometimes very 
clearly recognized in the case of the intestines. Who is there that has 
not felt griping pains in the interior of the intestines from some morbid 
agent lying there, or from drastic purgatives traversing the gut, accom- 
panied by pains or cramps in the leg, and pains in the loins ? — conveyed 
m the latter instance by the filaments of spinal nerves, which pass to the 
posterior part of the body or the lumbar region. And is it not a common 
occurrence in cases of uterine and ovarian irritations for the patients to 
complain of pain in the loins, but particularly over the posterior part of 
the sacrum ? The ovarian and uterine nerves traverse the ganglia of the 
sympathetic, and so reach the spinal nerves. Hence the morbid influence 
conveyed by the posterior branches of the spinal nerves to the skin over 
the lumbar and sacral regions ezplaios the lumbar and sacral pains experi- 
enced by such patients. 



IMFLOENC E 



LECTURE X. 

Mtmnilar and Cutoneoiu DiBtribntioa of the Nerres of the Knee — Dmlocjitioii and Con- 
trnctJoQ in Diaea^es of Knee-joint: — Treatment— Musculur and Cutaneoua Diatri- 
botioa of tbn Gluteal Nervea — Order o( Supply iu the DiHtribution o( Serve* to 
DiSeient Miisclee — Pain on One Side oF Peaia Depeoding on Diaeuie of the Peri- 
ne&I BmQch ol the loferior Gluteal Ni?rve— EnlnigBd Bursa on Tuberoailj of 
Ischium— Kelatiou of the Peritoneum to Uutimeoua and Husonlor DistribnCioa of 
Net»e«— Applioation to Pntctioe — Relation, by Nervoufl Distribution, of the Peri- 
caidiam to the Diaphragim. 

In the latter part of the last lecture I directed ^our attention to the nu- 
merous nervea whieh are placed around and within the interior of the 
knee-joint. 1 observed that those nerves are derived from many sourcea, 
uid I may now add that the great sciatic not only sends branches through 
the popliteal region to the posterior part of this joint, but its external 
popliteal branch supplies many numerous deep filaments to the outer side 
of the knee-joint, both above and below the inter-articular space. The 
dtstribution of these latter nerves is well shown in this sketch (Fig. 43) 
teken from Mr. Swan's book. 

I dwelt especially on the distribution of the great sciatic, the anterior 
ornral, and the obturator nerves to the three so-called flexor muscles in- 
serted on the inner side of the knee, and their fascial insertion, and to 
the overlying skin. I took occasion to remark that these nerves ought 
to be made the medium of an attempt to elucidate any sensations of pain 
which might be experienced on the inner side of, or within, the knee-joint. 
These observations are, of course, directed to those cases where the pain 
is extreme or severe within the knee-joint or on its inner side, when there 
is not the slightest evidence given by heat of local inflammation, the 
absence of which clearly indicates that such pain depends upon a cause 
situated remotely from the point of manifestation. I endeavored to show, 
that by tracing these nerves upwards or centrally, we may have an oppor- 
tunity of detecting the real cause of the pain. I think we should make 
ujse of these nerves for another purpose. It is quite certain that local 
aiuesthetics, applied to the cutaneous branches of nervea which supply 
the muscles, have a power of action upon those muscles which reduces 
their spasm, lessens their contractions, and thus removes one source of 
irritation from an inflamed joint. 1 shall not have occasion in this lecture 
to Epeak ou this subject again; but, as some think that in the use of fo- 
mentations it is a matter of little importance whether they be medicated 
or not, I beseech those who do so to carefully reconsider the opinions 
which they may have formed on this subject, because I am quite certain 
(and 1 speak from a fair amount of experience, and close observation, too, 
on the matter) that local anjcsthetics applied to the skin over the knee- 
joint have a power of diminishing pain — in the hip-joint for example. 
They certainly have a capability of diminishing excessive sensitiveness, 
even in the interior of the knee-joint. 1 verily believe (though this is re- 
ferring apparently to a small matter) that the reason why tlicae applica- 



I 



133 



ON THE THHRAPSUTIC 




tions fttp BO often ineffective, and why they aro not more froqupntly em- 
ployed, is, tfaitt the solutions are not strong enough, and th^it tho propor- 
tion of the aiia^thetic materiuls is not sumcieiit. This being granted, 1 
have no hesitation in saying that we have the power of acting upon the 
sensitive nerves, and diminishing puin in the niterior of a jVnnl, hv the 
local application of aiiiusthetics to the peripheral extremities of the 
nerves. 

. Another disturbing cause in an inflamed joint, as I have already inti- 
mated, is muscular force, the muscles unceasingly contracting day and 
night. In every case of diseased joint, if you will compete with this ina»- 
cular contraction by the means of some 
mechanical resistance, such as a firm, 
resisting' splint, you will counteract tta 
effect. 

1 will confine my observations in this 
lecture to the knee-jomt, and I only enter 
upon the subject for the sake of giving 
a little practical interest to what might 
otherwise appear to bo a matter of dry 
analomicjil detail. Having dwelt upon 
the anatomy, which is in iiself very im- 
portant, 1 feel that one ought not to 
lose sight of its practioul application; 
for if wc cannot make anatomy and 
physiology useful in practice, the lufor- 
roatioa is soarcely worth its acquisition. 
Fig. 43 represents a diseased knee- 
joint, where the muscles have had their a 
fullest opportunity uf doing, so to sneaky, J 
exactly what thev like with the joint,,! 
It follows the common rule of dlaloca.! 
tion of the tibia and fibula outwardK'| 
and backwards, and points at one 
the cause of the dislocation taking that I 
direction. I think it will be in accord' 
ance with experience that in almost I 
every case (I do not like to say every | 
cose, because some exceptional iitstatioa 
may have preseuted itself to those pres- 
ent) the tibia anAJUnda arc dislocated I 
backwards and outwards under tlie iff | 

J of the biceps, and rotated in- 
wards by the popliteus.* Now, th« I 
5 shown in my last lecture to be supplied from nerves whieb J 
o the interior of the joint. For the purpose of showing tho I 
[| of this point, I say we oii^ht to resist muscular force through T 
of splints or other mechanlcjil resistance, or we may divide tna 
tendons of the muscles which produce this displacement. I have a 
which will serve to illustrate this }>oint. It is only one of many* that I j 



* This diaplnoement b^iii!; [lermittsd to take place b; the •oflening and n 
of the ligameiitH, mora porticiilarl; iiiti crucial, the aalerioi of wbiuL checks t\ 
inwuila, and eo coouterscla tho pnpliieos, while the posterior pierents rotation out- J 
nrda, lbs aclion at the bicopo.— [Bd.J 




Interitcuidoa 



r put at t^ Imoc 



biceps "n 
supply a 
applicat. 
thei 



INFLUENOK OF BEST. 133 

might adduce, and hereafter I may be able to develop tJiis subject mora 
complete 1 If, 

This sketch (Fig. 44) was taken from nature on the 3rd of June, 1801. 
The history of the caae is very aliort. The patient is now sixteen. He 
was admitted under my care at Guy's 
Hospital in October, 1850. He had 
already been in a London hospital be- 
tween three and four months, and had 
left it sis months before 1 saw hira. 
The surgeon under whose care he was, 
judging from the boy's appearance, 
from the suppuration taking place in 
the joint, the general tendency to dis- 
placement, and the constitutional dis- 
turbance from which he was suffering-, 
the indications of perhaps a rapid 
death, proposed to the patient that the 
leg should be removed or the joint ex- 
cised. The boy was only eleven years 
old, so that he had not much voice in 
the matter; but his father and mother, 
when consulted, would not accede to 
the recommendation: the patient was 
therefore removed from the hospital. 
In October, 1856, he came under my 
care. At that time the joint was in a 
bad condition, there was a good deal of 
swelling, suppuration had occurred, and 
abscesses were discharging pus freely. 
The leg was rather more than semiHeAed; the pain in the joint was not 
very severe, except when it was moved or handled; and the amount of 
discharge was somewhat diminished. The whole of the joint and sur- 
rounding structures were much swollen from infiltration with serum and 
lymph. Seeing the boy in this condition, and having observed several 
other like cases (one as early as 1844, where active disease was going on, 
and where, after I had divided the tendons of the flexors, the patient did 
very well), I felt that I might trust to previous experience. Instead, 
therefore, of proposing amputation or excision, I resolved to divide the ten- 
dons of the flexors, which were disturbing the joint. 

Three weeks after admission, and after giving the patient chloroform, 
ks attempt was made to put the leg straight, but without success, the 
muscles being too contracted; so that it became necessary to divide the 
tendons of the flexors. I divided the tendons of the biceps muscle, the 
gracilis, semi -tend! nosus, and the semi-raembranosus. The latter were all 
divided in the popliteal region, close to the inner side of the head of the 
tibia, and the biceps tendon was severed about one inch above its insertion, 
taking' care, of course, to avoid tlie peroneal nerve. The limb was then 

Eut upon a straight wooden splint, and remained so during eight months. 
■y the aid of simple strapping and pressure, the joint soon became free 
from f)ain. At this time the leg was nearly straight, and the patient was 
almost free from any constitutional disturbance, the discharge being ex- 
ceedingly small. It was then thought right that he should go to the Mar- 
gate Infirmary, whither he was sent by the benevolence of the late Mr. 
C'ouchman In the summer of 1858. He remained at Margate one 



OK THB THEEAPBUTIO 

year and ten months, Bupporting himself on erutphes, and aftei 
using a stick for several months. WhiUt at Margate the wooden apli 
was removed, and a gutta percha one put on the limb, with a bam 
Soon after that the knee began to be a little flexed, and the tibia t 
dispUued slightly backwards and a little outwards, so as to defonn 
joint ill rather a worse manner than the sketch indicates. I think it wi 
an error to take off a resisting splint like wood or thick leather, juid 
put on gutta percha. The result of it w 
that the leg became a little more flexed, 
am certain that when the boy went out 
Guy's Hospital the knee-joint was straighl 
than the representation you have now befc ^ 
you. I need not trouble you with the further^ 
details of this case. During the next year and 
a half the boy did not use a stick or crutch; 
he had no pain, he could walk threp or four 
miles without difficulty, and was occupied thQ 
whole of the day in business. On examinii "' 
/ ' him, 1 found the patella affixed to the femi 

I but there was a slight degree of motion I 

I tween the tibia and femur. 1 think this is 

I good case for showing the value of ^ving rert 

I to a joint, for that is all 1 did. 1 did nothing 

^ \ more than any other Bui^;eon could have done. 

I simply divided the tendons which were the 
disturbing cause, and then we had no further 
difficulty in keeping the articular surfaces in 
contact. In the course of lime Nature consol- 
idated the parts, leaving the boy with hb leg 
in the state represented, which is not exagger- 
ated in the slightest respect, but is an exa^ 
representation, as far as tlie artist could le- 
of the leg as it was on June 3rd, 1861. I repeat that it 
seems to me that this is a very good illustration of the value of rest 
•x>nsidered with reference to the disturbing causes — those disturbing 
'»usea being the muscles, which disturbed the joint in consequence of the 
irritation in the interior of the joint being conveyed to the musclea, 
through the same nerve that supplies both the joint and the muaeles. 
Here (Fig. 45) is a ground plan of this boy's feet, showing that the right 
foot (the diseased side) was not quite so much developed as the left. 

I have made these observations for the purpose of forcibly reminding 
you of the value of rest, and its practical application. 

Having to trace a few more nerves in their muscular and cutaneous 
distribution, I will take the superior gluteal nerve Every anatomist will 
remember that this nerve is derived from the lumbo-sacral cord, and that, 
after passing out of the pelvis at the great sacro-sciattc foramen, Jt is 
distributed to the gluteus medius, the gluleous minimus, and the tensor 
vaginie femoris. In this drawing (Fig. 46) we see the associated cutane- 
ous lumhar nerves coursing along the lower part of the abdomen, then 
over the crest of the ilium, and distributing themselves to the skin over 
'the glnteous medius and the gluteous minimus. Vou may observe how 
thev seem to avoid the skin over the gluteous maximus, which, togetlier 
with that muscle, is supplied by the small sciatic. Thus we have another 
example of the same nerrea supplying muscles and the skin over tboM 







mplish it, I 



muscles, although the cutaneous and muscular portions do not, as is usual, 
travel together. 

Speaking of nervous supply, I might direct your attention to two 
Rer\-cs which take a very peculiar course, and may, to some minds, denote 
the special interest which belongs to 

this inquiry. I refer to the course '"" "■" "" "'"'■' 

of the spirial accessory and recurrent 
lamygeal nerves. We see the spinal 
aocessory arising from the cervical 
portion of the cord, passing upwards, 
and blending with the sub-occipital 
nerve. The sub -occipital is almost 
exclusively a motor-nerve; it is usu- 
ally devoid of any sensitive filaments, 
and is distributed to tbe superior and 
inferior oblique, the two recti, and the 
complexus muscles on the posterior 
aspect of the neck and cranium. Now, 
I think that the sub-occipttal nerve, 
before it sends filaments to supply this 
^roup of muscles, receives a branch 
from tbe spinal accessory. When these 

muscles are in a state of contraction, they carry the head backwards, a: 
it for a purpose which we shall see presently. The spinal accessory 
passes to the interior of the skull through the foramen magnum, and oui of 
it through the jugular foramen, where i t has intimate structural association 
with the pneumogastrio nerve especially (I do not detain you with the 
minutia; of this, but simply state the broad fact) ; and having established 
that communication, it takes its downward and backward course through 
the neck to reach the stemo-mastoid and the trapezius. Here, then, is a 
nerve taking the very peculiar course which I have pointed out. Now, 
it does not signify how fast the nervous influence passes, it must reach the 
nearest point first. Assuming, then, a message to be conveyed through 
the spinal accessory to the muscles, it would first reach, by the branch to 
the aub-occipital, those which have the power to fix the posterior part of ths 
skull; the message is then sent on to the stemo-mastoid and the trape 
Biua. The posterior part of the head being already fixed, these two large 
and powerful musolcs act more eflfectually m concert with the pneumogas- 
trio nerve in the process of respiration. From this explanation I think 
w« see one of the reasons why the spinal accessory nerve should take such 
a tortuous course. 

Let us now take the nerves to the larynx. And here I might at once 

Eoint out what I shall not now, unfortunately, have the opportunity of 
lying before you in its extended form — that the same nerves which sup- 
ply the mucous membrane supply also the muscular apparatus acting upon 
that membrane. This is a uniform law with respect to alt the mucous 
membranes of the body, and is well exemplified in the case of the larynx. 
You know that the superior laryngeal nerve of the pneumogastrio dis- 
tributes itself upon the mucous membrane of the interior of the larynx, 
including the laryngeal surface of the epiglottis. This same pneumogas- 
tric nerve sends off a recurrent branch, distributing itself to all the intrin- 
sic muscles of the larynx, except the crico-thyrodeus. Thus the pneumo- 
gastrio nerve supplies the muscles which move the vocal cords, and th« 
membrane lining the interior of the larynx. Here, then, we have an 



t3« 



OIT THE TnEKAPKTJTIO 



tUuBtration of the same nerve Buppl^n^ the muacular &ppanttus which 
acts upon the vocal oorda, with their investing mucous membnin^ as 
well as the rest of the laryngeal mucous membrane and the joints of 
the larjnji, just as we have seen the same nerve supplying the niuBcle, 
moving the joint, the interior of the 
joint, and the skin over the insertion 
of the muscles. The superior lann* 
geal (orsensitive nerve) Is accompauied 
by a motor branch, which proceeds 
directly to the crico-thyrodeus 
cle; and while considering this 
thyroid branch, I must remind you 
what 1 just now stated — that no ini 
ter how rapidly the nervous influence 
passes, it must reach the nearest point 
first, and that is apparently the reason 
why this little nerve takes so short a 
course to the crioo-thyroideus. It has 
long been my habit to regard the crico- 
thyrodei as the muscles which &re in- 
tended to tune the vocal instrument; 
and as the instrument must be tuaed 
before t can be played upon, so this 
lervous influence first reaching the 
cnco thyrodei, the vocal cords are put 
1 to a due state of tension, prepanr 
tory to the more precise and aocunba 
I fluence of the other muscles aotins 
d rectly and indirectly upon the vocu 
cords But let us try to explain wbj 
the recurrent laryngeal takes so peco- 
1 ar a course. Some say it must be 
because it has to wind over the 8ub- 
ola an artery on the right side, tuid 
aruui d the arch of the aorta on tiia 
left side. Now, it has fallen to my 
lot to .see examples in the dissect ing^-room in which the nerve did not wind 
round the arch of the aorta or the subclavian artery, yet the course of the 
nerve was, notwithstanding, equally recurrent, thus clearly indicating that 
it had no necessary relation with the subclavian artery or the aorta. The 
nervous influence, whatever it may be, which travels by these reoiurent 
nen-es, goes from below upwards. And 1 think it will be apparent why 
this nerve takes its course from below upwards. It is an essential thing,, 
to my mind, that the muscles which are acting upon the air as it escap< 
outwards from the lungs so as to make the voice, should be acting froi 
within outwards — that is, from the lower part of the larynx to the upper. 
It is quite obvious that if they acted in the other way, we should all be 
ventriloquists, talking inwardly to ourselves, as it were, and having no 
external voice; and it is for the purpose of determining the direction of 
influence from within outwards that we find this nerve pursuing this sin- 
gularly recurrent course, ultimately distributing itself to these different 
muscles. The spinal accessory ana the laryngeal nerves are, I think, two 
good examples of the rule — that there are strong reasons for the remarkable 
order observed in the supply o( ner%-ea to muscles (see pages 103 — 104), 




!eed»^^ 

Ml JW 
mat- ^^ 



ron^H 



i 



INFLUBNCB OF BEST. 137 

I will now adduce another Uluatratioa of the same nerve-supplying 
muscles and the skin assoeiated with the muscles. Here is a diagram 
taken from nature, intended to show the distribution of the small sciatic 
nerve, or, as some term it, the inferior gluteal. This nerve most fre- 
quently presents itself to the dissector as a single trunk. Here, however, 
you will observe that the muscular branches seem to come off from the 
great sciatic Now, although this is not quite in accordance with what I 
might have wished, I thought it better that all the diagrams exhibited 
here should be made strictly from dissections, a rule observed in every one 
of the drawings I have placed before you. In this instance it so happens 
that the motor filaments of the inferior gluteal nerve come off apparently 
£rora the great sciatic. I have very little doubt, however, that if these 
motor filaments bad been traced upwards towards the spine, we should 
have there found intimate associations between the cutaneous iilamenia 
and the motor portion of the same inferior gluteal nerve. 1 do not spieak 
lightly of this explanation, because I hove several times — not with this 
nerve, but with other nerves — found that to be the case. Where the 
motor nerve comes off unusually, it you trace It upwards some distance 
towards the spinal marrow, you will find that it is in communication with 
its proper cutaneous nerve. Let us suppose that these muscular and 
cutaneous branches of the inferior gluteal nerve are in their normal asso- 
ciation, and we shall see that this inferior gluteal nerve supplies the 
gluteus maximus muscle, and sends out cutaneous branches, which distrib- 
ate themselves over the lower edge of that muscle. It then sends a 
branch across the ischium, towards the perineum, and here it Is seen (Fig. 
48) coming close to the tuberosity of the ischium, near to the seat of a 
bursa placed there; afterwards it joins a branch of the pudic nerve, and 
tbey proceed together to the genitals. You will observe that the gluteus 
maximus is firmly inserted into the fascia of the thigh; it is one of the 
most importtint muscles in reference to this fascia, which may, indeed, bo 
considered as part of the insertion of the gluteus maximus. We ought, 
therefore, to find nerves proceeding from the same trunk which supplies 
the gluteus maximua to the skin over this great length of fascia; and so 
we do. The fascia is here cut through, and the cutaneous nerves are left 
distributing themselves with beautiful precision to the skin over the pos- 
terior part of the thi^h, and going down below the popliteal region, Thua 
the lUstribution of this nerve, which at first appeared to stand in opposi- 
tion to the principle of distribution which I have mentioned — -viE. of the 
same nerve supplying the muscle and also the skin over the muscle — is in 
reality a strong exponent of that view, when we admit that this fascia ia 
firmly connected with the gluteus maximus, and ought to be considered as 
part of the insertion of that muscle. 

With regard to the branch of the small sciatic which passes inwards 
to the perineum and genitals, I think we way see reasons, associated 
with coitus and the action of the gluteus maximus muscle, why a cutane- 
ous branch should go to this region. This is a subject, however, which I 
do not wish to dwell upon, but merely direct your attention to the fact. 

The recognition of the distribution of the pudic or perineal branch of 
ihe inferior gluteal nerve is sometimes important in practice. 

Cote ofl'ain on otif side <^lhe Penis depending on Disease <^ihe P^i- 
neai Branch of the Liferior Gluteal or SmaU Sciatic JVer^ie. 
Soon after the death of the late Mr. Key, a gentleman came to me 
'^yii'gi "I have something the matter with my urethra and bladder, and 



OK THE TITEBAPBUTlO 

nifler pain in the penis." He had been nnder the caro of Mr. Key % 
pnother surgeon, who had treated him for diseased bladder and vai 
Bther things. I begged hiin to show me precisely where the paiu 




el ^ 

■Itunted. He traced the pain, crossing the ascending ramus of tlie 
ischium, to one aide of the penis. This looked more liico a one-sided than 
a central cause. Upon careful eTamination of the neighborhood of the 
tuberosity and the ascending ramus of the ischium, I found a considerably. 



INFLUENCE OF REST. 



thickening of the soft parts, aiiil, after 

like mass rather bigger than whip-cord. On making pressure upon ii 



mUtion, I felt B 






he saiJ, '' That is wTiat gives me paio," It was quite apparent that the 

e must be associated with the perineal branch of the inferior gluteal 

lo other nerves go to the side of the penis. L 

I had well sought for the cause iii the pudio 







I 

L 



or the pudic nerve, for 
think Mr. Key and othe 
nerve, but had not 
detected it. It was 
obvious til at pres- 
sure upon the peri- 
neal branch of the 
inferior glutea 1 
nerve gave the pain 
along the side of the 
penis. Upon in- 
tjuiry it turned out 
that this gentleman 
was accustomed to 
sit upon a hard and 
w»aewhat uneven 
seat; this led to the 
thickening of the 
■oft parts, and to 
the pressure on the 
■ervc which pro- 
duced the painful 
sensations he had 
experienced. I ex- 
plained what I 
thought was the 
cause of the pain, 
and he said he was 
willing to do every- 
thing I thought necessary. 1 then applied some strong nitric acid over a 
circle about an inch and a half in diameter, covering the thickened struc- 
tures, which included the nerve, so that he could not sit upon the part; 
and I desired him to have a hole made in his chair, or to use a hollow 
cushion. He adopted that course, and immediately the symptoms began 
to subside, and in three or four weeks they were all gone. Not a. single 
thin^ was done but this. Wc sec, then, that an acquaintance with the 
distnbution of even this branch of nerve may be of the greatest impor- 
tance in practice. This patient was curod by removing pressure from the 
nerve, and so giving it rest. 

This case does not stand alone. A surgeon has sent me these notes of 
a case that 1 saw with him some years ago, which was cured by " rest." 

" Enittrged Bursa upon the Tiiberoeity of Ischium.-t-Oa August 10th, 
1830, my attention was directed by a lady, aged sixty, to an enTargement 
near, and rather on the anterior part of, the left tuber ischii, which was 
increasing in size, and becoming daily more inconvenient. She had been 
aware for a considerable time of some unusual numbness and painful sensa- 
tion in the part itself, and neighborhood of the labium on the same side, 
more especially when riding in her carriage an^ysitting in her study, but 
had only discovered a marked enlargement a f^ days before. 

examination, a deep-aeated movable 6r pliant swelling could be 



4B This flgnro la tek™. bj pnmialati. from drd In I 

>at elarneni Krenl ua omlUod)u 

Mentor nrlnn, 1, Dsip tiiin of npertetal haolB 
itwHrdL 11, Bractor pvnla. 4, ■■■— — — -■- — ' 
jth«r poTtloo of tba perinaal ta 



(inn«u wllb 1. t 
8. Tubemlty ol In 






140 ON THB THEEAPEUTIO 

deteoteii, wliich, on being compressed by the fingers, conveyed a some- 
what vermicular sensation, with a. sense of fluctuation in it, though cyst- 
like. The ejiamination was painless. Iodine was applied daily, and the 
use of a hollow seat recommended. The swelling increased in »ze, and 
became more painful. Mr. Hilton was consulted on Aug. 25th. The 
swelling had became more tense and globular, with indistinct flurtuation, 
surrounded by some undefined consolidation and enlargement. Mr. Hil- 
ton pronounced it to be an enlarged bursa, and thickening of the struc- 
tures surrounding it; no heat or i-eduesa; no local evidence of suppura- 
tion. The patient was directed to have a pad made, with a circular hole 
In it to receive the swelling, and made so that it could always be worn, 
and thus elTectually remove all pressure from the part. He directed an 
eschar to be made with nitric acid over the enlarged bursa, so as to pre- 
Tent the patient sitting upon the part, &c. The eschar separated on the 
sixth day, and the swelling gradunlly diminished. 

"At the end of September — that is, in one month — I could only de- 
tect an ill-defined, deep-seated vermicular thickening which has since 
■till further diminished. 

" May, 1861. — The patient continues to protect the part from pressure 
by the pad, and has not been reminded of her affection since October, nor 
does sho now suffer any inconvenience." 

1 had known this lady for soni« time, and was aware that she sat duly 
during many hours, occupied in literary pursuits. She explained to ine 
how she sat on a hard chair, with a, little table on her left hand, and she 
said, " As I read, I am obliged to sit sideways on my left side, in order to 
make my notes without getting up." I have no doubt it was that dis- 
torted position which led to pressure upon the bursa, and thence to thi^- 
ening of the surrounding structures, which, involving the perineal fila- 
ments of the inferior gluteal nerve, caused these unusual sensations in 
the neighborhood of the vagina. Here is another case illustrating the 
value of recognizing the distribution of even so small a branch as the 
perineal, derived from the inferior gluteal nerve. The bursa was cured 
by "rest," and the vaginal sjinptoms subsided. 

Afl a last observation with respect to the distribution of cutaneous 
nerves, and their influence upon the muscular apparatus — in the hope of 
laying the matter before you more explicitly another time — I would re- 
mark that part of the contraction resulting from the cicatrices of bums 
may depend upon the circumstance that when the burn takes place the 
nerves of the skin are exposed. The irritating influence of atmospheric 
air acting upon the denuded nerves or granulations may be conveyed to 
the associated muscles, and may thus in part contribute to the subsequent 
contraction. This may remind ua of the importance of using mechanical 
extension during the cicatrization of bums. 

It seems to me that if the anatomy which I have advanced for your 
consideration be correct, and the law of nervous distribution which I h«« 
ftifixed to it in reference to the joints be true as a broad principle, we 
ought to find a corresponding arrangement in the serous and rouootf 
membranes of the bodv. The same trunks of nerves that supply the m^ 
cular apparatus should supply also the serous membranes which thai 
muscles move. With regard to the mucous membranes, alao, the sain 
nerves that supply the muscles which move the walls should supply the 
mucous membrane which linea tliose muscular walls. Here, perhaps, it 
might be thought that irt dealing with the peritoneum, the pleura, and tlie 
pericardium, I urn treading on the domain of the physician. But s 



mooM^H 

thSH 
sam*^ 

!y the 
ipB, it 
id tlie 

J 



INFLUENCE OF BEST. 



141 



these parts belong as much to meaicine as to surgery, and to surgery as to 
tne<licine. It appears to me to bo a fictitious line which divides the princi- 
ples of medicine from the principles of surgery. Both must be essentially 
based upon precisely the same physiological and pa.thologieal laws, and 
therefore if I, ns a aurgeonj show you that there is a certain systematic dis- 
tribution of the nerves to the muscles, to the skin, and to the joints wfaioh 
those mufii'les move, surely 1 may be at liberty to extend my illustrationa to 
otlier parts of the body — vii., to the serous as well as the mucous mem- 
branes. On tliispart of ray subject I propose to dwell only for a, short time. 
}/ct as take, for e\araple, the peritoneum; and I will divide the ab- 
dominal parietes into two parts — an upper and a lower, the line of demar- 
cation being the umbilicus; the upper part of the abdomen being the 
respiratory portion, whilst the lower half of the walls may be considered 
«s strictly abdominal. You may see in Fig, 50, d, the nerves coming 
down from the spine to the abdominal muscles, and supplying also the 
peritoneum of the abdominal parietea. In this drawing (F'g. 4"), taken 
from a recent diaaeotion, we see some of these same nerves displayed 
upon the skin of the exterior of the al>domen. Here, then, we have the 
same nerves which supply the lower half of the abdominal muscles extend- 
ing themselves to the cutaneous aspect below the umbilicus, and distribu- 
ting filaments to the skin over the muscles which are supplied by the 
same nerves. I might also say that I believe that the same spinal nervea 
■end filaments to the visceral peritoneum covering the intestines. I may 
direct your attention again to the diagrammatic map (Fig. 41) which I used 
in my last lecture to point out the relation of the spinal and sympathetio 
nerves to each other, and to indicate the nerves of communication be- 
tween the spinal marrow and the svnipathetic ganglia. I venture to " 
express my belief that some of these filaments of spinal nerves go through 
the avmpathetio ganglia, and thence, associated with the sympathetio, 
tntvei upon the artery, and become ultimately distributed, I believe, to 
the walls of the smaU and 
large intestine. I remarked 
in that lecture that there 
cooM he hut few persons 
who had not experienced 
"painful sensations" in 
their intestines, and that 
sach sensations ci3uld only 
be derived from, or trans- 
mitted through, the spinal 
^nerves. The colon is the 
intestine which ought to be 
physiologically associated 
with the lower half of the 
abdominal walls, because 
they aid the peristaltio ao- 
tion ot the colon to empty 
the large intestines of their 
tecal contents. Here we 
see, then, that the same 
nervea supplying the ab- 
dominal muscles supply the 
parietal pi^ritoneum and the 
skin over those muscles: and furthi 




142 OS THE THKEAPEUTIO 

as Fig. 41, we may have the Indioation of some of tlie spinal nerves pro^ I 
ceediiig to the serous membrane of the intestines, or to tlie other struc- 
tures forming the walls of the intestines. The muscular upparatua of the 
abdomen, its serous membrane, the skin over the muscles, and the intes- 
tines themselves, are thus brought into harmonious association. 

1 think I am not putting this proposition too strongly when I say that 
we never see a case of acute peritonitis where the ab^min&l parietes are 
not drawn backwards upon the contents of the abdomen. Perhaps the 
only exceptions are cases of the asthenic forms of peritonitis which di^- 
pend upon the blood being poisoned; then the influence of the nervous 
system is as nothing, and we should not expect to find this tense and 
tight condition of the abdominal parietes. But excluding this kind of 
case, if the patient has acute peritonitis, the abdomen is, I believe, always 
drawn backwards, but with occasional spasmodic contraction, l^is, I 
apprehend, is an illustration of the effect of the same nerves supplying 
the peritoneum supplying also the abdominal muscles. The irritation uf 
the peritonitis causes the contraction of the abdominal muscles, and tbe 
sense of constriction or carrying backwards of the abdominal parietes 
towards the peritoneum. 

A patient suffering from acute peritonitis always lies with the thigh 
bent upon the abdomen. There must bo some reason for this, and I sup- 
pose it is for the purpose of removing tension, or rather, I should say, of 
removing opposition to the contraction of the abdominal muscles. I 
think the latter must be the true explanation of this position of the 
patient. This contraction may, in one sense, be regarded as a sponta- 
neous effort on Nature's part to secure quiet and rest to the subjacent in- 
flamed structures, suggestive, I think, of the value of fomentations 
strongly medicated with poppies and other aniCBtheties, such as betia- 
donntia, opium, or heniloek. I had an opportunity of seeing this point 
well and practically exemplified, some years ago, by my friend Dr. Daldy. 
He asked me to see with him a patient — 'Sir Benjamin Brodie saw him 
afterwards — who had extensive cancer in the rectum. This gentleman 
had considerable pain in the colon, and spasmodic contraction of the ab- 
dominal walls associated with his rectal disease, and he suffered a great 
deal of pain at night, so as to deprive him of his sleep. For the purpose 
of procuring sleep, it was essential that he should take opium; it was ad- 
ministered by the mouth, but the opium thus taken destroyed his appe- 
tite. Here was a patient suffering from cancer, tight abdomen, and pain, 
and we were giving him opium, and destroying his appetite, Weil, it 
was suggested that, instead of giving him opium by the mouth, we might 
possibly relieve him by rubbing the opium into the skin of the abdominal 
parietes. We accordingly had a strong solution of opium made, and 
rubbed it upon the abdominal parietes every night and morning. From 
that time the patient had scarcely any pain or spasmodic abdominal con- 
traction; he required no more opium bv the mouth to make him sleep, 
and he regained his appetite. This aSords a clear exemplification of 
cause and effect in the local application of ana'sthetica upon the exterior, 
leading to general repose or sleep, and actually nullifying or reducing the 
kbdominal contraction aud the pain. I believe this plan of treatment — 1 
mean the application of ann'sthetics to the cutaneous nerves — ia, as 
rule, moat imperfectly carried out in practice. 

We notice that, just in proportion as peritonitis subsides, so does 
abdomen become softer, more movable by the hand, and less tight to 
patient. If I have staled the facU and symjitoms truthfully, we hi 



1 



INFLUENCE OF BEBT. 

here evidence of the same muscular and cutaneous and serous association 
of nerves aa is observed in regard to the nervous distribution to the 
joints, &o. 

Let us now see how far we can apply this law to practice. Every 
sui^on knows that, after an operation for strangxilated hcmia, he need 
not make much difficulty about the general symptoms of peritonitis. He 
baa merely to put bis hand upon the abdomen: if he Buds the abdomen 
soft and pliant, however much the patient may complain of pain, there 
is no perilonitis, unless it be one of very low form indeed, aaaociated with 
py^m-ia, or depressed condition of th« system through the medium of 
poisoned blood, which would manifest itself by other symptoms.* 

I do not mean to assert that a tight abdomen per se is indicative of 
peritonitis, because that may be the result of flatulency and a distended 
condition of the intestines, or hysteri*. But in hysteria, although we 
may see great contraction of the abdominal muaclea, that contraction is 
very irregular or unsteady. Sometimes it Is in one part and sometimes 
in &notiier, and upon gentle pressure it subsides. Tension which is asso- 
ciated with true peritonitis, so far as 1 know, never subsides under the 
influence of gentle or even of more severe pressure. Taking the analogy 
of a joint, we may say that the peritoneum represents the synovial mem- 
brane, and the abdominal muscles the muscles moving the joint; so that 
if we meet with an abdomen the muscular walls of which you can freely 
move over its contents, we may conclude that the peritoneum is not 
inflamed, just as, when we see that a joint is perfectly movable and with- 
out pain, we may be sure that the joint is really not inttamed. 

Now, let me place before you another illustration from the upper part 
of the abdomen, above the umbilicus. Here we see the lower intercostal 
nerves, those which are associated with the false ribs after supplybig the 
intercDstals, passing through the edge of the diaphragm, or close to it, 
and then distributed to the abdominal muscles upon the upper part of 
the abdomen, and some going to the skin over the upper half of the 
abdomen. Here observe another relation between the cause and effect of 
a local inflammatory condition, which, if overlooked, leads to error in 
diagnosis, and the application of local remedies to the abdomen instead 
of the chest, In cases of costal pleurisy of the lower half of the chest, 
it is a common occurrence that the upper half of the abdominal parietes 
is tightly drawn backwards, and the akin over that part very tender to 
tha touch, yet depending upon pleurisy of the lower half of the chest. 

* It is not anij in cnaea of pjaemla t^nt peritoniCia inaj be mwbed or latent. Mj 
experienoe has beon (hat there is hardl.T any morbid ooiiditiciii which is tauHht mul 
deaoribed as poesesaing siR'ns so nnmiBtakable, and jet which, whea preseut, is so fre- 
qoeotl/ not diagniwed. The tranmatic oaoea which come unrler the nolioe of the sur- 
geon Bie oaoally, perhaps, more clearly markod, bat hare, too, tho presence of peri- 
tonitis 11U17 be miudced. Thos a patient who had been the eabject o( comitiCationHl 
■Tphilis hod ivhat proved to be a guniixiatoua tamor in hia liver ; this was diognatad aa 
a tumor in tba right reotus. and aa operncioti undertaken for its temovBl. After this 
the pntieat gxadnoUy aank, bat during the time that intervened between the operation 
and tbe eloae of his life (three ditjs! there was Hcarcely aDy e iri dance oF peritonitis, 
though after death this was foonil to be clonrl; marked and abundant. tJo, too, in 
■traiigiilated hernia, as in a oane of femoral hernia in which I latel; had occssloa to 
operate, the patient ma; dak with latent peri-toaitiH, and oomplaia of no pain whaC- 
erer to the last. In dia^oaing the exiaCenca of this oonditioQ. a sudden riaa of tein- 
petatore. abduminal dlatention, aspeoiall; a tyrapanitia which atcaltbil; but steadily 
incRHuei. and a gradaal pLochiag of the featiiTea. woald appear t« be far more troat- 
worthy laaa pun, a symptom nbich. on ooconnt ol its not infteqoent absence, wemi 
to me to be an unreiiable one. — [En.J 



Here also we have an excin pi ifi cation of the same nerve supplying the 
mustlea, the skin over the muades, and tUe peritoneum associntcd with 
theee muscles. The patholojjicul cause, in pleuritic inflammation, is with- 
in the chest, vet the »b- 
domiiial muscles ore velT 
much emploireiJ in respi- 
ration, and the nerves 
supph-iiig them supply 
also the skin over the 
surface of the same mus- 
cles. But I never like 
to mention a fact of this 
ki(id in normal anatomy 
without fixing upon it 
some point in practice, 
it has been my habit 
through professional Un^ 
nake this praoti^ 
omhi nation. 
In July, 18C( 
tleman, aged twenl 
t;wo, whom I had pre 
ously known, came ton 
looking very ill. After 
little detail, he said, " I 
have been very ill (or 
some time. I have had 
such pain and spasm in 
my belly. I believothere 
is something wrong 

about my hvcr. And 

then my stomach 
been getting bad. I bu 
been treated for diaei 
of the colon, I think j 
call it, and vai ' 
things, but 1 am not abi 
better." I inquired j 
him, " Are the pains 
both sides ? " " Yes," he said, " the pains are here," placing bis tit 
hands over the pit of his stomach; "both sides alike." Having jof 
before that time been lecturing upon the symptoms of diseased spme, | 
struck me, at first, it was a case of that disease. I accordingly examine' 
his spine, but I could find no cause there. I stated in a previous lectw 
that whenever we meet with an instance of symmetrical pains, the catu, 
is either centra! or bilateral. Well, not finding a diseased spine, I quel _ 
tioned him further, and ho said, " I ciiniiot lie down in bed on either aids, 
and in going up-staira 1 can hardly get my breath." I then thought I 
was upon the confinoH of a medical case, and ventured to percuss the 
chest, and recognized marked dulness on percussion. On applying I 
ear, I could recognize altered respiratory sounds. Ho had a collection 
fluid in each pleura. The wliole thing was now explained. He had b 
those pains and cramps in the upper half of his abdomen, which 1 
led his previous attendant, and induced him to concentrate hia &ltea 




m obovfi the ^jftpbrapiu ta i 

tloa Df the abdomlliAl vail And tho Hktn. t «. A.D 
wiilL f, HectoB Bbdomiol* miucJeL ff, OljCunUirDcrv 



INFLUENOE OF BEST. 145 

tion — which he did, I must say, with groat energy — upon the viscera 
lying' immediately under the upper half of the abdominal parietes. But 
the treatment was altogether misplaced. I directed this gentleman to be 
well and repeatedly blistered upon the chest, and so wo got rid of the 
fluid. Here, then, is an instance where the same nerves which supply the 
muscles supply the skin over the muscles, and where the local manifesta- 
tion of the painful symptoms was remote from the real caune of the 
symptoms. Through the medium of this nervous association and supply, 
and the symmetrical development of the pains, I came pretty accurately 
and quickly to the real cause; and we know perfectly well that, whether 
in medicine or surgery, nine-tenths of successful practice depends upon 
accurate diagnosis. I may here mention an additional circumstance of 
interest, that the upper half of the abdominal parietes overlap or cover 
those abdominal viscera which seem to be importantly influenced by the 
process of respiration — ihe li\'cr, and perhaps the stomach, but the liver 
especially. The liver lies between the diaphragm and the abdominal 
parietes, and must be subjected to their pressure, which aids the hepatic 
circulation, especially whea these two muscular structures are being 
actively occupied in the process of respiration. I have mentioned this 
subject before, and stated that the abdominal viscera are very likely to 
raffer from congestion when plethoric persons are suddenly confined to 
bed by accident, thus losing the opportunity of free respiration. Under 
mch circumstances the liver is especially liable to oongestion, sometimes 
leading to jaundice. 

If wp look to the relation of the perieardium and diaphragm, we dis- 
cover a correspondence in the distributiuii of the nerves which appear* 
^uite analogous to that which we find in the muscular apparatus moving a 
joint. May we not consider the fibrous pericardium as part of the fascial 
insertion of the muscular (Uaphragra ? The pericardium is most intimately 
blended with the diaphragm, distinctly identified with it, and capable of 
being acted upon by it at all times. It is also attached above to the deep 
I cervical fascia. It is thus kept tensa by the action of the respiratory 
f mnsclea in the neck attached to the cervical fascia above, and the dia- 
k phragm attached to it beluw; or, in other words, these two muscular forces 
r are acting on the interposed pericardium in opposite directions, and so 
I render it tense and resisting. And the special object, no doubt, of this 
'. piece of anatomy is that during a full inspiration, when the lungs are dis- 
|i tended with air and the right side of the heart gorged with blood from a 
\ suspension of respiration, the heart should not be encroached upon by the 
I surrounding lungs. Here one observes a peculiar circumstance. Howes- 
:' traordinary it is that the phrenic ncrva (a nerve so important to life) can 
l' pass through the chest between the dilated heart and the distended andex- 
, p&nded lungs, and yet, as far as we knew, never receive any untoward in- 
fluence from pressure ? It is true the normal healthy lungs have, as I 
' demonstrated long since, a remarkably definite concave form towards the 
I heart, arching over the course of the phrenic nerve; but when the lungs 
I, are emphysematous, it seems to me quite probable that these nerves might 
\ suffer from pressure, and cause some dilBculty in breathing, t pointed 
' out some years ago how it was, when extravasation of air occurs from rup- 
' Inre of the trachea or a large bronchial tube, that the patient died rapidly, 
and with extreme shortness of breath. The extravasated air enters the 
track of the phrenic nerve, thus causing extreme pressure on the nerve, 
and, by destroying the power of the diaphragm, leads to the rapid death 
of the patient. Let us trace these nerves below the diaphragm. The 
10 



I 



146 OK THE THSBAPEUTIC 

phrenio nerye, in its course from the neck, passes through the chest, ulti* 
mately reaches the diaphragm, and is then distributed upon the infe- 
rior aspect of that muscle. Now physicians tell us that if a patient has 
pericarditis, there is always a sense of oppression at the epigastrium. 
Some say there is a catch in the breath apparently associated with the 
diaphragm. 

I must not dwell upon this subject, but I ought to have said that this 
phrenic nerve gives off a small branch as it passes along the middle medi- 
astinum to the pericardium. I am not prepared to say, but I think it is 
probable, that tnis may be a sensitive filament of the phrenic nerve; and 
if so, we have the analogy to a joint pretty well completed. We have the 
diaphragm, representing the muscular apparatus; wehavp the serous peri- 
cardium, representing the synovial membrane; we have the fibrous peri- 
cardium, representing the capsular ligament, and all capsular ligaments 
have muscles attached to them. We have then, analogically, the repre- 
sentatives of a joint. Although time will not allow me to extend this subject, 
I may remind you that we thus have an explanation of the sense of con- 
striction and tightness and shortness of breath of which patients suffering 
from pericarditis usually complain, if through the medium of a cutaneous 
or sensitive filament going to the pericardium, pericarditis can produce 
muscular spasm, or contraction of the diaphragm, precisely as the nerves 
in the interior of an inflamed joint can lead to the muscular spasm of that 
joint. 



INfLUESCB OF BEST. 



LECTURE XI. 

Cntoneoiu and Xuisontar Nerve DmCribution in Relation to the Plenca — Appllmltou to 
the Treatmeat of ItiDameil Pleura— Meohaaioal aiid Physiological B«Bt bb applied 
to tbe rrcntineiit of Pericarditis — Anilog; between the Effuaion of Lymph bj u 
Serous Slembrana and the Production of Callua in » Fracture— Swollen Joint a 
H^nni Token by NatuiQ to Procure Rest for the Part— Rest lUuBtrated in the 
Treatment, N'atnraJ and ArtiGoial, of lojury to tbe Eye — Nerve Distribation of 
t^e HiieQtie Memliraoeo — Practioil ^ppliontion — Cbronia Cystitis Reliered bj 
Opiom Indudug Phjuological Rest^Otbcr Examples — Cure for OoaniBm, 

I WILL now proceed to consider briefly the anatomy ot the upper in- 
tercostal nerves, for the purpose of explaining' the same anatomical law of 
distribution with regard to the pleura which we have considered in refer- 
ence to the peritoneum and the pericardium. We observe that the same 
intercostal nerves which supply the iiitercoatal muscles moving the riba 
supply also the serous membrane lining the thoracio parietes and the skin 
over those different but physiologically associated structures, in order to 
produce hannonious and concerted action during the varied states ot res- 
piratioD. Here, then, we have the pleura representing the synovial mem- 
brane; the intercostal muscles representing the muscular apparatus con- 
nected with and moring a joint; and the cutaneous branches of the nerves 
H>read over the intercostal muscles, assimilating ii 
toe cutaneous branches which supply the skin ove 
muscles moving the joint. 

But this physiological anatomy, without some 
would, perhaps, be scarcely worth dwelling upon. 

Pleurisy of the pleura costalis, at the upper part of the chest, is often 
accompanied by pain and tenderness of the skin not only over the seat of 
the pleurisy, but also in the axilU, itnd over the front of the shoulder, re- 
sulting from the course and the peripheral distribution of the intercostal 

It will be recollected that some filstnents of the intercostal nerves pass 
through the walls of the chest to the skin covering it, and that some cross 
the axilla, and are then distributed to the skin of thcf rant of the shoulder 
and the iimer side of the upper arm; heuce the puiu and tenderness in 
these parts resulting from pleurisy. We may hero discover illustrative 
instances of pain on the surface of the body from internal causes, corre- 
sponding in principle with the remote pains associated with some oases of 
diseased joints; as, for example, the pain in the knee associated with hip- 
joint disease, or as in disease of the spine, where the pain is expressed at 
the cutaneous extremity of the nerves escaping from the part of thespino 
actually diseased. In all these cases the absence of the evidence of local 
inflammation dearljr indicates that the pstholoRipal cause is not at the 
part where the pain is expressed, but somewhere in the course of the norve 
proceeding from the real seat of diseasB to this part. 

''J^nay be noticed that persistent pain on the surface of the upper and 
■jor part of the chest, and upon the anterior part of the a 



plication to practice, 




148 ON THE THERAPEUTIC 

not unfrequently associated with disease of the heart or large blood- 
aels. Indeed, 1 think 1 might generalise on this part of my subject, ai 
make an artificial division of the back into three compartments. Fin 
high lip between the shoulders, where persistent paiiis — ^pains of nervoi 
continuity — as a rule, coexist with disease of the heart, aneurism of 
'aorta, disease at the bifurcation of the trachea and bronchi, disai 
glands, or stricture of the oasophagus within the posterior media^int 
second, betteeen the middle ana lower part fif the scupiUiH and a, tittle lot 
doieti, where the existence of like pains are most frequently associated with 
disease in the abdominal digestive viscera, and, 1 think, the tmnsveise 
colon, through the medium of the great splanchnic and the iiiteroostal 
nerves — (I believe I have seen some cases of disease of the transvena 
colon where the patients have had these tower interscapular pains); thi 
the surface in the lumbar region, where the pains are more distinctly 
sociated with local disease in the loins, such as disease of the ascendii^ 
or descending colon, the kidneys, lumbar lymphatic glands, spennatio' 
nerves, and testicles. 

Patients suffering from cancer of the breasts often complain of pain in 
the back, between the shoulders, or on the side of the iiliest, sometimes 
down the inner side of the arm and across the axilla. In such cases we 
not unfrequently find cancer tubercles under the pleura costalis, or can- 
cerous glands in the axilla, or in the posterior mediastinum. Such remote 
sympatnetic pains occurring a long way from the real disturbing cause are 
explained by the course of the intercostal nerves. 

These superficial pains, although depending upon a remote cause, may 
sometimes be relieved by local aripesthelics, as prussio acid, hemlock, bella- 
donna, and opium. Some few years ago I saw this point well exemplified 
in practice. Dr. Munk asked me to sec a young lady 'with him who was 
Buffering and likely to die from pulmonary tubercular consumption. I saw 
the lady at the Bank of England, and found thiit her oomplamt (for which 
I was consulted) was pain and tenderness of the skin in the armpit, thi 
shoulder, and down the arm on the right side; these pains were excessivdi 
distressing to her. Upon examination, I found she had had a large absca 
in the right armpit, and upon lifting the arm from her side, and lookii 
through an ulcerated opening in the skin, 1 saw the little cords of int< 
costal nerves denuded of areolar tissue, and proceeding across the axil 
towards the superficial parts, where her pains were expressed; and whi 
I touched the exposed nervca with a probe I induced a great increase 
the seventy of ihest- ]i:iins. I recommended that all the skin whereon the 
pain was expres.sed should be thickly covered with the extract of bella- 
donna spread upon soft leather, and that the arm should be kept quiet bl 
being bandaged to her side. By these means the patient was very 
relieved from the pain and tenderness during the remaining short 
of her !i fe. 

I would venture hypothetically to apply the following explanatinn 
the painful effects resulting from the local application of cold air up 
the peripheral branches of the intercostal nerves. I believe that the local 
influence of cold air may be sufKcietit to explain the occurrence of stitrh, 
or thiit cramp in the musctes of tlta chest which prevents a full inspiration, 
by inducing tonic or spasmodic contraction of the intercostal niusclca 
which are supplied by the same nerves (the interoostals) which supply the 
skin upon which the cold is applied. This explanation will haniiy be 
deemed untenable, when I remind j'ou that if a patient faints, we, anxi 
to excite respiration as quickly as jKissible, tiir^w I'^M wiiUT uver the fa 



«tal 

liii^H 
li^l 



'aa«H 



INFLUENCE OF REST. 



149 



or denude the chest and flip its surface with a wet towel, and throw cold 
WTiter abruptly upon the walls of the cheat. And we do it for what pur- 
pose ? It cannot be for the direct application of cold to the muscles them- 
selves. It must be for the purpose of exciting the muscular apparatus 
which moves the walls of the chest, through the medium of the local 
RpplicBtion of cold to the cutaneous nerves. 

Hitherto I have been looking at this associated anatomy chiefly in re- 
lation to symptoms leading from without to within. Now let us regard 
it from within to without, and see what external symptoms an inflammatory 
condition of the interior of the chest and pleura ought to bring about, and 
the suggestions which might arise in reference to our subject of rest as 
applied to them. 

May not the irritation of an inflamed pleura bring on a contracted 
condition of the muscles between the ribs (intercostala), and thus engender 
the limited breathing and the painful cramps and stitches from whicn such 
patients suffer, in addition to that which results directly from any local 
inflammation of the pleura, and which induces pleuritic patients to limit 
their respiration as far as possible to the action of the diaphragm ? This 
spasmodic contraction of the intercostal muscles, induced by the inflam- 
matory condition of the pleura, is precisely analogous to what we see In 
joint disease. When the synovial membrane is inflamed, the joint is 
always fixed and rigid, and dijficult to move. If the pleura be inflamed, 
we ought not to be surprised if we And its muscular apparatue in a like 
condition, excited to powerful contraction and a spasmodic condition from 
the association between the synovial membrane and the muscles. This 
seems to me a very probable explanation. What should we do, then, if 
we had an inflamed joint ? We should first keep it quiet by not using it. 
Do not use an inflamed pleura, then, I say; do not induce a patient to 
take a full hreathj do not permit him to caiTv on any long-continued con- 
versation, taking in a full breath, and gradually streaming it out in a large 
number of words and sentences. If we have an inflamed joint, we apply 
aniesthettc fomentations to its exterior. We know by experience that 
if we apply atnmg poppy or opium fotnentations, hemlock or belladonna 
poultices, or anresthetic embrocations, upon the exterior of the chest, in 
these inflammatory conditions of the interior, they give a great amount 
of relief through the medium of their influence upon the intercostal nerves 
which come to the surface. If a joint be inflamed, we put a splint upon 
it to keep it at rest. Why not strap or bandap^e the chest in cases of 
pleurisy when the acute mischief has passed off? Surely it would have 
the tendency to subdue the inflammatory condition by preventing any 
frietion between the two opposite pleural surfaces. 

All surgeons must have observed, in cases of pleurisy, that if the 
patients be asked to take a full breath, to raise the ribs and expand the 
lungs, they cannot do so without suffering pain. This is surely very sug- 
gestive of the importance of rest, and points to the value of strapping the 
chest in cases of acute or chronic pieurisv, with or without fractures of 
ribs (I have no doubt about its great utility in the latter complication); 
for it not only keeps the ribs quiet, but prevents any friction of the pul- 
monary pleura upon the inflamed pleura costalis. 

These observations of course suggest another practical Ipbsou — never 
to allow a patient suffering from piourjsy or pneumonin to talk or to an- 
swer questions except by raonoay liable 3, so as to avoid a full inspiration. 
Let the patient write all his or her wishes upon a slate. This may appear 
asmall item in practice; but I could mention several instances where thin 



ON THE THEEAPEUTIO 

elemont lias been the tuniing--poiiit in the case. A pli_ 
siding not very far from me, had under his care a. patient who had received 
a blow upon his chest by a fall upon the part; and as he was after several 
days still suffering a good deal of pain in breathing, the physician naked 
me to see him in reference to the poesibility of fraiitured ribs. I could 
find no fracture; but I observed that the patient had a most wonying 
wife. She was incessantly talking to him day and night, and there were 
continual contentions between them upon domestic aSairs. I suf^igeated 
to the physician that the sole cause of the pain was in all probability prO^J 
duced by the patient constantly moving the injured or bruised soft parts' ~ 
usinp his chest and lungs in speaking. All I recommended was, that 
should hold his tongue and have his chest bandaged. I rotjuested that 
wife would not say a word to him, but would provide him with a slate a 

; might write down all his desires. From that time he got 



1 



pencil so that h 
quickly well I'j/ local rest. 
I think it is a fair c 
inflamed pleura perfectly quiet, i 



i deduction, that if ■« 
1 prevent it suffering the il 



keep 



the 



I! effects of 
e friction, we certainly must contribute something towards arresting 
the continuance of the inflammatory condition. I do not think this im- 
portant subject is usually considered in this light; and I am convinced 
that it ought to receive a larger amount of attention than it has done. 

Agaiji, with respect to the application of local anjcsthetics to the out- 
side of the chest. 1 think I have shown that we have a power of acting 
upon the wnlla of tho chest and the muscles of respiration through the 
medium of an:csthetics applied to the cutsneous nerves associated with 
the nerves of the pleura costalis; but 1 admit we have very little oppor- 
tunity of acting directly upon the heart or pericardium through the exter- 
nal or cutaneous nerves associated with tho cardiac nerves, so as to induM 
physiological rest in that organ by the external application of aniesthet- 
!cs. Vou will be impressed with this conclusion when I remind you that 
there are but a few hiaments of the upper intercostal spinal nerves which ^ 
join the cardiac plexus of the sympathetic nen-e within the chest; 
that these same intercostal nerves distribute only a small number of c 
taneouB filamenta to the skin of tbe cheat and back. It nmst not, hoi 
ever, be overlooked, that the cervical spinal nerves commuuicate with 1' 
cardiac nerves derived from the sympathetic ganglia in the neck. These 
are apparently the only nerve-tracka extending from the surface ot th« 
body to the heart which would permit of direct aniesthetic influence being 
propagated from the skin to the heart. 

Let us now see whether the subject of " mechanical and physfologici 
re^t " can be made therapeutically Kvailable in reference to the treatmet' 
of acute periuarditis. The physician cannot fail to admit that, whiL _ 
treating pericarditia, he has to deal with a membrane investing and sur- 
rounding an organ with whose functions complete rest is incompatible, 
since tbe rhythmical movement of the heart is necessary to the persistenee 
of life. Vet he must allow that it is only through the medium of leBsened_ 
action and diminished distention of this organ, with a concurrent las c 
dition of the diaphragm and pericardium, that he can expect to i 
any relief from friction to the serous membrane itself. Allow me, tliei 
to put before you this suggestive question: whether, in a case of acut*-* 
pericarditis, it would be possible to over-estimate the value of local rest 
as a therapeutic agent ? We, as surgeons, see the ill effects of frction 
upon inflamed parts — as In cases of inflamed joints, of inflamed ulcers, m- 
Mmed con jUQCtivie, inflamed skin, &q. Hence we may fairly assume that ■ 



ivhioh ^^ 
; anifl 
:>fci^H 
hoi*^H 
h thJ^ 
These ' 
i th« 
i being i 

logic^H 

itmea^^l 
whilrilS 

Ltible, 

>btaiiH 
U>e^ 




IKFLUENOE OF BEST. 151 

friction upon the two free and inflamed surfaces, as in the early stao^ of 
pericarditis, must add materially to the local mischief, and tend to keep 
up the inflammatory condition. 

I assume — ^for it is not from direct clinical experience that I speak — 
that the physician's first anxiety is to quiet the action of the heart, to 
reduce the frequency of its pulsations, to diminish its muscular excitability, 
and thus to moderate the friction and its ill effect. I may venture, in 
addition, hypothetically to imagine that he would desire even to stop the 
movements of the heart for a time, for the purpose of preventing friction, 
provided that its arrest was compatible with life, or that he had the power 
to insure the resumption of its activity. But although this direct influ- 
ence is beyond the limits of human power, yet I think we discover that 
the treatment adopted in such cases is founded upon the principle of giv- 
ing all possible rest to the heart. Venesection, antimony, opium, digitalis, 
are, or nave been, I apprehend, resorted to for this purpose, or, if not em- 
ployed with this precise view, I conceive that their beneflcial influence is 
to be traced in part to their insuring less frequent and less rough friction 
between the two surfaces of the pericardium, by diminishing both the dis- 
tention of the heart and the rapidity of its action. 

With a view to the full and further appreciation of rest in idiopathic 
pericarditis, let us admit, for the sake of illustration, what I believe to be 
the right interpretation, that the effusion of lymph in this pericarditis 
results from some morbid condition in the blood. When this condition of 
the blood has been exhausted by the inflammatory pericardial effusion, or 
has been eliminated by Nature through some emunctory, such as the kid- 
ney or some other organ, aided by medicine, may we not discover some 
good in the solid plastic effusion itself ? I think we may — in the induced 
rest. 

What is the mechanical influence of the effused lymph (which may or 
may not glue the two pericardial surfaces together) upon the serous sur- 
ftboes, which are not only secreting, but also absorbing ? For it must be 
borne in mind, in anticipation of what I shall presently remark, that 
serous membranes are rapidly absorbing organs. I have no hesitation in 
saying, from both clinical observation and experiment, that these serous 
membranes are very rapidly absorbing organs indeed. Observe this illus- 
trative case of absorption by the peritoneum. Suppose a person has an 
injury to the abdomen, which causes an extravasation of a large quantity 
of blood into the peritoneum. This blood consists of a certain amount of 
serum and coagulable blood. Now, if the patient survive but a few hours, 
what do you find in the abdomen after death ? No serum ; every drop of 
it is gone. Gone where? All of it is absorbed. The clot of blood 
remains, but the fluid part of it has been taken up. There is no doubt that 
solid effusion has been known to exist during life between the pericardial 
surfaces, recognized by certain diagnostic sounds which have subsequently 
ceased; and the patient dying some time afterwards, the post-mortem has 
proved that the whole of the lymph had disappeared, no doubt by absorp- 
tion. 

The result of the effusion of the inflammatory fluid is, that the serous 
surfaces become defended immediately from direct and intimate surface- 
friction; thus that possible source of irritation is removed. Thencefor- 
ward this acquired rest, or freedom from direct friction, enables the serous 
membrane to recover itself, and then to resume its important function of 
absorption. So, too, in other parts of the body. For example, in the case 
of oroup, when effusion of lymph takes place, the false membrane adheres 



L 



i 



for a time to tlie mucous membrane; the mucous membrane tlius olrtr-im 
a physiologiial rest, and the little glandular struotures, imbedded in th( 
submucous tissue, recover their strength through their physiological re 
pose. They then raiiew their function of seeretion, and thus detach th» 
ftklse membrane. I think T might with reiiHon compare (in relation to the 
subject of rest) the effusioti of lymph in pericarditis to the "proviBional" 
callus formed by Xature in cases of bad fractures. There is no doubi' 
that the longer the inflammation of the pericardium continues, the 
unhealthy the membrane becomes, so that if inflammation of the perica^ 
dium becomes chronic or enduring, the pericardium acquires such itji un- 
healthy condition that it will not perform its second function of absorp- 
tion. Patients so affected are those who die with a large quantity of 
fluid in the interiur of the pericardium, constituting dropsy of the peri- 
(sudium. Thus, ii fluid be poured into a healthy pericardium, it is rupidlv 
absorbed; if into a very unhealthy one, no absorption takes place, ai»| 
^ose dropsies occur thct we so often see. 

We observe the curative principle of acquired rest diaplayea in other 
parts of the body when sufTcring from inflammation, such as the occur- 
rence of sohd effusion (callus) associated with the repair of some fracturps 
of bones, and the massive swellings which we see incumbering the exterior 
of intlamed joints, whether in cases of acute or of chronic destructive in- 
ilamiuation of the interior of a joint; the joint still, perhaps, going on to 
repair. When a bone is fractured, what do you discover upon the ex- 
t«^or of the fracture, when the fractured pieces are subjected to frequent 
local disturbance ? We know that Nature herself puts a splint upon the 
exterior of the bone, including the fracture, for the purpose of keeping 
the fractured ends of the bone in actual rest, and that, in truth, this e»- 
temul splint is developed in proportion to the amount of movement to 
which the fragments have been subjected, 

I eaw a most instructive case of this kind some years ago, which made 

B great impression upon my mind. On Sept. 3rd, 1846, Mary Ann L , 

hged thirty, washerwoman and ironer, attended as an out-patient at Guy's 
Hospital. She had a hard swelling, as large as a moderate-sized orange, 
in the middle of the right clavicle, supposed to be exostosis or malignant 
disease of the bone. ShQ told me that she thought she hurt it six weeks 
before, as she felt a sudden pain in the swollen part whilst trying to atop 
the fall of a ehest of drawers. In a few days the part began to swell, and 
continued to do so up to the time I saw her. A blister had been applied 
by n surgeon ten days before, without any apparent advantage. Thinking 
it a case of disease or new growth in the bone, I ordered her to rub the 
compound iodine ointment freely into the tumor, and to take some ammo- 
nia and bark; and, having fijted her arm in a sling, I enjoined her not to 
ose it, or make exertion of any kind, for she always had pain in the swoUi 
part of the collar-bone when she did so. I huw this woman again in t' 
weeks, and the tumor was a little reduced; and I was congratulating 
self with the idea that here was a case of malignant disease being 
by iodide of potassium. From that time I lost sight of her. 
anxious and determined to know the result, on the 24th of May, 184', 
went with Mr. Chabot to the houses of nearly all the washerwomen in 
Camberwell, and we at length discovered her. I examined the clavicle. 
There was a slight overlapping of the fractured ends of the bone, but thtt^ 
bone was consolidated. It was thus clear that she had had a broke ' 
clavicle, and what I had treated was the callus of a fracture. She tol 
me that the swelling went away gradually "'*<"■ a few weeks, and 



th*> ■ 
ken^ 



INFLUENCE 

found she could resume her duties B.t the wash-tub and ironing-board 
without pain. It thus appeared that by dx'ing the arm I had secured rest 
to the fractured bone, the necessity for that amount of callus which 
Nature liad supplied for the purpose of securing' rest to the fracture was 
dispensed with, and then the callus disappeared without any further 
treatment. 

This natural process for the purpose of securing rest to a fracture is 
porfeotly analogous in its elTects to the effusion of solid lymph which 
occurs between two inflamed serous surfaces. The function of tlie exter- 
nal callus, associated with fracture, is only temporary, for as soinn aa the 
fractured ends become harmoniously and mutually consolidated it disap- 
pears. Its purpose is merely to maintain the fractured ends of the bone 
in a state of quietude and rest, so that Nature may go on with her perfect 
work of exact repair without the fractured ends being moved upon each 
other, or in any way disturbed. In a case of doubtful fracture of a bone 
I have seen this subjet thus brought forward in a court of justice. A 
counsel has asked a su^eon this question, "Would you say that the 
plaintiff has had a fracture, seeing that you find no c-allua?" And the 
" No I should sav there was no fracture, because thet 



is no callus." Another surgeon, perhaps, is put in the witness-box, and 
he says, in answer to the same question, " I declare positively that the fact 
of there beiiif^ no callus is to my mind the best evidence which could be 
adduced of the perfect treatment of the fracture by the surgeon." Now, 
the fact of the absence of callus is, no doubt, the highest praise that can 
he won in tlie treatment of a fracture by the surgeon, who had adjusted 
the fractured ends so completely, that there was no necessity for Nature's 
Splint or callus to secure mechanical rest to the ends of the bone. 

This same physiological point is also well displayed, in practice, in the 
occurrence of the thickening of soft structures external to inflamed or dis- 
eased joints. This thickening has the decided edec-t of giving mechanical 
rest to the interior of the joint, tending to steady it, to support it, to ren- 
der it comparatively immovable, and to oppose disturbance by muaculftr 
contraction, showing the value which Nature attaches to rest as a curative 
agent. How conspicuously striking is the changed configuration of the 
inflamed joint when the inflammatory condition has subsided, when the 
joint has recovered itself, or when the disease has resulted in membranous 
or bony union of the articular surfaces ? Then it is that we may notice 
with admiring wonder the steady and sure removal by Nature herself of 
the external adventitious matter as a thing now unnecessary, and as being 
no longer required by the joint for its rest. So it is with the solid effu- 
sions which are intended to circumscribe the inflammatory abscess; it is 
noticeable that as soon aa such an abscess is opened, the necessity for the 
deposit around it no longer exists, and it is absorbed. Thus, I tnink, we 
may by analogy see the evidence of the beneficial influence of rest in the 
treatment of pericarditis; and we may discover some good to be derived 
from the inflammatory effusion by its giving rest to the pericardium for a 
time, and enabling it to resume its other function of absorption. By 
considering the subject of solid effusions associated with local inflamma- 
tion in this light, we recognize the folly of the surgeon who attempts to 
^t rid of the external callus of a fracture so long as the fractured bone 
IS not united ; likewise, the folly of expecting to get rid of the surround- 
ing swelling associated with chronic joint diseases before the joints them- 
selves are repaired; in fact, it cannot be done. 

Having examined the distribution of associated nerves in Ihe joints 



154 ON THE THERAPEUTIC 

and serous meraoranes, and pointed out some of its results as evident 
in the symptomB induced by it in the diseases of those parts, I now pur- 
pose to consider briefly the same anatomical and functional arrangements 
as they are manifested in the mucous membranes and their directly asso- 
ciated muscles. Let us look, for instance, at the conjunctiva, the orbicu- 
laris palpebrarum, and the skin covering the eyelid, in their due anatonu- 
c&l and physiological relations. These parts stand very much in the same 
relation to each other as the synovial membrane of a joint, the musc^ilar 

Sparatus moving that joint, and the skin over the insertions of the mus- 
:S. We iinil that the facial nerve is one of the motor subdivisions of 
the great cranial compound nerve constituted by the large origin of the 
fifth nerve, as the sensitive root, And the third, fourth, fifth (motor por- 
tion), sixth, and seventh cranial nerves, which together form the mc' 
roots of this cranial nerve; the wbole of this nerve association struct 
ally resembling a common two-rooted spinal nerve. The sensitive root. 
the fifth nerve supplies the conjunctiva and skin with sensation, and 
facial nerve supplies the orbicularis palpebrarum, the muscular apparal , 
with motor power: these two uerves are most intimately associated botb 
anatomically and physiologically; hence the constant and active sympa- 
thy between those parts. Now notice what happens when the eye Is m- 
flamed, or the light ia too strong for the eye. The eyelids are immedi- 
ately closed — the eye is placed in darkness, which is the eye's " rest. 
Here is an indication on the part of Nature which has been visible to man- 
kind from one generation to another, and soliciting, as it were, apprehen- 
aion; yet how little ia it appreciated, how rarely made the guide of prac- 
tice ! Surely the neglect of such an indication ia a great error, and re- 
quires correction. If the eye be inflamed (painful, irritable, red, con- 
gested, very sensitive) by exposure to a strong, glaring light or to intense 
neat, immediately the eyelids are instinctively closed, thus adopting the 
principle of rest as a means of restoration. Tears are secreted, analogous 
to synovial secretions in joint inflammations, to lubricate the conjunctival 
membrane, to interpose a layer of fluid between the globe and eyeli(" 
to prevent direct friction of tlie two mucous surfaces, and possibly to 
meiit the eye. If the eye be thus kept in temporary darkness, free fi 
friction, and thus rested, it will return in a few hours to its normal el 
without any other aid. 

It is certainly an interesting and most instructive fact, and 
worthy of distinct notice here, that the portion of the body in whi 
Nature displays most conspicuously her immediate appreciation of 
value of rest in relation to its restorative power is the organ of vision — 
the part of the human body, be it remarked, the most completely under 
the fullest observation of the surgeon, with the least amount of trouble, 
and where he may see the evidence of the good to be derived from rest to 
the diseased or injured organ most grapbieally expressed. I suppose 
every liring professional man of every grade, of every age, whether his 
intellectual acquirements be great or small, would advise the exclusion of 
light from an inflamed eye. This in reality is giving perfect rest to the 
organ, by removing tliat natural stimulus, wnich in excess becomes a great 
source of excitement. But 1 must add, as a stigma and opprobrium upon 
the mental perception of some of ns, that although we recognize the law 
and the principle as applicable to the eye, we do not appear to see it 
clearly, and certainly do not act upon it with the same fixed notions oj 
the same precision in its application to the other parts of the body whi 
suffering from oosident or disease. If the eye tie infiamed, the first thir 



por- 
ituS 



1 



IKFLUBNOB OF BEST. 155 

that happeDS is that the eye becomes placed in darkness in a dark cham- 
ber. Welly if you admit aarkness as necessary or important in the treat- 
ment of diseases of the eye, you will be compelled to admit as a principle 
the therapeutic value of rest in the treatment of diseases of the joints, 
and indeed in all inflamed parts. The other day I received from India 
this note from an old dresser of mine : — 

" Apropos of your subject of rest: Do you remember in 1857 little J. 

G burning his face and eye with gunpowder ? I got great credit for 

my skill in that case, and pocketed it; but the credit was really due to 
you in having instilled into my mind a deep-rooted idea of the importance 

of rest in surgical practice. J. G was letting off a squib ; the powder 

did not ignite well, and he lowered his face close to it, and blew to kindle 
the flame, which he succeeded in doing, and in an instant the squib ex- 
plodedy burning his face and eye. I saw him almost immediately, and 
zonnd him in excruciating agony; the face darkened, skin ingrained with 
gunpowder, the conjunctiva of one eye black, and looking puffy and half 
nMUited. The cornea had a peculiar appearance; the outer lamina and 
conjunctiva over it had shrivelled, presenting an uneven, opaque surface 
(pretty much resembling the appearance of a cornea that has been so com- 
pressed after death as to have had its laminar structure irregularly dis- 
plmoed, and so become opaque), with a sooty dust ingrained and deeply 
pitted on its surface. The eye was washed with warm water, the lid then 
dosed down, a drop of sweet oil having been first inserted under the lid, 
and a piece of plaster applied to keep the lid closed, but not to press upon 
the eye. The other eye was then also closed. Two days afterwards the 
inner canthus was washed with warm water, but the eye not opened. On 
the fifth day I opened the lid, and found the cornea bright and clear, and 
a new and healthy layer of epithelium covering the entire globe. Under 
the influence of rest, healthy nutrition had effected complete repair." 
This patient got quickly well. 

Observe the effect of morbid action in another portion of the mucous 
membrane, in order to mark this same nerve distribution. If you have an 
inflamed throat with inflamed tonsils, arc you not constantly, in spite 
of yourself, swallowing and producing pain in the throat which you would 
be s^iad to avoid? What is it that incites this involuntary act of degluti- 
tion ? It is an irritated or inflamed condition of the mucous membrane 
of the pharynx and palate which excites the associated muscular appara- 
tnSy through the medium of the glosso-pharyngeal and the pncumogastrio 
nerves. You are constantly forcing and rubbing the inflamed tonsils, 
pharynx, and palate upon each other; and thus "swallowing" is excited 
frequently, painfully, and against your will. This is exactly the same 
tning as irritation or inflammation of the synovial membrane producing 
contraction or spasm of the muscles moving the joint. This kind of case 
IS best relieved by the local application of opium — by painting the throat 
with a solution of opium. 

Some time ago 1 saw, with Dr. Herbert Davies, of Finsbury Square, a 
gentleman who oould scarcely swallow at all, for, directly ho put fluid into 
his throaty it produced a violent and choking spasm. Ho was then nour- 
ished by nutntive enemata. I saw him endeavor to swallow fluid, but he 
nearly choked himself. I touched his throat with a camel's-hair brush, 
and a violent spasm was produced in the pharynx and larynx. Numerous 
and different gargles, weak and strong solutions of nitrate of silver, had 
been well employed, but without any advantage, anJ the patient was rap- 
idly emaciating. I advised the use of a powerful anaesthetic to the irri- 



ON THE THEBAPEUTIC 

table mucous membrane. I requested him to use a gargle contHining 
prussic acid. From the first time he adopted this plan of treatment he 
began to improve, and ultimately recovered. This application of prussic 
acid was adopted on physiological principles, merely for the purpose of 
reducing the sensibility and irritability of the mucous membratie, attd ff 
putting an arrest to the associated spasmodic contraction of the muscles. 
Subsequently this patient went to Hastings, and there the pharynx was 
paiiited with a solution of chloroform, upon the same principle of induc- 
ing physiological rest to the throat, and he got quite well. 

Now take the larynx for illustration. Both the sensitive and motor 
nerves of the larynx are derived from the same pneumogastrio trunk, and 
hence we note that any irritation or inflammation existing upon the mucous 
surface of the larynx or of the laryngeal surface of the epiglottis induces 
excited muscular action immediately on the part of the associated laryngeal 
muscles. This irritable state of the larynx is usually treated by the local 
application of nitrate of silver iii solution, or in the form of a very fine 
powder, which is blown into the larynx; and the relief is sometimes vi ' 
complete and speedy, by the physiologit^l rest which it gives to 1,.. 
mucous membrane. I apprehend that rest is afforded by the nitrat«(ii. 
silver acting upon the mucua and albumen, fonning a solid albuminate of 
silver, constituting an adherent temporary covering to the muooi 
brane; thus giving it rest by defending it from the atmospheric 
BO dostroyhig for a time that nervous irritabilitv and muscular contractiiHi 
which produce a sense of suffocation. After all, the production of phyi'' 
logical rest is the curative principle, based npon the fact that the m 
nerve-trunk supplies both the mucous membrane and the muscular appi 
tns of the larynx. 

This principle of nerve distribution obtains throughout the whole dis- 
tribution of the pneumogastrio nerve, viz. the same trunk of neire sup- 
plies the mucous membrane and tlie associated muscular apparatus. It is 
the same with respect to the intestinal canal: the mucous membrane and 
muscular walls are supplied by the same nerves, causing direct syinpathv 
between them. I have no doubt in the world that the effect of most pur- 
gative medicines is to induce irritation and increased secretion from the 
mucous membrane, and increased muscular contraction in the walls of the 
intestines. I must therefore express my conviction that the frequently 
repeated introduction of irritating medicines into the bowels is very likely 
to do a great deal of injury by exciting muscular contraction, and thenw 
diminishing the calibre of the gut; and that subsequently a great length of 
time, with carefully managed diet, is required to replace the intestines in 
B [>erfcctly healthy condition. The continuous administration of purji^ative 
medicines is on this account, I apprehend, very often most injudicious. 

The muscular urinary bladder, with its mucous membrane and nervous 
supply, offers another example of this nervous distribution. We see tins 
exemplified in a patient who has in his urinary bladder a stone, causing ■ 

S'eat deal of increasing irritation, with frequent desire to pass his water, 
ow is this condition to be explained? It obviously depends upon the 
fact that the same nerve that supplies the mucous membrane supplies also 
the muscular apparatus of the bladder. Hence the stone, by annuying 



fine - 

.in 

and 



mbrane, becomes a constant source of excitation, 
causes contraction of the muscular walls of the bladder. Thus it happens 
that the bladder becomes in some instances so exceedingly diminished in 
its capacity, and so contracted npon the stone, as to leave scarce any room 
for urine, and hence the frequent micturition. If the stone be remuvsdH 



L 



INFLUENCE OF BEST. 

the local irritation subsides; and tlien the capaoity of the bladder is re- 
stored. In cases of irritable and painful bladder, my colleague, Mr. 
Cock, has lone been in the habit of injecting sedative solution of opium 
into the interior of the bladder, with great advantage to the patient's 
floadition; and I have repeatedly observed the good eSect arising from 
such a proceeding myself. Here is a case in point. 

Chronic Cystitis relieved by Opium Ljjection*, inducing "phyaiologi- 

cai rest." 

A voman, aged seventy-four, came under my care June 27tb, 1860. 
Twelve months previously she noticed that her urine contained blood, 
which was sometinies bright, sometimes dark and coffee-colored; there 
was also great pain, extending up to the umbilicus, of a " cutting " or 
"twisting" character. The urine seemed to scald the external parts, and 
she had great irritability of the bladder, passing urine every five or ten 
minutes. These symptoms bad continued with increasing severity up to 
the time of admission. She had become very thin, and had lost her appe- 
tite; she slept very badly, and her bowels were usually confined. There 
WB« alight tenderness a little to the left of the umbilicus, and on deep 
pressure towards the left loin, but no pain in the loins or evidence of dis- 
ease of the kidneys. The vagina and vulva were healthy, except that 
there was a small, but not painful, growth at the meatus urinarius. There 
was no tenderness over the bladder or in the vagina. No calculus existed 
in the bladder; the urine was ammoniacal, and contained phosphatic de- 
posits, with blood and muco-pus; no cancer cells could be detected in it, 
Kectum healthy. There were one or two enlarged and rather hard inguinal 
glands on the right side. On .funo 28th she was ordered an injection of 
fifteen drops of the sedative solution of opium in half an ounce of mucil- 
age. The bladder was emptied of its urine by the catheter twice daily, 
and the injection then thrown in. Five grains of Dover's powder were 
taken three times a day. Almost immediately uhe began to be relieved, 
and this is the report of her condition after four days of this treatment: — 
"The urine has now become clear and free from blood and pus, and on one 
occasion was neutral. She still has some pain during and after micturi- 
tion, but the bladder is much less irritable; she can now retain her urine 
sometimes for an hour." This patient was linally much relieved by the 
opium injections. 

This, then, is a case indicating the value of recognizing the anatomical 
distribution of motor and sensitive nerves, and of employing local anics- 
thetics. There is nothing more remarkable in introducing opium into an 
inflamed and irritable urinary bladder, to relieve it.s irritability, than there 
i« in applying a hemlock poultice to an inflamed joint to reduce its sensi- 
bility, or a belladonna plaster over the exterior of a painful shoulder, or 
dropping a solution of sulphate of atropla upon the conjunctiva to relieve 
the pain and muscular contraction of the iris in iritis. All this is done 
upon the same principle, and is based upon the recognition of the same 
anatomical and physiological facts. 

Again, if a man is suffering from acute gonorrhoea, he is likely to have 
retention of urine from contraction of the muscles or muscular fibre of the 
urethra, or he may experience a very violent erection. What does all this 
mean? Merely that the same nerves which supply the lining membrane 
of the urethra supply the muscular walls of the urethra, as well as that 
muscular apparatus which, by acting on the venous circulation of the penis 



158 0]!r THE THEEAPEtTTIC 

at its root, tends to produce a, congested condition, or a. fulness oF the 
penis. The irritation in the muoous membrane manifests itself by spasm 
or contraction of the muscles of the urethra, so as to induce spasmodic 
stricture and retention of urine, and interferes with the return of blood 
from the penis, so as to cause distention of the organ or a slat* of semi- 
erection. How frequently we see a. spasmodic condition of the urethra 
supervening upon old organic stricture, and causing retention of urinel 
No doubt It depends upon irritation, beginning with the urethra behind 
the stricture, which exerts its influence, first upon the nerves of sensation, 
and thence upon the musoles of the urethra, through the excito-motor 
function of the spinal marrow. Large doses of opium relax this muscular 
spasm, and the patient is able to micturate. 

We see this condition of the urethra and penis partially displayed S 
the case of fracture of the spine in the dorsal region, when a portioM 
the marrow is left uninjured below the fracture. In such cases, by B 
peatedly pinching the skin of the penis or scrotum, you may produce a spT 
modic oontraotion of the muscles of the urethra and penis, and a futoi 
of blood in the penis, so as to inake it resemble an imperfect ereetionj 
priapism. The pudio nerve, which is distributed to the mucous membn' 
of the urethra, supplies the muscles of the penis, the skin covering thei 
and the penis itself. It is the friction upon the nerves of the surface of 
the penis which induces the erection and emissions associated with sexual 
intercourse, or with masturbation, by exciting associated muscular con- 
traction in the muscles of the penis. 

Surgeons are often consulted regarding onanism and its treatment, and 
it is a very important matter. It is a habit very dillicult to coTitend w ith- 
in practice. I know of no way to prevent onanism except by freely bltt- 
tenng the penis, in order to make it raw, and so sore that it c&nnoc f^ 
touched without pain. This plan of treatment is sure to cure onftitiil 
I have adopted it during more than twenty years. Gentlemen have a 
to me and said, " I have for many years suffered from this abomiiu 
disgusting habit, and I have tried to cure myself of it, but I cannot; 
my morbid inclination overcomes my disgust when awake, and when a 
I think I am sometimes pursuing it. Can you ofler any sugcestiona'^ 
I have said, '' Paint this strong solution of iodine over the whole of tw 
skin of the penis every night; and if that does not make the organ too 
oore for you to touch it, then apply in the same way a strong blistering 
fluid to the penis," The result in practice of my cxjierience has been that 
in almost every instance the continuance of the habit has thus been e 
tirely prevented. 

Here is a case which bears on this subject. The notes are from t 
patient's surgeon, 

" W. B , aged fifteen, is one of eight children, all of delicate o 
Btitution. After repeated exposure to cold and wet, he called i 
surgeon Sept. 4th, 1800, compltiining of pain in the sucrum 
aud thigh. He was relieved by purgatives and salines. I saw hin 
Sept. 11th, with both knees flexed, and complaining of great pain in 
lower part of the sacrum, with so much tenderness as to l>e unable to ■ 
down. The left thigh and leg were very tender, and there v 
tenderness of the surface all down the spme. No local indications of h 
in any of these parts; bowels constipated; tongue coated. Ho was ( 
dered cathartic pills, colchicum, and an aperient mixture, in strong doi 
crotoD oil and tartar emetic liniment to be rubbed along the dorsal t 
lumbar portion of the spine. Within a week there was great pain a' 



INFLUKIfCE OF BEST. 



159 



the cervical portion of the spine, extending to the left arm. Saj-s tho 
motion of the shoulder is very painful; elbow free; left hand closed tightly, 
' uid any touch either of the fingers or wrist caused him great pain. Slight 
pressure anywhere on the spine produced great pain, according to his own 
state ment. 

" Sept. 19th. — Left hand firmly closed; both thighs drawn up; knees 
bent, and cannot be extended; toes of left foot inverted, and whole limb 
very sensitive. The mouth la closed for a few muiutes two or three times 

"This went on till Oct. 3rd, when a physician from London saw him. 
This gentleman, in consultation, thought that he recognized an important 
pathological state of the brain or spinal marrow, and pointed out with 
great precision the pathological anatomy which was sure to be found at 
the expected post-mortem examination. This prospect made the friends 
of the patient very anxious indeed. 

"On October 7th he was no better; head symptoms were now added, 
and for a minute or two he became unconscious. 

" 11th. — No better; valerianate of £.iiic, with compound rhubarb piils, 
quinine, &c., were continued. 

" I'Jth. — Consulted with the physician again; fits and trismua worse. 
He was ordered to have bichloride of mercury, iodide of potassium, and 
bwk." 

30th. — As the patient was getting worse I was requested to see him. I 
found him sitting in his chair, the left fcjreann flexed, with the left thumb 
turned inwards towards the palm of the hand, and the lingers flexed over 
it; his face (lushing very readily. The skin was cool, and there was no 
thirst. The pulse was not quick, but the heart was very excitable; the 
tongue clean; the pupils dilated; skin exquisitely sensitive to the touch 
when attention was directed to that point, hut not when the mind was 
diverted from it. The contraction of the Umb and hand was constant, 
bat could be overcome by persevering efforts on my part, giving way very 
suddenly. The spine waa tender the whole of the way down. I requested 
that he might be denuded. The penis was very sensitive, and the prepuce 
prolonged; the genital organs were cold, but highly sensilive; tho hands 
were cold and damp. He liad insisted on sleeping b}' himself, and in hav- 
ing a room to himself. The patient watched especially mv examination 
-of the genitals, and when I at that moment looked at Iiim seriously, 
averted his face as if ashamed. I felt coni-inced that the whole of the 
symptoms were the result of onanism. 

On October 30th I insisted upon his not sleeping alone, so that he 
might not be able to continue his habit unobserved. I ordered five grains 
of mercurial ointment to be rubbed once a day into the axilla, so as to 
divert his mind from tho thing 1 had in view, and 1 desired that a blister- 
ing fluid might be applied to the penis every night. In about three or 
four days the hands relaxed and opened, tjie legs remaining contracted; 
this contraction continued during sleep. The trismus persisted, but with 



I 



longer periods of muscular relaxatic 
small doses of morphia were given : 
the 20th of November. The mouth 
the mercury. The ointment w 
to tlie penis was maintained. 

Nov, 33rd.— This is the surgeon's report: Thi 



The blistering was continued, 
night, and the ointment used till 
as a little sore, having been made 
then omitted, but the application 

&o., continued 
t31 to-day, and to-day the trismus lasted longer than at any former time. 
He suddenly oi>ened his mouth, regained the use of his legs, and no re- 



160 ON THE THEBAPEUTIO 

lapse occurred. Subsequently a mixture of strychnia was given twice a 
day. 

I afterwards received this letter respecting the case from his sur- 
geon : — 

"My dear Sir, — Young B is and has been quite weU; he is now 

in London. He was cured by the end of last November " (one month 
from my visit). " A slight gleet remained for months after; I did noth- 
ing for it but cold baths, &c. The application I painted the whole penis 
well with was the compound tincture of iodine, made stronger by ten or 
twelve grains of iodine to each ounce. It * touched him up well,* I can 
tell you; but I don't think the friends ever had any idea what we consid- 
ered the cause of his illness." 

Here is a case, then, which bears upon what I have said — viz. that 
the same nerves which supply the skin supply the mucous membrane and 
the muscular apparatus of the penis — and which shows how a knowledge 
of anatomy bears upon practice. Not long after I had visited this young 
patient, a gentleman called upon me. When he came into my room he 
said, "You have performed a miracle, sir." "A miracle!" I said; "you 
really take me by surprise. What do you mean?" "Why, you cured 

young B ; he is quite well, and at school. Dr. said he would 

surely die from fits resulting from some constitutional influences inherited 
from his father and mother." I assured him that what I had done was 
no marvel ; that I simply acted upon common sense, experience, and phys- 
iological deduction. W ith that assurance and explanation he seemed to 
be satisfied, and so was I. 



INFLUEMOE Qj!" BEST. 



LECTURE XII. 

Irritstion ot Unoone HembraDe of Urethra aod Vo^iia — CompitratiTe Inssunhilit; of 
Upper Portioa of the Mucoaa Membmnf of ihe Hectam, lUoBtrated by Coses of 
Cancer. Vaaoulor Growth, and Overloaded Colon — Qient Sensibility, Difficult 
IMIatation, and Enduring Power of (.'ontcaotion. tbs (.'horncteriatios of Lower For- 
tiOD of Eeotam— Ulcers of the Heotam Cured by UechactciU nnd FbyBiological 
ResC^Anatomiuat ReUtions of the Seivea. Muticlea, and Uucons Membrane u( 
AnuH — Arterial Supply of the Bectnm — Arterial Association of Tarioas Parts of 
the Body— Enlnrtred Lymphatic Glanda near the Rectum — Sympathetio Pains 
Prodiicnl by Anal Ulceration — Division of Nerves and Miiscnlnr Fibre in these 
Cases — Anal Ulcer Producing Retention ot Urino and SyrapWrns of Prognanoy 
Cured by Dividing tbo Sphincter— Anal Ul<!eration Treated by Divinion of Spbino- 
ter — Intestinal Obstruction Treated by HeuhanicaJ and Phydologicot Hest. 

Towards tlie conclusion of my last lecture, I directed your attention to 
the physiological relation of the free surface of mucous membranes to the 
muscular fibres surrounding them, and I intimated that, as regards the- 
urethra, we could recognize that nonnal association causing, through the 
medium of the nervous system, certain symptoms, such as spasmodio 
stricture of the urethra, and of erection during gonorrhcea. In allusion, 
to the same eubject, I may now add, that cases of chordee, accompanied 
by a twisting or bonding of the penis, or by a lesser degree of fulness of 
that organ on one side, may depend upon one side of the urethra being 
more irritated than the other. 

The condition which is met with in gonorrhcea, and known as chordee, 
owes its origin at different times to different causes. In all of them there- 
is liable to be a twisting or bending of tie penis. In one set of cases this 
occurs very suddenly, and is due to spasm of the muscles which control 
the blood supply ot the organ, tliis spasm being in its turn caused by irri- 
tation of the pudic nerve, which supplies alike the erector penis and the 
irritated and inflamed miicous membrane. Another such condition, like 
the 6rst sudden in its onset and temporary in its duration, occurs espe- 
cially at night, and is due to something very like excito-motor action 
residing, and at this time aroused, in the cord, now that it is deprived of 
the control of the brain, the patient having usually just fallen asleep. 
The above cases are those which are relieved, as previously stated, by 
opium. 

Another condition, though described by the same name, is quite dis- 
tinct in its origin from the above. It is that twisting or bending of the 
penis which is brought about by effusion of inflammatory products into 
the corpus spongiosum; this condition often lasts some time, and may be 
very obstinate. 

We all admit empirically the physiological relation of the mucous and 
muscular structures when we treat such cases by the sedative influence of 
opium. I will relate an interesting case as illustrating the contraction ot 
the muscular walls of the vagina caused by exposed nerves upon its sur- 
face. In November, 18)30, I had occasion to see a lady who had been, 
and was then, suffering exquisite pain and sensibility of the vaginal sur- 
11 



ON THE THKBAPEUTIO 



163 

f&ce, and distressing cnntrartion of the siirrounding muscular walls. She 
had been married during twelve years, but had never hud complete coital, 
and coitus only very rarely, and with extreme sufEeritig. She had been 
under the professional care of many physicians and surgeons for the relief 
of her distressing state. A fortnight before my visit to Iter, a sui^^eoti 
had given her chloroform to inaenaibility, and used great mechanical 
force in ordi?r to dilate the vagina. I examined the vagina with care, 
and found sei-eral raised papilliE, or tubercles, exquisitely tender, so len- 
der that she could not bear their being touched. Dr. B, Hicks aubsc' 
quently examined her, together with myself, and we noticed that nierely 
blowing air upon tiie parts gave her exquisite pain. Chloroform was ad- 
ministered, and we removed the sensitive tubercles, and brought them to 
Mr. Quekett for his microscopic examination. Mr. Quekett explained to 
mo that he had found that the papillte were denuded of the natural 
amount of epithelium, and that exposure of the nerves running into thrm 
was the explanation of the highly sensitive character of the surface of ihe 
vaginal mucous membrane. The mucous mcniLrane ard the musrles 
being supplied by the same nerves wilt explain the extremely contracted 
condition of the vagina. For some time after this tipera)icn the ratipnl 
■was considerably relieved. For the purpose of asecrtaining whether the 
was much relieved permanently, I saw her a Ehort time since, and she ad- 
mitted that she was somewhat better, but not decidedly cured. This cnn- 
dition of the vagina has been described by the general 
mua, or some such name. The explanation w' ■ ' ' ' 
the only one that I can arrive at based on i 
irritation and nervous association sliould not b 
cause and effect in such a case. 

I now proceed to the consideration of the 
rectum. First I would allude to its want of se 
except at its lowest part near the anal apertu 

Accounting for the absence of pain and irritation from the almost dcy 
hardened fieces frequently lying there for a considerable time, and dis- 
tending the gut. The combination of little eensibility and great disten- 
sibility causes no direct warning or prompting by pain fo fstients except 
when the distention is extreme, or the mucous membrane irflemed. The 
anatomist and the surgeon may, 1 think, make a very decided end practi- 
cally useful distinction between the upper two-thirds or irorc, and the 
lower part of the rectum. The upper part manifests great disiensibility 
and scarcely any sensibility, while the lower portion prsBesEca extjuisite 
Bensibility, associated with great muscular force, which resists distenticn. 
Diseased conditions of the upper, middle, or lower port cf the rectum, 
except the last inch or two, induced but little pain. Hence cancer, ordi- 
nary ulceration, polypus, extraneous bodies, vascular tufts, or other dis- 
tnrljing causes, may exist above the lower two inches without cuusirg 
pain. I have often seen these observations confirmed by patients, who 
could scarcely believe it possible that they could have so senous a disease 
Bscancerof the rectum without feeling pain. Some time since a gentleman 
came to me in great mental distress, looking dreadfully depressed in 
spirits, He said, " I have been told that I have cancer of the rectum, and 
am sure to tHe soon. I do not feel any pain, and I can hardly believe it, 
for I never heard of cancer without pain." I examined the rectum, and 
found cancer clearlv enough, three or four inches above the anal aperture, 
and told him so. lie was rather angry at me for confirming the opinion 
of his surgeon. Experience, however, compelled me to force my com ' 



ich 1 have now offered is 
lorbid analcmv. Ovarian 
overlooked wliile I racing 



mbrane of the 
isibility in a healthy state, 



1 



INFLUENCE OF REST. 1G3 

sion upon him, notwithstanding his freedom from p:Lin. I know a gentle- 
man who has had cancer of the rectum live years without pain, and he 
still pursues his daily occupation. If remote pain or cramp in the lower 
extremities be associated with cancer in. the rectum, it is a bad indication, 
because it is suggestive of a direct encroachment upon some of the adjoin- 
ing- nerves, either by implication and enlargement of the glands, or by 
aiiDple extension of the original disease. 

I may mention another case illustrative of the slight sensibility of the 
upper part of the rectum. About fifteen years ago I saw a lady, with 
Mr. Prance, a surgeon at Hampstead, w}io had been for some time annoyed 
by something in the rectum. There was no distinct or painful sensation, 
only some uneasiness, with occasional loss of blood from the gut. She 
had noticed a groove or longitudinal depression upon her fi^ces. We ex- 
amined the rectum by the aid of a long narrow glass reflecting speculum, 
and we found, about four inches from the anus, a vascular growth, pro- 
jecting into the gut from its posterior aspect, which explained both the 
impression made upon the fieces and the cause of the hiemorrhage. I ap- 
plied strong nitric acid to this growth in the rectum through the glas 



speculum. After several applications, we ultimately cured it by sloughing. 
It was noted at the time that the nitric acid did not produce pain, but 
only a sense of extreme heat in the intestine. 

Puncturing the urinary bladder by the rectum is almost painless, and 
nitric acid applied to prolapsed gut produces but little pain if neatly done; 
on the other hand, if the acid be carelessly applied, and runs over the 
edge of the sphincter, then the patient suffers extremely. Distention of 
the rectum by fitces does not cause any pain to the patient. 

Thus I remember, on one occasion, seeing the wife of a surgeon who 
had oedema of the left leg. The cause of this had to be discovered. It 
was produced by a loaded colon and rectum, which explained the whole 
thing. I occupied two hours on two separate occasions scooping out the 
s, and at length succeeded in emptying the rectum. She could not be- 
BoTon and rectum could be s 



lieve that her colon and rectum could be so overcharged without causing 
pain or inconvenience, more especially as she had had her bowels slightly 
relieved every day. I mention these few cases simply to illustrate the 
practical relation of the little piece of physiological anatomy to which I have 
allnded. Little sensitiveness and easy dilatability are the physiological 
characteristics of the rectum, except at the lowest part, where great sen- 
sitiveness, little dilatability and enduring power of contraction are the 
normal physiological features. These natural local peculiarities should 
bo borne in mind both in forming a diagnosis and in considering the prin- 
ciple of treatment to be adopted in any case. The strength and endu- 
rance of the anal sphincters are well cxemplilied by their successful 
d-ntagonisra to the peristaltic action of the colon and rectum upon large 
quantities of fluid or solid feculent matter, constantly gravitating towards 
iJieanal aperture, guarded by the watchful sphincters. Who ia there that 
has not felt this kind of competitive struggle, this intestinal warfare going 
on within himself, fearing the Issue, and has not been thankful for the 
result, and full of gratitude for the enduring strength of the little indom- 
itable sphincter, which has averted the possible catastrophe? 

Simple ulcfr in the rectum, extending upwards from one inch above 
the lower margin of the infernal sphincter, m^ be spoken of as capable 
of being cured by physiological rest alone. Here is a case in point. A 
married lady, strong and healthy about thirty-six years of age, had 
enjoyed remarkably good health up to the summer of 1859, when her 



'3 



164 ON THE TUKEAPEUTIC 

towels licf^ii to be eonstipated, and eho had aome pain in passing 
motions, followed by it small quantity of blood. In August, 1853, the 
pain was so severe and constant that sho could not ait on a chair without 
great suffering, the pain being much increased after defecation, and con- 
tinuing during many hours, although she placed herself in a recumbent 
position, that being the one wlucJi seemed to suit her best. She had 
decided difficulty in micturition, and pain over the posterior part of the 
sacrum; her menstruation was healthy. She was advised to take " warm" 
purgative medicinesdaily (I suppose the term warm was employed that thi 
niiglit be considered the more inviting), to use fomentations to the i 
and to be careful in her diet. She strictly adhered to this advice 
the spring of 1860, suffering more or less the whole time. She had ni _ 
tinct purulent discharge from the anus, but thought she saw some matter 
occasionally with the motions; very small quantities of blood were com- 
monly mixed with the fteces. In April, 1S60, being then a great sufferer, 
she applied to a physician in my neighborhood, who examined her rectum, 
and treated her for piles, without any improvement in her symptoms, 
until the middle ot June, ISfiO, wlien, by the physician's advice, she con- 
sulted me. I passed my forefinger through the spasmodically constricted 
or tightened sphincter without giving her much pain, nor did I induce 
any pain by pressing my finger carefully and with attention over the 
whole of the inner circle of the sphincter, the ordinarv seat of painful 
ulcer. This freedom from pain induced mo to believe tliat there was no 
ulcer directly within the pressure of the sphincter. Extending the finger 
into the rectum, I found I gave the patient some pain by pressing upon 
the gut towards the sacrum, and on withdrawing my finger there was 
some blood upon it. I then introduced the small reflecting speculum, cut 
obliquely at the end, and, on directitig it towards the sacral aspect of the 
rectum, an ulcer was visible, ovoid, but irregular in form, its margii 
little thickened, with its long axis placed vertically. It waa about 
inch and a quarter in length, and three-quarters of an inch in wddth at il 
videst part. The lowest part of this ulcer was placed a full inch aboi 
the sphincter of the anus. All the painful symptoms before alluded '' 
were still in existence. 

I would most urgently press upon your attention that these cases 
■ to be treated by simple mechanical and physiological rest. I therefore 
[ requested her to be nearly always lying down, to eat no hard indigestible 
food, to live chiefly upon good and often- repeated fluid nourishment made 
from meat, plenty ot milk, with some lime water: to take, if necessary. 
the confection of senna, with bicarbonate of potash, in the middle of the 
dsy, in order to soften the motion, anti to secure relief from the bowels 
just before going to bed, she was also directed to use a warm'water enema 
everv night. After the bowels had bt^n freely relieved by these means, 
OTie large table^poonful of dr-cix-tion of starch, with twenty drops of the 
aedative solution of opium niixwi with it. was to be thrown into the rec- 
tum, to remain then-, Krvm the first time this injection was used she 
began to be relie%'ed fnun bc-r symptoms. All my recommendations were 
very carefully carrit'd out. At th^ vJcpiration of a tortnigbt ahe came to 
town again, ch«>rfu! and {tv« front anxi<-ir. She waa tree from pain 
I excepting occasionally, and she told nw she thought she was well. I 
examined the rectum again with the sprv-ulum, and saw the ulcer reduced 
to ^ort and narrow cUin<-nMons, and cir>atritiag bealihily. I persuaded 
her to continue the saow plan of ln<atnM<nt for «n<rtf>er fortnight; at ' 
expiration of that lime ma ouw to m* ^t« w«U ia «very respect. ' 



I 



J 



INFLDENOE OF BEST. 

introduction of the finger gave no pain, nor was ic followed by any blood. 
Tliis lady continued during several months perfectly well, since which 
time I have not seen her. This is a case, I think, cured Bimply by mechan- 
ical and physiological rest. It is not too much to say that she was cured 
in one month, after n year of suffering and unavailing treatment. 

To show the relative value of this kind of soothing treatment as com- 
pared with that by local irritants, let tne mention another C; 
tleman came to me on the 
i:th of September. 1S61. I 
well recollect the day, because 
1 was cold and shivering from 
an attack oE ague caught in 
Holland ; I was angry, ill- 
tempered, and felt very un- 
comfortable. The patient was 
between sixty and seventy 
years of age. He told tne 
that he had suiTered much 
pain in his rectum, and that 
he had been under the con- 
joined care of two surgeons, 
who had assured him that he 
had not any cancer, but they 
oonld feel and see an ulcer in 
his gut, to which they had 
applied, in the fonn of injec- 
tions, solutions of nitrate of 
silver, sulphate of zma, sul- 
phate of copper, and some 
preparation of lead. He 
added, " I must honestly tell 
yon that although 1 have ta- 
ken an immense (juantity of 
medicine, I um a great deal 
worse than when 1 went to 
them." I proposed to e 
his rectum. " No," he said, 

"yon must not examine me; I won't be examined any more. 
suffered so much already from that speculum." I said, " Vou 
foolish; 1 cannot tell with certainty what is the matter till I ha.\ 
ined you." But he would not permit any examination, and 1 was very 
angry with him. I advised him to get his bowels well emptied every 
night, just before going to bed, by large common gruel or warm-water in- 
jections; after that to inject twenty drops of sedative solution of opium 
mixed with a solution of starch. 1 finished by saying, *' Let me see you 
two or three weeks hence." "What," said he, "no pills?" "No." 
•■No medicine?" "No." "What, nothing at all?" "Ves," I said; 
"do not neglect your diet, take care that the ficces shall be soft and 
small, and not hard or massive." "What, nothing but that?" "No, 
nothing." He and his son then went away, and, feeling ill, I was very 
glad when they were gone, i scarcely expected to see this patient again, 
but towards the end of October, that is, in about six weeks, he called 
again, to inform nie that he had felt quite comfortable ever since his 
former visit, by only doing what I had told hiin. Now here was a case in 




(4tb) U|i|<lflll« Illi; 










rita- 

i 



ON TUE THEIliPEUTIO 

point. Thia man'a rectum had baen paiiiful for nearly three months; 
aides tho almost constant use of purgative medicines, two or three th 
& week he was examined by a speculum, and had injections of nitrate 
silver, or sulphate of ainc or copper, and all that sort of thing, adding, 
believe, to the local irritation, until his condition was hardly endurable? 
'By the simple means that I have mentioned he was at once improved. 
So far as I know, he was cured hy the method of physiological rest, as 
opposed to violence or physiological disturbance. I merely mention these 
facts as suggestive of the 
adoption of a plan of treat- 
ment by rest and quiet 
preference to one of irriti 
tion. I am further able 
state that this patient 
mained free from any 
quent trouble with regard 
his rectum up to the time 
his death, which took | 
in 1874. 

I would now solicit yoni 
attention to the anatomy of 
the immediate neighborhood 
of the anal aperture. I would 
refer to it only in regard 
tho muscles, blood -vi 
lymphatics, and nerves of 

This drawing or dia( 
(Fig. 51) represents the 
aperture, with its associi 
y,o. ta. muscles and nerves, 

ding sacral and pudio bi 
ofaes ; some of the latter are shown as perforating the muscular fibres 
reach the subjacent mucous membrane. 

Here is another drawing (Fig, o:i), which to my mind is of great ii 
eet, because it exhibits one of the important landmarks capable of 
ing tho surgeon in his operations. If you ask a surgeon, " Where ar 
going to cut to divide the sphincter of the rectum ? Have you any 
to direct you?" "No, none at all." But I think this wiU 
purpose. Fig. 52 represents tho lowest part of the rectum laid open, i 
Its walls partly exposed by dissection (c) ; a white line (/), which in 1 
living subject any surgeon can recognize, shows tho junction of the a' 
(o) and the mucous membrane (A), That white line corresponds e 
with the linear interval between the external (fi) and internal sphin 
muscle (fl. It is an important la,ndmark, exact and truthful, so that J 
can be relied upon. The circular fibres displayed abovo the line form tp 
lower portions of the internal sphincter fibres, which gradually b 
more attenuated as you trace them upwards within tho walls of the g 
The levator ani (.7) is seen in section on each side, in a position exte 
to the sphincter muscle. 

The special object of this drawing is to show the precise line of junc- 
tion or demarcation of the internal and external sphincter of the anus, and 
exactly corresponds (I have tried it several times) with the white , 
"' skin and the Internal mucous membrane. ^M 



of junctiot 



INFLUKNOE OF REST. 



ir.7 



had long ago traced the nerves through the walla of the put; from wlicnce 
some went to be distributed downwards upon the skin close to the ajiua, 
and others reflected upwards to the mucous membrane. I was fumiliur 
with that atiatomical arrangement, but I wua not acquauited with what 




n«l 
















nd >iAialnl 








































































o ^hlnolen. ud 




« 1 


JiKTl 




ion Itifl 





Fig. 53 8o clearly displays, viz, that filaments of nerves (and they are very 
numerous), derived front the pudic, and possibly from other nerves, pass 
throufh the gut exactly between the internal and external sphincter, 
therefore exactly underneath that white lineof union of mucousmembrane 
and skin, and thence some proceed upwards towards the lower part of the 
mucooB membrane of the rectum covering the internal sphincter, and 
others proceed to the skin near the anus. 

Ill order to complete the nerve anatomy of this part, which requires 
to be well considered for the purpose of explaining the varied nervous 
sTtnptoins which may be induced by an ulcer within the rectum and near 
tne anus, I have made (Fig. 64) a rough map of these parts, with an ulcer 
depicted upon the surface of the sphincter. Two lines indicating two 
nerves are seen directly communicating^ with the ulcer, and the arrows 
point to the fact that the sensitive nerve conveys its influence from the 
surface of the ulcer to the spinal marrow, and that the other, or motor 
branch of the same nerve, conveys motor power from the s|>ina] 
marrow to the sphincter muscle; thus explaining how the excitation or 
irritation engendered at the ulcer may be conveyed to the spinal marrow, 
and produce reflected efllects upon the sphincter muscle, leading to painful 
contraction. I would further notice that this "sign-post" map tells ua 
that the pudic nerve, which supplies the portion of the anus upon which 
the ulcer is placed, is intimately associated with other nerves arising from 
, the lower part of the spinal marrow. It also shows that some of those 
associated nerves go to the lumbar region, some over the hips, some down 



ON THE THEBAPKUTIO 

the leg, and others to the uriiiorj' bladder and urethra. It is an indispu* 
table fact that these anal ulcers cause lumbar paina, iliac pains, pains and 
loss of sensation, or cramps, in the leg', and irritation about the bladder 
, and urethra. These symptoms cannot be explained, except under the 
title of " anomalies," unless you choose to refer to the nerve anatomy of 
the part, when the explanation Is made easy and sufficient. 

Sir. Quain has shown that the upper part of the rectum receives a 
comparatively small quantity of arterial blood, while the lower part of it 
is very freely supplied, and this forms an important difference. I hope 
I may here be indulged with a short digreasion, with the view of alluding 
to the great precision which marks the supply of arterial blood to some 




I. E4.— a.U1nrnn opklnd 



jT motinn. b^h uluetift! to the HpliuL oi 



parts of the body. I might put the subject before you in thii 
and ask. Why should not Uie whole of the rectum be supulied with blood 
from the inferior mesenteric artery ? At first tliought there appears fo 
be no reason why that artery ejiould not carry the blood downwartis to all 
the lower part or the rectum as well as to the upper. Yet it is not so; the 
lower part receives its arterial supply almost exclusively from the pudic 
artery. A very few branches may be traced from the inferior mesenteric 
and middle sacral to join the pudio, but the chief supply is derived from 
the pudic arteries, which thus bring the neck of the bladder, the perineum 
and the urethra into intimate structural association with ihe rectum. As 
1 think this kind of definite distribution of arteries is a point not suffi- 
ciently dwelt upon, allow me to remind you of a few illustrative inslnnccs 
observed in the human body. Take, for instance, the ctpUac artery, 
which is distributed to the organs of digestion, and nothing else: it sup- 
plies the liver, stomach, pancreas, spleen, and part of the duodenum — that 
IS all that it does. As these are all organs connected with the process of 
digestion, the cceliaa artery might well be called the " digestive artery," 
Take another illustration: the os hyoides, placed between the larynx and 
the pharynx, is functionally and structurally associated with both, fiocs not 
anatomy tell us that the os hyoides receives a. hyoidal branch frcin the 
superior laryngeal artery, and a hyoidal branch from the lingual artery on 
each side ? Is not the os hyoides connected with the functional and struc- 
tural integrity of both the larynx and the tongue, intimating the reason 
of the double source of arterial blood for its growth and nutrition ? There 
is a disposition on the part of anatomists to think and to teach that 
nerves are distributed with designed accuracy, but that there is very litl 



] 



^ 



INFLUENCE Of BEST. 169 

design in the distribution of the arteries. I opened this subject many 
•years ago, when endeavoring to explaiu to the students of Guy's Hospi- 
' tal the purpose of the division of the subclavian artery into its numerous 
branches. I pointed out that the branclies distributed from the sulicla- 
vian trunk, apart from its continuation to the upper extremity, are dis- 
tributed with one simple purpose, viz. to supply all the parts concerned 
directly and indirectly in the process of respiration — that is the simple ob- 
ject of the distribution of the subclavian artery. Thus: — 

The vertebral, besides supplying other parts, is distributed to that por- 
tion of the spinal marrow from which the phrenic, spinal accessory, and 
posterior thoracic — all important nerves of respiration — take origin. 

The internal mammary supplies the sternum, cartilages of the ribs, 
orif^n of the pectoralia major, phrenic nerve, diaphragni, and the upper 
half, or the respiratory portion, of the abdominal muscles. 

The superior intercostal artery goes to the first and second ribs. Now, 
the first is the most important of all the other ribs in the respiratory func- 
tion, as it forms the lived point for the actlou of the intei'costal muscles 
in elevating the chest. 

Of the branches of the thyroid axis, the inferior thyroid builds up the 
trachea, a tube essentially connected with respiration, and sends a branch 

E wards (ascending cervical) which accompanies and nourishes the 
renic nerve and constitutes, in fact, an ascending comes nervi phrenici. 
'be transverse cervical supplies the trapezius uud the posterior border of 
the scapula, with the muscles attached to it, all of which may be consid- 
ered accessory to respiration. The su pra -scapular supplies the clavicle 
and scapula, both of which are rendered respiratory by the attachment 
they give to accessory respiratory muscles. 

Look at the arterial distribution of blood to the soft palate derived 
from several different sources. The soft palate is functionally connected 
with respiration, deglutition, and mastication, so we ought to discover that 
ita arteries are derived from the trunks of those arteries which suDpIy tha 
face and lips, those which supply the maaticatory apparatus, and the walls 
of the pharynx. Curiously enough, this soft palate receives six arteries, 
three on each side: one from the facial, the ascending palatine, which 
■eems to take a wandering, devious course up to the soft palate; one from 
the ascending pharyngeal artery; and one from the interna] maxillary, 
the true " masticatory artery: "* each of these trunks sends a palatine 

* Ur. Hilton, in his Lfctores on the Cnuiium, epenks thu^ of the coiltM of oa« or 
two brandies of the internal maxillary Hitery which at tirst eight Aeema to baTO notb- 
ing to do vith maaticatioii ; and Rrst of the courtie of tbe middle meningeal to the 
interior of the ekutl : " If iC were out; (or the sake of a snpplj of a certain qaautitjr 
of blood to the dura mntec. the spacial inCra-oranial Brteries. vix. the two internal 
oarotidB and the two vertebralH, would be amply snfHcient for this purpose, and there 
would b« no necessity for the entrance of thoae streams that are derived from veasels 
mpplying; parts on the eitf rior of the xkalL There must, iherefore, be Home design 
insndian arraagrement. The essential purpose of the interoal maxillary arteiy is to 
build op or uaniinh thotie parts directly ueoepsary or aocesaory to the prociiBO of masti- 
catioit, HO that it may be fairly colled the inasticatory artery. From this trunk ii 
derired tbe middle meningeal artery, whioh, whilst tamifying in the dnia matel, j^vea 
branches ontwords, that sapply tbe sqanmous portioa of the temporal, tbe greater 
icing of tbe sphenoid, the frontal, and the parietal boaes ; those bones, in foot, which 
ooolribute to form the temporal fossa, tbe chief origin of the temporal muscle, one of 
tbe most important agents of mastication. It also gives a branch inworda to develop 
and maintain that otber portion of the greMi wing of the sphunoid wbiob gives origin 
lo the external pterygoid — ^anothcr jiiipartanC muscle of masiicution. Tbe middle 
meningeal artery, therefore, may be said to be sent by tlie intoniul muxillary into tbe 



170 



ON T It ic T It :■; U A P E U TI c 



branch to the soft palnte. Here, then, is a BiinplQ piece of anatomy, 
which shows the precision and purpose of the distribution of arteries 
which seem to be associated with three different important functions: one 
in relation to respiration, associated with the muacles of the mouth 
derived from the facial artery; another in relation to deglutition, receiv- 
ing its supply from the ascending pharyngeal artery; and a third in rela- 
tion to mastication, receiving its supply from the masticatory artery. 
This digression opens an interesting topic as an appendage to the reaai 
why the lower part of the rectum should be supplied with biood from ti 
piidic, and not from the inferior mesenteric artery. 

The lymphatics of the rectum enter their glanda placed within the p 
vis, and sometimes lead to the inflammatory enlargement of those glan 
They can then be felt through the rectum within the pelvis, forming 
nodulated masses suggestive of malignant disease, and thus becom 
sources of great anxiety. I remember seeing, wilh the late Mr, 
Key, a private patient in whose case (chronic ulceration within tl 
tum) the greatest alarm had been expressed by another surgeon, becauae 
several hard nodular masses could be detected within the pelvis, encroach- 
ing upon the rectum, and leading liira to think that the patient was suf- 
fering from cancer. It turned out to be nothing more than swollen 
lymphatic glands in a state of eidargement or irritation, in consequence 
of their having received morbid fluid from the ulcer; and, as soon as the 
ulcer was cured, the glands subsided, and there was an end to the diffi^ 
culty. In that patient I repeatedly felt the enlarged glands, about thre 
inches within the rectum. This association of enlarged glands with ulot 
within the rectum is a point that should be borne in mind, but i 
ally overlooked. 

The pathological relation of the ulcer to the various nerves 
referred to is very clearly evidenced by noticing that the suffering of 1 
patient, from his remote sensations and pains associated with those nerv 
is relieved as soon as the ulcer is divided. From that time all those pai 
cease. It amounts pretty nearly to a demonstration that the ulcer was 
the cause of all the remote sympathetic pains propagated or induced by 
nervous continuity from the site o£ the ulceration. Physiology, anatomy, 
eTperience, and practice indicate that a patient may have pains over tbi 
loins and hips, pains down the legs with loss of sensation, puln and c 
trarlion of muscular fibre connected with the urinary and generative < 

Eans, all produced by an ulcer upon the internal part of the sphincter, I 
irgely is this supphed with nerves which endow it with exquisite a 
bility. 

Let us now apply th!^ local anatomy to explain the pathological aym 
toms manifested at the seat of the disease, as well as those remote (or i 
termed anomalous) symptoms of pain, cramps, slight numbness, and slight 

interior of the cronlam to buildup, and afterwnniH to nDuriHh, tbat portion of it* 
extent, which, in giving attnchmi^nt tn mastioator; musolcn. la teudered BnbBCrvieat to 
the moctic&tory fuucUoti. So fully, icdceil, is this intention earned oat, that a tsmall 
artery given off from the luidilla moninsaal, or the trmile at the internal niaiillaij 
ilwll, enters the oranium by the foramea oiale, apparent ty for Che exprew pnrpose M 
fuminhing nutritive materliU to the third division of the fifth— the nerve that fcupplisa 
the mniMjleB of moaUoation, Now, although the intra -aranial portion of tite tfaild 
diviiion of tiie fifth is aituated in suoh cl[>ae proximity Co the entrance of the internal 
earotid artery into the Kkull. yet it in not unpplied by this veMol. but, as wa observe, 
receive) a distinct offset from tho miisticnCory tnink. fli> that its nutrition tuay ba 
maintained in the closest possibii' relationa with that of the other » 
' taring to ^heaame funotioa." — [£t),] 





loBS of muscular power in the lower extremity, generally on the left side, 
or diffieulty in makinft water, with frequent desire, retention of urine, 
dilatation of the bladder, with pressure upon the rectum, &c. &c. AH 
these symptoms can be produced by an uleer within the rectum. The 
eharsct eristics of the ulcer within the circle of the external sphincter are, 
more or less pain when passing a motion, and severe and enduring pain 
for some considerable time afterwards. The severity of the pain is ex- 
plained by the exposure of sensitive nerves in the utcer, and the persist- 
ence is explained by the abundant supply of motor filaments which endow 
the sphincter muscle with the power to press, rub, and perseveringly 
squeeze the opposite parts of the ulcerated and sensitive surfaces upon 
each other. Reflecting- on the large amount of nerves which proceed to 
the sphincter muscle, one unJorstauds liow it happens that it is so endur- 
ing in its power. No doubt the strength of a muscle will in a great 
measure depend upon its extent or size; but the endurance of active 
power depends upon the number of nerves supplying the muscle: hence 
the great endurance of this sphincter muscle, and I know of none that 
can compare with it in that respect. The pnnciple of treatment of all the 
various forms of fissure or nicer near the sphincter is very simple, and 
usuallr effective. It is based, or ought to be, on giving the part phj^sio- 
logical and mechanical rest. To apply this to practice, the motions 
should be kept soft and pulpy, so that the sphincter may not be too 
widely opened during defecation, nor tlie ulcer exposed to the friction of 
a Ihi^ or hard motion. This is obvious common sense; the recumbent 
position should be observed, which is rest to the capillaries and veins — 
also common sense. If the case be a simple creek or fissure in the skin or 
mucous membrane, and we apply nitrate of silver or a solution of bichlo- 
ride of mercury to it, what do we do ? We form an adherent albuminous 
defence to the subjacent raw surface, in order to give it "rest," and 
Nature time and opportunity to fill up the gap by repairing the loss ol 
mbstancQ. The explanation ordinarilv givet • ■■ ' <■ ■ ■ n » 

these albumen-coagulating agents is, that 
they "set up a new action," as if the 
■gents took an active part in the repa- 
rative or reproducing process. On the 
other band, 1 believe their usefulness 
depends chiefly on their civing "rest " 
to the parts, and so enabling Nature to 
Gil up the gap. And if this be true, one 
can see how it is that the rude applica- 
tion of nitrate of silver may do liami, 
whilst the well-considered and gentle use 
of it may do a large amount of good in 
many eases. If a patient has a crack or 
fissure in the margin of the anus within 
the area of these numerous nerves, it is 
exquisitely sensitive, so that if the end 
of a probe is nressed upon it, the patient 

sometimes calls out n-ith pain; but direct- n.^nftm, ma muring at. uuupimuiir. 
ly you cover that surface with the nitrate 

of silver, the patient is free from pain. Now, what has led to the differ- 
ence? Simply that these filaments of nerves are not then exposed, but are 
covered by coagulated albumen. Thus the parts arc defendi'd from the ex- 
ternal air "and all morbid secretions, and in twenty-four hours, perhaps, that 



1 of the beneEcial influence of 




172 



ON THE THEBAPEUTIO 



crsck or fissure is healed, not by the nitrate of silver, not by the surgi 
but by Nature herself. But if you rudely apply the nitrate of silver, 
do it without a guiding principle, and will have to do it over again, and 
is not a scientific use of it. I often employ, as a local application in 
cases, a lotion composed of two grains of bichloride of niereuty, ten 
of nitric acid, and one ounce of water; this fulfils the object just as v 
nitrate of silver, since it is applied simply for the purpose of coa^ 
the albumen upon the ulceration, which acts as a mechanical di 
to the siu'face of the ulcer. 

If the ulceration, whether oval or circular, be limited to thi 
membrane, and very sensitive from exposure of nerve upon its surface, it 
may sometimes be treated successfully by the application of opium oinl^ 
ment,orbv starch and opium injections at night, or night and mornii 
the bowels being previously opened by a warm-water or a thin 
enema. For the purpose of ascertaining the sensit 
every part is not so), it should be exposed to viev 
speculum. The blunt end of a probe should the 
face of the ulceration, 30 as to enable the surgei 
point of exposed nerve, by inducing sharp pain, 
that spot, aud there apply a very small 



mina^H 




across the ulcer, yoi 



: point of the ulcer 
ly the aid of the 
be applied to the sur- 
to detect the precise 
Keep your eye upon 
ip of strong nitrio acid; the 
patient will be almost immedi- 
ately free from pain. In that 
way you may successfully treat 
a sensitive ulcer at the verge "" 
the anus, as you may best ti 
an irritable and painful one u] 
the leg; that is, by destroi 
the exposed nerve in the J 
Dividing the mucous membi 
by a bistoury is reeommeni 
by some surgpons to cure th( 
anal ulcers. How drawing 
knife across the mucous mi 
braiie of an ulcer 

; lintelligible to myself, CKi 
■I that by so doing you 
> lie nerves and destroy 
I ijiiisite sensitiveness of the _ 
ccL': but the rationale of cure by 
a simple division of the mucous 
membrane, without reference to 
the nerve, is to me utterly unii 
telligible. I do not desire to s 
presumptuously in llie prei 
of so much pn-ifessionftl < 
rience, but 1 feel con6dent 
the simple division of the mucous 
membrane, without the nerve as 
well, can do nothing curative for 
an ulcer of that kmd. On the 
other hand, when you succeed in 
dividing the exposed nervous fil- 
aments, by drawing a bistom 
■parate the ulcer from the trunk of 



I 



INFLUENCE OF REST. 

nerve, and 8o give it " physiologioal rest " by relievinj^ the pain. I must 
state, however, that in the majority of the anal ulcers which I have exam- 
ined by the aid of the speculum, the circular fibres of the sphincter 
muscle may be seen to fonn the base of the ulcer, and in such in- 
stances its edges are especially sensilive. I would have it understood 
that I do not speak with any degree of hesitation in this matter, because 
I have over and over again, by means of the speculum, seen the circular 
muscular fibres forming the base of the ulcer. I have observed them with 
as much precision as 1 see them in the diafrram before you (Fig. 56), so 
that I have not the slightest doubt upon the point. I may add, that if 
you touch the muscular part itself with a probe, it is not sensitive; but 
touch the margin of the ulcer in the same way, and the patient complains 
bitterly. It is that kind of ulcer in which the circular muscular fibres are 
actually seen, which is so successfully treated by dividing the sphincter 
muscle. 

The reason for this anal ulc«r being so very painful is the number of 
nerves associated with it; and the cause of the continued painful contrac- 
tion which accompanies it lies in the enduring strength of the sphincter 
muscle. Thus it happens that exposure of those nervous sensory filaments 
upon the ulcer causes excito-motory or involuntary and spasmodic con- 
traction of the sphincter, through the medium of the spinal marrow. 
The sphincter muscle contracts towards its own centre, and, as long as 
the muscle is in a state of contraction, it brings the sensitive edges of the 
ulcer into forced contact; this excites more muscular contraction, and 
thus, by time and exercise, the muscle becomes hypertrophied, massive, 
and increased in dimensions. It is worthy of notice that when the mus- 
cle has been divided in such cases, it soon returns to its more natural con- 
dition, by the muscular fibres resuming their natural dimensions. When 
we divide the sphincter muscle forming the base of the ulcer, what do we 
aooomplish by this ? We cause the two portions of the muscle to con- 
tract to their then more fixed points; that is, away from the ulcer. 
Therein lies the rationale of the operation so frequently performed— it 
prevents the muscle irritating or annoying the surface or edges of the 
ulcer by pressing them upon each other during its contractions. Hence 
I maintain that the sphincter ought to be divided through the centre of 
the ulcer, and then, as a rule, the operation is permanently successful. 
The treatment of such cases is really absolutely based upon bringing 
about local physiological rest, for by dividing the muscular fibre you 
merely prevent further friction by the contraction of the muscle, and, 
after a time. Nature repairs the ulceration by filling up the gap which the 
surgeon has made. 

I will now direct your attention to two or three cases Illustrative of 
the anatomical and physiological facts to which 1 have alluded. 

Case of Anal Ulcer, producing Retention of Urine and Symptomg of 
Pregnancy, cured by dividing the Sphincter Mutcle. 

The first is the case of a young lady, aged about twenty-two, whom I 
iw some years ago with the late Dr. Golding Bird. She was an excel- 
lent dancer, good company in a drawing-room, and thought to be a very 
agreeable and attractive person. Gradually she receded from that posi- 
tion in society, lying down a good deal on the sofa, suffering much pain, 
always uncomfortable, occasionally quitting the room, whether in society 

It home amongst her own relations. It was noticed that she had occa- 



J 



OS THB THEEAPEDTIO 

■jHonal sickness, menstruation was not regular, the abdomen was decidedly 
increasing in size. She became very fond of lying in bed instead of 
going to balls and dances — in fact, she said she could not dance or enjoy 
society at all — and was very uncomfortable, A surgeon was consultea, 
who, perceiving the patient's changed character, and finding the Iowar< 
part of the abdomen decidedly lai^ and prominent, mentioned a suspici 
of pregnancy to her mother. Her mother, who was personally aequaial 
with the late Dr. Goiding Bird, took her to him. He examined ber oa 
fully, and said, "She is not in the family way, depend upon it; I thil 
the symptoms arise from piles, or something wrong in the rectum," 
was under these circumstances that I was requested to examine ber. 
found her suffering from piles and prolapsed rectum, retention of ur 
nearly complete, enlarged abdomen, sickness, loss of appetite, always in 
pain at the lower part of the stomach, bowels constipated, frequent loffl 
of blood from tlie rectum, and extreme pain during and after defecation. 
Her illness commenced, many weelfs before I saw her, with great pain in 
passing a motion, and all her urgent symptoms resulted from the original 
anal ulcer. This was the order of events:^The nerves of the anus and 
neck of bladder being derived frum the same trunk-nerve — the pudii 
the nerve irritation exlended from the anal ulcer to the muscles of 
neck of the bladder ajid urethra. This caused them to contract, and 
duced difficulty in malting water, and subsequently the retention of 
The protracted distention of the bladdercaused pressure upon the recti 
interfering with the return of blood from near the anus, and this, adi 
to the straining of the patient to relieve herself, caused distention of 
rectal veins and partial prolapse of the rectum. Hence aroseall the ot 
symptoms to which I have adverted. 

I passed a probe between the projecting folds of the rectum, 
soon made out where the ulceration existed. I removed a portion of an 
external pile, and then obtained a, clear view of it, situated jost within 
the anus, full half an inch wide, and more than three-quarters ot an inch 
in length; muscular fibre formedits bsBe. I divided the sphincter muscle 
through the centre of the ulcerations, and nearly the whole of the painful 
symptoms quickly subsided, and the patient was soon well, and as happy 
and gay as ever. I have seen the lady several times since, and she hi 
remamed perfectly well. 



Case of Annl Ulcer accompaneeil bi/ Pain nlontf the Scialie Ne 
Pain over Lfjt Hip and Jjoiii, Piiin in the. Right Leg. 
of Arterial Hamtorrliaye frvm tin Anal Ulcer cured by Dim 
of the Ulcer. 



t liaA_ 

4 



one side was not relieved 
s performed. Time will 



A surgeon who had pain down the left leg o 
until the operation of dividing the sphincter v 

not allow me to dwell upon this case, i saw a case some iime since wiin 
Mr. Aiken, of Clifton Place, Sussex' Square. The patient had pains over 
the left hip and loins; he had no treatment except opium with diacetate 
of lead locally, and this without any benelit. The speculum exposed an 
ulcer about three-quarters of an inch long and a quarter of an inch wide, 
commencing just within the internal sphincter, and running directly down- 
wards; transverse muscular fibres formed a part of its floor, the other 
part was covered with granulations. The pointed bistoury passed through 
the internal and external sphincter, and, dividing the ulcer into two por- 
tions, gave him immediate and pecmauetit relief; he had no pain, ev^H 



INFLUENCE OF EEST. 

the firat tim? his hnwels were open, after the operation, Hb was kept 
rcrumhent during five or six days, and then began to move about without 
any inconvenience, Mr. Aiken saw this (gentleman the day he sailed for 
New Zealand, a. month after the operation; he was then perfectly free 
from pain. 

The next case is that of a young woman who had an ulcer at the 
antBrior part of the rectum; she had pain in one of her legs— the right 
leg. The ulcer was at the anterior part of the anus, close to the vagina, 
and it was necessary to be very cautious in dividing the muscular hbres. 
A very small knife was passed through tlie circular sphincter fibres of the 
anus, and the patient got quickly welt. 

In 1853 I saw a lady aged forty-two; formerly she had had piles which 
bled occasionally. For a year and a half before I saw her she had suf- 
fered severe pain during and after defecation, accompanied by consider- 
able arterial hiemorrhaee from the rertum, which had of late increased 
immensely. She was thought to be the subject of malignant disease in 
the intestines, stomach, or liver. A large quantity of blood was passed 
with the ffcces. The motions were white; she was in a state of advanced 
anemia. There was no bile in the motions, because she had little or no 
blood in her liver, and therefore no bile. As the patient had white 
motions, she had been treated by nitric acid and various alkalies, and 
afterwards by blue pill and mercurial ointment, to cure the supposed 
morbid condition of the liver; but the liver had no opportunity of doing 
its normal work, for it had no blood to do it with. I introduced the 
speculum into the rectum, and saw an ulcer towards the back part of the 
anus, on the patient's left side, and an open, bleeding artery near the 
centre of it, upon its floor. The sphincter was divided, and with it the 
artery which was bleeding; both were divided at the same time. From 
that period the patient began to get well, and has been so ever since; she 
felt no further pain, there was no more bleeding, and her general health 
rapidly improved. 

I must now relate, though from lack of time very imperfectly, another 
case of interest. It is one of intestinal obstruction, where mechanical and 
physiological rest did a great deal of good. The patient was a surgeon 
of great intellect. When I saw him, with Dr. Jeaffreson and Mr. Hancock, 
he had had insuperable constipation for thirty-one days. There wasgreat 
vomiting. We agreed that the obstruction must be somewhere in the 
neighborhood of the lower part of the colon, or the upper part of the 
rectum, We could not detect it with the finger. We thought that with- 
out relief he would die before the morning, and 1 ojrerated on the same 
evening. After opening the bowel in the loin an enormous quantity of 
feculent matter at once escaped, and continued to do so for a considerable 
period, to-the great relief of the patient. I had requested that he would 
not allow it to close up; however, he improved so much that he thought 
he might do so. The peculiarity of the case was this: that on the fourth 
day after the operation, from the relief of the distended condition of the 
colon, he passed motions by the natural anus, and continued to do so for 
some weeks, until a gradual accumulation took place, and then a recur- 
rence of the symptoms. I then operated upon him again; the same kind 
relief was afforded; and, as the bowels continued to be opened through 
: anal aperture, he went back to liis work, and saw thirty or forty 
patients a day. Later on he had symptoms of pain in the hip-joint, and 
ultimately disease of it, from which be died more than twelve months 
after the first making of an artificial anus. After the first operation he 



176 ON THE THEEAPEUTIC 

used to complain of great pain in the lower angle of the wound; when I 
operated the second time, I put the bistoury lower down, to divide the 
nerve which had given him so much pain, and from that time he was com- 
paratively comfortable. 

Upon making a post-mortem examination, it was found that there 
was no cancer. There had been a contraction of the intestine where the 
sigmoid flexure of the colon joins the rectum. This had produced an 
obstruction, and consequently a distention and overloading, of the colon. 
The weight of the ffeces had caused the colon to descend considerably 
below its normal position, like an inverted syphon; the fasces, therefore, 
had to ascend, and then could not pass over the fixed point where the 
constriction had taken place, the weight of the colon making this part an 
acute angle, and so producing insuperable constipation. When the open- 
ing was made into the upper portion of the colon, the weight of fseces 
was taken off; the accumulation in the lower part was then forced up- 
wards, and made to pass through the rectum. 



INFLUENCE 



LECTURE Xin 

Xauj DucwM of Joints Attriboted to Scrofolm the Remit of Acddent— Caae ot t>i*- 

ease vl the Knee- uul Hip-jotnta od the «*me Side— Knee Amputated — PTPniio 

Joint- InSamnutions iJtri Feren — Hip-joiat c.'nml bj Rest — Dbe*wd Jointo 

Baqairea Long Time tor Cnre— Jnnts Protected from iDjary or Orer-exciUolt 

generklljr Free from Diseaae — The Coeto-Ven«bral AitioiilBtioiH an Ei&mple o( 

thia— Petric Aiticnlatioru— Diaeued Jointa more Frequent in Che Lower tiitB 

tbeUpptrrExtreniities—Dueaaeot Onter Side of Foot more Frequent tbui Inner— 

I Healtlijr Joints not Likel.r to Deteriorate from Rest — Foot of a lliitiese Lady^ 

I Diiwuiea of Jointa Mtidified by kgv — Gnling S'DAUion in a Joint before Cim bj 

I Ancbylofds — Pecnliai Cooise FoUawed bj Diaeosei of the Jolats in Ctuldieo. 

Ix my seveotb lecture, after referring to the fact that the same trunks 
I of nerves suppiv the joints ani] the museles and skin over them, I stAted 
I ihst oDe of the norma! results to be obtained bj this distribution of nerrea 
was to insure meehanieal and phvsiolofrical n>nsent between the extemml 
muscular, or moving, forces and the i-ilal enduntnee of the parts moved, 
: chielty in the interior of the joint, during frietion or pressure; thus secnr- 
ing in health a true balance of force and friction. If this point of balanca 
or adjustment be overreaehed by accidental violence or undue exertion, 
then pain. Nature's warning prompter, is induced within the joint, and 
sug-gests the necessity of diminishing or arresting exertion. Without 
this muscular and articular nervous association in joints, there could be 
no intimation of the exhausted (unction of the internal parts. When 
I this functional exhaustion of the internal parts has been reached, and artic- 
J ular pressure with friction is nevertheless continued, then mischief to th» 
articular structures, whether in the soft parts or in the bones, commences, 
and what we term disease of the joints starts into existence. In this 
" statement are the elements of my opinion and belief, that diseases of the 
., joints in children are the results of accident or over-work, and that they 
are not simply selected by Nature for the development of the constitu- 
tional or scrofulous diathesis. Yet I do not think I wrongly express the 
prevailing opinion of the profession, or, at any rate, of many surgeons, 
when I say that there exists in their minds an inclination to believe that 
diseases of the joints in young persons are most frequently to be regarded 
■ as the manifestation of a constitutional tendency, spontaneously express- 
ing itself as scrofulous, and starting without focal injury. Indeed, by 
some surgeons, it is thought that such diseases of the joints may b» 
deemed, as it were, the local emunctory of a scrofulous or cachectic con- 
stitution, and that such cases, therefore, are not curable except through 
the constitution or general health. Further, that if the local disease of 
the joints bo cured, the same kind of disease will show itself elsewhere, 
perhaps in some part of the body more important to life. Now, this 
would be almost to argue the impropriety of curing the disease of the 
I joint at all. I must state my own conviction, that in comparatively few 
' cases ia the interpretation sound and good. I base this opinion on the 
1 ■Sg^B*'*' cases of joint diseases which are brought before the notice of 



I 



178 fJIf TUE THERAPEUTIC 

the surgeon both in private and hospital practice; indeed, I believe that 
tlie diseases of joints are almost invariably the results of local injury, Jtnd 
that if they were recognised early, and treated by appropriate rest, nearly 
all of them would get well. This, then, is to contravene the generallv 
received notion that ao many cases of joint disease are the result of scrof- 
ula, I will admit that the untoward consequences or results of such 
cases, originating, as they do, in slight local injury or over-exertion, are in 
some measure owing to the unhealthy constitution of the patient, and 
that the same amount of injury in persons perfectly healthy would, in all 
probability, have caused no such prolonged condition of disease. But 
then it should be remembered that if the general health be bad, it is 
equivalent to the confession that the powers of reparation are feeble, and 
that, therefore, rest, or freedom from local disturbance, becomes in such 
cases the more necessary. Unless a due and proportionate amount of 
rest has been maintained from the beginning, they do not offer a fair 






iparison with oases in which the constitution is absolutely healthy, 
'rtue of Disease of tlie Knee- and Jlip-Jolnta an Oie same side. 



is subject a practical bearing, I may just introduce a few 
short notes of a case which came under my notice some years ago. It 
shows the advantage of removing, in certain rare cases, a "scrofulous" 
joint, as it is termed, and also demonstrates the value of rest in the treat- 
ment of disease of the hip-joint in a "scrofulous" patient. 

On the last day of December, 1849, I saw near Ipswich, with Mr, 
Dartlett and Mr. Bullen, surgeons of that town, a young gentleman, of 
unmistakably strumous diathesis, suffering from severe disease of the left 
knee-joint, originally the result of an injury. This diseased knee was 
destroying his general health by pain, sleepless nights, loss of appetite, 
and other depressing symptoms, in addition to a very profuse discharge 
from sinuses communicating with the interior of the joint. His constitu- 
tional condition was very bad; he had at the same time — and this is the 
remarkable point in the case — serious disease of the hip-joint on the same 
side, with some local indications of abscess associated with it in the upper 
part of the left thigh. The question for our consultation was, whettier 
the removal of the knee-joint was justifiable and to be recommended, 
bearing in mind his scrofulous constitution, and the existence of hip dis- 
ease. We argued in this manner, that considering, in addition to the 
other symptoms, the quantity of purulent discharge constantly escaping 
from the knee, which might be regarded as, in some respects, not quite 
equivalent, but as representing or analogous, to small and frequent vene- 
sections, we might ejcpeet, if we could free his system from these sources 
of vital exhaustion, by the amputation of the limb above the knee-joint, 
there would, in all probability, be a great improvement in his general 
health. The knee-joint was very mucn flexed, and it would have been 
useless at that period to put it straight. We also argued that the free- 
dom from disturbance, which the removal of the knee would securo for 
the diseased hip-joint, might be a great advantage in reference to the re- 
pair of that joint. For by giving him a shorter lower extremity, and by 
making his Hmb less weighty for his enfeebled muscles to support, we 
might succeed in our expectation of insuring rest to the hip-joint. On 
these grounds especially, there being no distinct phthisis, we deoided 
that amputation of the leg should take place, and it was well done by Mr. 
Bartletl, wit4i the loss of but very little blood. The removal of the knee- 



INFLUENCE OF REST. 

joint allowed the appetite and genera! health to be quickly restored, and 
the patient was in a very short time oK his bed, and out of doors; still 
suffering from the disease in his hip, but yet going about on crutches, 
with a very short femur, and therefore very little weight of limb. His 
maacles, although feeble, were yet sufficiently strong to support, without 
any difficulty, the shortened femur, and to sustain its head in easy contact 
with the acetabulum, 

Here I may remind you that it ia impossible to obain anchylosis be- 
tween two articular surfaces in a joint unless the two surfaces can be kept 
in contact; and this is the reason why patients with hip-joint disease ex- 
perience so much advantage and comfort in being absolutely in the re- 
cumbent position. For if they be allowed to be up and about, it is im- 
possible, even with great efforts on the part of musoles already enfeebled 
fay disease, that the easy contact of the two bones, so essential to the 
acoomplishment of anchylosis, can occur. By shortening this young gen- 
tlemaji's leg we enabled the feeble muscles to draw the femur upwards 
towards the acetabulum, and ultimately the patient did very well. The 
n the neighborhood of the hip-joint soon discharged its contents, 
es closed, the hip-joint became anchylosed, and after a time he 
went daily into the town, where ho was occupied many hours in business. 
This patient has, since the amputation, had a serious disease and distor- 
tion of the spine, and some paralysis of the remaining leg. On the 14th 
of March, 1860, he reports to me that he was at that time better than he 
had ever been since he lost hia limb, which was ten years ago. In the 
mmmer of 1860 I saw him, and then he was in perfectly good health. 
Here was a case of "strumous" hip-joint disease cured by rest. As re- 
gards the knee-joint, that was disposed of in another way, but certainly I 
think I may legitimately conclud<i that the hip-joint disease was cured by 
rest, and that rest could not have been obtained except by placing the pa- 
tient in a recumbent position for a great length of time, or, as was done, by 
shortening the limb and diminishing the weight. The anchylosis, or per- 
fect local repair in this case, was accomplished in spite of the scrofulous 
constitution. In (act, I may say the hip-joint was cured by cutting off 
the leg. 

I would now ask. What is there in a joint, with its epiphyses, which 
should, independently of local injury, lead to the development of tubercle 
or scrofula? Joints show no special or peculiar inclination to manifest 
constitutional tendencies; rather the contrary. We never see cancer be- 

f inning in the joint, I believe syphilis in a joint is very rare; this may, 
□wcver, be, in the opinion of some persons, doubtful; but true malignant 
disease commencing in the interior of a joint is, as far as my experience 
goes, unheard of. So with regard to the vicarious influence of gonorrheal 
discharge, which is frequently said to be the cause of joint disease, I 
doubt very much its frequencv. It ia true we meet with gouty deposits 
in joints, but these occur chiefly in joints already deteriorated, and under 
the influence of disturbed health, and get well with its improvement. In 
cases of scarlatina or measles it often happens that, after their subsidence, 
the patient is the subject of some disease in the joints or the bones. I 
have seen this occurrence repeatedly, but this, I apprehend, is only 
the evidence that at the time when the patient came under the influence 
of scarlatina or measles, the Joint or the bone had been the subject of 
some local injury, which had deteriorated its vitality. The general or 
oonstitutional depressing influence of the. disease then led to the inflam- 
mation of the bone or joint, which especially manifested itself when the 



180 



ON THE THEBAPEUTIO 



acarlatina or measles was subsiding, or had subsided. If you go into the 
history of these cases, it will almost always turn out, upon close Inquiry, 
that the patient with diseased bones or diseased joints, as a sequel of scar- 
latina or measles, had, before the onset of the fever, a blow upon the part, 
or had used excessive exercise so as to tire himself, and to lower the vild 
endowments of the botie or the articulation by over-fatigue.* (See I^eci. 
XVI.) 1 have employed these points for the purpose of indicating mv 
belief that diseases of the joints are not 8o generally scrofulous as they are 
reported to be; that is the object of my remarks. 

I would Bsk again, Is a London hospital, or Southwark par exfeUeiift, 
if you like, a good locality in which to compete with scrofula ? Vet die- 
eases of joints in children do exceedingly well in these places, by allowing 
them rest and plenty of time. But I hold it to be impossible that joints 
importantly diseased can be cured with rapidity. When I hear it stated, 
therefore, by surgeons of hoapitttis, that they have had cases of diseased 
hip-joint or lyiee-joint, which were doing 
months, the extreme duration of possible 
then they were obliged to send them away, 
tions, I cannot but think that the governo 
laws or regulations prevent joint disease 
lotions. The period of residence in the 
months, it is a matter of i 
can be cured in that time, 
these governors could be ct 
in one or two, or, perhaps, 
gratefully delighted. How 
severity of disease can be ci 
must require at least manj- 

saw a really dise""^ *-' 

cured, in less thi 



ily well up t 
esidence in the hospital, that 
in accordance with the reguU- 
s of hospitals who make such 
i being cured at these insti- 
hospital being fixed at three 
possibility that joints importantly diseased 
am quite sure if the sons or daughters of 
ed of a seriously diseased knee- or hip-joint 
some cases, in three years, ihey would b« 
nfair, then, is the expectation that the same 
ed in three months within an hospital! It 
ontlis to cure the diseased hip-joint. I never 
d bip-joint go through all its stages, and be completely 
six months; and that I looked upon as an extremely 
rapid cure. 1 saw it once, and I was completely astonished. So with re- 
Bpecl to the knee-joint: 1 am quite convinced that limbs are amputated, or, 
perhaps, some other operation performed, before the proper probationWT 
period for a cure without operation has been allowed to elapse. I hold it 
to be impossible that knee-joint disease can be cured by anchylosis (and 



■ This explanation of Mr, Hilton's -would seem i 
which jomt-mflammAtioD niippani ver; earlj in : 
it oocora later on. »nd may be acoounted for by 
which have appeared in the com •-.-.. 

flammutios of joints after foTeis 
interesting:, io medicine. 



a acouunt tor those casM in 
:, nther than those when 
ulceration and tniiparatioo 
of the fever. The subject of pyfemia and in- 
ane of the most obeoure, and withal one of Chi 
lira moet oommonl; in the course of HcailatinB 
or measles, sometiraen in severer conea where there has been much olceration of ibt 
throat and neck, bat aino io much milder cases, where it is spoken of as ''rheumatiioii." 
It uIbo follows the puerperal state, and, as Mr. J. Hutchinson has shown from poat- 
mortem examinatiooN which he made on the partniient ewes which died on bis farm, 
its prescDce may be eiplaincd by a retnined and decompoaiog placenta. 

It ocoira after variolo, nnd also after typhoid fever, where there is adiaUuct uloer- 
stiie lesion. 

Dr. A. P. Stewart has shown how oommon pytemia may be in typhna whenfl 
rnacti are crowded together. Finally, jtiint tronblca, prohably of a pycEmio ns 
mora rarely, graver and even fatal symptoms of pyamiia, ore well known b 
gOuorrfatEa. 

The fact that |iyemta appears in some of the feven which bsve been mentioned 
abOTe, where no lesion no be detected, must moke na carcfaL I think, not to insist 
too mnoh on the presenoe of a auppnTating sarfnce as □ecosaoty to pyemia ; while 
auch cases as Dr. Stewart's go, I think. fnrUiet than this, and point to " ~ 
theory of the origin of pysmia as being a mra eauna. — |Ed.J 



4 

J 



INFLUENCE OF REST. 

th»t is tlie kind of cure to which I now refer), save very rarely, in loss 
I tliiui a year. That tliia opinion is proxiniutcly correct will be allowed 
■ when we remember the number and variety of soft structures which 
I occupy the interior of this joint. All of these must first become elrue- 
turaliy deteriorated, and then absorbed. Much th« lianie must happen to 
the dense laminae of bone which intervene between the articular cartilage 
and the cancellous tissue; and, when all this has been eSectcd, the grun- 
olattng bones must be brought into apposition before the period of direct 
repair can be said to commence in earnest. All these processes must 
necessarily require some considerable time for their acconipliahment. 
' Again, with respect to the tarsus: it ia not to be expected that a disease 
! of one of the ta^rsal bones or joints can be sufficiently cured so as to ren- 
der it competent to sustain the weight of the body, except after great 
length of time. 

I will now advert to two or three general considerations, which appear 
to myself to le-ad towards the conclusion that local injury is the most fre- 
quent starting-point of diseased joints. 

The joints of the human body which are the least likely to sufTer from 
iatamal injury, or from over-exercise or fatigue, are also the most free 
from disease. This indicates a probable relation between their freedom 
from oKternal injury or from over-work and their immunity from disease. 
] The costo- vertebral articulations afford a conspicuous example. These 

e' >int9 are scarcely ever the seat of disease, so far as we can judge, during 
fe; and I think it has happened to few persons to see in any anatomical 
museum a specimen of uncomplicated anchylosis, or bony union, between 
the head of the rib and its associated vertebnc. It is true, of course, 
^that ill cases of diseased vortebrte, we not unfrequently find anchylosis of 
^the heads of the ribs and the sides of the vertebne; that is palpable 
'enough; hut isolated disease of one of these costo- vertebral joints is 
f exceedingly rare. There are several circumstances which will appear to 
'be the cause of this freedom from disease: one is their mobility; again, 
' external injury can scarcely reach these joints; a third is, that they have 
their appointed rest; and a fourth might be mentioned, that they do not 
nadily become anchylosed because a band of fibrous tissue is interposed 
' between the head of the rib and the intervertebral substance. This latter 
jfact, however, forms no part of my important argument, because we find 
Sanehylosis in the knee-joint, notwithstanding the interposition of large 
Jmasses of interarticular structures; but this piece of anatomy does not 
lApply to the first, eleveiitli, and twelfth ribs; yet I have never found any 
tiiisease between the heads of those ribs and their associated vertebnc. 
I I had a patient — he is still a^ve, and therefore I have not an oppor- 
'tunity of presenting to you a pathologicaJ specimen — who had a diseased 
ilspine which was caused by a blow on the lower part of the cervical region. 
iHe ia now actively employed in business, and la thirty-two or thirty-three 
.'years of age. After being about four years in a recumbent position, he 
iis now again able to occupy himself fully in business, and yet not one of 
Jjiis ribs moves during respiration. If you were to look at his naked, broad, 
Jwell-formed chest, and put your hands upon his ribs, you would find that 
|not a single one of them moves during respiration ; all the breathing takes 
'place by the aid of the diaphragm and thu abdominal muscles, The actual 
condition of this gentleman's costo- vertebra! joints is very doubtful.* 



182 



ON THK THEBAPEUTIO 



This freedom from disease i; _ 

employed as are the oos to- vertebral joints, day and t 
k few words of explanation or reference. As I ha\ 
are two circumBtances that may contribute to i 
of tbese joints. It must be admitted, 1 tbick, tliat 



a remarkable thing in joints so active^ 
night, and it requtrea 
? already said, there 
: freedom frum disease 
scrofulous tendencies 
or diseases manifest 
themselves mostly iti 
earlv life ; and the 
earlier in life, in pro- 
portion to the inten- 
Bity o( the oonstitu- 
tional taint. It is at 
this Enuic eiirly period 
of life that the coslo- 
vertebral joints are 
the most actively em- 
ployed in relation to 
rapid breathing, and 
the bones, as well an 
the soft parts of t how 
joints, must be under 
the full influence ot 
friction, pressure, and 
tension — conditions 
likely, in the minds 
of some, to induce 
the local development 
of the coiiElitutional 
taint, ati in the lung«. 
thstandiiig 
those sources of struc- 
tural deterioration, 
these joints escape disease, because they scarcely ever suffer from direct 
local injury; indeed, they are so deeply placed, and so strongly connected by 
ligaments, that direct injury from -without can hardly reach them. Broken 
ribs, as we all know, are f refluent enough; and no doubt, if the heads o( 
these ribs were not maintamed strongly in their position, they might 
be frequently displaced. Reflecting again physiologically on the costo- 
vertebral articulations, we must remember that, although on occasion of 
any exertion their movements may be excited temporarily by volition, yet 
the respiratory movements must soon subside to their normal state of 
comparative quietude, and during sleep these articulations must have a 
certain amount of repose in accordance with the diminished frequency of 
respiration. Under all circumstances, they may be said to have the ad- 
vantage of what may be fialled their appointed rest— and this rest might 




ffvcr tfoa-ml civHTf 






Stoflk Exchange, Dnriiig this period he hiid faBemoptyBis several times, but. as no 
■tmotaral cliaDgs could be detected ia tbe luii|^, Mr. Hiltoa advised him to look upon 
the hanaoirhBge as a mtioiiB adopted by Nature for giving relief to tbe lungs in their 
fixed condition. Later on the ^oUeman removed to Devonahire. and here, after 
poaure to the cold, be died rapidlj after a sudden attack of pneumonia This ' 
marked by its great severity, the diatrass in breathing being much ng^ravated bj 
fixed Mate ot his ribs, a condition wbicb contributed a great deal to his ^ipeedy d( 
There was no post-mortem examination to nacertjun the nature of the old Injtujr, 
tlie condition of tbe ooato- vertebral jointa. — [Ed.] 



] 



INFLUENCE 0? BUST. 



1S3 



cert&inly be termed Nature's strong conservative principle, stronply 
marked in parts the freedom of which from disease is most necessary for 
active life. 

It has occurred but to few persons, perhaps, to note the number of lime 
that these articular surfaces are rubbed upon each other during respira- 
tion; but here are the figures representing the facts. I have taken the 
case of a cbild live years old, and the number of respirations at thirty In 
a minute (about twenty-six is said to be the number); this would give 
1,800 in an hour, 43,200 in a day, and the enormous amount of 15,768,000 
respirations in a year. Every respiration consists of two movements — 
inspiration (ascending) and expiration (descending), so that the friction 
mast be double. (Jonsetjuently, at five years of age, the number of move- 
ments is about 31,536,000 in the year, and yet these joints are never 
diseased. The chief explanatory conditions are their not being exposed 
to external injury, and that they have their appointed rest. 

Diseases of the pelvic bones or articulations In children are but seldom 
seen, except at the acetabulum as part of hip- joint disease. I believe that 
the cause of freedom from disease ni the articulations of the pelvis depends 
upon their immunity from local iiijury by accident or by over-exertion. 
One of these joints is here shown {Fitj. 58} between the sacrum and the 
OS innominatum, and you see a large nia.ss of ligamentous and cartilaginous 
tissue represented as lying between these two pelvic bones. These joints 
are very seldom diseased. 

Let us ask ourselves what inference can be drawn from the hosts of old 
dislocated limbs, due to previously diseased joints (especially the hip and 
knee), which we meet 
with in the streets and 
amongst the poor in 
an hospital ? What 
do these cases convey 
to the mind of an ob- 
serving and reflecting 
surgeon ? The facts 
speak for themselves; 
they all tell him in the 
strongest language 
which crippled Nature 
and deformed humani- 
ty can use, that the 
disease of the joint 
was not scrofulous; or 
that at least, if scrofu- 
lous, in spite of the ad- 
verse circumstances of 
constitutional taint, 
poverty, home discom- 
forts, foul air, improp- 
er and defective food, ; 




LlguuDUtoiLs uid anlk^ou 



id unconstrained r 



Luscular disturbance, or forced 
exertion for the sake of livelihood — that, notwithstanding all these draw- 
backs, and probably also the absence of good professional care, Nature 
has succeeded in relieving the patient, either by forming a new but imper- 
fect articulation for the dislocated bone, or, finally, Ijy consolidating the 
two or more bones which lie in contact in their displaced positions. 
A^in I say, let the surgeon ask himself what might have prevented the 



w 



II' Ulur 

^^ «t a: 

11- 



OK THE THKBAFETTTIO 

progressing to such an extent of severity ? — what 
sboitened or prevented ihe extreme suffering which tlia patient must hafe' 
experienced ? — what would have averted tlie deformity, and what wonU 
have secured for the patient, if not a complete cure, certainly a strong and 
oseful limb, without displacement and with little lameness ? On reflection, 
I believe he will reply, Rest, local rest, by iiiing the limb in a proper 
Bplint, aided by time. Nature's powerful coadjutor. 

Ad argument, supported by facts, against diseases of joints being con- 
sidered simply the expression of constitutional taint, and in favor of local 
injury being the earliest and true utuse of articular disease, may be found 
in the relative frequency of diseased joints in the lower as compared with 
the upper extremities. There will be no hesitation in admitting that dis- 

of the hip-joint are far more numerous than diseases of the ahool * 
ioint; and that the otily additional local disturbance to which the 
rould be liable would be that resulting from frequent fatigui , 

or direct injury. The same with respect to the knee and the ell 

le can doubt the greater frequency of disease in the knee-joint as 

pared with that of the elbow. Here, again, the same explanation woi 

apply — viK. the greater probability of accident or of over-enertion (whi 

structural and physiological exhaustion), and of continuation of lati] 

log exercise. 

It has fallen to the lot of but few surgeons to see many cases of i 
lated disease of the superior articulation of the tibia and fibula; jet that 
joint lies very close to that of the knee, which suffers such frequent dis- 
organization. This superior tibio- fibular joint is, however, seli'" 
of direct injury; hence its freedom from disease, except it be 
aion from the Knee-joint. 

With regard to diseases of the ankle and wrist, I do not know how tl 
may stand with respect to each other numerically, but certainly we ofl 
see disease or enlargement of the base of the radius in children. Now, 
think it must have oecn observed, that whenever a child falls, the hand 
put out to prevent its being hurt, and the whole impulse must concentratl 
itself upon the base of the radius. This is no exaggerated idea. Is it 
not so with adults in daily life ? If we fall, we put forth the outspread 
hand to prevent mischief; and what happens ? Why, the base of the 
broken by the impulse conveyed from the convexity of the upper 
rpal bones of the hand, and the radius is thus split or fractured. 
We more frequently meet with disease in the phalanges of the fingers than 
the phalanges of the toes; this fact, I apprehend, is to be referred to. 
.tie circumstance that in falling or in other fortuitous accidents, injurii 
the phalanges of the hands are much more likely to occur than to ' 
irrcsponding bones of the feet. 
In small accidents to the joints, a great deal of injury to the intei 
parts sometimes takes place without its being seen. Some years ago 
itad an opportunity of observing this occurrence. A man going 
Blackheath, rather the worse for liquor, fell down or jumped six oi ^ 
feet into a gravel-pit, and alighting upon his feet, his leg was vei 
severely broken. I amputated the limb below the knee. On examining 
the ankle-joint, which apparently had not been injured, I found the artic- 
ular cartilage upon the astragiuus actually depressed at one part, and 
another part I saw within it a large black, deep patch, and upon carex. 
lily cutting off th^t portion of articular cartilage, and bringing it up 
" Quekett, it turned out to be ■extravasation of blood, or eechymc 
local injuiy or bruise had no doubt occurred from the impulse of 



that 
di»: 

I 

-rat^^ 



are -. J 



INPLUZNCE OP REST. 

tibia falling upon and bruisinf; the astragalus on its upper surface. Tliis 
mischief to the articular cartilage would probably have led to disease in 
the ankle-joint, as the secondary consequence of the accident. 
r Those points are adduced for the purpose of combating the belief 
which seems to prevuil with respect to the generally scrofulous character 
of diseased joints. That this is an error is shown when wo nr>te the 
greater frecjuency of diseased bones and joints in the outer aide compared 
with the inner side of tho foot in children. Now, there must be some 
reason for this difference. I believo there are two or three causes which 
determine and eKplain this relative frequency — namely, that the outer 
side of the foot is more exposed to the result of direct accident, and that 
it has to sustain the weight of the body in an erect posture; it is, more- 
over, that portion of the foot which, during progression or walking, 
receives the chief concussion between I ho weight of the body above and 
the resistance of the ground below. Tims the outer side of the foot be- 
comes more likely to suffer local Injury from fatigue and continued exer- 
tion. Mr. Ward, who published one of the best and most philosophical 
works ever written upon the humiin skeleton, divided the foot longitudi- 
nally into two portions — the inner side, or the elastic portion, which in- 
cludes the astragalus, the scaphoid, u[id the three cuneiform with the three 
inner metatarsal bones; and the outer portion, the strong side of the foot, 
comprising the cuboid bone, the os calcis, and the metatarsal bones of the 
fourth and fifth toes. It was mycustom at Guy's to refer to this subject, 
not precisely in the same way as Mr. Ward, but to show that in order of 
development and ossification of the bones, the strong part, or outer side, 
of the foot takes some precedence of the other. These facts are well de- 
picted in Quain'a Anatomy, ed. 8th, vol. i, pp. 131, 122. We there see 
the early ossification of the os calcis and the cuboid, and the late ossifica- 
tion of the other or elastic group of bones; and it is especially worthy of 
notice that the scaphoid is the last to complete its growth as well as its 
OBsiSoation. In fact, it is this bone which completes and detennincs the 
elastic configuration of the foot. The os calcis and the cuboid bone are 
the first of the tarsal bones to be ossified, preparatory to their havinz to 
sustain the weight of the body in progression or ordinary exercise. ^Ve 
know, as a matter of fact, that children are often compelled to continue 
their walking e^ierc^ise notwithstanding; fatigue — which is muscular ex- 
haustion — and thus not only the frequency of diseased tarsus at that age 
is explained, but also the peculiarity of the position of it — that is, uti the 
outer side of the foot, in the os calcis or the cuboid. 

We very rarely see disease in tjie stenio-clavicular articulation in 
children or in adults. It is also rarely the seat of local injury. 

I might also remark, that the success attending the operation for ex- 
cision of joints tends very much to the same conclusion; for if all the dis- 
eased joints in children, or the majority of them, are the results of a 
scrofulous state beginning in the bones, how does it happen that these 
cases do so remarkably well when the joints are simply excised, when the 
bones ought to be unhealthy ? The bones which ought to be unhealthy 
and scrofulous do unite and become consolidated in such a way as to ren- 
der the limb, although a shortened, yet a very useful one. 

Arguing for, and urging the importance of, rest in the treatment of 
diseased joints, it becomes important tluit I should answer one or two ob- 
jections. Two arguments are advanced against the employment of long- 
continued rest it) the treatment of diseased joints — viz, deterioration of 
the general health, and anchylosis of tbo articular ends of the bones pro- 



[186 



ON TUE THERAPEUTIC 



that 

1 



healthy. Now, as regards the deterioration of health, i 
)sitively is this: that, taking for illustration extreme cases of dise&sed hip- 
int, I have never yet seen a case of severe liip-juint disease in which the 
wcral health has not been benedtcd by quiet and rest, even in a public 
capital, more or less vitiated as the air of such a place must necessarily 
be, and 1 shall by-aiid-by mention cases confirmatory of this statement. 

Many pcrsous, however, believe that the joints, their soft parts espe- 
cially, being unused and kept in restraint, although not at the time actuaLy 
diseased, may suffer irreparable structural change or deterioration by long- 
continued rest, and that healthy joints may become anchylosed as the con- 
sequence solely of that rest.* This opinion is advanced as an argument 
against the employment of long-continued rest to diseased joints. Now, 
I doubt the soundness of this conclusion; nay, indeed, 1 believe that it ia 
essentially untrue. It is possible, and may be probable, that a temporary 
alteration and a diminished elasticity of articular cartilage may occur; th^ 
e ligaments may become feeble, and the synovial membrane 
f its duties, without the stimulus of friction; that the bones may 
'muess, and the muscles their strength, from disuse; but : 
leteri orations are only temporary, fur reparation is perfected in all tl 
structures by careful and steadily increasing use or employment, 
ftfter a time they show no defect. For example, if the knee-joint be 
seriously diseased and the soft parts destroyed, in such a case a long-con- 
tinued period of rest to the whole limb, as well as to the diseased joint 
itself, is required to bring about anchylosis, or bony union ; yet the unused 
foot, ankle, and hip-joint are not damaged; they are ready for careful 
employment when their activity and structural energy are requirecL 

In chronic diseases of the knee-joint after long-continued rest, requlf: 
ing amputation, on examining the interior of the joint after removal, 
sometimes see that when the whole of the joint may be said to ha^ 
more or leas diseased, and the whole of it has been kept certainly iiti 
state of quietude or rest for a considerable period anterior to amputati 
the patella is fixed by bone upon the condyles of the femur. But, 
other hand, we see cases of extensive disease of the knee-joint requii 
amputation, where, after amputation, we raise the movable patella, 
find that a separata distinct joint exists between it and the condyles ol 
the femur, each part preserving its proper quantity of articular cartilage. 
Here is a case (Fig. 60), to which I am about to refer, showing that 
articular structures kept close to each other for a considerable time do not 
become anchylosed by rest, but may remain comparatively healthy, 
withstanding that the adjoininjf part of the joint shall be eomplel 
destroyed. These circumstances seem to me to point to the conclus 
^that the soft parts of joints are not neceasaiily damaged, although kept 

. " TboaSic J. Pugot (Clin. Lect., p. 97) speata as follfiirs r— " I hnvo smd adha- 

'-iDS in tbe &nkle-]'(Hnb8 ot legs amputated arter heiag luog nt re^C. though the joiota 

d not been evideatly innnmed ; and Hr. ButUn has related (Trnns. Path. Sou., vol. 

T, p. 212)acaBe nf anchylo^isuf a knee-joint in a limb which waa lung kept strmlKht 

nr the trootment of a [nictnred femur." 

InterertmR as these cassa. 6B|)eoinlly the laat, undoubtedly are, they should not 

■ Btoained in order to prove that ancliylosis will (oUow in perfoetly haalthy joints tarr 

becauae they have been kept long at rest. Thua, in Mr. Butlin'B cmte. the fall wl 

fracturod the femot (the einct scat of the fractme ie not given) m»y have caused 

chief rtt the time to the knee-joint, stigbt. but BafSciont to lay tba foundation of the 

aequfnC fibroiiB anchyloaix in ii w-iman at Qlty, about whose ooastlCutloiuU history 

^teidenL-i«s nothing is Btatfld. — [Bii.J 



not 
pt^l 



] 



INFLUENCE OF REST. 



n ]ookinf( at the late Mr, Branshy Cooper's desc 



lade of a 



ion of a Chinese 

structures form- 

distorteil, and the whole foot 



y disease of t 



;curred ii 



me m Chinesp ladies' 
which 1 shall employ 



lady's feet, I find no mention 
inj the articulations. The joint: 
dwarfed by rest and pressure; yet. 
dried preparation, no bony anchylo 
tions. 

It so happens that this College is rich at this t 
feet, and I place before you a very good Bpecimen, 
for the purpose of sustaining tlie view that 
1 entertain regarding the n on -deteriorating 
influence of rest on healthy joints. Fig. 
59 is a drawing of a preparation preserved 
in spirits. 1 ilo not know how old the lady 
was, but, looking to the appearance of the 
bones, we may fairly presume that she had 
arrived at, or beyond, the age of puberty. 
Now, these joints have been compressed 
upon each other during perhaps twenty or 
tnirty years, and yet their surfaces are in a 
perfect condition: and the articular struc- 
tures are not in the slightest degree de- 
teriorated by it. If one were asked to 
produce a notable instance where pressure 
and constrained position are exerted upon 
joints bytbe strong competition carried on 
lor many years between the efforts of 
Nature from within and the application of 
brute (though human) force from outside, 
without producing injury to them, this is 
Burelv the one. Yet there never was a 
case in which the conclusion could be more 
manifest than in this, for the articular sur- 
faces are perfectly entire and healthy. In 
a note that I had from Mr. Bader, one of 
the curators of the College Museum, on the 
23rd of January, 1361, he says, "The ar- ^„„.„^„ ™ mo i 
tioular cartilages from the articulation of cbanicmipnHiiniiponUiiii 
the Chinese foot are microscopically per- 
fectly healthy." This illustration ought, I think, to displace thi 
fear and apprehension, that the continued mechanical rest of joints may 
lead to their irreparable deterioration. 

To take another instance. If you strap up a foot firmly in order to 
cure disease of one of the tarsal joints, do the other tarsal joints become 
anchylosed? Certainly not necessarily. Here {Fig, liO) is an illustration 
of this fact. It b the foot of a young man whose limb I removed for dis- 
ease of the knee-joint. Upon the inner side of the foot there may be seen 
a well-marked specimen of anchylosis between the scaphoid bone and the 
astragalus; yet the joints nearest to it &re not in any way involved in that 
mischief; there is no anchylosis; they are perfectly healthy. The anchylo- 
sis had taken place about two years previously to the amputation of the 
limb. It is a very typical instance of anchylosis, and I employ it for the pur- 
pose to which I am now referring, namely, to show that, although pressure 
by strapping the foot, quiet, and rest were resorted to during a long period, 
in onler to cure the disease between the astragalus and scaphoid, yet the 




I 



. % ktat^MtK 8,11, o 



, IL Siaiiholil. S. Giinalfor 
klI buno. nllh phalsogm wv 



. 8,IIcu- 



nu^h the vfi^ia Had dlTcctlona nf th« 



I 

I 



188 



ON THE TIIEBAPEUTIO 




a. 6U.— ThiB dnwine from ni 



only two bones which became anchyloBed were those between which the 
joint was in an unhealthy condition. | 

Again, in a c^se of severe cut throat, is the larynx voiceless after ft 1 
reat of ais, seven, eight, or ten weeks? or ia a stomach, after a patient J 
has been fed by eneniata for three weeks, incompetent to resume it» 1 
duties of digestion, if provided carefully with food and a email amount ot *! 
Decessary exercise ? Certainly not. In cases of cataract, either eongeni- ( 
tal or of recent date, is the retina after an operation incapacitated to>l 
receive the rays of light carefully introduced into tha organ? Certainlyi 
not. Then, 1 say, if all this be true, what right have we to expect that A 
joint should present different phenomena ? 

I think I have advanced facts enough to indnce those gentle) 
entertain the opinii 
scrofula is so very conatanttyl 
the cause of mischief in di» 
eased joints, to admit ths^ 
other causes, such as a chronic 
inflammatory condition 
slight local injury, are by tat 
the most frequent; and, fiu>| 
ther, that rest to healthy joints 
docs not induce disease lei ' ' 
ing to anchylosis. 1 m. 
here say, that, in teaching o 
this subject at Guy's Hospitd»l 
now many years ago, 1 used toM 
take occasion to point out, tv.fl 
those whom I had the honor^ 
of instructing, that the genei 
ally received impression that M 
serofuia is, as a rule, the foun- ' 
dalion of joint diseases, is 
really not true. 
It is not stating too much to say that the diseases of joints are modi- 
fied by age, especially in one or two respects. In the adult period of lit 
see disease of the individual articular structures, whether of synovial t) 
brane or bone, and we observe that not only is the progress of the diss 
usually slow, but the progress of repair at that period is also slow, 
children, however, we note a very quick implication, if we may c 
it, of all the articular structures in disease, and quick destruction of t 
parts, and subsequently very speedy repair. In young children this pro 
ress is very rapid in acute disea 
I have here the outline of a cast 
an aiithylosed knee-joint. It dt 
not, perhaps, represent a specimen 
perfect surgery, but it indicates t 
rapidity of repair in a young perst 
The boy was three and a half yei 
old, when he fell from a window, and 
damaged his knee. The injury ted 
to suppuration within the joint, and 
enormous swelling around it; absorp- 
tion of all the true articular structures, 
bony anchylosis. The whole of this 



wtiUUilMiolntf 







INFLUENCE OF KE8T. 189 

hit I advance thia case in reference to another and very important 
point. It is a common thing for surgeons to conclude tliat a joint is 
irreparably damaged when they hear or feel the articular ends of the 
boDes grating upon each otlier. Now, 1 had a good opportunity of test- 
inif the value of that point in this child when he was very ill, and the 
joint was very much swollen, and suppuration going on in it. My dresser 
said to me, " When dressing this leg, I can hear and feel the bones grating 
upon each other; " and he rather looked upon this symptom as fatal to 
any probability of the repair of the joint. I remarked to him, "Before 
we amputate this limb we will look into the interior of the joint," I 
made a free incision into the joint, on its inner side, and washed out all 
the purulent fluid; and then I saw the dense articular laminte of bone 
still upon the femur and upon the tibia, and, on rubbing them together, 
the harsh, grating sound was produced. The internal soft parts of the 
joint were all destroyed. I saw that the articular laminie on the bones 
presented a worm-eaten, or minutely cribriform, appearance, indicating 
that interstitial absorption of the laminae was going on; and I came to 
the conclusion that it would be completely absorbed. I therefore secured 
the bones in as easy and as accurate apposition as T oould. I wished to 
divide the tendons of the flexors; but it was determined by the father 
thatasthe child was so ill he would not permit him to be touched any more 
in the way of operation; therefore wc did the beat we could with mechani- 
cal appliances to prevent flexion of the knee-joint, and ultimately the boy 
got well, and can now walk a mile or a mile and a half with facility. In 
this case I touched the interior of the joint with my finger, and I saw 
distinctly what was the cauae of the grating sensation when the surfaces 
were moved upon each otlier. It arose clearly from the persistence, for a 
time, of the articular laminse which exist between the cancellated struc- 
ture of the bones and the articular cartilage. The sub-articular bony 
laminie are, as we all know, very dense, compact structures, and it is 
intelligible how it occurs that when these surfaces are brought together 
tbey create the hard, grating sensation which we so frequently hear and 
feel on examining diseased joints. 

As another practical application of this point, I may say that the fact 
of this grating sensation sometimes determines in the minds of surgeons 
the propriety of excision or amputation. Now, it should not be over- 
looked that there must be a period in every joint disease which is to be 
cured by anchylosis when this grating sensation is to be experienced, and 
that is before the articular lamina is actually removed by absorption. 
When the articular lamina is removed, consolidation can take place, but 
just before that period it is plain that the friction or rubbing of two layers 
of compact bone upon each other may produce a rough grating, and 
might lead unjustly to the con clusinn. that those portions of the bone 
which ought to be in a healthy condition in order to secure subsequent 
Anchylosis are irreparably diseased. 1 have repeatedly heard and felt this 
grating noise in the fingers, anitle, hip, and other articulations, and yet 
the patient's joints have done well by anchylosis. 

I purpose placing before you the fact, that diseases of the joints in 
children follow a peculiar course, and one not perfectly in correspondence 
with that which obtains with respect to adults. In adults the individual 
structures of a joint may be diseased, and each may present its own local 
indicatfbns, or special local symptoms. Thus, we may meet with isolated 
inflammation of the synovial membranes and ligaments, or a disease of the 
articular ends of the bones in the adult. Now, although these structures 



^ 



190 ON THE TUEEAPEIJTIO 

11 periods of life necessarily continuous with each othi 
allied ill function, yet It is at the adult period — after the completion of 
their development — that each separate structure seems to have aoqmred, 
BTid thenceforward to manifest both in health and disease, a structural 
independence which gives a character of individuality and isolation to tbn J 
diseases of the different structures of the joint. 

In children all the structures of the joint must be formed, built up, and 
nourished io concert and in due relation to each other. On this intimaW | 
sympathy existing between the different parts of a joint during childhood, 
or during the period of growth, depends the tendency to diffuse disease 
contemporaneously in all the articular structures. Hence we see in our 
practice the quick propagation of inllammation from one articular strTic- 
ture to another, and a rapidity of implication of the various structures a' 
the joint in childhood and youth, which we do not observe at a lat 
period of life. 

It is, therefore, to my mind — and this is no new idea, for IhavetaughS* 
it publicly for many years — an unsubstantiated refinement in most cases 
of joint disease in childhood to attempt to depict the symptoms indicating 
distinct or separate pathological states of the individual structures com- 
posing a joint. It is certainly not in accordance with clinical experienoaa 
and surely it is not a sound basis upon which to fix and determine ti 
plan of treatment. 

This close sympathy between different structures both in growth a _ 
in disease, met with in children, is not peculiar to the joints alone; it u 
the great feature, it is the pathological type, which this young period of 
life constantly displays in other parts of the body. Some of those gsn- 
tiemen whom I now address know better than myself, and I take it upon 
the statement of those in whom I have confidence, that in adults yoti 
meet with pneumonia as a separate disease; vou may spe pleurisy aa a 
separate disease, or bronchitis as a separate disease, each recognlEed by 
distinct symptoms, and each treated in reference to the morbid condition. 
But not so in childhood; at that period of life you scarcely ever meet with 
pleurisy, pneumonia, and bronchitis as distinct inflammations. They all 
appear together, or there is a general and rapid implication of all tbeae 
structures nearly at the same time. - 

It is the same in diseases of the brain. It is a common thing to s 
disease of the membranes or disease of individual parts of the Dra' 
the adult; vet it is rare to see tbcsc in the same distinct and isolata. _ 
r childhood. In disease of the larynx in children all the 



' tbn^H 

anj 
nat>M 
ood, 
ease 

our 

ugh*^ 

^ases 

ting 

-ienoa^H 
«tli^ 



soft parts become equally involved ; whilst in aduit life, when tfae l«ra^ 
geal structures seem to have acquired a normal tn<l^rendence, which tney 
had not in earlier life, they appear to poaiiessthe same kind and degree of 



independence in disease. 

Now, I think we have here a fentnrf of high physiological and pathv 
logical importance, and very suggestive as a guide to treatnient in pra» 
tice — VIZ. the dlSenmce between the relative progress and implkiatioii of" 
tl»e Tarious structures of diseased joints in childhood and in manhood. It» 
children vigor and rapidity as to the diffusion and progress of inflamma- 
tory conditions, as well as rapidity of repair, stand in very strong and 
distinct antagonism to the like conditions (in all other respects eimilM'' 
which may attack the same structiires, but at a mora advanced period e 
life. ^ 



t^9 

the 

hey 

thoM 
iraa^H 

in 

ima- 
and 

J 



ISFLUENCE OF KE3T. 



LECTURE SrV. 

Hip joint Disease not Necessarilj Sarofiilous — Importance of DiatrnoEiag Hip-joint 
Diwase in an Early Stage — DiHU-ibiitioii of Narves to tbe Hip-joint — Earliest 
SjroptomB of Hip-joint DiBease— Diauaae of Shunidec- joint not Kept at Rest, 
Joint Destroyed ; Hip-joint Disease in tbe Same Patient Cured by Best — Dwarfed 
P'^lviH as a Renalt of Hip-joint Disease — I >iaeased Hip-joint Cored bj' Five Months' 
Rest — Another Case of Twelve MonCha' Btauding Cured by SeTon Months' Rest — 
Hip Disease in a Sorofiilons Patient Cured by Rest— Diseased Hip-joint. Limb 
Bent, Straig-hteaed Under InSiience of Cfaloroform, and Cured by Iteat— Distoca- 
tioa on Dorsam Ilii from Disease Eeducod, Anchylosui Proteeding— Similar Cum, 
Dislocatioa Twice Hedaced, 

It will be the object of this lecture to direct your attention to disease* 
of the hip-joint, and to demonstrate the value of rest as a therapeutic 
ag«nt in such cases. 

I may commence this subject by observing, that in most systematic 
works on Surgery, whilst diseases of the joints are arranged under one 
head, there is generally a separate chapter devoted to morbus ooxie, or 
morbus coxarius as it is termed. We are thus led to entertain the idea 
that there is some special peculiarity with respect to the diseases and 
ayrnptoms, or the pathological anatomy of the hip-joint, I believe this to 
be a mietaken idea. So far as I know there is nothing in anyway special 
or peculiar as regards the structures or the diseases of the hip-joint, when 
compared with those of other joints. Their physiological and patholoeical 
conditions are in no way peculiar, being obedient to the same laws which 
are observed to prevail in other joints. Nor do I believe that there ia 
anything distinct in the constitiitiona.1 tendency of hip-joint disease, 
though it seems to me that professional opinion points to the hip-joint as 
emphatically the chosen seat, or special locality, for the manifestation of 
BcrofulouB disease of joints. This, to my mind, is a great error — an error, 
also, which has b very bad influence. If we understand by the term scrof- 
ula a constitution highly cachectic, tuberculous, or at any rate disposed 
to the formation of tubercle, or with tubercle already existing in the 
diseased part, then if we regard a case of hip-joint disease as purely scrof- 
ulous in this manner, the prospect of relief to the patient will appear 
very small (something like that which may be expected by a person who 
is suffering from pulmonary consumption, with the probability of an early 
death before him), and the treatment will thenceforth be likely to assume 
a palliative rather than a strictly curative character. If the surgeon affix 
such an idea to every case, or to the maiority of cases of hip-joint disease 
coming under his notice, he will feel little disposed to adopt anything like 
a persevering plan in his practice, and without such a plan he will surely 
fad in the proper treatment of the disease. 

Another error often committed is one which wc have inherited from a 
previous generation of surgeons, the entail of which 1 should like to see 
cut off. It was, and is now iji some places, the disposition of surgeons to 



I 
J 



ON TUE THERAPEUTIC 

require that the patient suffering from hip-joint disease should ntsnifest 
those marked aymptoma which are deemed to be characteristic of hip dii- 
ease, such as the snortening or tbe lengthening' of the limb, a fulness or 
fatness over the gluteal region, want of symmetry in the sub-gluteal folds, 
pain at the inner side of the knee, greatly disturbed health, and consider- 
able lameness. Now, the very fat-t of its being the opinion of some sur- 
geons that shortening of the limb is charactenstic of the disease, and of 
others, that lengthening of the limb is characteristic of it; of some, that 
there should be a want of symmetry in the gluteal region, and of othai 
that the symmetry is not necessarily altered — all this, I think, i 
tory proof that these symptoms may fail us direct and positive itidioatioM 
As far. however, as 1 have been able to jud^e, lengthening or shorten^ 
of the limb in the early stage of the disease is almost always the result HI 
inclination of the pelvis. 1 have taken great care and trouble to det 
mine this point, by carefully measuring and comparing the two limbs, ai 
I do not know that I have ever rcen a case of well-marked anoomplica ~ 
faip-ioint disease where there was a. difference in the measurement in wl 
the lengthening or shortening did not depend upon the inclination of t 
pelvis, I am not speaking of cases of advanced disease about the joinl 
nor of cases of dislocation from disease. These highly characterial' 
symptoms which are put prominently forward as indicating diseaae of t* 
hip-joint are not the early symptoms of hip-joint disease. When we i 
such symptoms, we may be sure that the disease in the joint has made oi 
siderable progress, It seems to me, therefore, that we should search for Id 
local symptoms which precede tlie period referred to, for when t 
symptoms stand out so prominently and distinctly as to be recognizable ^ 
anybody, the local mischief must be great, and there can be but little p 
fessional credit in " making out " the cause of the symptoms. Il is higlfl 
important that the surgeon should recognize the diseased condition of tf^ 
joint previous to that period, for that is the time when the most benefits 
effects will follow a steady and long-pursued plan of treatment b^ '^^ j 

If we succeed in an early diagnosis of disease of the hip-joint, I f" 
quite confident that it will not fall to the lot of surgeons to see those fl 
and sometimes hideous cases which we so frequently observe, more pi 
ticularly in hospital practice. It is, 1 think, a most serious fault ( 
surgeons to assume that there is nothing wrong in the hip-joint, unless 
some of those very conspicuous symptoms be present. The all-important 
point is the early recognition of the first deviation from a healthy state; 
and I would anxiously urge upon you, that even a suspected state of dis- 
ease justifies a plan of treatment by rest, which, in my belief, would, in 
the majority of such doubtful cases, be the means of preventing the i 
rence of the more formidable symptoms. I would venture to affirm, 
if even the more advanced and more formidable symptoms be displayed 
still the case may be amenable to the inlluence of rest, and this I hope ^ 
prove by illustrative oases. 

Referring to hip-joint disease in children, let me say, it will be e _ 
oialiy important for the surgeon to bear in mind that the acetabulum in 
child is very shallow compared with that of an adult. It thus offers great 
facility for displacement. This I apprehend may be the reason why there 
is so often a tendency to dislocation of the thigh-hone in hip-joint dise 
at an early period of life. I do not know that this is the onlv ek'm_ 
which determines this dislocation, but I think it may be considered i 
influential one. I shall not dwell upon the anatomy of the hip-joia 
except to remind you that its muscles perform their functions in group| 



I, that 

espA^H 
n in a 

there 
diseu^^_ 
k-meqjH 
red^H 
>-join^H 
rroup^H 



INFLUENCE OF REST. 



li)3 



that each group has a trunk nerve of ita own, and that each nerve con- 
tributes & branch t» the hip-joint itaelf. In Figs. (12 and 63 yon see a 
branch of the anterior crural nerve passing to the hip-joint; a branch of 
the obturator going to the capsular ligament and to the ligamentum 
terea; and a branch proceeding to the posterior aspect of the hip-joint 
from the saeral plexus which auppliea tlie gemelii, the quadratus Comoria, 
and the obturator tnternus. This anatomy should he borne in mind, 
because it explains how it happens that the remote and Bympatbetic pains 
associated with an inliammatory condition or chronic disease nf the hip- 
joict are not always found in the same part of the limb. We all know very 




well that, in some cases of hip-joint disease, one of the earliest symptoma 
is remote from the actual seat of mischief — namely, pain within the knee, 
or on the inner side of the knee-joint; and we are familiar with the 
explanation of It — namely, that the obturator nerve, which contributes a 
branch to the ligamentum teres, sends a branch to the interior of the knee- 
joint, to the inner side of it, and sometimes even lower down. The 
inllammatioii or a diseased condition of this ligament necessarily involves 
the little branch of the obturator nerve, and a "sympathetic" pain is pro- 
duceil at the other end of the same nerve, on the inner side of the knee 
or within the knee-joint. As it is frequently with the obturator, so it 
ought to be sometimes with respect to the other nervea of the hip-joint; 
but the freqnency of this knee pain, whether within the koee-joint or on 
ita inner side, indicates that the ligamentum teres is the most comniaa 
13 



194 



OS THE THEBAPEUTIC 



seat of early disease, 
persona, who may or 
whom the If 

ain of 



> obseire 






lame "sympatlielLc" pain in (Hm 

may not have harl a alight injury to the hip, but ii' 

terea softens down and disappears. Such peraoQ 

re pain within or on the inner side of the knee-joini 

years ago I saw a case in which, after injury to the hip, this ayw 

if pain in the knee-joint was well and early marked. Afterwar 



ii 



' pain in the knee-joint was well and early marked. 
; limb was slightly shortened, and the foot everted, imitating' the 
pitted symptoms of fractured neck of the thigh-hone. I subsequently 
examined this patient's hip-joint, and found that the injury was confined 
to the ligamentum teres. 

Now, suppose the anterior part of the capsular ligament (which re- 
ceives a braneh from the anterior crural) is inilamed, applying the san 
law, you will see how tt may happen that a patient with a diseased hi] 
joint may have pain on the front of the knee, or on the inner side of 
anktc, because the anterior crural never sends branches to them parti 
lar spots,- Or if the inflammation or injury begins at the posteriorpart 
the capsular ligament, which receives a branch or branches from th« 
sacral plexus, then the patient may have a "sympathetic" pain actually 
at the heel or in the fool. I repeat these remarks in reference to the ner- 
vous supply^ because an impression, I think, is abroad that the "sympa- 
thetic " pain of hip-joint disease is always on the inner side of the knee- 
joint, and that this local symptom is essential to a correct diagnosis. 
This, it seems to me, is not true, I admit its greater frequency, because, 
as has been already intimated (p. J'iG), the ligamentum teres is, perhaj 
the part where hip-joint disease in reality niofit commonly begii 
this corresponds with the frequent observation of the " sympathetii 
on the inner side of or within the knee, To put this point more strongli 
it Eometimea happens in hip-joint disease that there is no pain in ' 
knee-joint at all (l have seen several such cases); this local pain, th< 
fore, must be considered as a fortuitous, not a constant, symptom, and 
always to be relied Upon as indicative of diseased hip-joint. 

We ought further to bear in mind that the hip-joint lies very deeply, 
and that therefore one of the earliest symptoms of an intlammatoiy con- 
dition — a sense of heat in the part^lsnot likely to be recociiized early in 
the disease except by careful maihipulation. There is no local sjnnptoi 
which characterizes the inflammatory condition of a joint so certainly ~ 
the increase of temperature in and over the part inflamed. This ' 
the symptoms on which every surf^on may positively rely when 
ing a suspected disease of any joint, provided he is able to make 
manual examination of it, in reference to the existence or non-< 

of an inflammatory condition. When this local symptom of i 

heat exists, it is absolutely satisfactory.* But you will observe it is 
of the symptoms which you may not be able to reach in a very early stage 
of hip-joint disease, because the joint which is the seat of the inflamma- 
tory heat lies so deeply, and is covered at some parts by such a large mass 
of soft structures, that it is difficult for the hand to appreciate an increase 
of temperature on the surface. When, however, with the other symptoms 

• Of the imporiwioe of an inoreaae of tempemtnre Sir J. Paget speskB as foUowi 
(Clin. Leat. and BsxayH, edited b; Mr. Howard Hiu'ah, p, 214);— "Bat, alter all, tbe 
mgti moHt to be relied upun loi diognaHiB between real and noiroUB diaeaM of joint* 
is tbe tumpcralnre. It is bo important to estiinate it accniatelf that I caauot too 
BtroDfTly nrge you to be alwnya stodyiug it. . . ." Foe the boat intonnution w« 
luTe on tbia anbjeet tlw lender ofaoold contnlt, loe. mpr. tit., pp. 130—121, mid ISI^ 
183.— iED.J ^ 




INFLUENCE OF If E S T . 

of lameness and tendenieEs to whith I will presently allude, you find an 
increase of heat in the neighborhood of the hip-joint, you may be sure 
of the existence of a subjacent intJammatory condition. 

Here, then, we see two sources of fallaoy which have existed in the 
diagnosis of hip disease: one as to the position of the sympathetic pains, 
and the other as to the non-existence of heat. If we say that the "sym- 
pathetic" pain is always on the inner side of or within the knee, and we 
are called to a case where it does not exist, of course it excludes from our 
consideration hip-joint disease. Or if we say that every inflamed joint ia 
marked by an increase of heat, and we are called to a case where this does 
not exist (but 1 think it is very rarely absent), of course that again would 
exclude hip-j'oint disease from our consideration. 

There is another source of difficulty in the diagnosis, to which I shall 
refer again (I^ect. XVI.), namely, cerebral or spinal-marrow disease, which 
may induce or cause some of the physical signs of hip- joint disea.se. 

\ow let us consider what may be the earliest symptoms of hip-joint 
disease in children. Here I may remark that I cannot conceive why it is 
that surgeons do not examine the hip-joint itself in the same exact, direct, 
and methodical manner that they employ in the examination of other 
joints: why, in examining a suspected or obscure case of disease in the 
neighborhood of the hip-joint, tliey should depend upon, or place so 
much reliance on, what might be called the outlying symptoms. If we 
are desirous of ascertaining the nature of an abnormal condition of the 
ankle, knee, elbow, or shoulder joints, we try to make out the actual con- 
dition by close and precise manual examination of the joint in reference 
to the exact site of the pain, the sense of hcat at the joint, and the influ- 
ence of direct friction or pressure upon the articular surfaces. But, with 
regard to the hip-joint, many surgeons seem to be satisfied with merely 
examining the general features of the case in order to recognize those 
outlying symptoms which arc described in books us characteristic and in- 
dicative of hip-joint disease. 

If we see a child with a slight degree of limping or lameness in walk- 
ing, that must depend upon something. If a child is suffering from a 
slight degree of lameness in walking, and we recognize no indication of 
an inflammatory state by the increase of heat in the ankle or the knee- 
joint or the foot, and no pain at all on isolated or definite pressure by the 
hand at either of these parts, we may he certain that the mischief is not 
there, and we may be pretty confident that it will be most probably found 
at one of the pelvic joints, or in the immediate neighborhood of the hip- 

J'oint, either within the articulation itself or the epiphyses of the bonea. 
'ossibly, on placing the hand attentively upon these latter parts, the pre- 
cise seat of the mischief may be detected by a greater or less increase of 
temperature at that spot, and this symptom is usually, and more especially, 
manifested towards evening, and after walking exercise. This point may 
be deemed by some unworthy of notice; but it is one which we ought not 
to forget — that a slight inflammatory condition may manifest itself by 
local heat in the evening, after the exercise of the day, but, by the rest 
of a few hours during the night, it may almost disappear in the morning. 
In hip-joint disease the femur is slightly bent upon the abdomen, and 
somewhat adducted, and this occurs from the combined action of the flex- 
ors and adductors, which compels the thiffh-bone to follow the mean direc- 
tion of the two muscular forces. There is a constant law to which I have 
already alluded — -that when a joint is inflamed, the movable part of it is 
obedient to the more powerful muscular action. If, then, you see a child 




;ii* bip-joi]it when the foot is 

.' .-e local symptoms, there he 

.i> iiielit, a litlle restlessness 

; i1k; liiiib, ihe suspected limb 

iilt sleep (an almost constant 

- thiit tlicse symptoms are ind!r«- 

• hip-juint itself. It will be remem- 

V to wliich I am now alluding, the 

^^i of several parts (Fig. 64). The 

Tiiajor is an epiphysis; so is the tn>- 

t; so likewise the head of the femur 

vsis, having a separate circuhition, 

. to the neck of the femur by a tem- 

.^^f '.^(iiihtge. This is no mere anatomical 

^gttmvmttf for 1 place before you a pathological 

^atoas which will testify to the fact that the 

^^k«f disease may be modified by the nor- 

^^WMlomyof that early period of life. We 

^f« hM« (Fig. 65) a drawing of a preparation 

%Mk Cay's .Museum, sent there by Dr. Holman, 

^ SltMte. It is the epiphysis of the head of 

^^ lki|d>-hone separated from the neck of the 

iVmnt of a girl fourteen years old. He discov- 

«Mil tl tyiiifr in the upper part of the thi^h, 

ahscesa associated with the hip-jomt 

, by making a small incision throngh 

tA» «>ri parts, he was enabled to take it out, 

Oti. Ilolman informs me that this patient is dead, 

' «li Mutt he had not the opportunity of examiii- 

^tlitt bndy. 

' Now, to revert to the symptoms of hip-joint 

If B patient presents such local and 

I symptoms as those to which I hs.ve 

1, it is hanlly worth while to go into the 

as to what tissue is involved in thn 

That, to my mind, is a pathological 

Wiient which is of no advantage whatever 

J treatmpnt of the c«se. I think it is bt- 

if any man to be able to tell decidedly, at 

iher the disease bo between the neck of the 

Wad, or whether it bo In the ligamentum teres, 

itttd of the bone, or upon the floor of theaceta 

i is diviiicd into three segments, indicating the 

Mlhroc individual purls — the pubes, ischium,. 



1 



so-called obscui 

nisinterpretatii 
:^tion. that they may be caused by teethinj 



iring from s 

a likely to suffer from t 



^^ 



I 



INFLL'EKCE OF BEST. 197 

or perhaps rheumatism. Tliese, I may say, are very common profeuional 

phantoms with the surgeon when considering such a case, so that all the 

attention is given to the innocent teeth and gums, which are scarified and 

punished unfairly for sins which do not belong 

to them, whilst the hip-joint symptoms are 

allowed to continue, or are left to tneinselves, 

to constitute what may be a fatal mistake. 

The other day I spoke to Mr. Thomas Bell as 

to what he had observed in his large experience 

on this matter, and his opinion coincided with 

tny own views as to this misplaced association 

of teething and hip disease. He added, "I 

wish you would also intimate that a very great 

deal of mischief is often done to the evolution 

of teeth by scarifying the gums too deeply." 

It is obvious that it must be so. If the guras 

are scarified deeply, the rudimentary apparatus, 

which determines the development of the teeth, 

must be very much interfered with, either in 

their direction or integrity, by a reckless or 

badly directed incision nito the gums, 

I should have no hesitation, in a case pre- 
senting the hip- joint symptoms to which I have 
referred, in expressing my conviction that the 
femur or acetabulum has suffered local injury 
in some of its epiphyses, or that the soft parts 
of the hip-joint itself are inflamed; and that 
the essential, and probably the only re(|uired " tnin 
remedy would be aullicient mechanical rest, umm 
secured to the patient by the recumbent posi- 
tion during several weeks. By persistent rest in such cases, you will 
surely anticipate the next series of more formidable sj-mptoms which are 
said to be characteristic of hip-joint disease. In cases presenting these 
milder or less striking symptoms of hip-joint disease, 1 admit that it re- 
quires a strong determination on the part of the surgeon to say to the 
tiarents, " This child has disease about the hip-joint, or symptoms which 
ead to the suspicion that the hip- joint is diseased, anil it is necessary that 
he should lie down for two or three months, with a splint upon the limb, 
to keep the joint quiet." But I know from experience that we may act 
upon it with great and not unmerited confidence. I feel strongly on this 
matter, because I am confident that if these early symptoms are properly 
made use of, and the surgeon will not wait for the next series (said to be 
the characteristic symptoms), which will be too conspicuous to everybody, 
he will not be troubled with long-con tijiued cases of hip disease, nor will 
he meet witli those old cases of defornied and displaced hip-joints as a 
result of disease, to which 1 have before alluded. 

A widow lady once brought me her son, who was a candidate for ad- 
mission to Christ's Hospital bchool. The lad presented these early symp- 
toms of hip-joint disease: lameness, flexed thigh, slight local heat, and 
so on. His mother had been told that he might he lame for life, and 
therefore not eligible for admission, and she said, "1 shall never be able 
to get him into the school if he has hip-joint disease; and I have come to 
ask your advice as to what I had better do with him, for he will soon be 
too old." I recommended that the boy should lie down uninterruptedly 




uiid he 






198 ON THK Tit K It APE U TIC 

for as long a period as his age would permit. The mt>t 
that he should not get up from his couch for four months: 
tion of tliat time he came to nie perfectly well, cured by re! 
was admitted into Christ's Hospital School. 

>~oine years ago the proprietor of & hydropathic establishment came to 
t me with a patient, and said, " 1 have brought you this young genlieman 
to examine. He is seventeen years of age, and has only reoontly entered 
my establishment. He consulted an hospital surgeon of eminence in 
LondoD, who assured him that he liad nothmg important the matter with 
the hip-joint — that ho was suffering from rheumatism or something of 
that kind, and advised liim to ta.ke abundance of exercise. Acting on 
this advice, fae is now suffering great pain, and is, as you see, very lame. 
His parents sent him to my establishment to be cured of his rheumatic 
hip-joint; but, finding that I am not doing the patient any material good 
by my treatment, 1 have thought it safer on the whole that he should see 
some one else." The patient, when he came into my room, was obviously,. 
suffering from acute disease of the hip- joint, and this was uot long afr ' 
he had been assured that he had nothing important the matter with 
This case shows that these serious mistakes do not belong to any on 
tion of our profession. 1 did not see this patient again, but 1 kn 
was placed under good surgical advice and superiutondence; it was 
ever, too late, and he soon afterwards died. 

The patient is less anxious than the surgeon respecting the p 
pathological anatomy of his case, for it hardly signilies to the former 
whether the trochanter major is involved, or whether it is the head of the 
femur, or any portion of the union of the three bones which oonatitute 
the acetabulum at that period of life. Neither the patient nor hia friends 
care anything about all this; the great object is, his freedom from pain 
and ultimate recovery. 

But suppose that time should show that you are wrong in your opin- 
ion regarding the disease in an obscure case, rest during one, two, or even 
three months is not a very serious matter to the child. Assuredly, if yM^ 
have given the proper advice, after the child has been lying down about M ' 
fortnight, many of those constitutional, and nearly all the local, disturb! 
ances which formed the early symptoms will have become much mitigate^; 
and it will then be apparent that if you have not hit upon the precia4 
pathological anatomy or the exact locality of the disease, you have diW" 
covered the right treatment of the case. 

I am anxious to inculcate the importance of recognizing, or of diagno- 
sing, a case of disease of the hip-joint or its neighborhood at a [wriod be- 
fore the full manifestation of those symptoma which are spoken of and 
traced in books as the characteristic symptoms of morbus cox&rjus. I 
must admit that it is still the opinion of some surgeons that inflammation 
or irritative disease of the hip-joint is sometimes associated with, or in- 
duced by, unhealthy teething. I caimot say that it is not so, but I think 
it must he a comparatively rare occurrence, for it certainly has not fallen 
to my lot to see more than one or two cases wliich could give any Icgi^ 
mate support to such an inter]>retation. On the other hand, 1 curtail 
have seen a great number of cases in which teething has been said to 
the cause of hip-joint sj-mptoma, where it has turned out to 1 
nothing to do with them, and a great deal of time has been lost, 
patient has been placed in danger by the delay. 

Disease between the sacrum and the ilium may sometimes bo i 
for hip-joint disease. I have seen several cases of this kind, but 



INFLUENCE OF BEST. 199 

sill be afforded me for brin^rtg them before your notice. Only 
recently I saw a lady, a little way in the country, who was thought to 
have hip-joint disease on the right side. I examined the hip-joint, and 
there was certainly nothing wrong; it niight be rolled about in every 
direction without pain; but on turning her over, and putting my finger 
on the space between the saornm and the ilium on the same side, she ex- 
claimed, "Now you give me a great deal of pain." I made equal pres- 
sure, and BO did the other surg-con who was with me, upon the sacro-iliac 
joint at the corresponding part on the opposite side, but there were no 
indications of pain or tenderness. 

I wish now to detail shortly the case of n patient who had incipient 
disease of the hip-joint, and who did remarkably well, in consequence, I 
believe, of the recognition of the early symptoms to which I have directed 
your attention. It was the case of a boy whom I saw in my private prac- 
tice. While dealing with this subject of hip-joint disease, 1 find myself 
obliged to refer to cases in private practice, because we rarely see these 
early cases in the hospitals. In truth, such cases are scarcely ever seen 
in public inslitutiona uniil the symptoms of hip-joint disease have become 
exceedingly conspicuous, and are advancing towards suppuration; and I 
am trying to rivet attention upon the state of the patient antecedent to 
such severe conditions, for no doubt can be entertained that the earlier 
the cases ai'c rightly interpreted, the fairer is the chance of recovery for 
the patient. 

CoK of dUeane in the Shonlder-Johii, the Joint not kfpt at Rfst, and 
the Joiid destroyed; Hip-joint Disease in the same Patient ctired 
by •'Rest." 

This young gentleman was bom in April, 1840. His mother was 

fhthisical; she had cavities in one or both lungs when the child was born. 
n 1847 the child hud inilammation or a diseased condition of the left 
shoulder- joint. The father took him to hospital Burgeons who have now 
passed away, and who did not recognize this as simply an inflammatory 
(londitioD, the probable effects of local injury, nor as a case to be cured by 
" rest," No, it was a scrofulous joint, and the shoulder was poulticed 
and the general health well attended to, as he had every possible advantage 
of good domestic care and change of air; but the arm, slightly supported 
by a handkerchief around his neck, was allowed to be used as a child 
would use it, without any positive restraint, except that suggested by 
pain. It ended in extensive suppuration, and in complete disorganizatioa 
of the shoulder- joint. The child's health became very bad, and there was 
a fair prospect of his dying from suppuration. I saw him professionally 
in 184H, and he had then all the symptoms of incipient hip disease to 
which i have alluded, and Mr. Key, in consultation, confirmed this opinion 
as to the distinct existence of hip-joint disease. The prospect for the 
patient was not good. The mother was dying, and did die, of consumption ; 
she had also hip-joint disease, with dislocation of the head of the femur, aa 
the result of a very slight accident whilst travelling with her husband in 
North Wales. The child was very delicate and unhealthv-looking, with 
a thin, fine, silky skin. Suppuration was then proceedmg abundantly 
from the shoulder- joint. In fact, his health was goin^ on from bad to 
worse, and every local symptom in the shoulder-joint indicated a decidedly 
bad reparative power. But be it remembered, no credit at all had been 
awarded to Nature as regarded the shoulder; not a single chance had 



L 



300 OH IHS T1I££AF£UTIC 

been ^ven to her to repair the injury; no UEefut kind of mechanical rest J 
hnd been prescribed; and the disease had been allowed to take its owa | 

Wlien I S!(w the patient in 184S, he had disease of the left liip-joint> 
1 had him pluced upon a well-stuSed hair mattress, with a leathern splint 
upon his leg, thieh, and pelvis, like that depicted 
Iiere (Fig. GC). I kept Kim lying there uninter- 
ruptedly tor the space of six months, — from Sep- 
tember, 1848, to March 29th, 1849,— with the left 
arm (the side diseased) fixed in a sling, but giving 
him permission to use the right as freely as he 
might wish, in order to amuse Tiimself with his va- 
rious playthings. The parents were coiistantW 
saying to me, " Let him (jet upj lying in bed wiu 
make him so weak, and hu general heallh will suf- 
fer," and I as constantly replying, " No, no, hit 
health is improving," and insisting upon the child 
remaining absolutely quiet (or at least six months 
The cliild waa then allowed to get up, and to be 
carried about out of doors, but tiie splint was t)ot 
taken ofT until tho end of August, eleven monthi 
from the time it was first applied. At that time 
the whole of the hip-joint symptoms had entirely 
disappeared, the general health was good, und the 
shoulder was also greatly improved and approaehing 
cure by anchylosis, yet dtBcharging now and then 
little fragments of cancellated bore. The hip-joint 
was movable, painless, and would bear the weig' '' 
of the body in standing without iticonvcnii-nce; so that, in truth, ii^tl 
same person, with the same constitution, the shoulder -joint had bet 
destroyed and the hip-Joint saved. 

What was the cause of the difiference in the actual condition of the 
two joints in this case? Just this, I apprehend. With the shoulder. 
Nature never had a chance of curing it by rest; and with the hip disease 
she Irad every opportunity offered to her, and she did not fail to make 
good use of it. Ihe treatment adopted for one joint was ineffective, and 
that for the other quite successful. In 1850 the shoulder was still sup- 
purating, still discharging a little thin pus and very minute portions of 
bone, and there was a large open ulcer at the posterior part ot the joint. 
In 1854 I had a leathern splint placed upon his shoulder and upper Arm, 
which he wore for two years, and at the expiration of that tinie the joint 
was perfectly well. I saw the patient early in June, 1858, and the hip- 
joint was then in a natural condition, and the left shoulder-joint completely 
anchylosed. The anchylosis and its remote effects manifested themselvee 
in this way; the humerus and scapula were dwarfed and moved rigidly 
together, and, in addition to the rigidity of that joint, the clavicle was 
short, as compared with the other side, and the chest on the left or shoulder- 
disease side was not bo much developed as on the other; hence the left 
lung and chest-wall were not in true concord as a part of the respiratory 
apparatus. The possibility in such cases of a want of harmonious and due 
proportionate growth of parts physiologically associated ought always to 
be borne in mind by the surgeon and the patient or his friends informed 
of it. Experience has taught me that it is an almost constant occurrence. 
The real importance of these remarks will appear when applied to tb|M 




int I 

.w I 



INFLUENCE OF BEST. 



201 



result of long-oontinued hip- joint disease in the female. Thus I have as- 
oertained by examination that the os innominatum on the side of the 
disease does not ffrow so rapidly, and finally is not so large as its fellow; 
• hence the area of the pelvis is not symmetrical, and thus may interfere 
with parturition at the full period of gestation. I may add that this pel- 
yic deformity is most conspicuous when the hip disease occurs in, or con- 
tinues into, the period of early menstruation. Time will not allow me 
to dwell on the other details ; but I must express my conviction that if 
the surgeon who first saw this child's shoulder had acted upon the idea 
that it was a diseased joint resulting from simple inflammation, the con- 
sequence probably of injury, and had given Nature credit for being very 
active in the reparative as well as in the formative process at that period 
of life, and had kept the shoulder perfectly quiet for some weeks, the 
shoulder-joint would have been saved as satisfactorily as the hip-joint. 

To disencumber this case of its details, it is just this: Here was a child 
who had manifested by his shoulder-joint a scrofulous taint, if you like to 
call it so (although I am not a believer in scrofula to the extent that many 
people are), whose mother died scrofulous, and from pulmonary tubercular 
phtnisis and hip disease; yet by giving this child's hip-joint rest for a long 
time, in spite of these constitutional and inherited dilHculties, he jyerfectly 
recovers from this affection of the hip-joint, because it was recognized 
early enough to enable Nature to repair the injury which the child had 
sustained. 

I may add that in February, 1861, I again saw this patient; he was 
then fifteen years of age. His general health was excellent; the formerly 
diseased shoul- 
der-joint was 
fixed and healed 
up, and painless: 
the hip-joint is 
normal in every 
respect; and the 
boy had great 
mental abilities, 
combined with 
considerable en- 
ergy. The left 
humerus was 
three inches 
shorter than the 
right; the left 
radius from half 
to three-quarters 
of an inch shorter 
than the right; 
and the left scap- 
ula nearly two 
inches shorter 
than the right, 

measuring from the acromion process to the inferior angle of the scapula. 
The left hand was smaller than the right, as shown in these cround-plans 
of the two hands. One of the most extraordinary peculiarities in this 
case was the remarkable development of all the muscles of the right arm; 
it had the aspect of the arm oi a well-trained awd xcvo^X ^^^^xV^ ^^^ro.^- 



/ 





Left Right 

Fia. 07.^011 oomparinff theae two flgnren, it Is obvloas that If the shoulder 
di se ase bad been on the right nlde, and the same andevnlopoi condition bad saper- 
▼encd. the valne of tbi» paticnt'it prospecu in after bfe might, from bis inefflcient 
right hand, have bem mnch impaired. 



202 ON THE tiii;i:ai>e VTic 

fiphter, I coulil not have conceived it possible that the muscles of i 
of tirteen could have acquired such large dimensions and such beautiffi 

development. 

Case of Diseased Htp-joint cttrad by Floe Mont/ts' Ufa. 

In 1847 I attended a young fjentleman in London, aped aevente 
with severe disease of the hip-joint. He was pale, unhealthy-lookt 
and flabby; lie had enlarged tonsils, and a thick husky voice. The I 
joint disease was the consequence of fatigue from a long walk, 
mother, four sisters, and two brothers had died of pulmonary consumptira 
so that his prospects, constitutionally speaking, did not appear to be v 
favorable to a cure. Sir Benjamin Brodie saw him in consultation w 
myself in 1847, soon after the symptoms commenced, and we both agreed 
that he had some serious disease of the hip-joint. I had previously applied 
a leathern splint or case to his limb and pelvis (Fig. W); and he was 
compelled to maintain the recumbent position, with the splint on, and his 
hip-juint in a state of entire rest, during five months. After that time 
he gradually resumed Lis walking exercise, and has been perfectly well 
ever since. Here was a case which, judging by the antecedents of the 
patient, by his actual bad healtli, and looking at what had occurred to his 
mother, brothers, and sisters, seemed to present an unfavorable prospect; 
but this young gentleman was in India for three and a half or four ye^rs, 
in very active occupation, during the late rebellion, and is now perfectly 
well. Ho can move his joint freely, and can walk seven or eight miles 
without any difficulty. He is rather thinner than formerly, but Is appar- 
ently quite well, 

I shall endeavor to show you that notwithstanding that disease of the 
hip- joint may have advanced to a period when the symptons of hip disease 
are conspicuously distinct, though the constitution may be very bad, and 
loft parts of the joint destroyed, patients may still get perfectly 



ip-joi 



jiidition of th 

I to which I shall allude f 



still get perfectly well^^ 
t once appear to nqnu^f 
necessarily existin^^^^^ 

le are taken from n^^H 
:ition cured in iScmh^| 



by rest with an anchylr 
tive the idea of a scrofulous < 
such cases. 

The notes of the next ca: 
private practice. 

Case of Hlp-joiiU Disease of One Yi'ar's Ihiration cured 
Montlu bi/ Jiesl. 

In January, 18.55, the patient (a little girl between four and five years 
old) lame, and in great pain, was taken to a surgeon, who pronounced 
that she had hip-joint disease, and that he regarded it as scrofulous, f" 
was under his professional care about eight months, He directed her 
be taken to tlie sea-side, to have medicine, and to move about 
exercise, that her general health might be improved, thus hoping to oi 
the case by invigoratina the constitution, but no direct rest was given to" 
the hip-joint. The local and general disturbance and distress increased 
so as to become excessively severe. In December, ISoA, eleven or twelve 
montlis after the appearance of the first symptoms, she was brought to 
my house. She could not bear the pain of being very gently and care- 
fully carried in the arms of her mother. The child was much wasted, and 
B picture of really extreme bodily distress, screaming with pain nearly all 
the time she was with me; and her mother informed me that she had hi * 
scarcely any sleep during many weeks from the pain in the hip and 






I 



INFLUENCE OF REST. 

<nit«r eicte of the knee, these pains bein^ especially severe at night. The 
thigh was flexed upon the abdomen, abducted, and the knee turned in- 
wards, evincing a disposition of the head of the femur to be disloctited 
backwards; there wore also fulness and rotundity at the back of the joint. 
The slightest preasuie upon the trochanter major or upon the sole oE the 
foot, for the purpose or forcing the head of the femur into the acetabulum, 
raiiBcd great agony. There was a marked disposition of the head of the 
bone to be displitced backwards (always a serious complication), and the 
distinct fiuctuation of an abscess below Poupart's ligament to the outer 
aide of the hip- joint. The patient was taken home with great care, and 
by my direction Mr. H. Bigg went to the house the same evening, and 
moulded this leathern splint (see Fig. C6), or case, upon the pelvis and 
upon the hip, with an extension to the foot for the purpose of keeping 
the hip-joint and the whole leg at rest. Great pain and distress were 
experienced by the patient whilst the limb was being straightened, but 
there was no alternative, and it was done. In adapting a splint to a case 
of hip- joint disease, it is important not only to prevent any movement of 
the joint, but also to insure easy, persistent contact between the articular 
surfaces without pressure, so as to Eacilitate bony union, supposing the 
soft pttTtsto be destroyed; or if the soft parts be simply inflamed and 
swollen, then to prevent undue pressure (the result of unconstrained mus- 
cular force) of the soft parts, mutually inflamed, upon each other. 
Another object in this cose was to prevent rotation of the limb either 
invrards or outwards, because it is obvious that if no such rottition Irn p«r- 
mitted, nn 'Xieloi'fttirm ctin occur. All the requirements were earned out 
in this patient by the splint. It was accurately adapted, and answered 
remarkably well. You will observe that a. sliding footpieoe is attached, so 
as not to interfere with the growth or elongation of the limb. Children 
grow very rapidly, especially so if well fed, when in the recumbent and 
supine position, and if the footpiece of the splint be fixed, there will be a 
constant contention, if we may so term it, between the restraint on the 
part of the splint and the changes incident to growth. The footpiece 
must therefore be allowed to elongate itself as the child grows. The 
splint is also provided wilh a transverse portion under the footpiece, which 
prevents the possibility of any rotation either inwards or outwards. The 
patient was placed on her back upon a well-stuffed hair-mattress bed, and 
this splint was kept on uninterruptedly, or nearly so, duringscven months. 
Jt was taken off three or four times by myself with care, merely for the 
purpose of examining the progress of the cure, and of facilitating ner- 
Bonnt oleanlitiess. During the latter portion of the time she was taken 
out of doors, with the leathern case or splint on, and lying horizontally 
upon a little wheeled carriage with easy springs. The medical treatment 
consisted simply of opium, in large doses at first, to secure sleep, and one- 
sixteenth of a grain of bichloride of mercury twice a day, with sarsiipa- 
rilla, during about a couple of months. No seton, no issue, no tartar- 
emetic ointment, no croton-oil liniments, nothing of the kind was used. 
The general health and appetite improved rapidly after the first month of 
confinement to bed. At the expiration of the seven months, all pain, 
tenderness, and constitutional disturbance having disappeared, she was 
allowed to take gentle and weil-watched walking exercise, without harm. 
The abscess in the thigh gradually subsided, and was finally absorbed. I 
saw the patient again about sixteen or eighteen months from the time she 
began to take independent exercise. She walked into my room quite 
comfortably, well in health, but rather flat-footed. She could then walk 



204 ON THE THERAPEUTIC 

two miles without any difficulty or pain. The muscles of the tliigh t 
log were increasing in size almost weekly. There was a slight limp in thf| 
walk, the foot very little everted, and there was, perhaps, from about ( 
quarter to half an inch shortening of that limb, as compared with t* 
other ; there was no abscess to be felt, no fluctuation to be detected ai ^ 
where, and the bony anchylosis waa perfect. For the purpose of testing 
this latter point of bony union, I placed the child recumbent upon ■ 
couch, and pressing downwards upon the pelvis, endeavored to flex theTI 
thigh-bone upon the pelvis, but I could not carry the thigh-bone towarda 
tlie abdomen without lifting the pelvis at the aame time; the other lower 
limb was perfectly natural in all its movements, I mig-ht suggeat that 
the slight shortness of the dise-ased limb was due to the arrest of growth 
on that side while the other side was growing, this defect in dcvelopmeidL 
as to the length of the limb being a constant result of hip disease. ThU 



B p^o^'es, then, that although hip-joint disease may have existed uncoil^ 

lied during nearly a twelvemonth, yet it is perfectly curable, with 

stiff joint, by rest alone, which may be styled the best possible result i 



sucb a condition of joint. The case, I think, shows also that there wi 
no scrofulous condition, no tuberculous state of bones, for I canm 
believe that if those bones had been scrofulous, we should have obtained 
such a rapid and perfect anchylosis, or bony 

I now come to another case of hip-joint disease, of which I have the 
pos1;-mortem results. The patient had been partly in the hospital, and 
partly a private patient; and the case shows that, notwithstanding ft 
tubercular constitution, yet by rest and proper treatment, persons wil" 
severe hip>jolnt disease may do well. 



Cate of Hip IHwaae oce^trring in a Scrofulous Patient ^ the M 
Disease cured by Jieat, 

A. R was thirteen yeara and a half old when he died, in Oct., 

1857. He began to be lame in 1855, There was no known accident. 
He had pain in the upper part of the thigh, but no pain in the knee or 
hip, so far as he or his parents remembered. He was taken toan hospital 
Burgeon, who believed the pain to be rheumatic. The patient waa ordered 
to employ walking exercise every day, and to take tonics, and he was sent 
to the sea-side to improve his general health; but the local disease waa 
not at all diminished, and he was, by particular request, admitted into 
Guv's Hospital, under a physician, in July, ISbH. He was then thouglA' 
to be rheumatic, and was treated for rheumatism. He remained for ' "" 
weeks without the slightest benefit. He was brought to my hi ' _ 

tober, 1S5G, fifteen months after the joint disease had commenced, cleari^; 
suffering from hip-joint disease, and presenting a very tubercular and scrof- 
ulous appearance. There were all the symptoms of hip-joint disease 
resembling those of the little girl whose case I have just mentioned. 
There was pain in and about the hip-joint, great tenderness, great fulness, 
evident suppuration, and a constant tendency to dislocation of the thigh- 
bone backwards. The foot was being turned inwards by the muscles, 
which were in a state of spasm, the spasmodic jerking of the Umb occur- 
ring most violently just as the ])atient was going off to sleep. I m»j 
observe that this is the time when dislocation most frequently occur 
There waa every indication, in fact, of dislocation taking place from thj 
cause, if means were not employed to prevent it. The tluctuntioa of i 
abscesa was obvious at the upper and outer side of the thigh, and tj 



1 

let.. ^ 



into 
ight^ 

sm 



I 



INFLUENCE OIT BEST. 



glands of the groin were enlarged, Hii 
" horrible; " he suifered much pain, had n 
feverish. The leathern aplint (Fig. 68) w 
siderable s' 



205 

1 nights, his mothnr said, were 
o appetite, and was exceedingly 
as placed upon the patient, and, 
e then forming, it was necessary 
to make an aperture in the splint to allow of some local application, and to 
enable me subsequently, if necessary or advisable, to open the abscess with- 
out disturbing the hip- joint. The patient died about a year afterwards of 
chronic tubercular peritonitis; he had also some tubercles and cavities at 
the apices of both lungs. In this case we find both in the peritoneum 
and in the lungs the pathological evidences of the tubercular diathesis, or 
(if tubercle is to be the histological basis of scrofula) of the true scrofulous 
constitution. Notwithstanding all this, by keeping the patient's hip-joint 





Tio. 8S. Epipbr^ 

perfectly quiet, we not only prevented dislocation, but allowed Nature to 
produce bony anchylosis of the hip-joint. If ever there was a. local con- 
dition which seemed to defy the probability of anchylosis of the hip-joint, it 
was in this case; orif^ver there was a constitutional state the very oppo- 
site of that which would suggest anything like a prospect of good repair, 
this was such an instance. But here (Fig- C9) is represented the hip-joint 
itself of this patient; the bones are not perfectly consolidated, it is true, 
although they are very nearly so, I have placed before you a faithful 
sketch, and you observe that the head of the femur is firmly joined to the 
floor of the acetabulum. In fact, so complete and so strong was the 
medium of union between the two bones that he had walked out of doors 



J 



ON THE TIIEKAPEUTIC 

8ev<>ral times without the splint, and conld bear hia weight upon tbe limb 
without pain. 

Here, then, wan a ecrofuloua conBtitution, but there is no evidence of 
tubercular deposit in the bones, and tbe repair is good. Tliis case is aiao 
very encouraging to the pursuance of a persevering plan of treatment by 
"rest." The medical treatment of the case was very simple. Whilst the 
boy was suffering from a febrile condition, he took the ordinaiy ferer 
medicines, and subsequently we gave him for a short time a smaU quan- 
tity of bichloride of mercury with sarsaparilla, and after that cod-liver oil 
and steel wine, securing at tbe same time rest to the hip-joint. j4.b«orj>- 
tioH of the abscess was proceeding in this case. The remains of tbe 
abscess were found in the form of a small quantity of sero-purulent fluid 
and a layer of semi-solid deposit upon tbe floor of tbe contracted abscess- 
cavity. This cavity communicated, by a very narrow, tortuous canal, 
scarcely larger than a probe, with the parts surrounding the joint, but 
we could not delect its exact termination. 

Several of the cases of hip disease which I have related occurred some 
time ago, and I selected tbem for the purpose of showing that they did 
well, and have since done well, the patients being alive and in pood 
health, with the exception of the one whose anchylosed hip-joint 1 have 
placed before you. I will now direct your attention to three other eases 
of hip-joint disease formerly under jny care in tha hospital, and from which 
sketches were taken. I tlnnk you will perceive they give some important 
evidence of the value of rest in the treatment of such cases. 



Tlie first case is that of 
into the hospital under my 

of the left hip-joint, and ii 



very Lad h 



aged SI 
1800, - 
faith. 




Uiseased Hlp-joInt / TAmh miicfi bent ; strai(/hleited under t/ie ir^ 
of Chlorofonii y SpUrt t applied/ mircd hy Rest. 

en. She was admittedil 
:th rather acute dlsPSMV 
'hree years ago she feUll 
down-stairs, & n d-ig 
was supposed 
have hurt her hip;* 
she had been moral 

irregular rest j 
and quiet, and get- 
ting about upon 
crutches, she was, after some time, recovering, when she was knoclced 
down by accident. This was followed by pain in the hip. She then 
became an out-patient at St. Thomas's Hospital during three months, and 
at Guy's during nine months, without any benefit. When admitted into 
Guy's, in June, I8G0, she had all the indications, local and general, of 
severe hip- joint disease, with deep suppuration in the anterior, upper, and <■ 
outer part of the thigh. The Hmb was flexed and ^dducted; the patiei^J 
was suffering great pain in the hip, had little sleep at night, and little or 
no appetite. Chloroform was administered, and the contracted muscle . 
of the joint yielded steadily and nicely to carefully applied extensionil 
The flexed limb was made straight, and a bug common iron splint (Fi|^l 
7(1) applied along its outer side, extending from near the axilla to thi 
foot, with a transverse bar to prevent rotation; the recumbent and supim 
positions to be strictly maintained. Inunediatuly after the applicution fl' 



INFLUENCE OF REST. 207 

the splint, all the disturbing symptoms bepan to disappear, and her appe- 
tite returned. So free from sti^erin^ did tlie patient continue, and so 
efficacious was the splint, that 1 did not disturb it fur Rve months, that is, 
till November, 1860, and then the joint was found to be fixed or anchy- 
losed to the aoetabiilum, and the experimental movements did not pro- 
duce much pain. The patient was ordered to continue the splint. In 
Feb., 18G1, there was not a single untoward symptom; the health was 
good. The splint having been removed, the bony anchylosis was firm, 
and the lower extremities were of nearly the same length. She had no 

Eain when direct pressure was made on the hip-joint below Poiipart's 
gament, nor when the sole of the foot was struck. This sketch (Fig. 71) 
was made on June 6th, 18(il. The child was quite well, except that Ui 




ns not to be opened under any circumstan- 
)f time, in the hope that it would be ab- 
n the lUth of June, 1S61, since which time 



abscess was still there, which w; 
ces for a considerable length f 
sorbed. The child went out oi 

The other two cases are more remarkable. They are specimens of hip- 
joint disease, cured, as far as possible, by rest. In both cases dislocation 
outwards and backwards on to the dorsum of the ilium occurred from dis- 
ease, and in both the dislocations were reduced, and the bones have since 
remuned in their proper positions. 

IHaloeation on Dorsum Hii of k/l J^mur from Disease; DUlocation 
rciliwed; Anc/tyhsie proceeding. 

C. B , a^d five. No accident or local injury was known to have 

happened to the child, who was previously in good health. He com- 



208 ON THE THERAPEUTIC 

plained of pain in the knee six niontha before lie bejran to be lame IT*! 
was undor the care of Mr. Stomiunt, of Chcshunt, eighteen months agw. 
He used to lie in bed for a week or ten days; then get up, and soon 
became lame again, lakinf; alternate rest and exercise, but on the whole 
steadily Retting worse until December, ISGO, when he could not get np, 
since which he has been constantly in bed, lying on his right side. Dis- 
location of the thiph-bone must have occurred when in bed. The left leg 
was drawn up. He suffered great pain in the knee and hip. The gen- 
eral health was very bad, and he oould scarcely bear being moved by ths 
nurse. This patient was in an hospital in London during the months '' 
April and May, 18C0. He had an issue made over the hip-joint when 
that institution without any benefit; no splints were applied; he 
more lame when he came out than when he went in; and he was repre- 
sented as incurable. He came under my care on the ^3d of Januarv, 
1801. He had then a dislocation of the'left femur on to the dorsum of 
the ilium. The dislocation was reduced three weeks after admission, 
under the influence of chloroform. The pelvis and lower limb were then 
carefully (and not too tightly) bandaged to a straight wooden splint 
placed on the outer side of the limb. The splint had a transverse fool- 
piece fixed to it in order to prevent any rotation of the hip-joint. There 
was scarcely any pain in the knee or hip-joint after that time. Ilia 
health appeared perfectly good, and the limb was in an excellent portion. 
There was no pain, hut simply an abscess upon the anterior and inner part 
of the thigh, which was left alone. Uony union had taken place belwi 
the head of the femur and the acetabulum, 

Thi3 appears to bo a good case in reference to the influence of 
the treatment of diseased hip-joint. 



gen- 
ths ■ 

ise|M 



Dislocation of TJiiijh-hone vpon the Dorsum 
location ttcice reduced ; Anc/tj/losis 



Dii fYom Disease, 
in good position. 



1 




The third case is a much more curious one. Mr. Stanley, who hap- 
pened to be at Guy's Hospital in the summer of 1850, saw this little 

patient. M. P , aged seven, was admitted into Charity ward on 

March Sd, 1859, under my care. Her mother stated that she had always 
been a very delicate child. In November, 1858, she first complained of 

Kin in the left knee, and was noticed to walk lamely; her health also 
gan to be seriously damaged. The mother took her as an out-patieni 
to a London hospital, where numerous blisters were applied without 
apparent benefit. The recumbent position was subsequently in part main- 
tained, while occasional blisters over the hip were prescribed. This plan 
was persevered in, but so severe was the pain expenenced in moving, thai 
it was not possible for her to continue her attendance as an out-patient. 
About a fortnight before her admission into Guy's Hospital, the deformity 
which is peculiar to the dislocation of the thigh-bone on the dorsum of 
the ilium first distinctly appeared; it occurred at night, accompanied by 
jgreat aggravation of the patient's symptoms. This led her friends to 
B©ek admission for hei- into Guy's. The report on admission states that 
she was a feeble, strumous-tooking child, with delicate skin, long eye- 
lashes, and somewhat prominent lips. She had lost her appetite, and was 
suffering a great deal of pain in the hip, especially at night. She was 
very restless, and the left leg was much shorter than the other. The 
thigh was flexed and adducted, the knee bent, the foot turned inwards, 
resembling the dislocation of the head of the femur upon the dorsum ilttf 



TErFLUEITCE OF BEST. 



n fact, the head of the bone could _ 

> leg was rotated inwards. 






the 



1 behind 



L 



the acetabulum when the leg was rotated inwards. A fortnlj^'ht after 
admission she was placed under the influence of chlornfonn, and the limb 
forcibly extended or drawn downwards to the level of the acetabulum, 
and then rotated outwards; and so the head of the femur was brought 
into contact with the acetabulum. The deformity having been thus 
removed, and the dislocation reduced, a long iron splint was applied to 
the outer side of the limb and pelvis to give rest to the hip-joint. The 
child was afterwards restless and irritable, and in a day or two succeeded 
in so loosening the bandages and splints, that the femur became again 
dislocated backwards, with its head upon the dorsum ilii. On April 
30th, 1860, ten weeks after the lirst occurrence of dislocation, she was 
sgain placed under the InOuence of chloroform, and the dislocation □ 
more reduced. A long straight splint was again applied to the limb 
and pelvis, and short splints put upon her hands, to 
prevent her meddling with the bandae'ea. This ma- 
nceuvre succeeded, and in a few davs the hand splints 
were taken off, as she found the long splint to the 
leg and pelvis so comfortable, and she waa herself so 
free from pain, that she did not wish to interfere with 
it. From that time she went on improving rapidly; 
ehe became better in health and plumper than she 
ever waa before. In the summer of 18»9, during the 
warm weather, she was carried Into the park or gar- 
den at Guy'a. She slept and ate well, and made no 
complaint of pain. The splint was replaced and re- 
adjusted at intervals, care being taken not to disturb 
the joint. October, 1859: The patient was examined. 
The diseased limb seemed rather longer than the sound 
one; the symmetry of the two hip-joints waa nearly 
perfect; the femur could only be slightly flexed upon 
the pclvia. There was still alight tenderness on pres- 
sureon the trochantermajor and the head of the femur, 
the anchylosis being not yet completed. On March 
26th, lUCO, the report states: Anchylosis is perfect; 
at least the pelvis moves firmly with the femur with- 
out pain: the patient can bear some weight upon the 
left limb, and can walk a few steps with a little sup- 
port. There is no tenderness on pressure upon the 
head of the femur or the trochanter major. About 
five inches below Poupart's ligament an abscess can 
be detected. The splint to be reapplied. This I 
looked upon as a pet kind of case. I have a photo- 
graph (Fig. 7^) of the condition of the patient as she 
stood before the artist. Mr. Furner, one of the sur- 
geons of the Brighton Hospital, obliged me by takin 
her nnder his care, and she was for three months i 
the sea-side, where she was in capital health, free 
from pain, and could walk a little about the hospital ward. At the exp 
ration of the three months her parents brought her to town by an cxcu) 
train; the splint had been taken off, and in the large and carele! 




IT put at tba Uilih 
..-h [E«mb- 

ot purnUrQl duld. 






crowd at the London terminus the child v 



3 pushed a 



nieened that 



the limb was forcibly turned backwards upon the pelvis, materially damag- 
ing the newly united structures at the hip-joint. She v 



SIO ON THE THEBAPSUTIO 

screaming with pain, and soon afterwards suppuration occurred near the 
hip. The discharge depressed her health extensively, so that when I dis- 
covered her home near Stepney I found her greatly emaciated, badly fed, 
and badly nursed; no splint upon the limb, and a profuse discharge from 
the abscess. She was admitted into Guy's Hospital under my care, with 
the second injury to the hip-joint. Her health gradually improved; the 
discharge diminished, and ossific consolidation again took place in the hip- 
joint. This case was finally cured, and remained so up to the last occa- 
sion on which I saw her, some years after the date of her leaving the 
hospital. 

In discussing the question of the influence of Rest in the treatment 
of disease generally, I thought I might, more especially by pointing out 
its application to the diseases of the joints, induce in the minds of some 
of our professional brethren a more philosophic consideration of the 
pathology and treatment of a class of cases which are not unfrequently 
abandoned to the care of the empiric and the mindless. 

By regarding this subject of physiological and mechanical Rest in 
what I conceive to be its proper professional light, the surgeon will be 
oompelled to admit that he has 710 power to repair directly any injury. It 
will induce him to acknowledge, in all humility, that it is the prerogative of 
Nature alone to repair the waste of any structure. He will thus realize 
that his chief duty consists in ascertainmg and removing those impedi- 
ments which obstruct the reparative process or thwart the efforts of Nature, 
and thus enable her to restore the parts to their normal condition. 



LECTURE XV. 

Diolocation of Riglil Femai ; Reduced Two Honths ofterw&rdB ; Deatti from Pjmaim 
— Hip Disease BQpposed Bo be ScrofnlouB cuted by Anchjtosis after Rut ; No 
Distinct Ab^ceas — Hrp Diseoao in a PhtbiHical Patient oared b; Auchjiotda ; AbsceM 
tbsorbed— Dlscasskon of tbe Proprietj of opeoing AbnceMes connected with Dia- 
eoaed Jiijntq — Hip Disease-, Uooj Anohyloiiifi; Opeaiog of Abscem deferrad ; 
Becoyery— Cbronio Abxcess absorbed— Abscess in Dorsai Region nbaorbed— Dia- 
ease of Ilip-joint ; Anchylosis and Large AbncesB absorbed — Diseaseil Uip-juinl, 
with Sapparation of the Loft Side cured by Four Months' Rest ; Abscess Absorbed 
^Diseased Eip- joint, supposed to be GoBorrhieal ; Abscess opened bj Nature; 
Portions of Bone extruded by GianolatiouB ; Cored b^ Itest, villi PermMteat 
Ancbyloeis. 

From the unfinished state in which I left the aubject of "hip-joint 
diseaae " in my Ust leeture, T feci bound to g-ive some further evidence 
in support of my assertion, that hip-joint diseases are not so commonly 
scrofulous as has been assumed, or, if scrofulous, are yet curable by 

I am well aware thnt my assertion, that diseased hip-joints are not as 
a rule so generally associated with scrofula as is commonly supposed, must 
be well demonstrated by facts before I can make an impression on the 
thinking and reflecting portion of our profession. I must be prepared 
to show, by a series of undeniable cases, that diseased joints, whether 
scrofulous or not, will yield to the treatment bv mechanical rest, before I 
oan induce my brethren to follow my plans in their daily practice, I now 
proceed to lay before you some additional facte and cases in support and 
corroboration of the views I have long entertained on this subject. 

At the conclusion of m;^ last lecture I mentioned two cases of hip- joint 
disease, in each of which dislocation of the thigh-bone had occurred frott 
disea,8e, and in each was subsequently reduced.* At that time one of the 
cases had been doing remarkably well up to the period of an accident 
which led to a severe injury of the new medium of bony union (anchylosis) 
between the femur and acetabulum. That child remained some months 
after her readmission into the hospital, and was Snally cured. I have lost 
sight of her for some years. The other patient also left the hospital, 
going on most satis fa ctorUy, and wearing a leathern splint. Here is a 
short report (March 11th, 186^) of the actual condition of the latter patieul 
from Mr. Stomiont, of C'heshunt ; " I saw the hip-joint case yesterday. 
His general health is very good ; the limb preserves its position and its 
length, and there is no pain at the hip-joint on pressure. The splint has 
not been taken off since his return home." 

J refer to these cases because they a.re very striking, and will possibly 

•In the form of an appendix will hefnund on extremely interBstingoMe of hip-joint 
disease formerly nndar the uare of Mr. Uilton : in this cose one femur was displao«d 
on to Ibe dorsum ilii, the other into the naighboibood oi the foramen or^e. — [Bd.] 



ON THE THEEAPEUTIC 

of such Attempts &t reduc' 



establish a precedent to justify the repeti 
*■ bring forwiird b. third 



panyiiig drawing (Fig. 74) represents 
femur and acetabulum, taki 



this subject. The accom- 

n of tlio epiphysis of the 

from the patient to whom 1 uin now abont i 



Dislocation of right Femur from, Disease of (he ITtp-joinl; JU,dH(ti<in 
of the Didocatiun Tmo Months qJicrwaTde; Death from I'l/ariitia. 

The patient, S, R , aged twenty-two, was admitted into Guy^ 

Hospital, uuder my care, on tne 3lst of October, 1801. Her history v 
this:— 

Four months ago sho was taken ill, without any known cause, ' 
pains down the right leg and thigh, which confined her lo bed. She Ii 
mained iu bed some time, her leg being- then nearly straight. She i 
suffering great pain in the hip, with inability to move the hmb. She fa 
been treated for various local diseases by different medical men, snd 1 
terly, up to the time of her coming to Guy's, most assiduously, by f 
homcEopathio physician, for "rheumatic sciatica." Two months befoKI 
■dmiasion, one evening, soon after falling asleep, the thigh became some- 
what suddenly beut, and the foot inverted. From that time she was 
unable to straighten the limb. She 
then had increased pain in the right 
gr n and right knee. 

Here I think it worthy of t> pus- 
ng CO isideration to inquire why it is 
that these dislocations from diseaiie al- 
most always occur just as the patient 
IB fall g off to sleep. It is theji that 
vol t on has withdrawn its influence 
f om the nervous system generally, 
a d tl e cxeito-motor function of the 
sp nal cord seems to obtain an exclu- 
sive authority over the limbs, and 
produces the involuntary spasmodic 
condition of the muscles which causes 
these displacements. Whether this 
be the true interpretation or not, you 
will find, upon referring to the history 
of these cases, that such displace- 
ments almost always occur just as 
the patients are going off to sleep. 
This patient came under my care 
n the 31st of October. On the fol- 
lowing day I found her lying in bed, 
on her left side, suffering much uain 
in the right hip, thigh, and leg, which 
was increased on attempting to move 
the limb. The position of the limb 
corresponded exactly in direction with 
Y the head of the thigh-bone when dislocated on to 




im tlia pnpanUan) 




that usually 



nof theilium; and this, she 
two months previous to her 






Isl 



etbis 



INPLUENOE OP BE3T. 



ivelythftt tTieT>one had been in that j 



213 



d counter-extension was ineffectually made. 
flexed it several times towards the abdomen, 
I the mobility of the displaced head and neck 
ext forcibly abduct«d, and then rotated out- 
its abnarmal position, and to tilt the head 



asserted most p 

for two months. The thigh was flexed and turned inwards, knee and foot 
inverted, and the limb shorter than that on the other side. Press tire npon the 
trochanter major caused great pain. She had a large, unhealty bed-sore over 
the sacrum. As no careful examination of the limb could be made without 
inducing extreme pain and distress to the patient, chlorotorm was adminis- 
tered. On forcibly inverting the right leg, the head of the thigh-bone could 
be distinctly felt under the muscles upon the dorsum of the ilium. All the 
other usual local symptoms of dislocation on to the dorsum ilii were 

\ powerful 
tion by simple extension ai 
I then grasped the thigh, anc 
BO Bs to give more freedom t' 
of the bone; the thigh was i 
wards, in order to lift it froi 

of the bone over the edge of the acetabulum. This being accomplished, 
the thigh was drawn downwards and inwards, the whole limb everted, and 
the head of the bone passed into the acetabulum, where it could be felt 
below Poupart's ligament on rotating the limb slightly outwards. The 
position of the limb had become in every respect normal, I mention 
these facts, because they aSord direct evidence that the dislocation was 
actually reduced, and reduced two months after the occurrence of the dis- 
location. She was placed upon her back, a long straight splint, with a 
footpieee and transverse support, was apphed along the outer side of the 
lower limb and pelvis, and simply bandaged to them, so as to prevent 
rotation of the limb, and any recurrence of the dislocation. In three or 
four days, although she had been suffering for as many months, all the 
untoward symptoms of this case had subsided. This improvement was 
simply and entirely the result of the rest which had been given to the hip- 
joint bv readjusting the two bones forming it in their proper relation to 
each otfter. She slept well, was free from pain and febrile condition, the 
swelling of the thigh had nearly disappeared, and her appetite was good; 
indeed, she felt better than for the four previous months, complaining only 
of the bed-sore. She was absolutely quite comfortable, excepting the 
annoyance of the bed-sore, and improving daily in appearance and strength 
up to the l^th of December, when she had an intense shivering, followed 
by fever, headache, and sickness; no pain in the limb or hip-joint, the 
pulse very rapid, and her appetite gone. She was, in fact, the subject of 
pyremia. These symptoms continued, and developed into pneumonia, 
which proved fatal in nine days. She died on the 21st of December, 
forty-four days after the reduction of the dislocation. The right limb, by 
accurate measurement, was found to be rather more than halt an inch 
shorter than the left. The body was examined on the following day, and the 
whole of the right lung was found pneumonic, with numerous, well-defined, 
small collections of pus in different parts oE it. There was no disease in 
any other viscus; but I may add that the bed-sore bud reached the inte- 
rior of the vertebral canal, and involved the membranes of the spinal mar- 
row, which extend downwards as far as the second portion of the sacrum, 
although the marrow itself ceases opposite the second lumber vertebra. 
I have several times seen fatal mischief result from a bed-sore extending 
to the interior of the vertebral canal, and causing inflammation of the 
spinal cord and its membranes. 

Fig. 75 is an accurate drawing made by Mr. Tupper from s preparation 
illastrating this important pathological condition. 



I 




Recurring to tlie pase we have been considering, you vrili observo eri- 
denoe (and it is well worthy of note) that at the a^ 
of twenty-two the head of the femur may be still in 
part an epiphyais. Looking at the whiSe prepara- 
tion (Fig, 74) patliologiually, it will be seen that rep- 
aration nad been proceeding in the joint very sat> 
isfactorily indeed; and I think we may fairly cc 
elude that, if the patient had not been the aubji 
of fatal pyaemia, this would have been a good 
to exemplify the great advantage Jikely to a 
from the reduction of a femur dislocated by dis 

The question occurred to my mind, on seeing tl 
bony union of the edge oE the acetabulum to a p< 
tion of the head of the femur, whether the true «] 
physis had boen displaced from the acetubuhim 
the lime ot the dislocation; whether it was not tl 
projecting portion formed by the neck ot the boi 
which I felt upon the dorsum of the iiiuro previom 
to the reduction of the dislocation. If bo, it would 
render the case still more interesting, because it 
would show that, notwithstanding that both the 
upper and under surfaces of the epiphysis ot tkte 
bone was diseased, reparation was in progress, and 
that, as far as the hip was concerned, it may be 
deemed a successful case. I thought this instanoe 
TCOuld be a good appendix to the two analogous 
cases which I had the pleasure of detailing in my 
last lecture. 
-■«« Hi~-»— »i«ivi Encouraged by these cases, I hope surgeons 

Krwrwb™iainiu!~o"'a!o! be induced to try to diminish to some extent, if 
iB»»i»,»nd(ifurinnitarv^ to completely remove, that extreme deformity wti 
Mm. »,\VnO«i««im t^pj so often meet with in cases of hip-joint disc 
of lb* anil di uui ncrum With dislocation of the thigh-bone, provided they se« 
BSo'*Ji«2^SSic iJm them before Nature has formed a substituted joint 
•MBU an Mn pnnading or a consolidated ossific union between the ilium and 
■■iniii dnn'uuH lo iih the thigh-boiie in an abnormal position. I know it 
•«™Bi.e.pun.mM«.™- has fallen to the lot of my colleague, Mr. Cock, M 

UdnlnecaoiUaiulru, ■nob- ,, . ie . . ^ l '.l . j 

mM und nntm iiin*] well as to myself, to treat such cases with great aOr 

SUSSiI'iIm'SS^wm'" vantage to the patients. Thus, when the head of th« 

Sa acrum. Nomwmi thigh-bone has been displaced high up on the do^- 

2)h^ ihTd^ mu(T™io S"™ °f '1)^ ilium, producing great defonnity, pain, 

ttiaiMUis^Britouanitaitht ^nd Constitutional distress, although it may not nave 

Ma HCMid ixiRiui at uis been in his power or mine to replace the head of tke 

3irkSinInuJI^S«i'i,)"'tbB bone actually within the acetabulum, yet we have 

thM. fiionh, uid flak far- succeeded, in some instances, in mitigating the de- 

tncriiin. formitv, in relieving much of the pain and constitm- 
(ional distress, and tn restoring the limb to nearly its proper length. 



lOM dte mada bjr nraill) 
la lalmluoad to nanlDd Uw 
nniaoR ot th« oloa* pnxlm- 
Kir ot t ba abaatta 1 1 ba (piiial 



iseasft^H 



L 



/% Z>M(aw, StrqMxM (■'), treated hy " Jtwt 
no distinct Ah*ct»a. 



atrtd by AneAj/lanii 
that of a girl wbo was sud to 



The next case to which t must allude ii 
tve scrofulous disease of the hip- joint. 
Elitabetii L , aged nine ya&ra, oame tmder my cajre at G&f^ OA 



INFLUENCE OF REST. 



215 



February 13th, 18C1. The mother sttuted that fifteen months hefore that 
lime the child fell on the pavement, and struck her riaht hip, hut after a 
day or two did not complain of any inconvenience. (It is worthy of no- 
tice that if we inquire of the parents or other intelligent person old enough 
and willing to tejl the whole truth, it will nesrly always turn out that 
patients sufTering from hip disease have met with accidents. Without 
ctaggeration, T believe we may almost always associate Accident with the 
origin of hip-joint disease. 1 am quite aware that it is BOnieUmes very 
difficult to ascertain the exact account from a child, especially when it hao 
been under the care of a servant; but I feel confident (hat most of the 
hip-joint diseases in children depend on small accidents.) About a month 
after this occurrence she spoke of having pain in her right knee, and was 
Uuie. These symptoms continued to increase, until she was compelled to 
U90 crutches. She attended at an infirmary for two months aa an out- 
patient, and liniments were applied without any relief. She then became 
an out-patient at Unirersily College Hospital during four months; had 
blisters applied over the hip, and took cod-liver oil; but she got gradually 
worae. Her mother then kept her at home for eight months, when the 
pain in the knee, with loss of sleep and health, became so severe, that she 
applied at Guy's for admission. On examination, she had all the local 
symptoms of advanced disease of the right hip-joint : the foot was turned 
inwards, and the thigh bent, with tendency to dislocation of the head of 
the thigh-botie on to the dorsum of the ilium. By accurate measurement, 
the liinb on the diseased side was three-quarters of an inch shorter than 
the opposite one. Much pain was experienced on moving the right Ii ,■>- 
ioint; some fulness (but no distinct fluctuation) existed over the front and 
oack of the joint. Chloroform was administered, the limb carefully and 
slowly straightened, and an ordinary straight wooden splint with a foot- 
piece applied along the outer side of the limb and trunk from the foot to 
near the axilla. She had a firm, unyielding mattress 
to lie upon; no medicine wa« ordered, but good food 
freely supplied. 

Now here was a young girl who for eleven months 
previously to her admission into Guy's Hospital had had 
disease in the right hip-Joint. Those who had seen her 
during that time had no doubt about it. Atthe time of 
admission hip-joint disease was unequivocally manifest- 
ed, and her general health was declining. The wooden 
splint was put on simply for the purpose of insuring rest 
to the diseased joint, and it remained on for five months. 
At the end of that time, on July 5th, I86I, the clinical 
splint has been re- 
3 been in every respect com- 
. pressure over the 
s any induced by pressing 
r by striking the neel; both 
3 in length; the fulness has 
o evidence of suppuration; the joint is be- 
mng firm. Splint to be reapplied, and rest contin- Pio. tb. 

ued." Then she is not examined again for three months 
more; nothing ia done but to feed her well and to keep her lying in bed. 
On October loth, 1861, after eif^ht months of rest, we find that the ten- 
derness over the head of the thifch-bone is entirely gone; the femur is 
united to the acetabulum; the thigh and pelvis may be moved together 



report states: "Up to this t: 
moved only once, as she has 
fortable; scarcely any tender 
front of the hip-joint, noi 
upon the trochanter major 
legs are apparently the s 




ON THK TnERAPEUTIC 






t pain; the right limb is 
laltJ 



shorter t 
1 the right leg — th&t is, the diseased 



8 lirst-rate. A leather 



plint was Ap- 




1 

i 



one — without pain ; her g 

made Cor her hy Miliken, ttnd she was permitted to get up. She left the 
hospital in a fortnight, with injunctions not to attempt to do too niach 
in walking, and to wear the leathern splint night and day. I saw hera?ain 
on January Slst, 186'2. She then had no pain in the knee, thigh, or hip. 
She could walk half a mile to and from school without pain. The right 
iimb was three-quarters of an inch shorter than the left; the right hip- 
joint anchylosed, and the limb in a good position. She was in excellent 
health. The drawing depicts her as she was a little while ago. It wsa 
desirable that she should take a proper amount of walking exercise. Ver- 
tical pressure upon the thigh-bone was permitted, but the 
plied for the purpose of preventing any accidental twisting o 
stress upon the new medium of union between the head ot the thigh-bone 
and the acetabulum. This patient I think you will admit was fairly ctire 
by " mecbanioal rest." 

Ilip-joint Disease; Phthisical Patient; Abscess absorbed ; 
cured by Anchylosis. 

presents more distinctly the scrofulous aspect. 

aged seventeen, a dressmaker residing 
Woolwich, came under my care at Guy's on the 10th of June, 1857. Her 
father was phthisical, and she herself had long been in bad health, and 
subject to prolonged attacks of cough. The patient stated that she re- 
membered that two years pre^-iously she fell, and hurt her left side or hip. 
!n the course of two or three days all apparent effect of this accident had 

Eassed away, and she behoved herself to be then in unimpaired health of 
mb. Four months afterwards she began to be lame; some days she 
could walk somewhat better; other days not so well. Bearing any weight 
upon her fool, or stamping, gave rise to pains in her left hip-joint. She 
paid little attention to these pains, for some of her friends said they were 
"growing pains;" other persons attributed ihem to " the rheumatics," 
which she inherited from her mother. She soon suffered from continuous 
and severe pain in the great trochanter and in the gluteal region ; and 
from that time she began slowly to lose flesh. In the course of another 
month or so she could only just manage to limp about. On admission to 
the hospital she was in a very weak condition, suffering from great pain 
in the hip, with cough and expectoration, and suspected disease at the 
apices of the lungs, there being slight pulmonic consolidation. She could 
manage with assistance to stand upright on her right leg, and then the 
toes of her left foot (or diseased side) just touched the ground. In tl 
recumbent position the left thi^h was firmly flexed and slightly abducti 
Great pain was felt in the hip-joint on pressing the knee or heel upwai 
towards the hip. A day or two after admission chloroform was admii 
tered, and the limb was forcibly straightened; and then a straight wi 
splint was applied alon^ the outer side of the limb. Towards the lal 
end of July the fluctuation of a deep abscess could be felt in the pi 
below Poupart's ligament. The splint was kept on till the middle ai £)e-' 
cember (six months), when it was removed, as she was then, and had 
been for a long time, free from pain. The hip-joint was becoming firmly 
anchylosed, for the pelvis moved w^ith the femur. Yielding to the inn)Ol^ 
(unities of the patient, whose condition had so greatly improved^ 1 ^M 



I 



INFLUENCE OP REST. 217 

!owe<l her to walk ttbout the ward; but she Boon afterwards had consider- 
able pain in the hip, and the swelling of an abscess appeared on the outer 
side of the thig'h. I admit that this permission to walk was a great indis- 
cretion on my part; for I had no right to expect that, in so unhealthy s 
patient, the new stmcturea which formed the medium of union between. 
the two diseased surfaces of bone, or the two articular surfaces which had 
been diseased, would be competent in six months to resist the morbid 
effects of direct vertical pressure, or of any movements, or even, perhaps, 
of continuous vibration upon them. For several days she suffered from 
shivering, loss of appetite, and other symptoms of hectic, but quickly im- 
proved again by resting upon her bed. On February 5tli, 1858, after 
eight months of rest, the femur and acetabulum were firmly united, and 
the fluctuation of the abscess had disappeared. Here, then, is a phthisical 
patient, bavins' unhealthy phthisical parents and severe disease of the 
nip-joint, who has, notwithstanding all this, by keeping the joint at rest 
by a simple but efficient splint, and remaining perfectly quiet in bed, 
actually improved in general health (this is the bugbear of many persons, 
who say yovi must not keep a patient in bed, because the health is dam- 
aged by itK and the hip disease is nearly cured — that is, anchylosis is 
eftected. The patient was able to get about, under my observation, for 
some considerable time, and then I lost sight of her. 

I may say that 1 have never seen a. severe case of hip-joint disease 
under treatment by rest where the patient has not been improved in gen- 
eral health by rest in bed. As a rule, nearly all the constitutional dis- 
turbance has usually disappeared after a short time — two, three, or four 
weeks. In my opinion, then, it is neither sound in argument nor true in 
fact to state that the general health of ar patient who has hip-joint dis- 
eaco sulTors uncompensated injury by lying in bed and keeping the dis- 
eased parts perfectly quiet. 

One of the most frequent, and sometimes one of the most important, 
concomitants of hip disease is abscess; but it does not necessarily follow, 
because we Rnd an abscess near a diseased joint, that it should be in 
direct communication with the interior of the joint. I have several times 
■een in the groin and in the popliteal region small abscesses associated 
with the hip-joint and knee-joint respectively, but simply depending upon 
an indirect communication through the medium of the lymphatics, and 
not the result of a direct extension of suppuration from withni the knee- 
or the hip-joint, I have also seen the following erroneous interpretation 
committed in consultation. The existence of enlarged glands in the 
groin, associated with hip- or knee-joint disease, or the Tike glandular 
cwndition in the popliteal space connected with knee-joint disease, and a 
similar state of enlarged glands just above the internal condyle or within 
the axilla, and accompanying disease of the elbow-joint, have been mis- 
taken as marked local evidence of scmfula. Such glands have entirely 
subsided as soon as the diseased joints have got well, thus showing their 
association to be simply with lymphatic absorption, and the arrest of mor- 
bid fluid within the glands. No doubt, however, the rule is, that when 
deep suppuration occurs in close proximity to a diseased joint, it commu- 
nicates directly with the interior of that joint, and then the question 
what is to be done with the abscess is brought before the surgeon for his 
decision. 




^r; 



ON THE THERAPEUTIC 



Disncaaion of the propriety of opening A hsceases connected wUk IHaeaitit 
Joints,* 

This is a very important subject, and tlie proper answer to the ques- 
tion should be deliberately considered and decided, on phyeiolo^ioal pri»- 
cipies and those of experience. Some surgeons would say, " I see r "^ 
harm at all in opening the abscess as soon as it shows itself ; " and tb( 
accordingly advise that treatment. For my part, I believe such a peooi 
mendation to be fraught with extreme danger to the patient, and that 
marks the indiscretion of the surgeon. In opposition to such a pli 
would solicit your attention to one or two considerations, for the pur_ 

ving that the attainment of physiological rest ought to be the guid- 
nciple to direct us in the right course. 
I the first place, we know that the healing process of the deeper- 
seated parts of the body always g;oes on better when the injured or dis- 
eased structures are not exposed to the external air, It must be adiuttted 
that if we open an abscess, communicating with the hip-joint, for exam- 
ple, or any other joint, and keep it open, we pennit the contact of the 
external air with its interior. It is well-known that this 18 th« chief 
agent — or starting-point, if I may so term it — in the putrefactive pro- 
ceaa; and it seems to be pretty wpII ascertained that if you exclude air 
from dead animal tissues they will not become decomposed. Agfain, if 
we have a cut, or raw surface, upon the finger or hand, and the denuded 
structures be exposed to the atmospheric air, wo suffer pain, irritation, 
and local inflammation ; cover the raw surface with some harmteM 
material, exclude from it the irritating influence of the air, and immedi' 
ately all pain subsides. Thu« we have analogically presented to us by. 
examples the evidence of the deteriorating influence resulting from 
admi.saion of air into the interior of an abscess. 

Experience teaches us that so long as an abscess remains unopenedj^ 
and its wails are kept free from local disturbance by the muscles or other' 
causes, no inflammatory condition is usually manifested upon the walls of 
the abscess. Then one might fairly say, " Why open it? — why not lesTB 






it alone ? It is not doing barm in any way, either as regards the orjjfinj 
local disease or the general health; why meddle with it ?" On the other 
liand, all surgeons know that when such an abscess is opened, it becomei, 



T it may become, inflamed, and great local and constitutional disturbance 
may supervene. The effects of that inflammation will he that the origin- 
ally diseased parts, as well as the new repairing structures within and oat; 



• The decision of this question is randecod comparatavoly ensy if atteDticm la . 
to the characteF of the atisueio. Two kinds of absceRsea are met with in or near joint!, 
vie. tiie cbronio, or " cold," and tho acute, or inflnmmatoiy. The first vorietj ii 
ohftl'aoteriied not only by the attrihutei denoted by the above names, by the absenoe 
of heat, redness, and pain, bat also by the qunlities of the pna, which is often thin. 
presenting caaeoiis magses tn the naked eye, and microecopically buC few well-formed 
pas cells, much molecular diaintegraCiou, aud abnnduit choleeterine ciystala. Thew 
are the nbscessea which may be left untouched, ia the hope of their conlenta being 
absorbed. Very different are those abacenos which, to diiitin^ish tbem from tho 
above, may be called aonte or iDllnmmntory, coming an with comttitutlanal diatotb- 
anoe, ri^ra (often absent or overlooked jn cbildreo), &o. These should be oponsd at 
an enrly date : if in the joint, they only prepare the way for further changes ; md, it 
peri-artioulaT, they extend rapidly, separating the mnaclcs, and making their waj 
amongst them in dllTerent directions, so that the sac, orijpaslly single, oomea to harv 
numerous processes ; lastly, there ia slwaya to be borne in miud Che liability of theil 
bursting into the joint, especially in the case of the hip and knee. — [Mu. \ d 



p^W 



IKFLUENOE OP REaT. 

side the joint, will participate in both the local and constitution a. disturb- 
ance, which lowers their vitality. They then softeji down or uioerate, and 
become subservient to the law, that iii/i<ivtetl or neu>ly formed or renewed 
ttructurea aiijf'er rapid deterioration J'rom constitutional or local disturb 
aiice. This is no eKag'<rera.ted statement; I have seen many illustrattona 
of it. Thus, we know tliat i[ a person has had an ulcer recently healed 
up healthily, or a sore which has closed well after a burn or scald, and he 
contracts erysipelas (a blood poison), not at the seat of injury, but else- 
where, or ia attacked by smalf-pox, scarlet fever, or measles (blood poi- 
sonst, the cicatrix, which was perfectly healed, will quickly ulcerate, 
break down, disintegrate, or entirely melt away. If this be true with 
re^rd to exterual parts, may we not argue that it is equally true with 
regard to internal structures ? If we can see the fact manifested on the 
surface of the body, that scarlet fever, erysipelas, &c., or local inflamma- 
tion, can so damage new tissues as to lead to their destruction, whilst 
those which have not been previously diseased or structurally deteriorated 
will pass unscathed through that ordeal, surely that is a potent argument 
against the propriety of opening these abscesses eariy. These facts form 
the b^sifi of one of our arguments against the propriety of opening an 
abscess connected with a diseased joint before it ia absolutely necessary, 
or before the medium of reparation deposited within or about the joint, 
or interposed between the bones, is so completely consolidated, and so 
efficiently organized, that it is structurally competent to resist the two- 
fold deteriorating luQuences of local and constitutional disturbance, or' of 
«ither of them. 

Let us look at this subject from another point of view. If a person 
suffers from the escape of a. large tjuantity of pus daily, may we not deem 
it tantamount to his being bled to some extent every day ? I think we 
may. Assuredly, if we were desirous of inducing a healthy local process, 
or of aiding the general power of repair in a patient, we should not daily 
drew even a few drops of blood from him, with the hope or intention of 
improving either his general health or the local disease. That would be 
adverse to sound physiological principles, against common sense, and 
opposed to the experience of every one. If a large chronic abscess be 
opened, it very often, nay, generally, happens that its interior surface 
freely pours out an abundance of serum, lymph, and pus. It must bo 
admitted tliat the more it discharges, the more it drains the patient indi- 
rectly of his blood, so that I apprehend, under such circumstances, he is 
being bled eveiy day, and it is painfully apparent that his health becomes 
greatly and sometimes fatally damaged by it. Nothing can exemplify 
thia position more empiiatically than the case of psoas abscess. We see 
cases where a large psoas abscess exists, and the patient scarcely suffers at 
all; but directly the abscess is opened, and opportunity is given for it to 
discharge its contents, from that point starts a course of events which 
ultimately leads to the patient's lingering death. 

A gentleman from Esses brought me his only son (nearly twenty-one 
years old), one of a numerous family, having a large abscess extendin_^ 
under and below Poupart's ligament, associated with diseased spine. The 
young man had not suffered any pain, nor was bis general health declin- 
ing, and he was out of doors taking exercise every day. His surgeon 
Suggested that 1 should see him, as he did not wish to open the abscess. 
I acquiesced in that advice, and explained to the distressed father the 

Erobable contingencies of his son's condition. He went homo, and was 
ept lying down. Soon the abscess began to discharge. From that day 




230 ON THE THERAPEXJTIC 

he had an exhausting ilhicss, which gjadually wore him out, and i 
moiitha, in spite of all that could be done for him, he died. Ue m 
to death by the [irofuse discharge. 

Instead of hesitating as to what we should do in the case of an 
commutiicttting with a diseased hip-joint, I would advise that the opening 
be deferred as long as possible, until we can be pretty well satisfied tlist 
anchylosis or bony consoHdation haa actually taken place in the joint. If 
the bony union be perfect, then we tnay open the abscess without involT- 
ing the patient in undue risk as regards the repair of the joint, 
regards the general health. 

Hip Disease; bony Anchylosis; opening of Abscess deferred; 
Recovery. 

Here I may just refer to a case in point, which 1 saw some years 
with my friend Mr, Ray, of Dulwich. It is a case which shows well 
influence of rest in the treatment of hip-joint disease, as well as the advan- 
tages of deferring the opening of tlie abscess until consolidation ha« taktat 
place between the femur and acetabulum. You will observe that the hip- 
jotnt cases with which I am now dealing are not trifling, but serioos cases 
of disease ; but they may usually be said to terminate well, provided anchy- 
losis can be accomplished. This patient, a young lady, came under the cars 
of,.Mr. Ray in 184(i, suffering from disease of the right hip-joint, and con- 
tinued under his treatment during IS47, '4S, and 49. The patient had 
repeated and well-marked symptoms of hip disease during that period. 
These were removed at each interval by rest for a short time. In March, 
1849, she had an attack of dysentery, which nearly proved fatal, and lefl 
her much enfeebled. In June the hip-joiut symptoms on the right sidfl 
recurred, but yielded to rest, counter-irritation, cod-liver oil, &c. She did 
not, howe\-er, regain her former heallh, and in the early part of Decem- 
ber, 1849, between three and four years from the first indication of hip 
disease on the same side, much more marked symptoms occurred, with 
great constitutional disturbance. The pulse became very rapid; the pain 
was of an intense character, suggestive of inflammation of bony structures, 
and was referred to both the hipand the knee; the upperpart of the thii * 
became swollen ; and considerable enlargement could be readily felt at t 
posterior part of the trochanter major. Leeches and linseed poultices wi 
applied to the groin, opiates and bichloride of mercury administered, ai 
she was directed to wear a leathern splint. In January, 1850, I was con- 
sulted. The constitutional and local symptoms were increasing in sever- 
ity, the pain in the right hip-joint, except when influenced by opium, 
being unendurable; the child dreading and feeling almost the slightest 
movement of persons walking gently in the room; the paroxysms of pain 
and jumping of the limb recurring with increased seventy at night. Up 
to this time the joint had not been sutBciently fixed, nor the local rest 
sufficiently complete or prolonged, to enable Nature to repair the mis- 
chief. A long straight wooden splint, with a footpiece, was now applied 
to the limb, sedatives freely given towards night, and good fluid nutri- 
ment administered. The pain and constitutional disturbance steadily 
subsided. A large abscess presented itself at the anterior part of the liip- 
joitit, and slowly descended the thigh. Cod-liver oil, steel wine, and qui- 
nine were administered as medicines; the recumbent and a fixed position 
of the diseased joint were strictly and uninterruptedly maintained. Thi 
were all the means employed. No counter-irritation, none of the ' 






ol«H 



I*FLUENCE OF BEST. 231 

■doctoring style of treatment — no setons, issues, or painful applica- 
tions of any kind. In March, ten weeks from my previous visit, I saw the 
patient agaiti, and found that her health had steadily improved. The 
abscess subsequently diminished in size, and descended lower down the 
thigh, and appeared perfectly unconnected with the joint. After eight 
months of rest, the femur and acetabulum being firmly united, there being 
no pain in the joint, and no constitutional disturbance, the abscess was 
opened at its most depending part; it discharged a strumous, purulent 
serum, containing cheesy flakes and masses. The thigh was afterwards 
carefully strapped and bandaged, so as to bring the walls of the abscess 
together, the pressure being made upon the cyst from above downwards. 
The abscess closed somewhat rapidly. The recumbent position, with the 
splint upon the limb, was maintained a few months longer, and she 
regained perfect health, with a firmly anchylosed hip-joint. 

The conclusion of the case is this: — She is now in her twenty-first year, 
in good health, and well grown. The right leg is only half an inch 
shorter than the left, and she may he said to walk without even a limp. 
She is an excellent dancer, frequently dancing for a whole evening, and 
but few persons know, when she sits down, that the right knee-joint ia pur- 
posely bent at right angles with the thigh, and tucked under the chair to 
meet the inconvenience of her fixed hip-joint. 

This case shows that notwithstanding the continuance, more or less, 
for several years, of symptoms of diseased hip-joint, with every indication 
of most serious ulterior consequences, yet by " rest " during many months, 
and with an appropriate hut simple splint, the patient may get well. It 
also exemplifies in a most emphatic manner the advantaj^ of deferring 
the opening of the abscess till the medium of union is consolidated 
between the two bones, so producing perfect anchylosis of the joint. 

I may conclude the reasons for recommending delay in opening these 
chronic abscesses with joint disease by reminding you that the abscess 
may be absorbed without any harm to the patient. Most surgeons have 
seen hip disease associated with the clearest possible evidence of tluctua* 
tion, from a considerable collection, probably, of purulent fluid in the 
thigh, and have yet witnessed the spontaneous disappearance of that fluc- 
tuating swelling. One of the cases which I have already detailed, and 
some others which I shall hereafter adduce, open up this question — Is it 

Eossibte for an abscess to be absorbed ? I may reply, that I have not the 
tast doubt about it. 1 have no doubt whatever that those portions of 
the contents of an abscess which are not absolutely solid can be com- 
pletely absorbed. The solid residuum may remain permanently amongst 
the surrounding soft parts, not doing or leading to any mischief, unless, 
perhaps the patient should suffer from typhus fever, scarlet fever, measles, 
Of any other physical or moral cause producing severe constitutional 
depression, as we see exemplitied in the cases of bullets that have been 
buried in the living body for many years, without producing any detri- 
mental effect until some serious injury to the general health occurs, and 
then there is a discharge. Some years ago I saw professionally a general 
officer who fought in Egypt against the first Napoleon, and who at that 
time received a bullet in his right groin; it remains somewhere in his 
pelvis, and he informed me that he never felt any inconvenience from it 
except when his health got out of order, and then a small discharge from 
the wound in the groin occurred. I am strongly of opinion that abscesses 
can be absorbed without any danger to the patient; but I apprehend that 
before what may be termed healthy absorption of an absce^ occurs, the 



ON TUE TUEEAPEUtIo 



p, and then the altered fluid results of th« 
ithout injury to the constitution. The solid 



piiB globules are broken i 
aliscess may be absorbed \ 
parts of tlie abscess may remain. 

Chronic Abscess absorbed. 
Tn the year 1850 I bad a patient under my fare at Guy's Hospital, in 
whose forearm there was a Urge chronic ubscess. Thinking it a css» in 
which 1 might put the question of absorption of pus to the test, without 
risk to the patient, 1 passed a line troc4ir and canula into it under th« 
adjoining healthy skin, so as to draw off a small quantity of pus. That I 
might be sure there was no mistake about the character of the fluid in 
this case, a small quantity was examined microscopically, and then 
aperture in the skin was carefully closed. The abscess was kept quiet 
the arm being placed upon a splint. In a few weeks, and without * ^, 
constitutional disturbance, the abscess completely disappeared. TlUF 

tiatient died some months afterwards from disease of the cheat, and I 
ooked with interest to discover the remains of the old abscess at its for- 
mer site, and there I found some solid cretaceous-looking material, whieh 
was doubtless the residuum of the abscess, interposed between the Casoi* 
and the subjacent muscles. Anxious to be quite satisfied on this head, I 
requested my friend, Dr. Odiing, to undertake the chemical examination 
of this residuum, and here is the result in his own words; "A tough sub- 
stance, of a yellowish color, having the appearance of artificially dried puft 
Like the solid residuum of pus, it consisted principally of a butyraceooa 
fat, and of soluble and insoluble albumen, but also yielded an aqueous 
extractive, or pyin, and an alcoholic extractive. The mineral constituent! 
were chiefly chlorides, sulphates, and phosphates of soda and lime, corrttii 
spending with the coustituents of the ash of pus," 

I think 1 could not place a more conclusive ease before you in answi 
to the question — Is it possible for an abscess to he absorbed? The ab*- 
scesa in tliis case was proved to demonstration to exist; pus was drawn 
o£F, and examined microscopically; all the fluid portion of it disappeared 
by absorption; and probably less of the solid residue would have beea 
found if the patient had lived longer. 



itl 

Tl£V 
A r 



I tlie Dorsal Region ahaorbed. 



m 

od 
ea 



A large Abscess i 

I had under my care a man who had a very large abscess projeotil^ffl 
backwards, and associated with diseased spine in the dorsal region. Thi* 
lar^ abscess, holding, 1 should think, a pint and a half of fluid, received 
a distinct impulsive movement from the interior of the chest during oouffh- 
ing or a full inspiration. By rest in bed for several months the spine dift-._ 
ease was cured; and by blistering and rest the abscess subsided — in faof 
was gradually absorbed. July, 1862.— This patient is now in Guy's Hoi 
pital, suffering from an accidental injury to his foot. There is not tbl 
slightest indication of the former dorsal abscess, nor of anything wronj 
about the spine. 

It it be asked — What are the conditions of an abscess associated wit! 
hip-joint disease which recommend or justify the making an opening 
it by the surgeon? I should say, with all reasonable submission to tbi 
experience which I see before me — -It the abscess be enlarging i 
rapidly, and Nature seems incompetent, from her feebleness (a bad i 
coition), to make a successful effort to limit it by a natural barrier, thai 
opening may be made, and half, or more, of the pus be drawn off (with>l 



INFLUENCE OF REST. 



223 



out squeezinfT the abscess). Tlie opening slioiild be immediately and 
carefully closed up, lest the outpouniij; of the fluid may be oontinuoiia, 
«.|]d a drain of pus be produced so as to alTect the general health. The 
abscess should be subsequently supported by plaster or bandage, in order 
to keep it Bt rest. 

If the walla of the abscess become inflamed, hot, and painful, with 
great febrile and constitutional disturbance — or if the abscess contain air 
fresonunt on percussion), from decomposition, mixed with the fluid, the 
opening ou^rht to be mitde lar^ enough, and at the most depending part 
of the abscess, to allow gravitation to detennine at once the evacuation 
of the whole of the fluid in the abscess. Subsequently the walls of the 
abscess should be kc^pt in contact for the purpose of inducing, by pres- 
sure and rest, mutual adhesion, and of limiting the extent of surface 
capable of dischai^ng too abundantly pus, aeritin, or lymph, which would 
diminish both the tjuality and quantity of the blood, and so deteriorate 
the general health. 

ifelt myself bound to return to this subject of abscess associated with 
diseaacd jomts, because my experience will sustain my recommendation 
as to what should be done in such cases ; and, further, because it is a fact 
that surgeons by the bedside are often in doubt as to what course they 
should pursue. I hope the facts and arguments which I have now adduced 
may be a slight contribution towards a right determination on this subject. 



Diseaie of t/ie Leji Uip-joint {^Scrofuloua?) ; good Anchylosis ; 
Abscess absorbed. 
J. W. 



lari/6 



ame under my care in 1853: he was thci 
age. The drawing before you represents the patient as hi 
Tne disease came on without any known accident. 
He had measles badly in July, 1850, and had not 
recovered his health when the pains began in his 
left hip, in the early part of October, 1850. He was 
under treatment at home, getting daily worse, until 
his admission into Guy's Hospital, Feb. 3d, 185'^. 
His general health was then very bad; ronstitional 
disturbance excessive; thigh flexed an<l adducted; 
foot turned inwards ; dreadful pain in the hip, 
and some pain at the knee. Considerable diffused 
general swelling existed, and extensive fluctuation, 
most distinct at the upper and anterior part of 
the thigh towards the outer side of the hip-joint. 
He could not bear any weight upon the foot, which 
was pointed downwards and inwards. Nothing was 
done beyond placing him in a recumbent position, 
and then applyinga long, straight wooden splint, ex- 
tending from the foot to the armpit; giving hira 
good food, and occasionally some aperient — no 
other medicine of importance. Within a few days 
after the application of the splint, his freedom from 
pain and the subsidence of the general constitu- 
tional disturbance were so marked, that it was not 
thought necessary to adopt any new measure; the 
splint, occasionally readjusted, was worn uninter- fiii.7T. 

"uptedly for four months. At the end of that time, 
lis friends, seeing him apparently so well, begged that ho might be al- 




J 



THE THERAPEUTIC 

ne, at Bexlcy llcath, for change of nir. He 
I about siK weeks, rather worse, not having hoe 
or kejit so quiet ns he ought to have been, Wh( 
the straight splint was reajipiied, and kept t ^ 
onger; after thut he hud a leathern splint (likQ 
embrace the pelvis, thigh, and knee, and he was 
'ore this Bplint during the next year until he waa too 

?iJod pusition, but a little shorter 
Deal indications of disease were 



I 



224 ON 

luwed to go to their hoi 

there, and came back ii 

sufficiently nourished, n 

he returned to Guy'a, 

during three months 1 

Fig. 66) made, so as to 

allowed to get up. He i 

big for it. The diseased limb was then 

than the other; the abscess and all otii 

fone. I feel confident that if I had ventured to open the abscess, I should 
ave made a starting-point of deterioration in his health which woidd have 
led to his death. I feel as eonfident as experience and reflection can make 
me, tha.t that would have beeo tho result. On looking at the drawing 
(Fig. 77), you see very strong evidence of n former most seriously diseased 
condition of the right hip-jonit. From the time he left Guy's, he moved 
about with his crutches, in good health and growing fast, doing nothii 
beyond attending to school during nearly three years, when he found ' 
could walk very well without his artiticiaf support. I saw this lad reps 
ediy, and watched his progress with great satisfaction. On the 24tii 
March, 18GI, the patient called upon me in good health: he had not 
really ill since he left Guy's. He could walk seven miles easily with a 
thick-soled and higb-heoled shoe. The growth of the left limb had not 
kepi pace with that of the right. The left half of 
the pelvis, measured from the median line to the 
posterior or to the anterior superior spinous pro- 
cess, was not so broad by three-quarters of an inch 
as the right. Here is a point worth bearing in 
mind, especially in reference to females under 
like circumstances — whether with hip-Joint dis- 
ease there may not be some defonnity or want of 
symmetry in the two sides of the pelvis (see 
SOI). I think we have distinct evidence that 
is so: it was well marked in this case. The 
posteriorsuperiorspinous process was nearly till. 
quarters of an inch above the transverse level 
the right; the left side of the pelvis was alto- 
gether higher on the left than on the right side; 
and he said he had himself noticed that his left 
hip was nearer to his ribs on that side than on the 
right side. I may here allude to the fact that great care is required in 
taking the measurements, soas to compare with accuracy the relative lenstfa 
of the two lower limbs. The patient should lie flat on his back on a firm 
mattress, with the legs extended and parallel. The point of the anterior 
superior spine of each OS innomiuatum should be felt for, and the ovei^ 
lying skin marked very accurately, for tho mobility of the skin in this 
region may easily cause an error in the measurements. These should, 
then be taken from the above-mentioned point of bone, along the in 
side of the patella, down to a transverse ridge which can be felt upon 
inner surface of the internal malleolus, and just above its tip, By notii 
Ihft following measurements, it will be seen that there is defective dovel 
cpmcnt in each segment or portion of the lower limb on the diseased sidf 
Measured from the anterior superior spinous process of the ilii 
lower part of the inner malleolus, the length is as follows: — 




iiing^^ 



It ol 



Urn rigbt l» 



INFtUENCK OF BEST. 



Femur 

Tibia 

Length of foot.. 



IIS . 



Right patelk lar^r thau left. 

Here, then, is a case of hip-joint disease, very sevpre in character, very 
etiduring, cured by "rest," and the abscess absorbed. The patient, when 
I saw him last, was perfectly well. He was to be found at Ueckenhain, 
selling books for Messrs. Smith and Co. at the railway station. 

lu all the cases of bip disease which I shall detail, a straight splint 
was applied. I believe an impression is abroad that, by applying a 
straight splint to cases of this kind, we are likely to Efive tne patient an 
inconvenient limb, in consequence of the limb benig fixed in a straighter 
position than the other, and that this would necessarily interfere with pro- 

S-ession: and perhaps it would be so if the limb retained its proper length. 
ut it is a fact that the diseased limb does not grow quite so fust as the 
other; hence it is always a little shorter. And again, although a straight 
Hplint be applied, the direction of the thigh-bone is scarcely ever perfectly 
straight downwards from the pelvis, but a little forwards and downwards. 
I do not, thcrefure, aetjuiesce in the view of some surgeons, that it is 
better to put on a splint ivhich makes the hip-joint perniajiently somewhat 
Hexed. 1 believe, on the whole, a straight splint is the lest. 

IHteaaed Hip-joint, vUk fuppiiratimi of the Left Side ; cured by JFbtir 
Moiit/is' Rest; Af/t)i:esg ubaurbed. 

William T , afi^ed eighteen, was admitted on the 30th of Septem- 
ber, ISfil. He is a clerk in a printing office. Three months ago, when in 
good healtii, he slipped down several steps, but did not fall. Ho strained 
his left hip severelv. immediately became lame, and on the following day 
could not stand, He had been lame and confined to the house and to his 
bed up to the time he came to Guy's Hospital, except when on two ocoa- 
sions he was taken in a cab to different hospitals, where he was ordered 
lotions, blisters, and medicines. On admission, the thigh was flexed, 
ftdduotcd, and fixed towards the abdomen; the hip-joint was extremely 
painful on moving it in the slightest degree, or on making pressure over 
the anterior part of it, where the distinct fulness and fluctuation of an 
abscess could be felt; pressure on the trochanter major caused pain in the 
hip-joint; so did striking the sole of the foot, or pushing tlie limb up- 
wards from the knee-joint; great starting and jumping of the left leg, 
especially on going o^ to sleep. Full diet. 

Oct. "8th, 1861.— Chloroform was administered, and the limb forcibly 
straightened: a long outside wooden splint applied; no special medicine, 
except opium to induce sleep and to relieve pain; some aperient medicine 

In a fortnight the pain and jumping of the limb had subsided gradu- 
ally, and in two months all pain was gone; ho was quite comfortable, and 
could move himself in bed without pain. 

Jan. 2nd, IJHIJi. — The splint was taken off to-day; the limb can now 
be moved and handled without causing any pain in the hip-joint, whilst 
formerly it caused exquisite pain; no pain on pressing tlie trochanter 
major, or tapping the heel or knee; no swelling over the joint anteriorly. 



226 ON THB TUEBAPEUTIO 

Oh attempting flexion of the femur, the pelvis moves with it, indicatiiif 
anchylosis. The limb appears longer tlian the Bound one (although t 
reality it is a quarter of an inch sliorter), on account of the obliquity ' 
the pelvis. There is also llattenin^ of (ho nates on the affi^uted sid«. 
Feb. 3rd. — There is now no puiii w!;alever in the hip; he can w«l 
fvery gently about the ward without the uiil of either crutches c 
and feels perfectly well in health. 

4th. — The patient left the hospital to-day, with directions to be c 
ful that his exercise in walking does not cause a return of pain in h' 
This is important advice, for the fisiB structures — t/ie Medium C^ 
solidalion — will not bear rude concussion or straining. Here ia a 
ing of his actual condition at the end of February, 1SU2 (^'S> '■'^)> 

I saw this patient in 1863; he was wearing a leathern splin 
taking very moderate or limited exercise. Being an intelHgent lati 
I literary turn, and connected with the printing business, he used to o 

I himself with reading at home, and taking very carefully adjusted e 

^^^^^ ioBe; the union between the acetabulum and the fumur not beiiij 
^^^Vtime, perfectly consolidated, 

w 



[ ^Haeaaed Hip-joint, «\<pposed to be Gonorrliteal in orif/in ,• 
opefted tnj Niiture ; portiima of B\me extruded by Grau 
cured by Best, viUh permanent Anchylosis. 

F. P , aged twenty-two. Early in the sprine of ]f<5t), his 1 



left him. In June he had ecvere pains down the inner side of t 
right thighj and the iiuier side of and within 
knee-joint; these were attributed to riieumatisi 
and a physician who was conaulted gave (i 
ion that it vas gonorrhoea! rheumatism in the knj 
and hip. However, the pains became iucreusing),^ 
severe, in spile of abundant medicine, blistere, 
leeches, &c. The 13lh of July, 185^, was (he first 
day on which he remembers having any pains what- 
ever in the hip-joint, and, although ihey were slight, 
hewasobh^d to use a stick to get about the house. 
The anti-gonorrhceal treatment was continued until 
the 24th of August, when Mr. Elwin, a surgeon in 
my neighborhood, saw him for the first time. " He 
then had extreme pain in his hip-joiut; the slight- 
est movement — even a person walking across the 
room — appeared to shake him, and caused him 
great agony in his hip." This is Mr. Eiwi 
statement. " His diseased leg was apparently thrt 
or four inches shorter than the other, from tf 
femur being flexed and adducted, and (he kiMJ 
joint flexed. There was the fluctuating swelling'd 
an abscess in the groin." I saw the patient, in c 
Bultation. on the Ist of September, 1859, and I 
oinmended the application of a long straight w 
en splint, ahsolute quiet in the recumbent posiltoi 
good diet, and the twelfth of a grain of biohlorid 
of morcurjr twice a day in some hitter infusiof 
The only known injury the patient could connect with his hip disci 




IKI-trBNOB 



OF BEST. 



227 



resulted from ft BudJen and violent effort he had made in swimming, which 
produced at the time some pain in the right groin and hip. The straight 
splint was applied immediately. I savr him again in November ; he was 
then free from pain; the right leg was a little shorter than the left, and 
the hip-joint had become anchylosed, the pelvis moving with the thigh; 
both the swelling in the ffroin and the fluctiiatioti had nearly disappeared. 
He was reeommended to keep recumbent a few weeks longer, but without 
the splint, except at night; and thencieforward to use great caution m 

In such cases I think it is better, when a patient ia improving, to put 
the splint on at night, especially in the case oE children, because the in- 
voluntary muscular action which often takes place on going off to sleep is 
likely to disturb the hip-joint again. During the time the patient was in 
bed with the splint on, his general health did not suffer — indeed, it was 
improved; the only difficulty was with his bowels which were constipated; 
he had also temporarily e. small bed-sore on his sacrum. 

In January, IStiO, no could walk about well with bis crutches. He 
passed the summer and autumn of that year at Swanag^, getting out of 
itoon uucAaiiniaUy, and mstit^ the joint at other times by lying down, 
During his stay at the sea-side an afcaceas appeared in the thigh, and 
opened spontaneously by ulceration. Several portions of bone have come 
away at intervals through three sinuses since March, 18G0. When I saw 
him in February, ISGl, his health was excellent, he was free from pain, 
was able to walk a distance of two miles, and could stand about all day. 
He can now {IS&2) walk ten miles without pain or weakness in his right 
leg. 1 have some of the portions of the Ixine which came out of the 
apertures !n the three sinuses. The anchylosis is now perfect. 

This case, 1 believe, supports very decidedly the view which I have 
expressed as to the great value of " rest" in the treatment of dlseaae of 
the hip- joint. 



ON THE TUEBAPSUTIC 



LECTURE XVI. 

Hip-Joint Diseace; No Imown Accident ; Seqael to Scarlet Fever; coied bjr 
Bin, after a few montlifl uf Kc»t — LiKsal AEFectioiiB alter tnicb Diaeosea i 
tinii. Mens-lea, eto., arise from PrBvioualy ITuhealtliy Structures Suffering B 
Deteriorfttion from the Elfeot at the CoiutitutionBl Distnrbanoe — Two Cat 
lUiiatcation — Dieeaaed Hip-Joint, with MeccoeiB of Acetabniam, Cored by R 
Hip-Joint Disease — Aacliylosis. with Thigh somewhat Bent — Cases Simuladl 
Hip'Joint Disease Due to Deficient Nervous luQuence; Treatment — ^C 
crum, ('niiaiiig Outtyins S^'ioptiOniH of Hip-Joint Disease— Coitgeuital I 
o[ both Hip-Jointfl— (.'ongenital Deflcienoy of Development of one Lower Eitrei 
ity BeanltioK Id its baiog Short«r Cbon its Pellow ; EffE-cts of this— 
Saom-llisc Joints — Diseaxe of the taxt Lumbar Vertebra Siranlauog tli»t of ti 
Hip- Joiot— Severe Disease of Spiua oloae to Pelvis Cured by Rest— Dise 
tweeu bounini nud Ilium, with Intense Pain in tlie I^ of tbe same side. 

PuHSL'iN'G the Bubject of hip-joint disease, I purposely selert the next 
case for your consideration, because it was apparently associated with 
Bcarlatiim as a cause. I think it must have fallen to the lot of almoj 
every surgeon to see disease of the joints or disease of the bones o 
as one of the important sequelie of scarlet fever. It appears, as 
can ascertain, that the cause of that Bssoeiation has not hilherto receive 
its proper or true interpretation. I will not pretend that the cause whi<j 



I shall offer. 



L 



only one (according- to many, these sequelie ha' 
pyemic origin), but it is one that long- ago occurred to my mind, aud 1 
which I have frequently referred iri my hospital teaching. 

mp^oitit JOUease; no knmon Acciitent/ Seqttel to fkarlet 
cured by AnchyloaU, <0er a /ew monthg of Rest. 

A young gentleman, aged fourteen, a toleraby healthy tad, had ft 
severe and prolonged attack of scarlet fever, at the Bluecoat School, in 
the winter of 1^59. As he was recovering from the fever, or soon after- 
wards, ho complained of pain in his left Itnee, and became tame, without 
the occurrence of any local injury. This was thought to be rheumatism, 
and local applications, including strong mustard poultices, were applied 
to the knee, and anti-rheumatic medicines were administered, without anj 
improvement in his condition. As his general health was at that th 
not good, he was sent home for change of air, and I saw him at my 
house on February 10th, I860. He had then all the local indicationa 
scute disease in his left hip-joint — viz. intense pain in his knee and hi 
joint on attempting to bear any weight upon the pointed 
ing any attempt to move the hip-joint; but none in the knee on movement 
of that joint only. The thigh was flexed, and the fool turned downwards 
and inwards, with a strong tendency on the part of the head of the femnr 
to dislocation backwards. Obscure fluctuations could he felt deeply seated 
behind the trochanter major under the gluteal muscles. Three days after- 
wards 1 went to his home, and applied the splint here delineated (Fit 
80) to the left leg and pelvis, in order to prevent his moving the liml 



i 



t 




INFLUENCB OF REST. 223 

He was directed to take a doso of castor oil or of confection of senna oo- 
casionaily, and one-sixteenth o[ a grain of bichloride of mercury, with one 
drarhm of tincture of hark, twice a day. At hin residenoe, near Hiphgate, 
he wa3 placed in a small hut iiirv mom on a hair mattress, and not allowed 
to get up for any purpose, \\''ilhin a fortnight he was nearly free from 

Eain both day and night; whereas, before the application of the splint, 
is nights were dreadful to himself, as well as to his father and mother, 
who heard his expressions of distress. 

During the three following months the patient remained uninterrupt- 
edly in bed, with the limb securely bandaged to the splint. When the 
severitT of the symptoms had subsided, I was par- 
ticularly struck with the rapid and marked im- 
provement which occurred in this case, when 
measured by the entreme simplicity of the treat- 
ment adopted. There was no other surgeon in 
attendance, and I saw him only once a month, 
and then merely for the purpose of readjusting 
the splint. In the latter end of May, 18(10, all the 
symptoms of active disease were absent, and the 
deep sub-gluteal tluctuation had disapp-eared : an- 
chylosis had taken place between the femur and 
acetabulum, with the limb and fiH>t in a good posi- 
tion; the pelvis moved with the femur, and the 
length of the left limb was the same as that of the 
other side, without either inversion or aversion of 
the foot. On taking; him out of bed, at the expi- 
ration of four months, he found he could bear some 
weight upon the lame leg. From this time he was 
allowed to get up dailv, and move carefully about 
with the support of crutches. In June, 1860, he 
went to Margate, and remained there until the end 
of September, being the whole lime in excellent 
health, and free from pain. He lived out of doors 
the greater part of the day, walking with the aid 
of his crutches, but usually bore more or less 
weight upon his lanio leg; and he sometimes 
walked short distances with the support of one 
crutch and the arm of his mother. On his returr 
hia walking exercise, with daily increasing s 



■nBlfc i 



! he continued 

* leg. 



tch for security against accident. The general health was per- 
fect (this is not too strong an expression) until the end of October, 
when, with one crutch, he climbed into a loft containing apples, of which 
" forbidden fruit " he desired to taste. Soniebow his crutch became en- 
tangled between his legs and a hamper, forcing his left leg behind the 
right one, and he fell helplessly upon the floor. Unfortunately, he fell 
upon bis left leg;, striking his left knee, aod straining with great violence 
the left or diseased hip-joint. He became faint and nearly insensible, and 
was carried from the apple-loft indoors. The knee became much ecchy- 
roosed and swollen, and the hip near the trochanter major was very pain- 
ful when pressed upon; but no fracture could be detected by the surgeon 
who then saw him, and the two limbs were of the same length. The 
patient was confined to his bed about a month,, and then allowed to get 
tip Knd resume his walking exercnse. 

In the early part of IdGl he found that the neighborhood of the tro- 



230 



ON THE THKRAPEUTIC 



mj- house on M»r<! 
reight upon the li 



chftiitor major had become enlarged. I saw hin 
}Otli : he was in very little pain; hi^ could bear &c 
Htnb, but less than when he came from Margate ^ 

found ft large abscess behind the trochanter major, with a very thin 
ing of slightly reddened skin at one part; considerable increase in 
the upper third of the thigh-bone; little or no pain at the hip-joint ii 
but tfinderness on pressing or grasping the trochanteric epiphysi 
adjoining portion of the shaft of the femur. His general health w»a 
Two days afterwards I opened the abscess, and let out nearly a pint a 
unhealthy pua mixed with some clotted blood and some curdy matter, I 
it was not decomposed or offensive to the smell. The abscess waa at oi ^ 
completely emptied, and nicely adjusted pressunil 

A«^ ^ was made by a thick pad of lint and a band«ge 

\ ' k round the pelvis, so as to coapt the outer and 

'■* " A inner surfaces of the abscess; the lancet aperture 

/" was left open, and he was desired to lie quietlv 

in bed. Little constitutional disturbitnce id- 
lowed the opening of the abscess. 1 saw him 
again in a fortnight : he was well in health; appe- 
tite most excellent; the walls of the abscess bat* 
adliered throughout nearly four-fifths of its < 
tent; and the discharge was chiefly seroua, am 
in quantity, and mixed with but little pus. TM 
enlargement of the shaft of the bone neai 
trochanter major was considerable, and slight puH 
was complained of on direct pressure. 

I saw no more of this patient until Janui 
15th of the year 1S62. He was then seventeea 
years of age, and could walk live or six mileseasily 
without pain. There waA scarcely any lameneaa, 
and liere is a drawing of his actual condition 
(Fig. 81). This is a good caee, which not only 
illustrates the advantage of treating hip-joint 
disease by " mechanical rest " — as a very simple 
but successful means for cure — but alsc 
with it another important indication; 
that the injury whion he received later o 
trochanter major did not lead to any se 
deterioration *t the hip-joint itself, showing the perfection of th 
which had there taken place. The case also clearly points o 
tage of acourat^y ooaptliig the walla of a largo absoeas after it bat 
openefl. 

I now aviul myself of thia ease to introduce one or two remarks whiA^J 
bear upon it. jM 

I tlunk it may be fnirlv {itated that unhealthy structures suffer rapiAfl 
det«rioration from the depressing inHuence or eSect of any severe oonsti^-' 
tutional disturbance, such as occurs in scarlatina, measles, erysipeW, sm^l- 
pox, and similar diseases. And heroin lies the interpretation which I 
would, with all deference, submit to you in Teeord to these cases of local 
disease, apparently Associated with, and resulting from, the develo[»nent 
of scarlatina, raoiulcs, siuall-pox, or erysipelas; namely, that at the tinw, 
or previous to th« ocoarre^ce, of this depressed oonstitutional condition — 
a condition, in all probability, of blood poison — those p*na which subse- 
u a diseased ODDditioo were not in a healthy state. If th>S>l 





namely, 
1 to the 
:ondar^ 
e repair 
e ad van - 
i been 



INFLUENCE OF BEST, 



231 



be true, these obscure oaaes will ooi 
endeavoured to present to you in the 



le under the law which I have just 
e few words; namely, that unhealthy 
structures suffer rapid deterioration from the depressing effect of any 
severe constitutionaf disturbance. I will now place before you two cases 
which tend to sustain this view, and which are to my mind satisfactory 
s of this class of cases. 



Necrona of L^ Tibia and Anchylosis of Ankle^oint consequent upon 
ikartaitTia ami prtvio^is Local Injury. 

The following drawing (Fig. 82) represents the legs of a patient who 
had scarlatina, and, as a sequel, netrosia of nearly the whole of the shaft 
of the left tibia between the upper and lower epiphyses, leaving the knee- 
joint unimplicated, but involving the ankle-joint, which has become an- 
chyloBcd. The shaft of the tibia has been reproduced by Nature. 

The other drawing or jfrounrt-plan shows also that the two feet have 
not developed in an equal ratio (Fig. 83). 





The history of the case is very short. The patient was at school in 
Scotland, and Dr. White, of AthorPlace, Perth, has obligingly forwarded 
to tne these brief notes: — "The epidemic of scarlatina at Glenalmond 
School began the last week of September, and G was sent into hos- 
pital OD the 6th October with a slight sore throat and other precursory 
symptoms of an attack. In this condition, but with no eruption, he con- 
tinued till the 12th October, when the throat affection left him, and he 
first complained of pain and swelling above the internal malleolus of the 
left ankle. In a day or two it assumed the character of a diffused inflam- 
mation of the cellular tissue, associated with severe constitutional dis- 
turbance, and the local mischief rapidly extended upwards to the knee, 
followed by extensive suppuration and sloughing of integuments over the 
^ia, exposing the denuded bone. About the 22nd of October the throat 
affection again appeared, accompanied by an eruption and other aymp- 



232 



ON THB THERAPEDTIC 



toms of acarlatinn; the efflorescence (which was dusky and livid) beg«n t 
fade in three or four days, and desquamation followed, as in ordinu 
cases. On the :i3rd November he left Glenalmond for London." 

Now it aujieared, upon inquiry of this young gentleman, that c 
the summer he had felt at times an achinjr pain in his left leg, which 1 
thought was due to a blow from a cricket-ball. When he was at 
tired, it ached so much thut he could hardly walk, but etill there v 
no appearance of injury. Here, then, was a patient under the influenel_ 
of blood poison In the form ut scarlatina, which never developed itself 
thoroughly or completely, but seemed to concentrate all its morbid 
influence — upon what part ? Why, upon the part which was recognized 
by the patient as being at the time of the occurrence of the scarlatina ' 
a depressed condition vitally, and perhaps structurally also, for he had s 
fered pain in it after ordinary exercise; therefore there was an indicatiol 
of something wrong. The lad was brought to London, and when I £ 
saw him his general health and his leg were in a most deplorable c«ndi<^ 
tion. The whole of the tibia, from the lower epiphysis upwards to (he 
tubercle of the tibia, was exposed and necrotic. The integuments had 
sloughed to a very considerable extent, and there was acute disease of the 
ankle-joint, with great oedematous awelliiig about the foot. 

Judging by the history of the case, it was associated with i 
local injury previous to the scarlatina. Notwithstanding the 
condition of nis health and the great extent of local mischief, we _ 

Coltambell and myself) thought, considering his age, that we might, per- 
haps, by time, good feeding, and careful professional attendance, enable 
Nature to repair the injury, and renew the destroyed soft textures and 
bone. His leg and foot, swollen snd painful, were placed upon a 
splint, provided with a screw behind the knee, so that we might graduallj^ 
straighten the flexed knee-joint, and the whole limb was swung under y 
iron cradle. He was in excessively bad health, and his life was, doubltesli 
threatened. However, by great perseverance, e.vcellent nursing, and u 
remitting domestic care on the part of those in the house, he arrived at 
the state you see represented here (Fig. b'i). The whole of the middle 
part of the tibiu became separated, and 1 removed it in several portions; 
new bone was thrown out, and all the soft parts healed over, except at 
the point indicated in the drawing, which whs tlie outlet of a sinus pass- 
ing under the tendons of the extetisors over the ankle-joint, and probably 
connected with diseased bone, wliich, however, I could not discover. 
Fifteen mont lis after his scarlatina, he entered my room walking with 
crutches, but bearing some little weight upon his leg, and he found that 
he could stand upon the diseased leg with the aid of a little support. He 
is now (18T(i) a clergyman, doing active duty in the neighborhood < 
London, and able to walk five or ten miles without any difliculty. 
tibia has been thoroughly and firmly restored. 

This case displays the wonderful reparative powers of Nature at i 
early period of human life, and, 1 think, justilies the interpretation v ' ' 
I have affixed to it — viz. that his leg was in a deteriorated conditic 
regards the bone, at the time when the scarlatina occurred; and thai 
the depressing influence of that blood poiaou led to the death of the bon^ 

DUeaae of the Lower Jaa eoimeqtient vpoii Scarlatina and preaiouB 
Local Injury. 
Here is another instance, which carries with it the same kind of hi^ 
tory, and, I think, the same inteqi relation. ^| 



I'll iiL,^ 
dsu^B 
satio^^l 

to (he 

>f the 
I sora^^l 
-e (M^H 
able 

,'9 



opened. 
Thee 


nd [mm one of tlie 
xplanation of the c 


not & sev 
goes hon 


ere one, upon his k 
welVmg, no evidpue 
ie, comes within th 



INFLUENCE OF REST. 233 

V young gentleman, aged fourteen, remembered that he had a blow- 
on the right side of the lower jaw with a hockey stick in March, 1857. 
He had previously been in his ordinary health. After the blow he had 
occasional pains in the jaw, but nothing important occurred. In four or 
five weeks, he did not exactly know wTiich, he went home to Sydenham 
to see his brothers and sisters, who at that time had scarlet fever. He 
stayed at home a fortnight, and then returned to school at Blackheath. 
In a few days he became poorly — feverish and depressed, with a very 
■light sore throat. Tlie lower jaw then, for the first time, began to swell 
and to bo very painful. 1 saw him at Sydenham, with Mr. Corbould, early 
in June, 1S57, about three months after the blow, and six weeks after the 
exposure to scarlatina. The lower jaw was then enormously swollen; 
every tooth on the right side was loose, and could have been easily taken 
from the jaw by the fingers alone. The incisors, the canines, and the 
bicuspids, on the left side, were all more or less loose. The whole jaw 
was painful and tender on pressnre, from ostitis and periostitis. There 
lubsoqtient suppuration, resulting in several small abscesses, which I 
I removed a thin plate of the lower jaw. 
Q appears to be this; — The boy has a blow, 
rcT jaw; he has occasionally slight pains in 
of local inflammation manifests itself; he 
_ intluenco of scarlatina, or a blood poison, 

returns to a healthy spot at Uluckheath, becomes very feverish, has sore 
throat, the lower jaw becomes swollen, and then he returns home in the 
condition I have described. There he remains under the influence of tol- 
erably good air, abundance of fluid nourishment, and scrupulous domestic 
caro, and ultimately regains perfect health. 

The subject of " rest " is well exemplitied in this case. We found all 
his teeth loose, and felt certain that if we were not very careful to pre- 
vent their disturbance they would fall out of themselvea. On the other 
hand, it was essential to his cure that he should be well nourished by 
food: fluid nourishment and wine were abundantly and carefully admin- 
istered, and the result was that all his teeth became refixed by Nature, 
with the exception, perhaps, of one, and the jaw subsided to its natural 
dimensions. I called on the father of this patient recently to ascertain 
his actual condition, and present it to you free from exaggeration, and 
with every element of truth. His father said, "My son is in Scotland; 
the front tooth is not out, but it is rather loose; as regards everything 
else he is perfectly well." JCow, here are three cases. I could adduce 
many others equally illustrative, which 1 think display in a striking man- 
ner the depressing inlluencc of blood poison upon parts already in an 
unhealthy condition. This may or may not be the true interpretation of 
such cases; but I venture to express my opinion and conviction that it 
is so. 

Case of Diseased Iftp-Joint, toith JVetrosw oj" AcettdnUum, cured Sy 
Jlest. 
The next case of hip-joint disease ia one complicated with disease of 
the acetabulum; and that Js its special feature. A delicate, pale, un- 
healthy-looking young gentleman, agCTi fifteen, in the spring of 1846, 
after taking a long walk, suffered much pain and some swelling in his 
right hip-joint. He was then in Edinburgh, and was kept in bed during 
three months by his surgeon's advice, his thigh being strapped up with 
some irritating plaster spread upon leather. Slowly recoverin-j tram, ttvi 






234 ON THE THBBAPEUTIO 

attack, he continued well until August, 1847, when over-exertion bi 
on hU hip-joint Bymptoms again more severely than in 1840, twA 
remained at home in London, under the care of an hospital 
alternately keeping and quitting his bed at ehort inter\*alB, so thftt 
joint had not the advantage of cmntinued rest, until the end of 1; 
when, notwithstanding numerous leeches, lotions, strong counter-imtanl 
and abundance of medicine, all hia hip-joint symptoms became mi 
worse. As to leeches, he said to me, *' I have had upwards of 1,: 
applied to my hip in the course of a few months ! " The loss of hiooil b; 
1,^00 leeches may be estimated at about 300 ounces. This is pretty 
for a delicate lad suffering from hip-joint disease. He told me he had 
taken " pailfuls of horrid medicine. The loss of blood, the physii 
the counter- irritation reduced hia strength, and brought on loss of ap| 
tite, want of sleep, with jumping and starting pains jn the limb, to s 
an extent that he was compelled from sheer exhaustion to keep flat b] 
his back, and so remiiin uninterruptedly at rest upon his bed; and 
that time he began to improve in tvery respect. 

Here, then, was a case of "forced rest" against the judgment and 
discretion of the medical attendants — forced rest compelled by direct fee- 
bleness on the part of Nature; and from that time the patient began lo 
improve. He continued in bed until the summer of 1849, nearly eighteen 
months. The blistering and counter-irritants ihat were applied were, 
according to liis own account, something awfui. Even when exhausted 
in bed his surgeon would not let him clone, but still applied blisters, 
setons, and counter-irritants. A large nhscess made ils appearance in 
the spring of 1849, just above Poupart's ligament, near the anlertor supe- 
rior spinous process of the ilium. The skin was allowed to ulcerate, the 
discharge was immense, and was dashed out of the opening by coughing 
or eneexing, or by taking a full brpath, indicating an intimate associatioa 
of the abscess with the interior of the abdomen and pelvis. 

i first saw this patient in the autumn of 1849, lying on his bed, not 
pale, but almost transparently white (1 never saw a man so while — I 
might almost say translucent — asi he was), thoroughly exsanguine, and 
exceedingly emaciated. Abundance of thin pus was escaping from two 
sinuses — one at the upper and inner side of the thigh, and the other, 
before alluded to, close to Poupart's ligament. Through the open- 
ing of this latter abscess I passed & long probe into the pelvis behind the 
acetabulum, and there felt necrosed or carious bone. The discharge from 
this abscess occurred most abundantly during the effort to evacuate 
bowels, when it would gush out. There was scarcely any pain in the bq 
joint. I ascertained by careful but painless examination, although 
in great fear the whole time, that the thigh-bone and the anterior part 
the acetabulum were firmly united; the limb was in good position, except 
that the foot was a little too much everted. Seeing no advantage in hia 
lying any longer in bed, he was daily dressed, laid upon a couch, and, aa 
Boon as the weather and his own. extreme feebleness permitted, h< 
taken out of doors into the garden, lying there all day upon the couch. 

In the spring of 1850 he passed nearly all his time out of doore, aitti 
in a Bath chair in the garden, or being dragged about in a small liai 
carriage. From the time of ray first visit he left off all medicine ex< 
cod-liver oil and steel wine, and took porter, wine, meat, &c,, in abl 
dance. In 1851, amongst other efforts, he went to the Exhibition, 
ing on his crutches; and in 1852 he was employed in a public > 
where he has been constantly occupied ever since. 



rora^^ 



INFLTENCE OF REST. 



935 



On March 21st, 1861, he called on me In good health, ■well covered 
"with firm flesh. He belongs to a niie corps, goes through the drill, and 
can walk ten or twelve miTea without pain; but the exertion of walking 
beyond that distance brings on fatigue, which he attributes to his stiff 
hip-joint. Several Braall portions o! cancellated bony structure have been, 
extruded from the upper abscess at throe or four different times, but none 
during the Isat four years. The sinus from the intra-pelvio abscess docs 
not remain closed for more than three or four months at a time, when a 
little pain and fulness occur under tho closed aperture. This soon opens 
of itself, or he himself opens it. About a teaspoonful of pus escapes, and 
in a day or two nothing but a thin watery fluid oozes out, and then it 
remains closed during another three or four months. Ho walks somewhat 
laiuely, dipping the pelvis a little to the lame side when he touches the 
ground with the foot of that leg. Standing upright upon the sound 1^, 
the heel of the lame side is about an inch and a naif or two inches from 
The head of the femur In this case is a little anterior in 
rhcro it ought to be. That explains a slight fulness below 
Poupart's ligament which impedes the easy return of the blood, and pro- 
duces a varicose condition of his superficial I'eins, The muscles of the 
damaged teg are exceedingly well developed, but not quite so much so as 
on the sound side. 

1 think I might fairly refer to this case as one of diseased hip-joint 
complicated with disease of the acetabulum, not placed under very favor- 
ftble circumstances as regards profi^ssional treatment, and, consequently, 
not as regards rest. Vet, iuspite of all, so strong have 
been the energetic efforts made by Nature, that the pa- 
tient Is, in his actual condition, happy and comfortable; 
equal to all the duties of the office in which he is employ- 
ed, capable of taking exercise, and able to form part of 
a volunteer corps. 






The next is a case of hip-joint disease, with anchy- 
losis. The patient was sent up to me for the purpose 
of reducing, if possible, the hip-joint deformity. The 
drawing before you represents the state of the patient 
when ho came under my care at tho hi>Epitai. The 
bant condition of the limb was all he had to complain 
of. Daring the course of the hip disease he had never 
been kept at rest on his bed, but allowed to get about 
daily upon his crutches. The course of tho disease had 
been slow, and its results was anchylosis of the thigh- 
bone to tha acetabulum. In November, 1S55, chloro- 
form was administered, and powerful attempts were 
made to straighten the leg; but our efforts, limited to 
what we thought judicious and discreet force, failed, 
and the patient left the hospital with the limb in the 
same condition as when lie was admitted. With re- »< 

spect to this application of force to disturb anchylosed 
joints, it is not my intention to do mora than express a doubt 
propriety of it in many cases, especially in hip- joint disease. The 
is remarltably simple in its construction. The adaptation of thi 
head of the thigh-bone to the concave or cup-like cavity of the 




23() 



ON TUE rilEKAPEUTIC 



lum allows of easy coaptation, and this is ono of the conditions which 
tribute to quiet and perfect coniioEldation of the opposett bony SUTfaoe& 
I can hardly conceive any important disease occurring' in the hip-joint 
terminating in a simple fibrous adhesion. In this instance I used all the 
force I thought justihable, and it failed to improve the ]>oHitioa of the 
thigh-bone. 

I saw a. distressing case of this kind somo years a);o. I had at- 
tended the daughter of a grocer, suffering from severe hip-joint disetiM, 
in the Kent Road, and had taken a great deal of trouble with the 
patient in order to obtain anchylosis of the hip-joint, and fortunately 
succeeded. I lost sight of the young girl for some time, when the 

iate Dr. Barlow said to me, " I wish you would call at Jlr. 's; hi 

daughter is now very ill, and she wishes to see you." I called, and 
soon as she saw mo she burst into tears, and said, " I am sun 
and I am anxious to express to you my deep regret that I did not folh 
your advice. When I left your care I had a stiff hip-joint, and you ad' 
me to bo satisfied with that state. Following the advice of friends, I ' 

to Mr. , who said he could cure my stiff joint and make it movkl 

This gentleman employed a great deal of force in order to disturb or bi 
down the bony union; fresh mischief was set up, which resulted in lai^ 
suppuration, so extensive as to resist all subsequent treatment. Her 
general health was so much depressed by it that she died of phthisis, with 
the hip-joint deformity worse than when I had last seen her. That is the 
short nistory of a case which I consider exceedingly melancholy. The 
patient had a useful, painless, but stiff hip-joint. My surgical 
assumed the power of correcting Nature, and rendering the lin 
and movable; yet it turned out in the end that his efforts only resulted, 
in the patient's death. 



Cases of Lamtnes» 



I Children, ^ue, per/iapfi, to deficient Iffrvo 
etice, simitlatrnff J£ip DUeaae, 



rS 



No doubt it happens to most consulting surgeons to see cases of lame- 
ness in children (in some instances both lower extremities being affected, 
in others only otie^, which are only to bo diagnosed by the law of exclusion, 
as not being explicable by any recognized morbid condition. They occur 
sometimes as a sequel of a severe fever, as in the case quoted below. They 
seem to result from some defect in the supply of nerve influence, as evi- 
denced by the wasting of the limb and the retarded growth of the muscles 
and of the bones. Tnis leads to want of power in tlie limb, and deficient 
precision of step, and thus to unsteady gait; but the limb is not flexed or 
adducted, nor is there usually anv distinct pain when the patient walks, 
which he does limping a good deal. This limp, however, is unaccompanied 
by the peevish anxiety which usually attends the existence of hip disease; 
there is no evidence of local heat, or pain, or tenderness in the hip-joint 
itself ; in fact, the symptoms of hip disease are not well marked. 

As the affected Imib is, as a rule, strikingly defective in warmth, I have 
found that the best method of treatment is to endeavor to remedy this 
defect by rubbing the whole limb night and morning with sperm oil, either 
by itself, or, when extra stimulation is required, by the addition 
liquor ammonite to the oil. During the night the limb should he 
rounded by cotton wool, and during the day with flannel or any sir 
material. 

Should the ankle or knee show any tendency to yield laterally, 



this 
ther 

I 



INFLUEKOK OP BEST. 



most simple mechaniciil apparatus should be used, i 



ntake pressure upo; 



Wdlking exercise short of fatigue 



possible, be daily persevered ii 

Typhus Fever foll'-icril hy ParalynU of the Left Leg ; Hecovery much 
aided by rubblny the Limb with i^perm Oil, and subeeptently reith 
Sptrm Oil and Liquor Ammotii<e. 

A little girl, aged etx, having previously had good health, was seized 
■with severe fever (with brain disturbance during about a fortnight), from 
■whic:h she recovered gradually. The left leg and foot, however, remained 
shruulcen, with greatly diminished power, and inability on the part of the 
patient to direct the foot with precision. The limb waa always cold 
except when made wann with artificial heat; various kinds of friction and 
electricity had been tried duriTig many months, but without any improve- 
ment, wlien I was consulted in this case I advised that sperm oil 
(liquor amraoniffi was added afterwards) should be well rubbed into the 
limn night and morning, and lamb's-wool stockings worn. 

By tliesc means the limb was made warm, and maintained so. Notliiug 
else was done. I have seen this patient since several times, the last occa- 
eion beii^ April, 1876, She can now walk and run with precision, the 
inascularity of the limb is much increased, and its warmth well sustained. 



Here is a case where the indications were more precise. A young 
lady aged seven, in August, 18G1, being then and previously in good 
health, was residing at tlie sea-side, and, after playing and amusing her- 
self during several hours upon the beach on a bright sunny day, had a 
sudden chill, then became hot and feverish, had violent headache accom- 
panied by great heat of head, and for a day or two was delirious. She 
was confined to her bed from ten to foiirtoen days, when, on attempting 
to walk, it was discovered that she was lame in tho right leg, and that she 
could neither bear any great weight upon it, nor control and direct its 
movements with force or precision. I will not go over the long particu- 
lars of this case. I waa desired to examine it in reference to the question 
of hip-joint disease. There was no indication of it as far as I could detect; 
no local heat at ail; no pain upon carefully manipulating the hip-joint; 
no special loeal tenderness upon applying pressure below Poupart'a liga- 
ment over the hip-ioinf, where there ia always a degree of more or less 
tenderness, especially in children, this being a rather sensitive part. There 
was no indioation of anything wrong in the hip. This child was treated 
by tonics. On January 6th, 1SC2, the patient walked into my room, in 
every respect improved — less lame, the IJmb being increased in size, and 

* Gaaei (akjn to those of which Mi. nilton is apeaking) where a lower extremitj' la 
affected with infantile puralfnU nrs occaaiDQull; thoug'ht M be due to hip- joint ilioeasa 
On tlie diiignosia betweea the two, Mr. Mulinoa (tjy«tera ot Surgery, vol. t. p. 848) 
■peaks oa follows ; — "Tho hip joint is Icfa eoEily nudar observation, aod the morbid 
■[iDsibility which oocompanieBsaran of ihtse cases of pnralTsis giyea more rpsem bianco to 
hipdiseKse on first handling the limb; but the diNtinotion isuHaally eoaj'toniakQ. Par- 
aljais generally affeeta n preat part or the whole of Ihe lower limb ; hip di»Ba»e only 
causes losB of movement ot tha part alTocted. Ta the former, posaiie motion is eony 
and canses do pain, or not more than any other modoo ; in the latter, the joint is stiff, 
and on attempt to move it causes acite Buffering ; finally, in paralysis there is no wast- 
ing of the h'lttock unless the whole limb is wasted, nor ia the position of the troohantei 
over ottered." — [&D.\ 



OW THK THEEAPEUTIO 



maintaining ita temperature nearly a 
1862, 1 had the following note:— " Thi 

Case of a Curved Sacr 



i well as its fellow. On Jui 
e patient is now greatly improvadb* 

? of l/ie "Oittli/ing Hi/iivptotm^ 
of Hip-Joint Disease. 
Here is another case where hip-joint disease was Bimulated hy a struc- 
tural disturbance which had taken place in the sacrum, or the last luniW 
vertebra. The history of the case is briefly this:— T. J. H- 
nine, residing at Gillingham, Kent, was admitted into Luke w 
a9th of September, 1859, under my c 
■ • ' eofthel 



leg from long-standing disease o 



very pai 



i supposed to be 
e left hip-joint. His mother gave 
history of his having bad 
four years ago, and that si 
time his left leg had always 
weaker than the right. Ti 
months after this he fell from 
wall six feet high upon his left kne^ 
which became much swollen and 
inful, and it continucKl to 
Soon after 
this the hip-joint of the aune side 
was supposed to have become af- 
fected, esnaing him to walk with 
drfBculty, and to rest 
leg to ease his left hip. A Eh< 
time after the pain of the hipc 
menced, ho observed that the 
IcfT waa becomiiijT contracted 
shorter than the right, so that whi 
he stood upright he rested with the 
great toe only of his left foot upon 
the ground. He came under my 
care three years after he had had 
the fall from the wall. His left 
leg was about half an inch shorty 
than the right. Tlie muBcIea 
Pio.gs, Flo. as. *1'^ *"'' limbs were nearlr equi 

developed. Looking at nim 
behind, a slight curve of the spinous processes of the sacrum was 
Ue, its convexity encroaching upon the right ilium, and lifting the 
terior portion of the ilium upwards. On looking at the front, 
placing a piece of tape across the abdomen from one anterior supei 
apinoua process to the Other, the left was proved to be about half an ii 
the higher. By carefully meaauriDg with a piece of tape the distal 
from the anterior auperior apinoua process of the ilium to the inner an 
of the suspected side, and comparing it with the other, it appeared ll 
they were each of the same length. There waa nothing wrong to be de- 
tected in the hip-joint itself, which I examined with care. As there was 
no definite remedy to be adopted in this case, the patient was sent away 
&om the hospital in the condition which you sea represented iu the ' 
drawings (Figs. 85 and 81i) placed before yi 




>rith 
i oht 

i 



Mafpo«ieio7i of both. Hippointt — Coiiffenita,. 
are other kinds of oases which simulate hip-joint or spinal 

of these is certainly that of congenital malposition of the 



i 



INFLTJENOE OF EEST. 239 

joint. Such cases are rare — at least as far as I know, I have iiere 
skrtt'hea (Figs. 87 and 88) of two patients, both presenting congenital 
malpositioiiB of the hip-joints, which are sitiiated posterior to their normal 
or natural position; and this abnormal position neceseitates, that the 
erect position may be maintained, a remarkably curved condition of 
the spine. This curve of the spine, a-nd the growth and direction of 
the shoulders and head backwards are for the purpose of bringing' 
the weight of the head and chest and shoulders over the hip-joints, 
which are placed behind their natural position; in fact, the spine is 
curved in order to counterpoise the malposition of the hip-joints. This 
instunt'c (Fig. 87} caine under my notice on the 25th of May, 185iJ. 
I Imd never seen a case 
like it before. She was 
then four years old. Her 
^it was very extraordi- 
nary, utterly unlike the 
awkward modes of pro- 
gression which we see 
dependent upon disease 
of the hip-joint or epine, 
the Bhoulders and body 
being turned backwards. 
The case was thought to 
be one of diseased hip- 
joint, or of curved spine, 
requiring some remedy 
to be employed. It 
seemed to be, however, 
a case of malposition of 
the hip-joints. Not be- 
ing certain of the matter, 
I requested the advice 
of Sir B. Urodie, whose 
e^sperience 1 thought 
might help nie. We 
took the patient up to 
hia house, and he said, 
"I think 1 have seen a 
case exactly like it. I re- 
member observing a lady 
in society who walked 
very much as this child walks, and I determined, if the opportunity 
should offer, to ascertain the cause of so peculiar a walk. After a time 
■be consulted me with regard to some disease of the breast, and I then 
took the liberty of inquiring what was the cause of her peculiar gait. 
It turned out to be exactly this kind of case — a malposition of the htp- 
joints posterior to their natural position; and the curve of the spine was 
simply compensatory." The mother of this child asked us this very 
proper question: "Suppose my chUd g^ws up and is married, will this 
._. — I — „. -n _,:.i^ pregnancy or parturition?" Sir Benjamin Brodie 




mterfere at all < 
said, "The only 
child: that Is my sole expei 



givt 



1 th. 



considered satisfactory by the mother. 

growing' up in perfectly good health, but retaining ber remarkable gait. 



that this lady had had ' 
! matter." That, I believe, ■ 
The child is reported to i 



240 



ON THE THKEAPEUTIC 



I saw this patient again ii 
same charact^riatio gait wa 
Her stature is short for her 



n July, 18G3. She «a« in excellent health. Th« 
i observable, and the same deformities exist. 
ago, but she is otherwise well developed. 

On mentioning this case to my surgical class at Guy's Hospital, one 
of the students said, "A friend of mine has a case of this kind now under 
a surgeon who attends partiouIarLy to spinal affections. Whenever the 
spinal apparatus is put upon the child for the purpose of straightening, 
the spine, it throws the child's head and shoulders so far forwards that 
the child falls down, being utterly unable to walk." The child w 
wards brought to me witn the spinal apparatus on. This turned out^ 
be a case of congcnitally malplaced hip-joints. Of course no spinal trc 
ment could cure a case of that kind. It would be in oppositio 
Nature, and, as a rule, Nature beats the surgeon. The mechanical meahi 
employed were here obviously useless, and after a tinie, by mv advice, the 
spinal apparatus was given up. The child now runs about with the pecu- 
liar gait (see Fig. 88). 

Some time ago, happening to be in a surgical -instrument makei 
room, he told me of his want of success in treating a case of anterior o 
vature of the spiue. By his request I looked at the child; it had 1 
peculiar and characteristic gait of malplaced hip-joints, and the curv 
spine was compensatory to the error liici of the hip- joint. The real cause 
of the deformity had been overlooked, and no further attempt was made 
to correct the curved spine. 

A fourth case has como under my notice of congenital dislocation n 
the hip-jointa. I was asked to see this by a consulting surgeon in 
West-end of LoTidon. In this case a medical man had, for no less t 
two years, been using spinal apparatus and futile manipulations of t 
hips. 



' afloc^H 
out^^H 

;e, the 
ake^H 



Congenital D<;/i< 



ttlff : 



/ of Development of one Lover Exlremity, i 

t its being Shorter than it» J'ellwc. 



As I am now bringing before your notice the diagnosis of hip-joUl 
disease, I would next advert to a condition whiuh is often overlo( ' 
and which simulates disease of the hip-joint, in some cases by indi 
lameness, in others by causing lateral curvature of the spine, marked k{ 
a want of symmetry in the height of the two shoulders. The explanatij 
of the above lies in a want of due and symmetrical development of tl 
two lower limbs as regards their length, a fart which can only be r 
nixed by careful measurements. I may add that I have seen so niaiiyd 
these cAses, that 1 am persuaded that they occur not infrequently, i " 
that they are usually overlooked. Tlius I have seen many patients WM 
ing spinal supports, in order to correct a lateral curvature, when the 
formity might have, and has been subsequently, corrected by plai 
within the shoe or boot a piece of cork thick enough to compensaLs I 
the shortness of the less developed limb. Half an inch, or indeed a qui 
ter of an inch, of difference in the length of the two limbs is quite s 
cient to generate some of the outlyine symptoms of hip disease, vi 
limp, and also pain (which is usually felt in the hip) after fatiguing e 

The following is a case in point. About eighteen years ago 1 w 
consulted by an anxious mother who had noticed for some time a litt. 
limp or lameness in her daughter's walking, and had recenllv observail 
that her left shoulder was a little lower than the right. This want t 



INFLUENCE OF BEST. 241 

symmetry in tlie two shoulders had been rendered more conspicuous by 
the child's lately wearing a silk dress with stripes across the back, the 
stripes now dipping on one side. 

By a surgeon and instrument -maker it had been stated that the spine 
was affected, and that some mochanica.1 support was required. As this 
method of treatment was objected to, I was consulted. Nothing wrong 
with the spine could be detected, but, on measuring the length of the two 
lower limbs, I found that the left was nearly halt an inch the shorter of 
the two. The patient having been made to stand upright and barefooted, 
thin pamphlets, one over the other, were placed beneath the left foot 
until the left shoulder assumed its proper level. The thickness of the 
pamphlets required to make up for the dehcieney in length of the left 
limb, and to bring the shoulders level, was just upon half an inch. A 
cork sole of the same thickness was placed inside the shoe, the want of 
symmetry of the shoulders disappeared at once, and has not returned, the 
same method of treatment having been continuously employed. 

In the next cose, the fact that one limb was originally half an inch 
shorter than its fellow seems to be the esplanation of the commencing 
actual hip-joiot disease, which apparently began in the strain thrown 
upon this joint in unlimited walking. A. W., aged thirteen, noticed pain 
in the right knee in the spring of 1875, at first only after long walks, but 
subsequently the pain became continuous. When 1 was consulted iDi 
January, 1876, I found that the left leg was half an inch shorter than the 
right. On account of the symptoms of commencing disease in the right 
hip-joint, viz. pain, increased temperature, Sc, I advised that a Bpiint 
should be applied, and the patient kept lying down. After awhile^when 
the above symptoms had disappeared, she was permitted to go about 
wearing a cork sole on the left foot. There has since been no Betum of 
the paiu; in fact, in the words of Mr. A. R. Martin, the medical attend- 
ant, the patient may be considered cured. 

Diseases of the Sacro-iliac Joint and the neighboring Bones. 

Before leaving the neighborhood of the hip-joint, I woofd direct your 
attention to some cases of disease of the sacro-iliac articulation. Such 
cases are sometimes mistaken for hip-joint disease. The diagram (Fig. 
58, page 183) will remind you of the powerful ligaments which hold the 
sacrum in its due relation to the os itinominatum on each side; strong 
ligamentous tissues are interposed between the lateral aspect of the 
sacrum and the inner and posterior part of the os kinominatum. It is 
impossible to look at the form of the sacrum — its wedge shape, the broad 
or massive part of the wedge being above — or to regard the extent of the 
articular surfaces of these bones, and the strong Egajnents which fix them 
together, without perceiving that great strength, is a part of their natural 
function. If any disease should occur at the aacro-iliac joint, I think it 
will be apparent what the symptoms would be. If a patient should have 
disease there, he could not sit very comfortably even, on the sound side, 
because then the whole of the weight of the body would be transfeirad 
through the medium of the spine to the sacrum, and thence produce pres- 
sure upon the articular structures of the joint, which would, if diseased, 
induce pain. Nor could the patient stand upright without great pain. 
Hemombering the relations of nenes. to that joint, one would say that 
sacro-iliac disease might manifest itseli by pain, taking the course of the 
distribution of the obturator nerve, which passes just over the front of 
Itl 



243 ON TIIK THEKAPEUTIC 

the joint. (Vide Fig, 39, page 124.) The great sciatic nerve miffht, 
from its closer proximity to the joint, and its sending nerves to it, induce 
remote svmptoinB of pain iii the hip- or in the knee-joint, or the back 
part of the calf. There is aUo the superior gluteal nerve lying close to 
this joint, vpbiob supplies the deep glutei muscles and the tensor vagiiiie 
femoria, and that nerve might lead to spasm or wasting of those muscles. 
The psoas magnua is lying close at hand, and, under tno influence of irri- 
tation, it would bo in a constant state of contraction, producing a flexed 
condition of the thigh. Thus we might have a flexed state of hip-joint 
or thigh, inability to stand upon the limb, or to sit with coinFort, pain in 
the knee, pain in the leg, wasting- of the gluteal region, or flattening of 
the muscles (these are the outlying symptoms of hip-joint disense), these 
symptoms depending entirely upan the disease of the sacro-iliao articula- 
tion. 

I think it will be almost impossible, however, to indicate with precision 
in the living body any marked diagnostic symptoms between disease which 
may show itself between the fifth lumbar vertebra and the saorum, and 
between the sacrum and the upper part of the os innominatum in some 
oases. If we were to treat this question with a skeleton only before us, 
we might presume that the local symptoms would be precise enough; but 
when these deep parts are clothed, with soft structures, there ia a great 
difficulty in making an exact pressure, as, for example, upon the upper 
part of the sacro-ihac joint so as to isolate it from the sacrum, or the sac- 
rum from the last lumbar vertebnu Hence it will be necessary for me, in 
treating this part of my subject, to group together the morbid conditions 
of this neighborhood. I shall endeavor to point out the distinguishing 
marks; but for all practical purposes we might identify them all as form- 
ing a little group. 



I 



9 



Case of J}ineaee of the la»t T^umhar YerUhra sitnxdatmg Jlip-ji 
iJigeuse. 
On the 28th of January, 1860, by a physician's reque.st, a little ( 
was brought to me, supposed to be suffermg from diseased hip- joint, 
physician sent this note with the patient: "The little child 1 send to 
came before me for supposed disease of the back, but it seems to me xo 
be an affection of the nip-joint. I have, therefore, advised the friends to 
take y<^ur opinion." The patient, a delicate child, had had a most severe 
pain in the region of the left hip for a week before I saw her. She could 
neither sleep nor bear any weight upon the left limb. She had pain id 
the hip, knee, and thigh, was very lame, and sufl'ered intensely upon 
making any attempt to walk. Considerable constitutional disturbance 
crevuiled. On examiaation I found the hip-joint free from pain; that is, 
tm movement of the hip-joint — isolated movement — the patient experi- 
enced no pain, nor was there the slightest evidence of any local heat at 
the hip-jomt. Although there was no pain in the left hip-^'oint, she pro- 
■ented all the " outlying symptoms "of disease in that joint — lameness, 
pain iu the knee and hip, thigh a little advanced, intense pain in the hip 
on striking the sole of the foot with the hand, and flattening of the nates 
Cn the left side. But on pressing the os innominatum towards the sacrum 
she complained bitterly. The same thing occurred on making pressure 
upon the last lumbar vertebra and upper part of the sacrum. There was 
also pain on deep pressure towards the posterior and superior part of the 
sacro-iliac articulation. Some increase of heat was to be felt in thi^g 



IKPLUENOE Oy BEST. 



243 



neighborhood bj placing the palm of the hand upon it, and by comparing 
the temperature of the oorresponding parts on the opposite side. Thus 
the case was made out to be disease between the lower lumbar vertebra, 
EAcrum, and ilium. On seeking for a cause of this local disease (it only 
came out upon subsequent inquiry), it was remembered that about six 
weeks before the lameness she bad fallen upon the ice, but the fall pro- 
duced no urgent symptom beyond temporary lameness. Spine disease 
seldom manifests itself only on one side in children, so I was disposed to 
attribute the mischief to the upper part of the sacro-iliac symphysis. Tho 
case was to be treated simply by mechanical rest, and tlio only way of 
securing rest to these parts is by the patient lying down uninterruptedly. 
This plan was carried out. The constitutional disturbance subsided in & 
fortnight. In two months, in direct opposition to my previous strongly 
expressed wishes (as she appeared to be in every respect so well), she waa 
allowed by her parents to get up and walk about, and soon afterwarda 
unmeasured exercise was taken. 

In R few weeks the lameness and all the other untoward symptoms 
were again apparent, with occasional shivering. These symptoms con- 
tinued uncontrolled, and she was allowed to be moving about the house 
until she was brought to me in the early part of June, 1860. She was 
then accompanied by the family surgeon, who said he was excessively 
sorry to see these nice quiet people, good patients, and so on, bo dis- 
tressed about their poor scrofulous little child, with a diseased spine, and 
a large abscess fonning; adding conliiientially to myself, that although 
the case was utterly hopeless aa regards the treatment, still he thought it 
right to bring the case for me to see, aa I bad seen it before. An abscess 
could now be distinctly felt, deeply sea.ted upon tho inner and posterior 
part of the ilium, on ike pelvic aspect, near the sacrum and last lumbar 
vertebra; and there was some increase of heat and abnormal lirmness of 
loft parts. A hemlock poultice with bread was ordered 
er the abscess, and the recumbent supine position to be 
ind continued witliout intermission. The mother was 
rry out this plan of " rest " carefully, and for any extent 
oi time. The child was to take the air daily, weather permitting, in m 
little four-wheeled carriage. The diet was to be good, but not stimulat- 
ing. It was intended that the patient should go to the sea-side for the 
remainder of the summi.'r, but some domestic circumstances interfered 
with this arrangement, and she was kept at home in the country. The 
abscess opened of itself in September, near the posterior part of the crest 
of the ilium. It broke in the night, and nearly a quart of matter came 
away, soaking through the blanket and mattress; and abundant pua, 
scrum, shreds of lymph, and more solid caseous material were discharged. 
The health remained good. The abscess gradually ceased to secrete, and 
I «aw the patient in January, 1861, well. 

Now, here is a child suffering severely as regards health, kept lying 
in bed, secunne the parts from disturbance, and, after seven months' per- 
sistent rest in the recumbent position, her health has gradually improved; 
and the expression that her health remained perfectly good is not exag- 
gerated. The abscess by degrees ceased to secrete, and when I saw her 
in January, 1861 (up to which time she had been lying down), she could 
stand up and walk without pain. She was fat, plump, and in every re- 
spect well, except that there was a little weeping of thin fluid from tho 
mouth of the sinus of the abscess; there was no pain anywhere. Tho 
fourlh and fifth lumbar vcrtebrte seem firmly consolidated, and do not 



the surrounding si 
to be applied o\ 
again resumed, 
nowwillin 



2i4 ON TIIE TIIERAPEDTIO 

field like the other vertebrae on bending the spiae. The discharge 
ceased in February, 1861, when she was brought to me, at my request. 
She is now, and has been since Jsjiuary, 1861, in good health. The Ust 
lumbar vertebra projects backwards a little, but not abruptly. She runs 
about with the other children, up and down stairs, and stoops to pick up 
anything oS the floor. Sept. Qtfa, 1863. — The mother writes to me thus: 
" You will be pleased to hear that my little daughter is quite well, and 
has not felt the sjiglitest return of her weakness." This presents a case, 
then, of diseased spine putting on the symptoms of hip-joint disease, 
with extensive suppuration. The child was thought to be scrofulous 
both bv parents and by the surgeon in attendance; but, in spite of that, 
the cliild is now perfectly well, without a single drawback. In additii 
I think it shows conclusively the value of mechanical rest in the treatmi 
of cases of this kind. 

Severe JXseaDe of t^ine, close to Pelvis, cured by Rest, 

In the summer of 1851, Miss A fell down some steps and bruised 

her back in the lumbar region. Tliis was soon followed by pain and some 
tenderness at tha part, as well as some pain in the legs. The pain and 
weakness in the back increased, with some loss of power in the lower ejt- 
tremities, accompanied by a marked inability to sit up long, or to go up 
and down stairs, the pain in the legs being very severe. !She consulted 
several London Hurgoone and physicians, alT of whom advised tonic plana 
of treatment, change of air, exercise, and counter-irritation. One at 
geon treated her moHt energetically for neuralgia. These varied kinds 
treatment were pursued with irregularity, and without any benefit to 
patient, up to the time when I saw this ]ady in 1854, nearly three y< 
from the uegiiuiing of her symptoms. She was then emaciated and weak, 
had a frequent and irritating cough, with hectic and distressed expreeuan 
and rapid pulse; also her health was reported to me as very greatly dete- 
riorated, and still getting worse. She could walk but a very short dis- 
tance, and that with dilficulty. She had pains and cramps, and dimin- 
ished sensibility iu both legs, and she could not stand upright without 
support; both legs were somewhat wasted. The fourth and hfth lumbar 
vertebras were painful on. pressure, and slightly projecting backwards; 

firessure upon them producing a severe pricking sensation down the left 
eg, in the course of the branches of the anterior crural nerve. Deep in 
the loin on the right aide the fluctuation of an abscess could be detected, 
extending towards the crest of the right ilium. The abscess was opiened; 
her health gave way, and she really appeared to be on the very verge of the 
grave. I then had her placed on one of Alderman's beds, and removed in 
an invalid carriage to Brighton. She remained on the coufh uninterrupt- 
edly, never quitting it, except for the purposes of personal cleanliness, dui^ 
ing five months, and then she was lifted horizontally off the bed on to a 
couch or sofa, and put back when the bed was ready for her. Her health 
gradually and quickly improved; and at the expiration of a few months all 
the pain in both legs, and the pricking sensation in the left, had disappeared, 



1 



>lana 



ind both legs were improved in sine and power. She continued recum- 
bent until the discharge had ceased, and all the wounds had healed. At 
the expiration of fifteen montlis she could stand upright without p«in, 
and, after a few days' trial, with confidence in herself. Taking walking 
exercise with crutches, she gradually got well. When last I saw this 
patient she was in perfectly good health, with not a single drawback !a 
respect to her condition. ^H 



JWFLDENCE 



This case, then, shows the 
hftd not the patient been comi 
been taken of her, she would r 



value of rest. I am ([tiitc confident that 
^Iled to lie down, and had not great care 
ive died. 



Cas6 of Disease between the Sacrum and Zlhttn, vitlt inten»e Pain in 
the Leg on. tfte same aide of the Boily. 

This case is of much interest — in one respect especially, berausc I waa 
enabled by the recognition of the course of the nerves to the leg to ascer- 
tain the real character of the case, the true position of the cause of tha 
svmptoms, mid thence to deduce the proper plan of treatment. The de- 
tails are not very long. 

On November 2:3rd, 1861, I was requested to sec, with Mr. Bamea, of 
Chelsea, a youn^ gentleman who was suffering, and had been suffering for 
some considerable time, from intense pain in the calf of his right leg< 
The thigh was slightly flexed, and he was unabla to walk or stand upoa 
the limb. He was sitting upon a couch, the limb every now and then 
jumping involuntarily, causing him to cry out with puin. This occurred 
Be\'eral times while I was in the room. lie had shockingly bad nights. I 
requested that I might have all the possible details of the history before 
making any examination. It appeared that on Apiil )!4th, 1860, the lad 
slipped down two stairs, and struck the lower part of his back, but no di- 
rect injury was suspected. He soon became lame in the right log, and, 
in attempting to walk, his foot turned somewhat inwards. He continued 
lame and weak in tiie right leg for nearly throe months, after which time 
he gradually resumed the natural occupations of his period of life. He 
had repeated attacks of lameness arising from slight casual accidents. In 
February, ISfil, whilst bowling hia hoop, he trod unexpectedly, and with 
force, upon a stone, and aprairied his foot; and from that time he became 
again very lame, and went about on crutches. In the early part of Octo- 
ber, 1861, he had a third slip and fall; and from that time he could not 
stand or move about without pain in his right leg below the knee, with 
cramps in the calf of that leg. During six weeks the pain in his teg was 
rerv great day and night, depriving him of sleep, and distressing his gen- 
eral health very much. He was lifted off his bed and carried to the house 
, of a consulting hospital surgeon, who, seeing him suffering from so much 
pain and tenderness in his leg, which made it almost impossible to examine 
the limb carefully, from the additional pain and spasm which were induced 
by it, and finding nothing wrong about the knee or hip-joint, came to the 
oonclusion that probably there might be deep abscess near the back part 
of the tibia, and that the tibia itself might be diseased. He directed the 
treatment to be adapted to such a view of the case, and ordered a bella- 
donna plaster to cover the leg. The night following this visit to the sur- 
geon was passed in greatly increased pain, with cramps and twitching in 
the right rimb. After ten days, there being no alleviation of the severe 
symptoms, the opinion of another hospital surgeon was sought. He saw 
the patient in bed, and examined him carefully; but I believe he gave no 
intelligible or satisfactory opinion as to the cause of the painful sj-mptoma. 
He directed the patient to be kept quiet on a couch or bed, the knee-joint 
and leg to be supported by a splint, and the knee to be covered with cot- 
ton wool, 

I hope this statement will not imply anything like self-laudation. I 
Only mention the facts in detail for the purpose of pointing out the 
method of proceedingwhich led toa right interpretation of thesymptoms. 

No improvement occurring, I was desired to see this suffering ^atleivt^ 



246 ON THE TIIEKAPEUTIO 

Mid I went to him with the eipectfttion of doubtful benefit to be derived ' 
from my examitiation, considering the eminence of the two surgeons vho 
hod preceded me, and from whoso suggestions no good liud been derived. I 
found a very intelligent lad sitting upon a sofa, with his right leg lying 
on its outer side, supported by pillows. The pulse quickened, but with 
flittle febrile exoitement: the tongue was not much furred; the thigh 
slightly ilexed, and not to be straightened without pain. There was most 
severe pain in the leg, which was every now and then, at two or three 
minutes interval, suddenly and intensely increased so as to make him ciy 
out. The back part of the calf of the leg was very sensitive, both on sn- 
perKciai and deep pressure, the muscles of the part being in a state of 
Bthenio contraction and quivering, but there was no marked increase of 
temperature at the part, nor any distinct fluctuation. By steady And con- 
tinued pressure upon the calf of the leg, the pain was not increased, and 
I thou^t the spasmodic condition, of the muscles seemed to su)>side. 

Thsse local symptoms, with their natural suggestions, excluded any- 
thing like local disease in the neighborhood of the posterior part of the 
tibia, or within the calf of iho le^, where the pain was expressed. The 
muscles subsided in their spasmodic action, the pain was relieved rather 
than otherwise by pressure, and there was no increased heat at the part; 
no pain in the linee or hip-joint when the examination was conHned to 
either of them, nor was there any heat over or near them. On pressing 
the right trochanter major, he experienced pain somewhere in the hip — 
not in the hip-joint. No attempt was made to put him upon his legs, he- 
cause he could not bear any weight upon his right leg, and recent experi- 
ence bad shown that the pain had been greatly aggravated by m&king 
■uch an attempt, 1 thought it was clear that the real pathological c-ause 
of the pain was not at the part wherein the pain was expressed, and that 
there was no local inflammation in the part; for there was not the local 
indication or constant concomitant of il — namely, increase of teniperature. 
The nervous supply to the deep and superficial muscles of the leg, an ' ' 
the overlying skin, being derived from the great sciatic nerve, sugg^ 
to my mind the belief that the cause, whatever it might be, wouli 
found anatomically associated with that nerve, to the exclusion of t 
anterior crural and obturator nerves. 

These considerations induced me to examine the structures near i 
which the great sciatic nerve travels towards its distribution. The patiei 
being gently turned over on his stomach, I pressed with my thumb upctf^ 
the junction of the sacrum with the ilium, and near to the last tumnar 
Tcrtebra, on the right side, and he immediately scrc:i!.:ned out that I gave 
him the pain in his leg. On making a like degree i' local pressureon the 
<x>rresponding part on the opposite side, no pam was induced at the point 
of pressure or in the leg; by repeating the pressure on the right aide the 
pain in his leg recurred. Thus the real cause seemed to be discovered in 
the form of disease between the sacrum and ilium, or thereabouts; and 
tlie obvious and first remedy was to give rest to the joint. That 
could be obtained only by the patient lying flat upon the back uninter- 
ruptedly, and by the application of a long straight splint to the leg and 
pelvis, so as to prevent any disturbance; the recumbent and supine posi- 
tion to be strictly maintained during two months. The splint wasapplted 
immediately by Mr. Barnes. He had no medicine — not a drop. The pa- 
tient was not allowed to turn in his bed, or to sit up for any purpose; 
and in a fortnight all the painful symptoms had subsided, so that he was 
quite comfortable in every respect. J 



IKFLUXNOE OF BSST. 247 

I did not see this patient again until two months after my previous 
visit. I found him happy, free from pain, health and appetite good, com- 
phuning only of a little headache from his head being too low. I turned 
nim on to his left side, and examined his riffht sacro-iliao joint by direct 
pressure; but it did not produce any pain, either at the part or in the leg. 
Thus mechanical rest had aided Nature to repair the mischief, whatever 
it mieht have been. Considering that he had been more or less lame since 
April, 1860, it seemed unreasonable to suppose that the diseased structure 
of the sacro-iliao joint could be repaired in so short a time as two months; 
hence it was arranged that the same plan of mechanical rest should be 
persevered in for one or two months longer. 

The diagnosis, in this case, was established chiefly through the me- 
dium of a recognition of the anatomical course of the great sciatic nerve 
which supplied the part where the pain and spasm were expressed. In that 
respect the case is important and of striking interest. The patient's 
health, I am happy to say, was in the end perfectly restored. 



ON THE THKEAPBUTIO 



LECTURE XVIL 

Bwro-Iliao Disease in a Boy aged Five, cured by Meohanirjil BcBt-Rncfo-Iliao 
SBBH ia a Man of Fortj-two, cnred by Ruat — Sacro Ilinc DiaeBge in thi 
Side after Panuritiou ; Suppuration within the PuItIb. Abucess Abaorhed, 
by Rest— Disense of the SQoro-eoocjBeal Joiot, from Injury, ourad by 
Inllaniinatioa of the Coccygeal Joints, fioiu Injiuy, cured by KeBt — Pain 
Poat«rior Portion of the Coocyi in Hjaterioal Case*, ExptanatioQ of— Ci 
NoQ-DeTelopment of both PateUs up to the Age of Three and a Half Yean — 
Dineose of Knee-Joint iScrofoloas?) Treated by Mechanical Rest, cured by 
Firm Bony Consolidation — Diseoaod Knee-joint, from Injury, witb Partial C»- 
lies or Neorosia of tlie Patella, cured by Rest — Traumatic Dialocatiun af the 
Tibia, treated by Beat and AppUcatioii of Cold— Wounils Penetrating the Ensa- 
Joint trestei) by CtM and Rest — Disease betwcea the Shaft and Lower G^Hphy- 
eia of the Femar — DiKeruts of Knee Joint ; Binepa Divided and Limb Stni^it- 
Qi:ed~Old Di£eu.HB ol Knee-Joint ; FJexois Divided— Troatxueut of Loose Caxtiltffi 
in Knee-Joint by Beat. 



In my last lecture I alluded to cases of disease occurring; betvn 
the sacrum and the ilium, and 1 mentioned two or three instances whi 
were cured by rest. I shall now detail some similar cases, not only 
cause they are comparatively rare, but because the real scat of disease 
is BO frequently overlooked; while, if the diagnosis be once correctly 
made, the treatment is exceedingly simple. All this is in accordance with 
the general impression in the profession, that nine-tenths of our success 
in practice depends upon accurate diagnosis. Some surgeons are disposed 
to think that acute or chronic diseases between the sacrum and the itium, 
if of a serious character, are almost incurable, and are hence disposed to 
pay but little attention to their treatment, except in palliation of 
symptoms. I think we have clear clinical and pathological evidence 
they are actually curable by the employment of proper means. 






tdto 
thftH 
thi« 



Sacro-iliac Diaeasi in a Boy aged Jive, oared by MecJtanical Kest, 

For the purpose of showing that these oases occur at all ages, and in 
both sexes, I shall have occasion first to allude to a young gentleman 
whom 1 saw on October 29th, 1853, with Mr. Taylor, of the Kent Road. 
The child was then five years old. He had been increasingly lame in the 
left leg for about a month, from some obscure cause. He was suffering 
from much constitutional disturbance, rested badly at nic'ht, and wu 
unable to sit, walk, or stand without pain in his left leg. Up to the time 
of my visit he had been allowed to move about as well as be could, having 
been treated medically since the first appearance of his symptoms. His 
left thigh was a little flexed, the body somewhat bent forwards, and he 
could not bear any weight on that side. The case, then, might he one of 
hip, spine, sacro-iliac, or possibly cerebral disease. On placing him in tha 
recumbent position upon his back, it became evident, by carefully manlp- ■ 



INFLUEKOE Of REST. 249 

ulating the hip-joint alone, that tliere was nothing wrong about it. The 
spine presented nothing abnormal on diruct pressure nor in appearance ; 
but, on striking the ao!e of the foot upwards, ho had pain in the neigh- 
(borhood of his left hip. Pressing the left os innominatum towards the 
Bacruni, or pressing the sacrum itself fonvards, and exerting, with the 
thumb, defined pressure over the posterior part of the left sacro-iliac artic- 
ulation, gave him considerable pain. Thus the case seemed to be made 
out to be disease between the sacrum and ilium. Nothing wrong was 
detected in the abdomen. On inquiry, it was thought possible that some 
local injury, whieh would explain his symptoms, might have originated 
in a fall which the little patient had v/hilst trying to drag a braneli ofi 
a tree, some short time before the lameness manifested itself. 

A belladonna plaster spread upon leather was placed upon his back 
and hip, and it was arranged that he was not to move from his recum- 
bent position for any purpose whatever. With that uuders tan ding, 
neither splint nor mechanical appliance was made use of. Simple means 
were employed to keep the bowels relieved, and he was ordered to take 
syrup of sarsaparilla and lime-water. After lying down a month, his gen- 
eral health had recovered itself, and he was nearly free from pain; but he 
was not allowed to get up before the expiration of three months, when he 
was in every respect well and free from pain and lameness. For some 
time afterwards proper care was observed as to the amount of exercise 
permitted. 1 wrote to Mr. Taylor in April, 1S(>0, to ask him about tha 
case, and lie replied, " The recumbent position was enforced strictly for 
three months, and the boy has perfectly recovered — and, I would add, by 
rest." I do not know whether this last remark is to be considered only 
as a complimentary expression to myself, but those are the words he 
used. 

In this kind of case there is no rest to be obtained for the saoro-iliao 
joint except by placing the patient in a recumbent position. Whether 
sitting or standing, under any circumstances the weight of the head, 
neck, shoulders, and chest must all be transferred through the medium 
of the spine to the base of the sacrum, and the sacrum will have a con- 
stant tendency to wedge its way between the ossa innominata, and press 
upon those structures which constitute the soft part of the sacro-iliao 
synchondrosis. 



Case of Sacro-iliac DUeaae in a Man aged forty-two, cured by Me- 
chanical Jiest. 

Wm, F , aged forty-two, a carman, came under my care at Guy's 

in December, 1857. Six months previously he began to suffer pain, as 
he said, in and about his " left hip." His occupation rendered it fre- 
quently necessary for him to lift heavy weights, and he thought he might 
Have strained the parts in some way, although he could not definitely fix 
the time or manner of the accident. The pain, which was at first only 
intermittent and comparatively slight (coming on only after exertion), grad- 
ually became constant and severe. Lifting weights became impossible to 
him, and at last he could not bear his own weight, and walking caused 
excruciating pain, which he described as "running down to the upper 
part of the thigh." Before admission into Guy's he had been treated for 
rheumatism, sciatica, and hip-joint disease. On admission, it was found, 
by eareful examination, that the seat of the greatest pain corresponded 



250 



ON THE THEEAPEUTIO 



with the right eacro-ihac synchondrosis. Pressure upon the sacrum i_ 
ilium in such direction as to disturb the sacro-iliac synchondrosis gave dm 
to great pain, as did also pressure applied directly over the joint Detween 
the sacrum and the oa innominatum. On the other hand, the pelvis being 
steadied, the hip-joint could be moved about and manipulated in any way 
without producing pain, so long as the movement did not affect the sacro- 
iliac synchondrosis. At times there was pain about the gluteal region; 
there was never psin in or about the knee. The patient could not lie fm 
hia right aide without pain, was unable to stand or to walk without very 
great pain, und the attempt to stand produced yielding in the lower 
part of the back; but there was neither shortening nor lengthening 
of the limb, nor any marked alt-eration in the contour of the gluteal 
region. The patient had had neither shivering nor any other symptoms 
of irritative fever. He was ordered to keep hia bed, and remain abso- 
lutely at rest upon his back. I will not trouble you with the minor detailsi, 
About two months afterwards, in February, 1858, he was furnished witi|_ 
a strong pelvic bolt of leather, provided with buckles and straps, a 



and prevent, i 

patient 1 
months) 



) possible, movement of the si 
mbent in Ik ' 
3 permitted t 



, r April 

1 he did without 



pain. In a few days he got up (wearing the belt), walked slowly about 
with the aid of a stick, and with scarcely any pain at all. From this 
time he steadily improved, and at the expiration of five months he li *' 
the hospital, returning to his occupation three weeks afterwards, 
time spent in rest was therefore six months, 1 requested the patient to oi 
upon uie in 1861, and he did so in March. He could then carry two c 
without difhcultv, and had done so during the last two years, but he 
laid great store by the pelvic leather belt, which gave him more comfotitf 
and a greater sense of security than anything else, and the lighter it v 
Strapped the more comfortable it was to him. 

Thia man presented clear evidence that he had disease between the 
sacrum and the ilium, from which he had suffered during six months pre- 
viously to my seeing him. He was perfectly cured by six months' rest. 
The whole of the good effected was by keeping the pelvis in repose — not 
interfering with the natural efforts towards repair, which were ultimate 
made with success. The advantage of the circular belt no doubt d 
siated in its maintaining the disea&ed parts in forced coaptation, for I b 
lieve the man has now anchylosis between the sacrum and the ilium. 



/Sacro-iliae DtMme in tkf- Lr^ .SWe afler Pnrhtrition; * Su]^ 
teifhin the Pelvis; AUce»a obaorbed; cured by MeciutnicalJtett. 

In 1853 I saw a lady, aged twenty-four. After a tedious and a 
but natural labor, she had teen delivered on April 17th, 1853, of a health^_ 
and strong child. She remained in bed, and everything went on well for 
two or three weeks, when, on moving abruptly in bed and turning quickly 
on her side, she felt pain for the first time in her left hip. It was not then 




*A Bomewhnt similar esse of Bacro-ilinc diaeaae. wbeM the patient " bad heea de- 
livered with grent difflcultj of a very lar^e child." i« meationed hj Professor Esniarefa 
hi hia moDogrspb on Cold, translated in the aeries of tho Kew Sji. 8«c. for ISdl.-— 



IHFLUBNCE OF REST. 251 

severe, but gradually increased in severity, particularly on attempting to 
stand or walk. She had at the same time obstinate constipation of the 
bowels. She continued lame, suffering from pain in tlie hip and on the 
inner side of the knee, restless nights, with profuse perspiration, and 
depressed general health. She took quinine, sulphuric acid, and other 
tonics, and had a belludonniL plaster applied to the gluteal region. On 
June 25lh, seven weeks after her t'onfinement, I saw this lady, in consul- 
tation with Mr. Sinclair, of Halstead. There was some difficulty in 
making out the seat of the disease. I found her reclining with her right 
side upon a couch, to and from which she was carried by her husband, as 
she could neither stand nor walk without pain in the left hip-joint and 
knee. The left limb was shorter than the right, because the leg could not 
be perfectly straightened, and the thi^h was a tittle bent upon the abdo- 
men and slightly adducted. (These are very much the outlying symptoms 
of hip-joint disease.) She was really in extremely bad health; her nights 
were sleepless, her appetite gone, she vras always in pain, with symptoms 
of commencing hectic. On attempting to stand, it was impossible for her 
to bear the slightest weight on tjie left leg without agonizmg pain. The 
buttock was flattened on the left side, and when the sole of the foot was 
struck she had intense pain in the left side of the pelvis and in the left 
hip-joint. On grasping the lower limb, and being careful not to disturb 
the pelvis, but to limit the movement to the hip-joint, no pain was expe- 
rienced in it by flexion, rotation inwards or outwards, nor on pressure in 
front of the joint; at least, there was not more tenderness than is usual 
in that situation. It was plai[i, therefore, that the hip-joint must be ex- 
cluded from suspicion. On pressing the ossa innominata towards each 
other, thus compressing the sacro-iliao articulation, the pain in that joint 
and the hip and knee on the left side was excessive; and on examining 
the back, and pressing upon the posterior part of the left sacro-iliac joint, 
great pain was felt near the point of pressure. On accurately measuring 
the two limbs, it was shown that the apparent shortening of the ieg de- 
pended on the slight elevation of the left side of the pelvis. On passing 
the finger into the rectum, to ascertain the cause of the constipation, and 
to discover if any local mischief existed there, it reached a fluctuating 
■welling towards the left sacro-iliac joint, and pressure upon the supposed 
ftbscoBS gave severe pain through that joint. 

The case seemed now to be clearly made out to be disease in the left 
sacro-iliac articulation, with abscess within the pelvis, originating in 
parturition; the treatment indicated was evidently rMt to the saoro-iliao 
articulation, and that could only be accomplished by a persistently 
recumbent position. She was placed upon a hair mattress, and a large 
belladonna plaster, spread upon a thick leather, was applied so as to cover 
and support the whole of tno pelvis posteriorly and laterally, Including 
the hip-joints. She was not allowed to move from her position in bed 
■nd upon her back for any purpose. Some saline febrifuge was to be 
Caken daily; and nothing else but plain food; no stimulants. 

On July 4th I saw this patient again; she was cheerful, and in every 
respect better. Quinine and iron were now ordered; opium to relieve 
pain, and chloroform liniment to be rubbed over the gluteal region and 
knee; the belladonna plaster to be continued to the back of the pelvis, 

August 20th. — The general and local improvement has continued, and 
the fluctuation within the pelvis is not so prominent; the left leg is now 
Btraight, and Hes flat upon the bed by the side of the other leg, Apelvio 
oiroular belt waa applied, and constantly worn. 





252 ON THE THEBAPEUTIO 

It was plain that this lady had a, long illness bi?fore her. As she had 
been of extremely delicate health at alltimea, as her residence at tkU 
time was by a river-side and damp, and as winter was approaching-, it was 
thought better to send her to Brighton. She was taken there to lodg- 
ings opposite the sea, without being moved from the horizontal position. 
She returned from Brighton in October, 1854, quite well; indeed, she 
had been so for some considerable time previously. 

In the spring of 1855 she was able to take any reasonable walking 
exercise without pain or inconvenience, and was considered cured of her 
sacro-iliac disease; she has remained in that respect quite welt. 1 mig'ht 
add that the abscess entirely disappeared. She never passed any purulent 
fluid from the rectum; hence we may iiifer that 

absorbed. Several superficial abscesses formed in the left leg belowj 
the knee, ar ' 

I think it i 
with the experii 
surgeons, that w 
absorption has taken 
if the person be not 
healthy, the secondary abscen- 
es, which may perhaps be the 
consequence of that absorp- 
tion, have, generally speaking, 
unhealthy and offensive pus 
within them. I have noticed it 
repeatedly; and it becomes a 
happy provision on the part 
of Nature when she selecia 
those parts of the body where 
the secondary abscess may be 
comparatively harmless. 

This lady wore a belt em- 
bracing the pelvis (luring near- 
ly the whole period of lierreu- 
dence at Brighton, and took 
cod-liver oil and steel wine 
somewhat irregularly. The 
only therapeutic agent effi- 
ciently employed was local me- 
chanical rest to the sacro-iliao 
synchrondroais, and that prin- 
ciple was most completely and 
satisfactorily 

Since that time she has htH: 
no children, 

n her right knee-joint, which 

was brought on by trj'ing to ^ 

idious thing, but she got over 

ing it rest, and by apending 

She was 



became 



e following year she had disease 
■nilen. She thought it 
save the left leg in walking. This was a 
it by applying a splint to the joint, and so gi 
a summer in Wales. In January, I8C1, Isaw her aeu 
excellent health; indeed, I never saw her looking so well. 

These are all the cases of sacro-iliac disease which 1 think it necessary 
to adduce (they are not all which I might have placed before you) to show 



I 



1 



INFLUENCE OF REST. 



253 



how this disease may be dia^osed; and that, when once dearly diagtiosed, 
the treatment is one o£ extreme sirapiioity. We must jivo rest to the 
joint by the recumbent position, and 
aid anchylosis throug'h the medium 
of close coaptation of the opposite 
■urfaoes of the bones by a pelvio belt. 

Before quitting the neighborhood 
of the pelvis, I would make a few re- 
marks on some cases of disease of the 
saoro-cocoygeal articulation; but first 
let me refer you to this diagram, show- 
ing the sacral nerves passing over the 
posterior surface of the sacrum, and 
spreading their branches over the 
lower part of the sacrum and coccyx 
(Fig. 89). 

In the sketch (Fig. 90) you may 
Bee the attachmctit of the gluteus 
maximus to the coccyx. It must be 
obvious thitt if the sacro 'Coccygeal 
joint or the coccyx itself be inflamed, 
and the gluteus maximus be used to 
any extent in the act of elevating the 
body from the sitting posture, or in 
sittin^r down, or in rapid progression, 
the coccyx or sacro-coccygeal articula- 
tion must be much disturbed. Hence, 
although the patient may be able to walk gently, slowly, and carefully, 
yet, on attempting to stride out, he suffers considerable pain from the 
disturbing influence of the gluteus m&ximus. Then notice the muscular 
aasociation of the posterior part of the external sphincter of the anus in 
this drawing (Fig. 89,^) ; its fixed point is at the apex of the coccyx. 
During defecation, and subsequently, these muscles contracting towards 
their more fixed points would tend to disturb or displace the coccyx, and 
pull it away from the sacrum. Some of the symptoms of which such 
patieuta generally complain are thus explained. 




Disease of the Sa<yro-coccygeal Joint, JYom Injury; eitred by Rest, 

I saw the young woman, to whose case I am about to refer, on the 2nd 
of April, 18()0, and she gave mo this history. Ten months before she fell 
upon the corner of a chair, which struck the coccyx forcibly, and gave her 
much pain. She had pain on defecation, on attempting to rise from a 
seat, little pain in walking slowly and carefully, but she could not run or 
walk rapidly, and she experienced great pain in going up-stairs or upon 
flitting down. 

On examination, the coccyx was found to be turned forwards almost 
at a right angle with the last bone of the sacrum, and to encroach upon 
the rectum. The joint between those two bones was swollen, and very 
painful on pressure. The coccyx was tender along its whole length, and 
pressure at its free end caused pain at the sacro-coccygeal articulation. 

For treatment, she was directed to lie down as much as possible, to 
take the twentieth of a grain of biohloride of mercury, and a drachm each 



254 



ON THE TnEEAPEUTIO 



of tincttire o( rhubarb and tincture of bark two or three times a day, anj 
to keep the intestinal evacuations soft with confeotion of senna. 

She continued lying down until April 20th {eighteen days), when I 
saw her again, and she was in every respect better. She then went home 
to lie down a month longer. After tne lapse of that time she was so 
much relieved from all her symptomB that she began slowly to resume her 
duties of attending upon an invalid lady — a case of diseased spine. 

In July, 1860, I saw this person again. Anchylosis had taken place 
between the coccyx and Hacnim, and alio suffered no important inconve- 
nience unless she happened to ait abruptly upon a hard flat surface; then 
the angle of union between the coccys and sacrum was painful. The 
pointed end of the coccyx annoyed the rectum somewhat, but she wi 
getting accustomed to that. In ]8(jl she remained well, could take 
amount of exercise, and suffered no pain during defecation. 

Here, then, is B case of disease of the sacro -coccygeal joint, ftnd 
appropriate method of securing rest requires to be considered in refere 
to the treatment. The objects to be attained are, to avoid the action of 
the gluteus maximus upon the joint, to avoid sitting upon the coccyx, to 
avoid any extreme action on the part of the sphincter, and to take can 
that no great amount of expulsive force shall be required for the puqxa^ 
of defecation. The motions should be kept soft, and the patient shoi ' 
therefore take a lai^ amount of fluid nourishment, which is readily 
Borbed, and leaves very little fecal residue. These are the chief ind 
tiona in the treatment of such cases, and they all relate to the subject 
mechanical rest, the securing of which is the secret of the succeHsfiu ii 
of these cases. 



'i'he 
iddJH 



Injlammation of the Coccygeal JuinU, from Injury ; cured in/ ResCM 

The last case of this kind to which I shall allude is the following:- 
In consultation with the late Mr. Duchesne, I saw a young lady, aged siX' 
teen, in the summer of 1853. She had slipped down the steps of the door- 
way during the frost of the preceding winter. She fell upon the gluteal 
region, but said she did not strike bersclf where she subsequently felt the 
local pain. Soon afterwards she had pain in defecation, in assuming the 
erect posture, and in attempting to walk. At the period of the accident 
she was in every respect in good health; but since that time — about stz 
months — she had suffered so much from pain, constipated bowels, and Ion 
of appetite, as to render her general health anything but good, and 
had lately been losing flesh. Her easiest posture was the recumbent, . 
the plan of lying down had been occasionally adopted, with benetit, a> 
part of her treatment, up to the time of my seeing her. I need not troubl 
you with many details. The whole length of the coccyx was tender to 
the touch; the different portions of it were pliant and movable upon eadi 
other, but painful; indeed, the whole of this bone was in a state of slight 
inflammation. The patient was placed in a recumbent position upon a 
hair mattress, and not allowed to get up at all during the flrst eight 
weeks. At the expiration of that time it was found that nearly all the 
local symptoms had disappeared. She then took gentle, limited, and 
carefully watched exercise (parlly at the sea-side), and ultimately got 
quite well. I saw her father on February 23th, 18CU, and he reported ta 
me that his daughter had been, and was then, quite well, except a slight 
disposition to be constipated, 

I had intended, if this patient had not been relieved by rest, to hart 



low 



INFL0ENCE OF BEST. 2oo 

put a bistoury under the skin and celjtilar tissue, and detached the exter- 
nal aphincter from the coccyx. I di<I this operation some years ago in 
the case of an hospital patient, who had suffered from the same kind of 
injury and had the same local Bj-mptomH, The operation was followed by 
a slight suppuration on the pelvic side of the coccyx, but it ultimately led 
to the cure of the patient. I think it right, however, to add, that I nave 
since that time seen several such caaes, (juite as severe, which have done 
well by time, and perseverance in the method of -treatment by rest alone. 

Sui^eons are consulted by persons who have great pain and tender- 
ness in walking, some pain in defecation and in sitting, and pain about 
the posterior part of the coccyx. This kind of case occurs more espe- 
cially in " hysterical " women. I have seen many cases of this kind. The 
coccyx is very tender on its surface, and sometimes exquisitely sensitive 
to the touch; but there is one very notable circumstance, — namely, the 
entire absence of any increased heat in the part, the want of that local 
indication which is always positive as regards the existence of inflamma- 
tion. Such patients scarcely ever, or rarely, receive any benefit from re- 
maining in the recumbent position. The explanation of the symptoms is 
this: — You will remember that there are numerous sacral nerves spread 
bver the posterior surface of the sacrum and coccyx, and that they arc in 
intimate structural communication with the anterior sacral nerves, which 
join with the hypogastric plexus of th« sympathetic within the pelvis, and 
tbenoe proceed to the uterus and ovaries. There is pain and sensitiveness 
in the skin and over the sacrum and coccyx, difficulty in walking, and 
some trouble in defecation; hut no evidence of an inflammatory condi- 
tion. If the finger be put into the rectum, and the coccyx grasped be- 
tween it and the thumb, the coccyx will move backwards and forwards 
without pain, These, then, are "hysterical" affections, and are to bo 
treated in reference to such an interpretation, 

I now leave the neighborhood of the pelvis, and proceed to the knee- 
joint, for the purpose of considering the value and true relation of 
"mechanical rest " as a remedy in the injuries and diseases of that joint. 
But first I would solicit your attention to an interesting case of non- 
development of the patcllie until three and a half years of age. 

Case of Non-development of liotk Patellm vji to the aye of three and a 
half years. 

This child (a female) was bom in IS35, at the full period of gestation 
— the mother says with one leg turned upwards, so as to rest upon the 
chest, where an indentation existed, and an abscess subsequently formed. 
There had been no deformity iu anv of the mother's previous or subse- 
quent children. I saw the child at C u »I en he was three months old. 
Her legs below the knee could be n an pula ed to any position, back- 
wards, forwards, or laterally, w bout p She could flex the legs com- 
pletely. No patella or distinct 1 gun e turn pat ll-e ould, after moat care- 
ful examination, bo discovered bv h u g o s to the hospital, or by my- 
self, in either knee, Subaequen ]y '^ \stle Cooper examined this 
child's knees, with the same result, but he assured the mother that her 
daughter would walk well after a few years, for he had seen a similar 
case, and the child ultimately walked well. lie had a drawing made of the 
patient by Canton in 18D6, with the feet, or one foot, turned upwards. 
It would be BU interesting drawing to obtain. I have explored the Col- 
lege coUection of the drawings bought of the late Mr. Bransby Cooper, but 



256 OK THE TKEEAPEUTIC 

I cannot find it there. This child came before nie a^aln trhen a) 
about twenty-two months old. I happened to see her in a f Bmi-houi 
thought it most extraordinary to meet with two such cases withi 
years; but it turned out to be the same child. Thnre were no patella! 
that time — not a rudiment to be felt; and I saw the child walking abc 
the room, bearing its weight upon the condyles o( the thigh-bones, witJi 
the legs turned forwards, the feet in the air, the soles of the feet present- 
ing directly upwards, and the child hugging one foot, and sucking one at 
its own great toes. The mother assured me that the cliild used to go to] 
sleep in that way. She could not stand upright by herself on her f< 
but moved about upon the posterior surface of the condyles of the thi' 
bones. I advised the parents to place forms around the room, so that 
might rest her hands upon them, and in that way begin to employ the K . 
as organs of support and progression. This plan was curried out, and tl 
child was not allowed to walk as hitherto, nor to pull her legs direct 
upwards towards the face, which she was very fond of doing. The h 
were from this time kept quite straight when in bed or lying doi 
When three and a half years old she had no patella, but at about f< 
years very small ones, like peas, manifested themselves, resting in a ru 
mentary ligamentum patellie, which Mr, Owen, of Finchinfield, then 
soon afterwards recognized." From that time she began to be safer 
her legs, and when she was about five years old she could walk, i 
ing herself by two short walking-sticks. Afterwards she walked 
ingly well, but not safely; for the legs used frequently to give way undtt 
her, and she would fall down. At between six and seven years of age I 
examined the patient. Site could walk uprightly, but not with perfect 
steadiness. Each patella was about the size of the rounded end of an 
adult's little finger, and Ijoth joints were very loose, and yielded to later"" 
displacement much more than they should have done naturally. She f 
mained at home until she was sixteen, and it was not until she was ten 
eleven years old that she appeared firm upon her legs. 1 saw her in Ji 
nary, ISG*^. She is short in stature, capable of walking any reasonable 
distance, and is upon her feet the greater part of the day. The patella 
are small, but well shaped and in good position; indeed, on looking at thtt 
knees, nothing peculiar presents itself, but she says that if she suddenly 
comes down upon her feet a little on one side, she is apt to full, I saw 
nothing peculiar in her manner of walking when in my room. 

Here is a case, then, where " mechanical rest " was the starting-point 
of the freedom of a patient from ulterior deformity. If she had been 
allowed to go on walking upon the condyles of the femur, it would have 
necessarily followed that the strung crucial and lateral ligaments, em- 
ployed to maintain the bones in their normal relation to each other, and 
to oppose inordinate muscular force, must have been so stretched that it 
would have been a matter of impossibility to render the joint serviceable 
iu maintaitiing the erect posture, or in aiding progression. 

It is worthy of remarlc bow long a time is required for the repair by 
anchylosis of serious or severe disease of the knee-joint; but we cannot 
be surprised at that circumstance when we recollect the large number of 
soft tissues which have first to be destroyed by disease, then absorbed by 

' A mdimentar; pat«tta hu bem notioed nt the third montli ; it remuna oaitQa- 
Klncms np to about tbe third fear, when oaaification Donimencei Dsnatl; by a Btngla 
DootetiH. To meet the increuiDg stnin upon tbe bone, OMiftcatiiui should be oomplett 
about pnberty.— [Ed.] ^M 



an 

m 



ISFLUEKCK OF EKST. 957 

Nature or dischu^cd bj oatural suppuration, in addition to the dense 
artimlar lamince of the bones iheniselves. It is true that in young per- 
sona repara,tion and growth are very active, so far, perhaps, fomtine a 
happy compensation for the frequency of disease of this joint at thai 
period; but it is impossible that all the articular structures can be difl- 
posed of, and bony anchylosis supervene, encepl by the lapse of a consid- 
erable length of time. Surgeons ought to intimate this to the friends of 
the young patient, so that the consequent delay in the cure may not take 
them by surprise. 

DUeaae of Khet-joint {SfrofttJtnia?) treated hy Mechatiical Rest; ctatd 
by Jinn Sony Consolidation. 

F. L was nine yeare of age when I saw him. His knee com- 
menced swelling without obWous cause and without much pain ; for a few 
days lotions and poultices were applied, and he was kept in bed. After 
two months of treatment, as he was not only 
not improving, but the pain, tenderness, and 
swelling were increasing, Mr. Robertson, of 
Chatham, brought him to me in March, 1&53. 



He was then wasted, and ii 



Y bad health ; 



he suffered from Iom of appetite and sleep, 
was generally feverish and thirsty, with a 
rapid pulse. The knee was a good speci- 
men of what might be termed scrofulous 
white swelling. All the tissues of the joint 
were swollen, soft, and yielding; heat of 
the joint increased; no redness of skin; some 
fluid within the joint; no rough pressure or 
movement of the joint could be borne; the 
knee was flexed, and could not be straight- 
ened without inducing extreme pain. Bis 
father had a portion of deal gouged out so 
as to make a deep trough, in which the child's 
leg was nlac«d. The edges of the trough 
were higher than the prominence of the pa- 
tella; the two long bones forming the joint 
were kept straight, and the edges of the 
splint prevented the bed-clothes from touch- 
ing the leg at night. Steady pressure upon 
the joint, by strapping it with soap plaster, 
and perfect rest to the joint by the splint, 
with attention to his general health, were 
continued during several months, when, find- 
ing the joint diminished in size, leas painful, _^^^ ^^^ _^^_^_^ _^_^ „ ^^ „ ,„^ „- 

and still slightly movable, a thick leathern "i«iMti«wt "" 

splint was made to embrace the upper two- 
thirds of the leg (the knee only laterally and posteriorly) and the lower 
half of the thigh, so as to oppose the flexors {the biceps especially), which 
were gradually and slowly displacing the tibia backwards and outwards. 
This leathern splint he wore nearly five years, the latter part of the time 
at night only. For sixteen months he was not allowed to make the 
slightest attempt to bear any weight upon his log. He was carried about 
iri the anns of liis mother, or placed in a little carriage, and drawn out 
17 




r 



Si58 ON THE THBRAPEUTIO 

daily when the we&ther permitted. Then be began to get about 
cautiously on crutches. His general health was very bad, but the knee 
wa» diminishing in siKe. From that time the limb became more sightlv 
and more usefuL He was taken into Wales to the seaside, and he hiul 
all the advantages that good air, domestic comfort, and extreme care agajiiat . 
injury coutd provide. After staying there some months he waa brougk^^C 
to town by sea, and I then saw him. There was obviously defined flucti^^| 
ation above the knee, as well aa in the popliteal re^on; the patella wtfm 
firmly hxed to the front of the femur, and the tibia was partly atiitei 
to the condyles. The absceases did not communicate with each other, «o 
lar as could be ascertained. His health was better than formerly, but he 
was still very feeble and delicate -looking. I thought it better to defer 
opening the abscesses, in consequence of his depressed health, and the repair 
of the joint not being as yet perfect. He returned by sea to Pembroke for the 
winter, and in a few months the popliteal abscess broke, and the one above 
the patella was opened by the surgeon as soon as the skin covering the ab- 
scess became very thin. The purulent discharge was not excessive, the walls 
of the abscess did not inflame, and the joint remained free from furtbeT im- 
plication. In the spring his health had much improved, and the discharge 
from the sinuses soon ceased. Finding he could bear some weight on his 
leg without pain, he took (with his crutches) a gradually increasing ex- 
tent of exercise during the next two years, when the crutcnes and leathern 
splint were put aside. He was tlien slightly lame in consequence of the 
knee being a little bent, and the leg below the knee not being quite so 
well developed as on the sound side. No doubt he had a long illness, but 
ultimately nis leg reached the condition represented in this drawing, 
which was made on the aoth of June, 1861. In April, 1861, the report 
respecting him is this: " He is now in bis nineteenth year, c-an take almost 
any amount of walking exercise, enters into tbe sports of his college, 
plavs at cricket, is strong, and pulls well in a boat. The knee is firmly 
ancnylosed, his general health excellent, and his lameness scarcely per- 
ceptible." By such careful but simple management, and tbe use of ''^ 
leathern splints (which he regards as a sort of trophy, and Miys faa 
Dever part with), he ultimately recovered. 

JHaeaaed Knee-joint, from It^ury, toith partial Caries or Ifucroaia 
(Ae PateUa; cured by Mechanical liest. 

The next case ia one of diseased knee-joint, depending upon, or 
wated with, necrosis of the patella. Surgeons will admit that disease of 
ibe interior of the knee-joint, connected with a necrosed or carious condi- 
tion of the patella, usually involves a considerable amount of risk to the 
joint. Of tiie few cases of this kind which 1 have seen, amputation has 
been required in order to save the patient's life in three instances. 

This young gentleman, J. H , aged six years, a highly slrumous 

lad, although of healthy parents, fell upon some pebbles or gravel, and 
struck his knee-joint, in the early part of May, 1857. He was afterwards 
■een by Mr. Lovell, of Chelmsford, who found the knee much inflamed, 
and directed that it should be kept quiet, and some spirit lotions applied 
to it. I saw him on the 17th of June, lgS7. He then had suppuration 
external to the knee-joint, and effusion of inflammatory fluid ijito the ' " 
terior of the joint. He had strumous ophthalmia, some ulcers upon 
cornea and at the margins of the eyelids, and his general health waa 
ccedingly bad. 



] 



] 



INPLUBNOE OF KE8T. 259 

Here was an important and serious complication of an external abscess 
connected with disease of the patella and eSusion into the interior of the 
knee-joint. There was no apparent fluctuation between these two oollec- 
tions of fluid, the one being externa], and the other internal. Having 
made out with Hufficient distinctness that they did not communicate, I 
opened the external abscess on the front of the joint, letting out between 
two and three ounces of unhealthy pus. I passed a probe carefully to- 
wards the patella, and there felt a necrosed or carious condition of the 

The removal of the fluid from the abscess rendered the fluctuation 
within the knee-joint more apparent, and the whole of the joint was hot, 
swollen, and painful, requiring great gentleness in moving the limb. A 
short, thick, leathern splint was applied to the back of the lower half of 
the thigh and upper half of the leg below the knee. The splint was worn 
day and night, with a small poultice to the wound. The general treat- 
ment consisted first of alkalies and bitters, and subsequently of steel wine 
and cod-liver oil, together with good diet and good air. He wore the 
splint uninterruptedly during eleven weeks. The abscess was slow in 
healing; exuberant granulations were projecting from the wound over the 
patella, suggesting the persistence of some deep-seated local irritation — 
probably unhealthy bone. These granulations were kept down to the 
skin-level by nitrate of silver. The pain, heat, fluctuation, swelling, and 
pufliness of the joint gradually subsided, and in a few more months he 
could walk about without difficulty, but with the joint still a little 
swollen. 

In March, 1858, he had a second fall upon the same knee, which 
brought on fresh subacute or chronic inflammatory action within the 
joint, associated with much constitutional disturbance. Soon after this 
period 1 saw him again; the knee had become flexed, and the tibia showed 
a tendency to become dislocated back~wards and outwards. An extended 
straight splint of thick leather was now employed, embracing the leg and 
thigh, so as absolutely to prevent flexion of tne joint or displacement of 
the tibia and fibula backwards, and to keep the whole joint at "rest," 
Horseshoe-shaped blisters were applied over the joint repeatedly, and this 
plan of blistering was continued until the end of June, when the local in- 
dications of mischief had much subsided; but there remained a general 
thickening, and some heat about the joint. He was taken to the sea-side, 
where be remained till the middle of October. At that time I again saw 
him. All the joint symptoms had nearly disappeared. The splint had 
been worn uninterruptedly; but from this time it was kept on at night 
only. From this period the use of the splint was gradually diminished, 
and moderate exercise, slowly increased, but always short of inducing pain 
or increased heat in the joint, was permitted. 

On March 17th, 1861, the surgeon says, "I have examined the knee 
to-day. He can do anything he IJkee with it, and can move it in any 
direction. There is no deformity of the joint. The patella is, perhaps, 
not quite so freely movable, in consequence of the scar of your lancet, 
half an inch in length, at the lower part of the patella, which remains, and 
Is the only vestige of former disease. This has ' puckered in ' the sur- 
rounding skin, and is adherent to the bond. He has been well these two 
years. He walked with his knee stiff for some time, but gradually got 
the free use of it. I look upon his recovery as an extraordmary one. I 
used to think if he got off with a stiff ^oint he would be very fortunate; 
for, if you remember, the head of the tibia was inclined to be displaced 



I 



260 ON TUB THEEAPEUTIO 

backwards. But here he 19, and to see him w&lk you would imap 

he never could have had the serious disease of the knee-joint he hod." 

This ]:iatient certainly did present the appearance of what is tern 
a. scrofulous and strumous constitution, as evidenced by his bad g«net 
health, enlarged glands in his neck, and ulceration of the cornea and ef 
lida. I might add to these facts by noting that the disease of the patel 
was brought on by a, comparatively aUght accident. Yet he is now ] ' 
foctly well. It is probable that small portions of carious bone may fa 
been extruded with the purulent discharge, but none have been seen. 

The next case to which 1 will allude is 



A Case of Traumatic Dislocation of the Tibia forwarda and t 
wards, treated by Jiest and tfte persistent Application of Void. 

It is to this latter circumstance I would take the liberty to direct yi 
©omest attention, because I feel certain, from experience, that we do 1 
make )>roper and sufficient use of the local application of cold in order'. 
prevent the occurrence of inflammation after local injury, or to subdue' 
when it may have supervened. 

On the patient's admission, October 30th, 1858, he was found to hal 
a fracture of the left radius at its middle third, and a dislocation of * 
left tibia forwards and outwards. There was an abnormal and marl 
prominence at the anterior and outer part of the left knee, caused by 
projection forward of the head of the tibia; the concavity of ita uw 
surface could be distinctly made out through the integuments, l 
patella and its ligament were inclined obliquely forwards, and the extern 
muscles were quite lax; upon the back of the limb could be seen and ft 
the two rounded prominences of the condyles of the femur, and the V 
dons of the flexors (especially the biceps) formed tense cords on the lati 
surfaces. Slight ecchymoais existed on the outer and lower parts of 
thigh, and the injured limb was somewhat shorter than the other. Chlo- 
roform having been administered, the muscles became relaxed; extension 
and counter-extension were effected upon the thigh and displaced tibia; 
i)y the employment of but little force the tibia returned into its right 
tion, accompanied by a slight snap, and the limb at once resumed its 1 
ral appearance. A common wooden splint was put upon the back of 
limb, reaching from the foot to the middle of the thigh. A bladder 
taining ice was constantly applied to the knee for seventeen days 
nights without intermission, m order to keep down the temperature i,. 
the knee, the result of which was that during this period no symptom of 
local inflammation was observed. On November 26th the patient had 
gone on so well that the splint was removed; but as it was found that «n 
unnatural extent of lateral movement could still be made to occur at the 
knee-joint, indicating defective crucial and lateral ligaments, the limb waa 
put up in a starch bandage. The patient suffered little or no pain in his 
knee, nor was there any constitutional disturbance, although the local in- 
jury to the interior of the joint must have been very severe. The only 
local application was ice; the only medicines, slight aperients occasionallr 
and ton grains of Dover's powder to procure sleep. He got quickly wr 

This man had dislocation of the tibia, and must have torn all the 
ternal and most of the external ligaments of the joint. During seventi 
days and nights the joint was never allowed to get warm, and he had 1 
a single bad symptom, except on one occaaioUj when, for the purpose 



Libta; 

nata^H 
ftUH 
ooM 
ana^^ 



ISFLUES^CK OF BEST. 261 

^Observation, the application of the ice w&s left off for & few hours, aiid 
then the joint b^an to get hot &nd painfuL 

Permit me to itdd another case ulustrstive of the good effeci of the 
local application of cold in preventing the occurrence of inilauimation 
after a wound in the knee-joint. 

A young man came into Guy's having received, a few hoursbefore, an 
incised wound, uearlj- three inches long, penetrating into the anterior and 
outer part of his kiiee-joint. The Huib was put upon a long straight 
wooden spiiut, and, thus supported, the foot and knee were elevated, 80 
an to relax the extensors and facilitate the return of venous blood from 
the limb. The coarse edges of the wound were nicely adjusted by fine 
superficial sutures, and the only local application was iced water by irri- 
gation, by dropping cold water during twenty-three or twenty four days 
and niehts. The patient had not one bad symptom, except wten we took 
away the cold irrigation by way of experiment, and then he began almost 
immediately to experience pain, heat, and more swelUng wtthtn the joint. 
Ho finally got perfectly well, the joint completely recovering itself with- 
out permauent defect or injury of any kind. 

1 cite these two cases, l>ut I could add many more, in order to prove 
the right value of the local application of cold as a most potent, and 
therefore valuable, agent in preventing or controlling infiammation after 
traumatic injury. The cold should be applied with a spirit of defiance t« 
the mfiammatory condition, and a fixed determination not to permit its 
occurrence. I feel confident, from what I have seen in private and hospi- 
tal practice, that if we could only make proper use of cold locally in cases 
of accident or injury, and employ it efficiently — that is, continuously and 
of sufficiently low temperature to keep the injured part cool, or free from 
heat — we should find it eminently serviceable. This 1 do know, that the 
way in in which we now apply cold lotions is absolutely ridiculous, and 
often futile. If you order a cold lotion to be applied to the seat of local 
injury for the purpose of keeping down the temperature of the part, in 
ten minutes it becomes warm, and so it continues till the nurse chooses to 
renew its application. By this method of proceeding the true advantage 
to be derived from cold cannot be obtained. Cold applied locally is a 
most potent remedy, acting powerfully and vigorously upon the nervous sys- 
tem, as well as upon the capillary and larger blood-vessels, and 1 must add 
that, as a rule, it is moat unpbyaiologicaUy and feebly employed in this 
country.* 

1 have here a case of traumatic injury to the knee-joint, on which I 
must dwell for a few minutes. 

Jxicerated and contused Wound laying open the Kne^oint; Suj^ura- 
tion viithin and around the Joiii/,; Portions of the Ariieuiar 
Surface of the Hones extruded; Anchylosis of the Joint; Livtb 
fixed in a good position by the aid of a firm wooden iSplitU, to 
insure for it Mechanical Rest. 

William K , engineer, aged eighteen, a strong healthy-looking 

youth, whose leg had been caught in the machinery of a steamer near 
Dover, was admitted into Guy's Hospital on October 28th, 1861 (sixteen 
hours after the accident), with an extensive lacerated and bruised wound 

ti the oae of oold In enigerj referred 



h 



over the inner condyle of the left femur. Some portion of tlie inte^B*i 
ment had been partially torn off. The wound passed under the intega- 
ment into the interior of the knee-joint. The edges of the wound 
brouj(ht together by pins and flgure-of-B suture; the limb w 
flexed; ice was constantly applied over the whole of the joint, 
.swollen and hot. Low diet was ordered, and aperients admintBt 

October 29th. — The Icnee is v«ry much swollen, and, in spito of 
oontinued application of lai^ hagm of ice, ita temperature continues 
high. Bowels oj)ened; pulse 90 to 100. 

30th. — The joint is very hot and painful, with mueb effusion within 
Patient gets no sleep. Pulse 90, full; tongue furred. Pins taJcen 
wound suppurating. Two grains of opium ut night. 

31st.— Patient la flushed; pulse 100, full. Ice to be discontinued, ai 
»arra poppy fomentations applied to the knee, and the limb to be 
placed on a splint. The bowels being costive, aperients were ordered. 

November 3nd. — He is much quieter; the pain is lessened. There is 
discharge of much healthy pus frojn the wound. Slept four hours during 
the nignt; bowels opened; pulse 90, Ordered full diet. Listoit's splint 
applied. 

7th. — Patient is comfortable. The discharge is purulent and profuse. 
Appetite pretty good. 

11th, — Much inflammatory suppuration around the joint; itKusiona 
were made above and below the joint to give exit thereto. Ordered 

2^nd. — Suppuration is eitreme, both from within the joint and from 
the soft parts without. Patient ia rapidly emaciating. Several pieces of 
bone have come away, one of them having a distinct portion of ■rticolab- 
ing surface upon it, 

38th. — Patient does not sleep well, and is getting thinner. Ordered 
opium every night, 

December lat. — The joint seems thoroughly disorganized. It is bein^ 
Straightened gradusily upon a wooden splint. 

4lh. — Much difficulty is experienced in retaining the limb in a proper 
position, owing to the tendency oi the tibia to be dislocated backwards 
uid outwards. 

loth. — It has been neoessary to "put up" the limb afresh evajy two 
or three days. Dislocation of the tibia is with much difiBculty prevented. 
The plan now adopted seems to answer the purpose, Liston's back spl)' 
ia applied behind, a short splint on the inner side of the thigh, and alo 
■plint (interrupted opposite the knee), extending from the foot to the 

fit, on the outer side of the limb. The discharge is much diminishi 
&tient feeds and sleeps well; pulse SO. 

January 5th, 1862. — Lately there has been an increasing tendency in 
the tibia to be displaced outwards. Small sand-pads carefully applied 
av6r the head of the fibula and bandaged in position, with a short epHnt 
over them and the long inside splint, have counteracted this teudenoj. 
Patient's condition is improving; the discharge is very slight. 

17th. — The knee is in good position. There is a smult Buperfi< 
slough at the outer side of the foot, resulting from the pressure of 
splint upon it. 

26th. — Wound in the knee nearly healed; foot nearly well. 

February 18th. — After four months' rest, the joint seems pretty lii 
anchylosed; no pain in it. The patella ia fixed to the femur; the joint 
returning to its natural siie. 






splint 
enoj. ^^ 

irnilH 
int^H 



IKFLUENCE OF BEST. 263 

March 3rd. — With the exception of an attack of erysipelas near the 
knee, wliich fortunately did not aftcct the new repairing' structures, noth- 
ing untoward has happened to this patient, who may now be said to be 
well. The left leg is nearly an inch shorter than the right. This patient 
left the hospital with a short wooden splint upon the back of the knee, 
and supporting hia weight upon cmtclies. 

Soon after leaving Guy's he fell, and struck and twisted his anchylosed 
knee. He came again under my care, with pain, heat, and swelling of 
the knee. A splint was applied to the back of the limb, which was ele- 
vated, and ice was constantly applied to the knee, so as to destroy the ck- 
cess of heat. With these simple means, and rest upon the bed during a 
month, his knee became free from pain, heat, and swelling; and he again 
quitted the hospital, capable of bearing some weight upon the limb. 

This case does my dresser, Mr, Sergeant, great credit. The patient at 
one time was desperately ill, and if I had been at all disposed to cut off a 
limb, 1 should have seized that occasion as an opportu- 
nity for doing it; but 1 rather preferred watching and 
admiring the surgical elTorta of Nature than any effects 
of my own interference, and here is a representation of 
the result. The great diificulty in this case was to pre- 
vent displacement of the tibia from the femur. My 
dresser, Mr. Sergeant, successfully resisted that ten- 
dency by the application of splints, and it does him 
great credit. Here (Fig. 93) is a sketch of the man's 
limb. The bones are firmly united to each other, and 
there is no displacement of the tibia laterally or posteri- 
orly. The biceps was our great opponent, and I threat- 
ened to out its tendon asunder; but thinking we might 
beat it without any cutting, we applied a small firm bag 
of sand over the head of the fibula &nd under the side 
splint, so as to press the tibia inwards, and it succeeded. 
I verily believe that if the dresser and house surgeon 
had not been absolutely determined that displacement 
of the tibia should not ocour either backwards or later- 
ally, this man would have had a very deformed and 
almost useless limb, but he now has one that scarcely 
offends the eye at all, and which will be a very useful 
member both for support and progression. 

I venture to append this further remark: I feel 
quite confident that provided surgeons will adopt and 
follow out with inflexible determination this plan of 
securing " mechanical rest " to inflamed and suppurating 
joints, they will very seldom see much deformity in such 
cases, and very rarely be required to excise the joint i 

Injury to the medium of union between the shaft and lower epiphysis 
of the femur is not very rare; from what I have seen in public and privattt 
practice, I think that it is a pathological condition not unfrequently over- 
looked, the local symptoms being misinterpreted. Any injury to tne epi- 
physis itself, or to the soft tissue uniting it to the shaft of the thigh- 
bone, requires the aid of mechaoioal rest for its relief or cutej and here 
is a cose in point. 




r amputate the 



OH THE Tilt 



Diaetim betteeen the Sftqft and Lo«>er ^iph;/ns of the Finutr- 
puration; Abacesses open&l; t-uml by lieat. 

Funny H , apeil ten years, was aiimitted into one of ray vrards an 

April 13lh, 1859. M'hen three years old she had a fall over the end of a 
lied, which stunned her. When taken up she could not put her ri^ht 
foot to the ground; and the knee became flexed, so that the great toe was 
two or tJiree iiichea from the ground. In a short time, however slie 
became much improved; but her father noticed a slight weakness in her 
walking. On April 21«t her right leg was very slightly shortened aav a 
ijuarter of an inch ; the knee-joint could be neither extended nor flexed per- 
fectly. There was pain on pressing a spot one inch above the knee-joint 
both on its outer and inner side; the temperature was much iticre«sed at 
both points, and some swelling existed there. The upper part of t he pop- 
liteal spaue was hard, full, hot, and tense; with pain at intervals occiirritig 
twice or thrice a day, and lasting about ten minutes, A long straight 
splint was put on the limb, extending from the axilla to the foot; she 
was ordered one grain of iodide of potassium with infusion of bark three 
times a day, and poppy fomentations to the swollen part, 

April 23rd. — The long splint could not be borne, and it was removed. 

27th, — No improvement. The patient silvers very much. The limb 
was then placed upon a double inelined iron splint, and swung. Six 
leeches applied upon each side of the knee. Two grains of mercurj- with 
(ihalk and three grains of Dover's powderto be taken night and rooming, 
and some saline febrifuge during the day. A hemlock poultice was 
applied over the painful part. 

ililay 0th. — There is distinct fluctuation of an abscess to be felt under 
the vf^us intemus, anterior to the tendon of the adductor magnus, 
An opening was made through the skin and facia lata with a lancet ; a 
grooved director was then pushed through the vastus intemus, and formed 
a guide to the dressing forceps, which were thus introduced into thfl!^ 
abscess, from which about two ounces of healthy pus quickly flowed. 

Juno 7th. — A deep sub-muscular abscess was opened on the outer a 
nt the knee, and sixteen days subsequently another opened of itself in 
|>opliteaI space. 

July 20th. — The leg has been at rest, swinging upon the iron splii 
and the knee can now bo perfectly straightened without paiti. There 
no distinct swelling, but a little general thickening of the lower part 
the femur immediately above the knee-joint. The wounds have all cloa 
The iron splint is to be left ofT, and a firm leathern splint is to be appli 
GO as to keep the limb straight and the seat of disease undisturbed. 

This mechanical support was continued through several weeks, and 
that, and for a longer period, she was not allowed to put the foot 
to the ground in order to bear any weight upon it. She ultimately got 
quite well, without any untoward symptom. 

I have no doubt that this was a case of disease between the slmft and 
epiphysis of the femur, resulting from injury and inflammation of the soft 
medium of union between these two portions of the bone. Disease of this 
]iart is not, I think, often referred to, but I am convinced that it is not ol 
unfrequent occurrence. 

1 am anxious to impress upon the profession generally my strong 
iction that in all coses of accidental injury or inflammation of the ki 




L'lla 



•ery disease of this articulation, the knee should 



I 



INPLTTENCE OF EEST. 



265 



kept uni'ntemiptedly at rest and straight, until its reparation is c( 
I believe that as soon as suffipient importance lb given to such views wo 
shall cease to witness those numerous and extraordinary deformities 
about the knee-Joint, resulting entirely from the want of mc-i'hanical 
resistance to that muscular force, which causes so often dislocation of the 
tibia and fibula outwards and backwards, of which you may find so many 
sjx-ciniens in the metropolitan and other pathological museums. A fixed 
' rigid splint will certainly prevent such defonnities — I feel positive about 
it — provided the splint be sufficiently resisting. A gutta-percha splint 
will nL>t accomplish it, not being sufficiently strong. A firm, padded 
splint of leather, wood, or iron ought to be placed along the posterior 
and la.eral part of the joint ; and I may add that in all such cases it is 
advisable that the limb be swung, as in cases of fractures of the leg. 
During many years I have swung nearly ail my cases of acute disease of 
the kree-joint, and I have found it contribute immensely to the comfort 
of the patient. 

He-e are two or three cases in illustration of the deformity which 
ensues from the non-employment of mechanical resistance, to disturbing 
muscuar force, and the method of proceeding to be adopted in order to 
remedj the deformity which may have occurred. 

Case (f diseased Knee-joint; tlte Knee Jkxed, and the Tibia partially 
do/ocated backtoards ; the Biceps Tendon divided, and the Limb 

altuit/htened ; cured by Mechanical Rest. 

A jDung -woman, 3. M , when she was two years old, had a fall 

upon mr right knee, and sneered a.fterwards from symptoms of acute 
irillamnalion of the joint, followed by contraction of the ham-string mus- 
cles, anl extreme llexion of the knee. Two abscesses, one in the popliteal 
region, ind one above the knee, were associated with this diseased joint. 
She ws not able to walk without crutches after the accident ; very 
tnooDvelient instruments were employed for the purpose of putting the 
leg straVht, and she thinks she received more harm than good from their 
applicatbn. On March 29th, 1860, she came under my care in Guy's 
Hospital; she was then eighteen years old. When standing upon the 
left leg, he heel of the right foot was between four and five inches above 
the grouid. The patella was fixed firmly by bone to the femur. Chloro- 
form havng been given, forcible extension was employed, but we could 
not atrai;hten the limb ; the tendon of the biceps muscle was therefore 
divided wont one inch above the head of the fibula ; forcible extension 
of the hee was continued, and the limb straightened, after which a 
straight wooden splint was applied to the limb upon its posterior aspect. 
After theoperation, ice in a bag was constantly applied to the knee, in 
order to [revent the occurrence of any inflammation, and fivt 



Dover's 



S"^ 



^ ordered to be taken at night. On the 13th of 



April, witin a fortnight of the forcible extension, her leg was straight, 
and very omfortable. The splint was constantly applied until May 31st, 
and here i the final result. This drawing (Fig. 93) was made in January, 
I'&Syi, andiccurately represents her present condition. You will observe 
that the guund-plans of this patient s feet present some notable peculiari- 
ties ; the ight foot is altogether smaller than the left, and its outer por- 
tion is Imtimperfectly developed, whilst the groat toe is exceedingly pro- 
longed, lis, I apprehend, is owing- to the period of life at whicli this 
was a conjaratively useless foot. The great toe has, however, grown 



268 ON THE TJIEBAPEUTIC 

most extraordinarily since alie has been using the limb. Von may remeni- j 
ber th&t on a previous occasion (Lecture Xlll.J I romiDded you that w« J 
might divide the foot, attatomically and physiologicalty, into two longitU' I 
dinat parts — into the outer or strong part, and the inner or more ela9tift| 
part, connected, structurally and functionally, with the more adv&oced 
period of life, when the foot is required to be in a state of perfection, 
seems tbat this patient formerly used her right foot scarcely at all, and il 
did not grow with the other foot ; but soon after the biceps tendon wta 
divided, and the foot came into active use, the growth of the foot has been 
something marvellous, and especially on its inner side ; hence the protoii- 
gatiouof the great toe seen in the ground-plan. The patient is uovsboul 





k 



twenty yean old, and can take a considerable amount of exercie without J 
difficulty. 

In tnis case I did not find it necessary to divide the tend-ns of 
semi-tendinosus or the se mi-mem bran osus muscles ; these, afte* the d 
sion of the biceps, yielded to the influence of extension. 

Before operating upon the tendon of the biceps muscle, it ii necessary 
to bear in mind, and to ascertain, the exact position of the exernsl pop- 
liteal nerve. Previous to the administration of the chlorofom, there u 
usually no difficulty in distinguishing the real characters of the tense 
cords which you may feel passing along the tightened part d the pop- 
liteal region, as we see it when the knee is much bent from jid disease 
of the joint. The nerve may theu be recognized by the pan which is 
induced when pressure is made upon it. Its course being ascrtained, the 
other cords must be the tendons ; and further than that, as f r as I have 
observed, upon closelv examining the parts, you may trace tb individtuU 
tendons up towards their respective muscles, and so identify hem. ■ 



INFLCKSCB OF BEST. 



OUI-diteoMd Siteg'Joint ; Shee bent; TVtia ditplaaedbatJaearda; Flexor 
Tfndoiis dipided; treated by "MecAanicai Sett." 

Martha M , aged fourteen, was admitted into Guy's Hospital, under 

my care, in January, I860, suffering from the effects of old-diseased right 
knee-joint. The tibia waa drawn backwards and upwards, so that she 
oould only just touch the ground with the great toe by inclining the pel- 
vis to that side. .\t five years old, when quite healthy, she had her kne« 
struck by a little hammer; and it becajne chronically inflamed. She had 
no splints; and although she waa under constant professional treatment, 
she continued to gi?t worse during two years, when she was taken to a 
London hospital, with advanced disease m the knee-joint. She remained 
there seventeen weelcs in bed, and during the latter part of the time she 
liad scarlatina severely. A gutta-percha support was applied to the knee, 
yet the knee became more and more flexed, so as to form nearly an acute 
angle with the posterior part of the thigh. The bending oi the joint 
chiefly occurred during the time she had scarlatina. The surgeon proposed 
to amputate the leg as soon as the health of the patient became good 
enough, but the parents would not entertain that question; so she was 
allowed to get about at home on crutches up to the time of her admission 
into Guy's, with the right leg useless, because the kueo was flexed and 
the tibia displaced backwards, the condyles of the femur projecting for- 
wards. The patella was firmly anchylosed in a good position upon the 
condyles of the femur; the tibia was movable upon the femur to a slight 
extent, with membranous anchylosis between the tibia and femur. Chlo- 
roform having been administered, the leg was extended, and the tendons 
of the biceps, semi-tendinoaus, semi-membranosus, and gracilis were di- 
vided. The leg was forcibly drawn first downwards and then forwards, so 
as to overcome or correct the deformity resulting from the displacement 
of the tibia backwards. In this we were only partially successful, although 
some tearing of the tissues was heard during our efforts at extension. 
The limb was then bandaged upon a straight splint; the tibia, however, 
oould not be brought to its proper position as regards the femur. In ten 
days another splint was applied, with a screw attached to it, so that the 
knee could be gradually extended and the tibia advanced until the limb 
was nearly in its preseiit condition. She left the hospital eighteen weeks 
after admission, with the screw splint upon the leg. As soon as it waa 
found that the Hmb could be maintained in that improved position by the 
patient, a common leathern sjilintwas apjplied toit, for the purpose of sup- 
porting and defending the joint. This leathern splint was worn day and 
night for fourteen months, during which time she has walked more or less 



on the latne leg, gradually increasing the distance, and going to school 
'lily, with her health improving. 

Feb. 7th, 1SG2. — She can walk two miles without pain or much fatigue 



in the leg; do heat or swelling in the knee. The right leg, properly 
measured, is quite an inch and a quarter shorter than the loft leg; but the 
pelvis is inclined to the right side, and the spine somewhat curved, thus 
compensating for the shortening of the right limb, so that when she walks 
she scarcely appears lame. The right half of the pelvis is half an inch 
less in circumference than the left. Here is a sketch of the actual state 
of the patient, and ground-plans of the soles of her feet, clearly indicating 
a defective development in the right foot as compared with the left. 

These are cases, I think, which maintain the conclusion that "physio- 
logical rest " (by division of tendons) is an important agent to be employed 



THERAPEUTIC 



ill correcting some of the dcformitiea uf diseased knee-joints. The defor 
mities, however, might as surely be prevented by the application of splia 
in the enrly part of tlieir treatment, 

1 had intended, if time had permitted, to adduce some factstending tl 
prove that one kind of loose cartilage may be absorbed from the knea 





joint, by retaining the loose cartilage accurately at rest in contact w 
the same part of the synovial membrane during several weeks, and c 
ploying counter-irritation over it at the same time.* 

* Id a clinical lecture on looBe cartilages in the kDeo-ialnt. poblished in tbe Onj^ 
Hospital Reports (or 1808, Mr. Hilton gives several oaHea id wbioh a loose carlilag* 
gradually disappeiued when kept Qied by strapping, so as to be pressed firmly against 
the synovial membrane. He concluduH by saying. '' Synovial membrane is menaly a 
modi&oatioii oF serous merabrane, and aa such ia endowed with seureting and abaorbmg 
powers. Yon must use thie latter function in order to get rid of the important dineaae 
which is now occupying oar attention. How is fluid in a joint absorbedt By the 
Bynovial membrane only, and by no othei means. With clot in a knee-joint would yon 
open that joint ? Certainly noL The oloU of blood will iuidoDbt«<Ity be abaorbed. 
Recogniie, then, this absorbent power of synovial membTanes. and use it in the oai« 
ol loose cartilage." For a mention of two other cases treated with complete bucoqib, 
see a short bot iutercKtiug paper by Mr. Munby in the Birmingham Med. Iteviem 
Jnly, 1875.— IED.J 



ungham Med. ltevieiK|^H 



lirpLCBNCli OF B£ 



LECTURE XVlll. 

._ n of both Elbow -ioints; Joints well Anohjloaed, but in b*d P 

— TKsease of Uie Wrint caned bj Beat — Cose of Itiiptnre of tho Ligamentom Pk- 
tcllK ftt the Junction of the Ligsment with the PklelUt — DisMae of the Cuboid 
and Oh Colcia; Diseased Bose lemoTed -. New Bone formed; Curs uded bj- 
" Mechanicnl B«aC " — Diseaae of the Os Culnie; Bone remored; Boce renewed 
^-Disease of the Epiphjuig of the Os Cilcia— IMstribution of Third «ud Konrth 
CerWc^ and Pint Dornal Xerres to Upper Portion of the Chest — Disease of Right 
&t«Rio-claTicaliu Joints cured by R«b — Suppuration in Left Stemo-clmTioalar 
Joiot, opened by Ulceration, cured by Heat — Disease of Right St«mo-olatiiMlar 
Joint, produced by Foriable Traction; Death from Pjieniia — Disease between 
First and Second PonEons of the Stemnm. cutod by Rest — Effect of Miuontu' 
E^atwtion on the Joints of the Foot — InflamtuatioQ of Right Aukle^joinl and 
Foot; Suppuration; Dislocation of the Foot; Cured by Rest — Injnry to Soft 
Structure uniting Shaft of the Tibia to Its Lower Epiphysks; Oatitia ; i^ub-porioa- 
teal Suppuration ; Death in TweNe Days — ConctnaiDn. 

Ix a previous lecture I mentioned that, although some diseased joints 
may occur in persons of a scrofulous constitution, it does not necessarily 
follow that the joints cannot repair themselves by time and opportunity. 
Here is a drawing (Fig. 97) which will portray such joints, 

Sirumotts Disease of both Elhoie-joinlit ; JoinU leetl anchytosed, but m 
bad Positions. 

This drawing from nature represents another instance of anchylosis 
of both elbow-jointa, occurring in ' ' 
In spite of this the eibow-joints 
are perfectly anchylosed — anchy- 
loHed, however, in a very unfortu- 
nate position, because he could 
not feed himself except by bend- 
ing the head towards the left hand, 
nor could ho dress himself or make 
any important use of his arms. 

The following is a brief ref- 
erence to this case:— W. S 

was fourteen years of age when 
he became, some years ago, an 
in-patient of mine at Guy's Hos- 
pital. His mother stated that he 
was always an unhealthy child, 
and that when four years old he 
hftd small-pox, followed bv what 
the doctors called " scrofular ab- 
scesses," Disease began simulta- 
neously in both elbow-joints. No 
splints were applied in order to 
determine the direction of the forearms, which 
the position represented 



1 termed a scrofulous youth. 




■n graying. 



our THB THKlt APBtrno 



370 

had been removed at different periods from both joints. There was d 
pain in either joint, but aome thickening remained in the surrounding 
soft structures. By passing a probe into the opening of a sinus seen upon 
the right elbow, loose pieces of bone could be detected. 

Although a markedly scrofulous constitution was manifest in thia j 
tient, yet in both joints anchylosis had been accomplished. 

These two drawings (Figs. 98 and 90) show the hand and forearm 
a young girl, aged eighteen, who came under my care in 1852, with ex' 
tensive disease of the carpus and wrist- joint of the right side. The caiuff 
of the disease was not known. Suppuration amongst the bones had 
occurred, leaving several discharging sinuses both on the anterior and 
posterior aspect of the wrist. It was very painful, and the bone-s could 
be made to grate upon each other: a probe detected denuded bone. An 
hospital surgeon, seeing no probability of saving the arm, had arranged 
to amputate it in a day or two; but, before doing so, I was consulted, 
and, as the girl was in tolerable health, I advised her not to submit to the 
operation. A leathern splint was moulded upon her hand and arm, so u 
to keep the wrist absolutely at rest. This splint was worn day and night 
during several months, and she was sent to Margate to reside. The pain 
and discharge soon diminished, the sinuses closed, and she got well aa 
regards the wrist, except that the wrist-joint was anchylosed, so that she 
could not bend it, but she could move 
herlingersand thumb with great freedom 
in 1853, and her condition at that time 
is represented roughly in the drawings. 
The dark patches seen upon both the 
anterior and posterior aspect of the 
wrist indicate the sites of the former 
sinuses, now closed; the skin is healthy 
and movable upon the subjacent struo- 

The following is another itluBtrative 
case, with a rather curious history; — 
r saw a lady four or live years ago who 
came to me with disease in some of tba 
carpal bones. Bhe had had a ganglSi 
on the back of her hand over the — '■ 
and she went to a surgeon to hi 
cured. He proposed to nipture it 
striking it with a hard leatnem-bound 
book, but his arm was not very steady. 
He tried several times to break or burst 
thia ganglion, by striking it with th« 
___ __ ^__^ ^ back of the book, but he cogld not suo- 

ceed. At length, however, he gave her 
hand a tremendous blow with a larger book, which ruptured tne gan- 
glion, but the blow led to inflammation amongst the carpal joints. This 
resulted in suppuration with disease of the carpus, and the proposal 
of amputation of the forearm. It was then that 1 saw this lady for the 
first time, with a painful and swollen wrist and hand. Two sinuaea were 
discharging pus, and a. probe introduced into them came in contact with 
bare bone. A leathern splint was moulded upon the hand and forearm, 
BO as to secure perfect rest to the wrist. No more probing of the wound 
was permitted. She went to Margate, and remained there during several 



1 




tba 



INFLUENCE OF REST. 

months: the sinuses closed, and althougb the wrist is stiff, yet she has a. 
very useful hand. 
I These are the only references I shall have time to make to disease of 

the elbow-joint and carpus cured by " rest." But these will be sufGaient 
to intimate the value of " rest " as a therapeutic agent in their treat- 
ment. 

There is, perhaps, no part of the human body in which the bene6ciai 
influence of mechanical rest can be established so perfectly, in so many 
different ways, and in relation to so many different accidental lesions, as 
' the neighborhood of the knee-joint; so that I could easily extend this 
I subject over two or three lectures, with appropriate illustrative eases; bat 
I the only one to which I will now briefly allude is one of forcible separa- 
tion of the ligamentum patelUe from the patella. This is a comparatively 
rare accident, and it requires to be treated by absolute rest to the leg; 
to elevate the leg and foot so as to relax the extensor muscles lying upon 
the thigh, and at the same time to employ strips of plaster, horseshoe- 
I shaped, to pull the patella downwards towards the detached ligamentum 
patellie. A case of this kind was admitted under my oare at Guy's Hos- 
I pit&l. 

Case of Rupture of the Ligamentum PaleUoB at the Junction (^ the 
Jjigament leith the Patella. 

Robert B , aged forty, was admitted into Cornelius ward on the 

12tb of October, 1861, with a good deal of swelling and eochymosis over 
the whole of the knee-joint, and complete inability to lift the leg. The 
account he gave of the accident was, that he was standing on a plank 
which was suddenly tipped up, and his heel became fixed in a deep groove 
in the plank. He was thrown with rapidity first forwards and then back- 
wards with great force, whilst his leg was bent under him. He felt 
something give way at the knee, and from that time he lost the power over 
his leg. When placed in bed, the patella was found entire, drawn upwards, 
and unnaturally movable, especially in the long axis of the limb. There 
was a strongly marked depression immediat^y below the apex of the 
patella, into which the finger could be thrust almost to the joint, so that 
the condyles of the femur could be easily felt ; the lower end of the patella 
could be directed backwards to a great extent, or could be tilted forwards 
by pressure on its upper edge so as to project the apex under the skin. The 
limb was extended upon a straight back splint, and placed in an elevated 
position, so as to relax the extensors of the knee-joint. A lead lotion was 
applied over the whole of the joint. When the general swelling had sub- 
sided, two long pieces of strapping were applied, crossing one another 
above the patella, so as to draw it downwards, and to keep its apex near 
the upper part of the ligamentum patellae. 

November I7th.— The patient was allowed to get up, with a short 
splint extending along the back of th« thigh andleg, so as to keep the 
joint at rest, and to prevent traction upon the ligament. 

23rd. — He left the hospital by his own desire, cured so far only that 
the configuration of the joint was nearly normal, except some fulness, and 
tenderness on pressure at the junction of the patella with the ligament; 
and as yet he had not the power to lift the hmb by his own efforts. Ho 
was ordered to continue the use o£ the short back splint, and to got about 

I oa crutches. 

^^_On quitting the hospital, although the anion of the patella to its liga- 



372 



OK THB IHEBAFBUTIO 



Dictit was tolerably good, yet it was not at all equal in strength and firti 
ness to what the patient required of it. He x-entured to walk about «* 
great deal too much upon it, and he soon came back to the hospital with 
the parts inflanied and swollen. Raring remained in the hospital at raat 
upon his bed for a short time, he went out again much improved, with the 
intimation from me that it would take at least six mouths before the re- 
pair would be complete. 

In a former lecture (Leet. Xlfl.) I adduced several arguments and 
many facts against scrofula being as frequently the caume of discaaea in 
the bones and joints as accidental and local injury. On« of the fads 
which 1 adduced in support of that opinion was, that in diseases of tbetai^ 
sus the cuboid bone and the os calois are more frequently affected thananj 
other. Almost all the weight aeema to concentrate itself upnn the out«r 
part of the foot; and I apprehend these are some of the reasons why dia- 
ease of the tarsus occurs so frequeii tly on the outer side. It receiTea mon 
of the weight of the body, and is thus rendered liable to all acdd^ita 
associated with that early and indiscreet period of life and of unmeasured 
rxerciae — childhood. Now, to give rest to the tarsus it is necessary that 
the foot should be elevated and freed from any pressure. I may now 
place this subject practically before you by referring to a case. 



Case of Diaeate of the Citboid atid Os Culcis ; Diseaaed Bone 

New Bone formed ; Cure aidrd by "Merliimical Rest." % 

On April 3nd, 1836, a gentleman brought bis son to my house euffei^ 
ing from disease of the tarsal bones of his right foot. He had been 
several months under professional treatment, having abundance of medi- 
cino, but allowed to get about at home as well as he could, without giving 
any decided rest to the foot. The cause of the disease was supposed to be 
scrofula, brought on by over-exertion, with possibly local injury. When 
I saw this young gentleman he was eleven years old; not very unhealthy 
in appearance, but presenting florid cheeks, thick lips, feeble pulse, cola. 
hands and feet, and enlarged tonsils. The whole of the right foot ^ 
swollen, especially the outer side corresponding with its tarsal and 
tarsal portions. Ulceration, the sequel to an abscess which had 
of itself, existed for about one square inch over the cuboid and its arttcQi 
lations with the os calcis and the two outer metatarsal bones. The sur- 
rounding and overlapping akin was dark and congested. PoulticeB had 
been continued up to the time of my seeing him. On passing & probe 
into the wound, bone denuded of periosteum was at once detected, but he 
would not allow of a close examination of the part; and, as the foot wu 
swollen and inflamed, I thought it better to send him home to Hammer- 
smith, and place him on his bed with his foot and leg elevated, so aa to 
get rid of their congested state. 

I saw him again at hia home on the 21st of April. His foot had 
come much smaller and less painful; he had more sleep at night, 
Buffered less pain ; he was already improved by "rest." I might extei 
my remarks with respect to the deyation of a limb suffering from a ■' 
of congestion. It is at least an important point in treatment, wl 
appears to be not sufficiently attended to in practice. 

After inhaling chloroform (for he would not allow me to touch 
otherwise), I explored the wound; and finding the cuboid necrosed 
carious, with disease of its articulations with the os i-alcis, I removed 
loose pieces of bone, leaving the periosteum and the whole of the 



e, cold^^ 
ot w^^^l 

ipeneq^l 
irticoi^^ 



INFLUEHOB OF BEST. 

rounding opaque Goft vascular structures undisturbed. The whole of the 
cubuid bone and a portion of the os calcia were removed. The excava- 
tion was large and deep. He was kept in bed, with his leg raised, until 
May 9th (tive weeks), when his knee was placed upon a wooden leg, with 
a horizontal rest for his leg, and a. footpieco of leather (an important 
adiUtion to this kind of apparatus), to prevent any accidental injury or 
disturbance to the foot itself. Two months after nis first visit to me I 
saw him at my house on his way to Margate, much improved both as 
reifards his health and his foot : the wound was quiet, and disposed to 
close. He had his crutches and wooden leg, which he was to use at all 
times when moving about, under the supervision of his careful and anxious 
mother, who was dotingly fond of him, and much alarmed at her son hav- 
ing been thought scrofulous. Iodide of lead ointment was to be applied 
lo the feeble wound, and over that a pad of cotton wool. He remained 
at Margate until the end of September, 18oK. During his stay there, sup- 
puration and ulceration occurred in the sole of the foot, opposite the dis- 
eased bones of the dorsum of the foot. He came to me on the 7th ot 
October, 18515, at the end of six montlis. The ulceration on the dorsum 
of his foot waa nearly closed, but there waa still some discharge from the 
sinus in the sole. Direct pressure made over the site of the cuboid, or 
through the fourth and fifth metatarsal bones, gave bim some pain, and he 
could not then bear any weight upon t}ie foot. He continued to use his 
crutches and artificial leg for a year, until April, 1857, when all the parts 
were healed, with some depression and adhesion of the skin upon the dor- 
sum of the foot over the cuboid. He was then allowed to take careful and 
well-watched exercise in walking, and he got quite well in every respect, 
although he waa thought to be scrofulous. 

Here was a case, then, of disease of the cuboid bone and anterior part 
of the o3 calcis undoubtedly relieved through the medium of "mechanical 

In the summer o( 1859, whilst in a state of somnambulism, he jumped 
out of his bedroom window, a distance of nearly twenty feet, upon some 
soft grass in front of the area of the house, where ho was found by hia 
father, the marks of both feet being well seen on the ground where he had 
alighted. His foot suffered no harm beyond a severe strain. He was a 
good deal shaken by the leap, and was confined to his bed, but soon re- 
covered, and has been well ever since. At my request this patient, with 
his father, called on me in March, 1801, and 1 
took this note of him : — He is now sixteen, can 
walk, run, &c., like other active lads, but thinks 
that his right foot is not quite so strong as the 
other. The outer side of the right foot is 
rather shorter than the corresponding part of 
the left foot. This is well explained by the two 
outer toes being abruptly shorter on the right 
than on the left foot. 

Here are ground-plans of his two feet, 
roughly taken by myself. Notice the two outer 
toes of the right foot, which are associated an- 
atomically with the cuboid bono — that bone 
which I know was diseased, and removed. na. luu. 

Their growth has been impeded, and the result is the peculiar configu- 
ration of the foot, as regards those two toes which articulate with the 
cuboid. At the seat of the former disease, the space naturallv occupiL-d 
18 




274 ox THE THERAPEUTIC 1 

by the cnhoid bnne is now perfectly filled up to ita proper level; tbd 
skin and sulijucent colSiiliir tissue are perfectly bealthy; ftiid it apf)earsfl 
me that the metatarsal bones, the new cuboid, and the ob cak-ia nre nOM 
anchyloseil, or blended together; but there is little or no difference in HM 
distance from the posterior end of the ob calcls to the base of the G^l 
metatarsal bone in either foot. ■ 

As far as I can interpret this case, the cuboid bone has actaally beM 
reproduced. This leads me to remark that surgeons should be very cwfl 
tious not to disturb iin necessarily the periosteal membrane which tbM 
meet with in operations associated with diseased bone. On the contraM 
they should be careful to leave all these vascular granulations which sin 
round the diseased bone and line the inner aspect of the periosteum ; M 
I think that experiments, experience, and sound physiology show that, d 
we can secure these bone-producing vascular structures from local injiujfl 
we give Nature a fair chance of manifesting her powers of speedy tgpM 
duction or renewal of bone. Thus I believe that the minimum of distiuM 
ance which I inflicted upon the periosteum, when I removed the neerosS 
and carious bone, may have contributed something towards the go9 
result obtained in this case. V 

Case of Disease of the Os Calcls; Sojie removed; Bone renewed. I 
In 1855 I removed nearly the whole of the os calcis of a young patiofl 
by making au incision along the outer and back part of the foot, I tod 
care to leave the periosteum as complete as I could, and not to distnoj 
unnecessarily the surrounding granulating surfaces, and especiollv fl 
guard against any interference with tM 
epiphysis of the os calcis; and heftf 
(Fig. 101) is roughly depicted the con- 
dition of the foot some time after the 
operation. 1 have seen the patient 
since that drawing was made: tlie foot 
is quite consolidated and healthy, but 
not so fully developed as on the l«ft 
side, although there seems to be almost 
as good an os calcis as in the other ft 
It is lisrd and solid; there is no pai 
sure; and the bone seems to I 
I perfectly reproduced. If that 
true, and the explanation correct, it ■■ 
Ro. 101. another instance of how highly impor- 

tant it ia to avoid any interference with 
the periosteum and other tissues which surround these necrosed 
portions of bone. 

IHteaee of the ^tphysis of the Oa Caicin. 
I must now allude to a morbid condition which I believe to b*i not ^ 
very rare occurrence, namely, disease of the epiphysis of the os calcis. \ 
have had this drawing made from nature merely for the purpose of remiiiL 
ing anatomists and surjjBons of the existence of the epiphysis to tho4 
calcis. Here (Fig. 102) is the foot of a patient thirteen years o( ■ 
indicating the precise extent of the epiphysis at that period of life, 1 
see a thin plate of hone surrounded by a temporary cartilage attaehed fl 
the posterior and inferior part of the os calcis, preparatory, no doubt, ^ 




nost 

1 



INFLUENCE OF REST. itO 

its fuller development, the epiphysis having relation to the perfection of 
the foot, giring to it inereaseii leverage, and adding especijiHy to its elns- 
tioitf. It is worthy of remark that Uie tends Achillis is attached exclu- 




sively to the epiphysis of the heel bone, hence tt is apparent that if wo 

haie any disease in the epiphysis, or in the medium of union between it 

and the bodj of the bone we shall find a prpat antafconist to mechanical 

rest in the tendo AchiUis 1 his 

18 the great foe with which v-e 

have to contend for the purpose of 

preventing any disturban<.e of th 

joiing bone and its epiphysis — 

that IS to the comparatively soft 

tissue situated between the epi 

phjais and the body of the os 

calcis It IS necessary in cases of 

disease of or injury to, the epiphy 

81S of the OS calcia that the ps 

tieiit should tceep tht. k lee Dex 1 

for the purpose of relaxing tl 

tcndo Aehtllis and so giv igr t 

to the injured or diseased ep phy 

813. 

This drawing (Tig If 3) repre 
sents part of the foot of a pat ei t 
aged nineteen, there remains but 
little structural evidence of an ^ _..,_. . 
epiphysia to the os cikn, although 

you may distinctly recognize a slight indication of it in the lower and 
posterior part of the os calcis; I may add that the os calcis in this foot 
does not seem to rae to be at all well developed. 

I here produce pathological e*-iden<?e that the epiphysis of the os calcis 
is sometimes diseased and spontaneouisly separated. This dried prepara- 





ON THE THBKAPEUTIO 

tion (Fig. 104:) is, in fact, the epipbysis of the os calcis separated s 
taneously from uii hospital patient of mine o^d about nineteen or tweotld 
as the result of injurj to the heel, and subsequently suppurntlon. 

Quitting the foot, 1 ask you to notice a diaf!^ 
taken from nature (Fig. 105), showing the i 
anatomy of the cervical muscles on the right t 
and the same parts covered by the fascia on the 
side, with tha third and fourth cervical nerves 
flcendiiig: upon the fascia to the skin covering the cla*j 
cle ftod the anterior part of the chest. The termiiM' 
tion of the first intercostal nerve is also seen. 

This simple nenoua distribution ou^ht to t 
us of the fact, that if a patient cumpluins of pain « 
this part of th e cliest, the cause may lie in one of ti ~ 
different directions. For, as nothing but these nerv 
can express the pain, it may depend upon disea 
in the cervical region, associated with the third aad 
fourth cervical nerves; or upon some disease con- 
nected with the origin of the upper dorsal nerves 
(near to the upper dorsal vertebrae), or with their 
'"" course towards the sternum. 

The right side of the diagram represents a portion of the Btemum as 
well as a portion of the clavicle cut away, so as to expose the stemo-ol«- 
vicular articulation, composed of two articular surfaces, one of the iter- 
num and the other of the clavicle, 
and separated by the interposed ar- 
ticular disc of libro-cartilage. It is 
worthy of notice that the clavicle 
has but a very small extent of bony 
articular coaptation at its sternal 
end; it rests chiefly on the upper 
part of the sternal end of the first 
rib, to which it is fixed by a strong 
ligament. This, no doubt, is fnte of 
the reasons why, although the whole 
of the articular surface of the two 
bones, as well as the interarticular 
fibro-oartilage, may be destroyed by 
disease, yet this joint scarcely ever 
becomes anchylosed. To secure an- 
chylosis you must have previous 
bony coaptation, and it is hardly pos- 
sible to obtain this between the cla- 
vicle and sternum except as the re- 
sult of destruction of all the sur- 
rounding ligaments. This, together 
with its mobility, is the explanation 
of the extreme rarity of sterno-cla- 
vioular anchylosis, and I have not 
been able to find a pathological speci- 
men illustrating its occurrence in the 
human Bubject. Last summer I was 

at Leyden, and I looked over the rich collection of diseased bones 
but I saw nothing approaching suoh a specimen. 




INFLUENCE OF KE 

The next two cases show the value of rest in the treatment of disease 
in the stemo-clavicular articulation. Disease of the sterno-clavicular 
articulation is comparatively rarely seen in its early stage; but I have a 
preparation showing recent inflammation of this joint, taken from a 
patient of mine who died from pya?mia. When this joint is diseased it is 
easily diagnosed; hut it is very difficult to cure, chiefly on account of its 
mobility, which is the consequence of its structural and functional asso- 
ciation with the mechanism of respiration, the movements of the hond 
and of the upper extremity, the movements of the head having reference 
to the action of the stemo-mastoid. "With all these functions attending 
its anatomy, it is a very difficult joint to keep in a state of rest. I will 
n three cases of disease of this joint. 



Case of Disease of the Right Sterno-clameular Joint, cured by Heat. 

In October, 1859, a man about forty years of age was admitted under 
my care at Guy's Hospital, witli disease of the right at erno -clavicular 
articulation, produced, as he thought, by a strain in lifting a weight. The 
joint was swollen, red, and painful, discharging thin pus from an ulcer> 
ated hole in the skin (with irregular and overlapping edges), about the size 
of a half-crown, just below and in front of the joint. A probe could be 
passed along the sinus into the joint, apparently between the interarticu' 
Ibt cartilage and the sternum, and dead or bare bone could be there de- 
teoted. This condition of joint had continued for nearly a year before 
hi8 admission, during which time the patient had supported his arm con- 
stantly in a sling, and was allowed to -walk about. His heiilth was good, 
but he had great pain in the joint whilst taking a full breath, when mov- 
ing the head, espeoiaUy when rotating it, and on trying to lift his right 
upper extremity. The treatment consisted in placing the patient in bed 
upon his back, with his shoulders raised upon pillows, in order to secure 
his chest against motion; his right shoulder, including the scapula and 
humerus, with the forearm, were included in a firm starch bandage, which 
was passed round the chest. This kept the diseased joint at rest, and left 
the ulcer and sinus exposed to view and free to discharge their contents. 
All this was done simply for the purpo^se of keeping the diseased parts in 
a state of rest. The local symptoms of disoase — pain, redness, swelling, 
and discharge — began to improvo almost immediately after we had fixed 
his clavicle; and in between five and six weeks apiece of the articular sur- 
face of the sternum was pushed to the orifice of the wound by the granu- 
lations, and I removed it with forceps. From that time the local symp- 
toms rapidly subsided, and the sinus soon afterwards closed; he was then 
allowed to get up and walk about, still wearing the starcii bandage. He 
continued in the hospital several weeks after this period, cliiefly for the 
purpose of preventing him from using his right arm before the newly 
repaired structures were perfectly sound; he then went home into Kent, 
with the injunction that he was to wear his bandage for a short time 
longer, and to return to the hospital sbould he not continue well. Since 
then I have not heard of him. 

Disease of the Left Stemo-claviciilar Joint ; Suppuration in the Joint ; 
opened by Ulceration y cured by Jtest. 

same kind, hut a little more interesting in 

n the left 8temo-pla\'icular joint, produced 



2(8 ON THE THERAPHrTTO 

by violence. In 1R50, a gentleman, aged thirty-six, came to me suffering 
from a sinuii nnd n.\tcn&ive ulceration in the skin and celiular tissue at 
the lower part of the neck on the left side near the sternum, the seqad 
of an abscess eonnected with disease of the left <?lavicle and Btcmo-cla- 
viimlur artioulation, which had existed during five months, I passed a 
probe through the ulceration and along the sinus behind the Btemo-mastoid 
into the at erno -clavicular joint, iia far aa I could judge, the probe ap- 
])cared to pass nloso to the clavicle and into the joint between the bone 
and the interarticular fibro-cartilape. He had been under the profea>| 
siiinal care o£ several surgeons during 6ve months, whose names I do d<' 
mention, as some of them are still living. The abscess had been Open 
long before the time of his visit to myself; and as the ulceration a.._, 
sinus, which ran under and behind llie slemo-mastoid, would not heal, 
one of his surgeons advised, as a last resource, that the whole length of 
the sinus should be li^d open so as to expose the deeper parts, and "com- 
pel them to heal up from the bottom of the wound." I apprehend that if 
the §terno-niastoid had been divided, and the sinuses had healed up from 
the Itottom, the cure would have resulted not from any compulsion on lh« 
part of the surgeon, but from the fact that he would have given the dis- 
eased part "rest," because the sterno-mastoid was one of the great dis- 
turbing influences. Unwilling to submit to any cutting operation, the 
patient sought my opinion. Finding that the diseased state was simply 
the result of local injury, and believing that it was curable by long-con- 
tinued mechanical rest, I advised him to adopt and carry out that p" 
as preferable to laying the sinus open, the result of which might bo 

The patient then told me the history of his case. Between six ai 
seven months ago he had a <fuarrel with his coachman, whom he aocua 
of robbing him. Soon afterwards the coachman went up-stairs into his 
master's private room and became very insolent to him. The result was 
a violent contention and personal struggle, during several minutes, for the 
mastery. The coachman drew an openltnife from his jiocket, closed upon 
his master with the intention of stabbing him, but tht? latter, a powerful 
mnn, fortunately caught hold of him round the right arm and waist, and 
witli great effort succeeded in getting him out of the room ; he thei 
threw him right over the baluster down-stairs, and so escaped the kail 
The coachman was subsequently fried, convicted of the robbery, and trai 
ported. Immediately afterihis struggle the gentleman fonnd that he 
damaged his loft stemo-clavicular joint. From that time the tendemi 
&c., to which I have alluded, begun. The stemo-clavicular joint 
beC'ame inflamed, and then suppurated. The nmi nas carried m a slii 
The discharge was considerable, and ho suffered a good deal of pain 
attempting to raise the left arm or take a full breath, or cough or sna 
or turn his head abruptly. The skin was red over the joint, and the stu*' 
rounding parts were much swollen. Sir Benjamin Drodie s»w 
patient afterwards with myself, and acquieaceii in the propriety 
attempting to cure him bv rest. He thought the diseese would be 
in that way if we could keep the parts suflioienlly quiet, but thst, 
observed, was not an e-asy matter. W'e subsequently, biiw over, succeed) 
in accomplishing it tolerably well by ibo aid of a broad, Itiatheni, 
moulded splint, which embraced and fixed the whole of his shoulder, includ- 
ing 1 he scapula and the upper half of the humerus. The upper arm was fur- 



fe«>^^ 



iseo 



I position to the side by a strap and buckle, whit^ P*""^ 
~ ■ ' ' ' } ordinan- trough of tealbq^ 



The forearm rested i 




If FLI7ZSCE 

which sapported it and the hand. Thb mechviioii] apparatus had iho 
effect of keeping ihe stcmo-cla^-icular joint nearly, but not (juiie, at re-st. 
The Btemo-mastoid had still some li'.tle disturbing' influence npon the dis- 
eased joint when he tamed his head to the right side, or when anr niti»- 
ciU«r exertion required him to make a fall inspiration. I projiosed to Gs 
the kit slemo-mastoid by putting a bandage or fillet round the head, and 
fastening it to the arm; but this he said he could not submit to. He wore 
the splint, Ac, four or five months uninterruptcdlj". From the first w«efe 
of local rest to the joint he began to be tree from pain and to improve, and 
the result was, that the joint repaired itself in about eight months, when 
the ulcer and sinus had healed up. H« continued to use the apparxtua 
for several months afterwards, as any forcible movement of the arm hurt 
him at the seat of injury. 

These injured parts were repaired by mechanical rest. Nothing els6 
was done, except to attend to his general health, and to provide a proper 
apparatus for keeping the parts perfectly quiet. He was sent into the 
country to amuse himself ; he used to ride a short distanoe with ihtt 
hounds at the latter part of the season, but did not use his left arm. On 
the Cth of June, ISGl, this eentleman called on me at my request. His 
belief is that he did not, as be says, " get over the accident " tor nearly 
two years. The mbvenients of the left arm are now the less perfect of 
the two ; he cannot lift it so easily, or roll it backwards when raised, 
quite so freely as on the other side. A large, sunken, whitish, thin- 
skinned cicatns is still visible over the anterior part of the sternal end of 
the clavicle, which is not normal in form ; it is flattened anteriorly, and 
wider from above to below than the corresponding part of the other clav- 
icle, and some small'pointed outgrowths of bone can be felt on the upper 
border of the former articular surface. The clavicular portion of the 
stemo-Qiastoid ia much atrophied. On closely examining the injured 
j'lint, it is quite obvious that its articular movements are much less than 
on the other side. The chief structural defect seems to consist either in 
a loss of the Interarticular fibro-cartilage or its consolidation witli the 
clavicle, with membranous anchylosis or ligamentous luiion between the 
sternum and interarticular fibro-cartila^c. Here, then, is a case at injury 
to the aterno-cUvioular articulation, the history of which ia complete, and 
the result as perfeot as it could possibly be maiie by the surgeon securing 
that local quietude which encourages Nature's efforts at repair. 

Case of JJisease of the ItiijJU Steitio-cla»iotJ<ir Joint, produced fit/ /br- 
cible 7)-action -upon t/ie right upper extremity ; lieath j'rom J*ij- 

A lady, rather stout, and aged between fifty and sixty, was standing 
on the platform of a railway station in London, and had firm hold witli 
her right hand of the hantlle of a carriage door. The carriage moved 
suddenly and unexpectedly, and she was dragged forcibly fo^^vBrd^ by the 
arm. She had some considerable pain in the right stBmo-olaviciikr artic- 
ulation immediately. A large abscess fonned over and behind the ioint 
subsequently, which received pulsations from the subclavian artery, lead- 
ing to the suspicion of aneurism, and on that account I was requested to 
see her. It was clear that there was no ecoentric expansion in the tumor, 
but that it was a soft fluctuating swelling, probably an abscess, receiving 
ft distinct propulsion from behind, where it was in contact with the subcla- 
vian artery. This relieved the minds -of her friends, and the lady wont 
into the country. The abscess opened of itself, and dischargL'd pus abun- 



2S0 ON THE TnERAPEUTIC 

dantlj. A splint iybs appli<^d, and the arm was kept quiot for a elia 
time. I saw the patient several times, and with a probe could deco 
disease of tho clavicle at its sternal end, extending into and impliciui 
the whole of the stemo-clavicular joint, where she suffered a great dea' 
pain. She had subsequently several attacks of bronchitis, with coug-h i 
expectoration, wliich disturbed the joint very much. Ultimat^lr she died, 
I believe of pytemio, after a few days' severe illness, but I could not suc- 
ceed in obtaining a post-mortem examination of the case. 



The case to which I will now briefly allude is one of great interest— - 
namely, disease between the first and second bones of the stenium. Tw^ 

patient, D. J , was formerly a medical student. He was twenty-tig 

years of age when he first consulted me in March, 18o3, for pain And n 
easiness about the upper and middle part of his chest. He stated XM 
for several months he had been unable to take the least amount of exii 
else without considerable pain and difficulty of breathing; any att 
even at g«ntle motion, as in walking, full breathing, coughing, or IndM 
the least movement of the head or arms, was sufficient to increase his sU 
fering. He had constant dull pain in the neighborhood of the stenium, 
extending towards the lower part of the back of his neck and between his 
shoulders, which during damp weather was of the most severe and gnaw- 
ing character, accompanied with a sense of oppression and constriction 
about the air-passages, as though he were being choked. Any attempt 
to take a deep inspiration produced pain in the same part. Pressure made 
with the hand upon the front of the chest during expiration was attended 
with pain of the most severe and lancinating kind. He jumped and started 
in his sleep, and was disturbed by frightful dreams. His appetite had 
failed during the last few weeks, but he did not appear to have lost much 
flesh. He had consulted many eminent physicians and surgeons in towa 
and country, but could not learn from them any distinct cause of his si 
fering. He had been leeched and blistered over the chest and spine, m 
had passed in succession through the ordeals of boating, cricket, qnoit^ 
and gymnastic exercises; indeed, every possible kind of treatment ap- 
peared to have been pursued, but without benefit, and he was now worse 
than ever. 1 might say that he had not been previously examined care- 
fully with respect to the sternum or spine. The physicians and surgeons 
who saw him were satisfied to take his indications of pain, as he ' ^~ 
professional man. 1 suppose they did not think it worth while to 
— .k- ,. ™i — , ^[,3 j^g^ mischief was found. I examined 



1 



apine very carefully, but could not discover anything wrong there, 
breathing was regular and natural, but limited m its extent by pain in hia 
chest; the heart's action was normal. Tiiere was acute pain on percuss- 
ing the chest; and on approaching the middle line in front, the pain, bv 
pressure upon the sternum, was much increased. On placing my thumb 
directly over the junction of the first and second bones of the sternum, 
and exerting alight pressure upon that part, the pain was so intense that 
he nearly famted. It was evident that the secret of all his morbid symp- 
toms lay in this joint,* and indeed there was some enlargement and thick- 



* The two upper pieces of the Btemnin am UFiuall; dencdbed as united bj caltQ- 
a^, boa; unioD being' rare enve in late aid sgc Hr. ItiTin^ton. Med. Chr. Trf., vol. 
IviL, tine drawn utCentlon Co the fact t)int two rorms of joint are foiiad hers, the ~ ~ 
phi-anhrodiul, and tlie artbrodiui orgiii.liiig rtuietj of the diurthiodiiJ joint. — ["~ 



-(BK.JH 



INFLUENCE OF RES 

ening there. Upon close interrog;a,tioD as to the probable cause of all this, 
he said he could remember three years ag;o having received, during a spar- 
ring contest, a very violent though friendly blow upon tho part now af- 
fected, although it was not until several months afterwards that be expe- 
rienced any severe pain. Finding a diseased joint in this patient, and 
bearing in mind the means he had already employed witliout benefit, it 
appeared to me that everything had failed in consequence of the sternum 
not having been kept quiet. I directed him to return into the country; 
to lie upon his back for six months; to apply two or three leeches to the 
tender part of the sternum; to encircle the chest with a bandage so as to 
limit motion in the ribs, and so in tho walls of the chest; to use no exer- 
tion of any kind which required prolonged or violent rcspirution ; to keep 
the stemo-mastoids relaxed; not to do anything with the upper extremi- 
ties which would require tho sternum and ribs to become the fixed points 
of the pectoral muscles; to take sufficient morphia to insure a good night's 
rest; and to live upon plenty of nutritious food. 

The terms I have employed in enumerating and describing the symp- 
toms of this case perhaps hardly give a correct expression of the severity 
of the patient's symptoms. He really was absolutely miserable; he could 
not stand, he could take no exertion, he could not oougli or talk aloud; he 
could scarcely do anything without great suffering. 

At the expiration of four months of absolute rest, he had so much itn- 
proved that he believed himself capable of pursuing his usual duties (which 
were of a light character), and this he continued to do until the end of 
1859, at which time I saw him again. AH tenderness of the sternum upon 
any amount of pressure had subsided. In writing to me soon afterwards, 
ho states that he is confident that had he carried out the plan of absolute 
rest for the six months as I enjoined him, he would have been well by 
that time; and that although he took in every other respect the great- 
est possible care of himself, his recovery was prolonged by getting up too 
early. In January, 1860, he wrote this note: — 

" My dear Sir, — I enclose you some notes of my case, and you are at 
liberty to use them as you think fit. I may now tell you that I consulted 
live London and two provincial hospital surgeons, and three London hos- 
pital physicians, previously to my interview with you. The boating was 
ordered by a physician, and other athletic sports by the London surgeons, 
and certainly they played the very devil with me. I shall never forget 
tugging off to the Isle of Man for a month to have plenty of rowing. You 
can imagine my state on my return homo. My condition for many months 
was most intense and painful miscnr. I am satisfied that, had I not fol- 
lowed your advice, nothing short of an opening and exfoliation, and God 
only knows what, would have been the result." 

This ease will be satisfactory, I think, as pointing out the importance 
of examining the part where the paii\ was complained of, while, at the 
same time, it displays the value and importance of mechanical rest in cases 
of this kind. 

Before concluding these lectures on the therapeutic influence of rest 
in its relation to the treatment of diseased jointSj 1 am desirous of placing 
before you a familiar illustration of the iuexphcable good which arises 
from due rest in cases of over-fatigue to joints by exercise or muscular 
exertion. 

Two persona start upon a pedestrian tour, and after walking a certain 
number of miles, feeling fatigued, they seek relief by lying down and 
{Tiing to sleep. After a repose of an hour or two, with perfect rest of 



2S2 



ON THK THERAPEUTIO 



mind and body, but especially of body, they rise invigorated, " gi&iits . 
freshed," and proceed on their journoy with renewed strength, and a 
ently without the slightest inconvenience. Now, what have they obt 
during the period of repose? Anything or nothing? No food has h 
taken, and therefore no strength has been obtained by the addition of tu 
new material to the system. The hypothesis is, that the various enfeebUi 
structures have had time and opportunity by rest to become invigorate 
by selecting and appropriating to themselves, in the form of nutritioi 
new material from the capillary circulation, which is proceeding within O 
near them. 

Let us, for the purpose of pursuing the inquiry, modify the illustrat! 
by the supposition that, although both pedestrians are much fatigued 
walking, only one of them takes bis rest, and that the other proceeds on 
his journey, notwithstanding his fatigue. 

The one continues walking, and, after going some considerable dis- 
tance, at length arrives at his mucJi -wished- for resting-place. When his 
friend, who has been taking his rest in the middle of the day, overtakes 
him, he (the one in front) is found to be the subject of a painful condition, 
or poRsibly of an inflammation of the ankle, knee, or hip-joint. What baa 
occurred in the one case, and not in the other? The one, wearied by 
exertions, lies down and takes his rest, and suffers no harm; the oth< 
while still under the influenoe of fatigue, continues his journey, and h 
the subject of a. joint -in [I am mat ion. What, 1 ask, has really happened 
him who suffers? We must assume that there has been in his case a te: 
porary physiological exhaustion of the various structures which have been 
especially concerned in walking. We may presume that the synovial 
membrane no longer secretea its proper lubricating fluid; that the elasti- 
city of the articular cartilage is for the time much reduced; that the same 
kind of deterioration in function may probably be present in the bones 
themselves; that the ligaments are no longer capable of resisting the 
effects of either misplaced steps or unsteadiness of gait; and that the muB^^ 
cles being wearied and fatigued, the person has not had the advantage 
that muscular adjustment which would have secured his joints from t] 
ill effects of any jar or sudden concussion as he walked. 

The influence of this latter condition {which we may, T think, tei 
" muscular adjustment ") you will recognise at once, when 1 remind 
of what often happens when walking in the dark. If you abruptly r 
with a little descent of only two or three inches, and your foot conies d 
unexpectedly without your having prearranged or nicely adjusted your 
muscular force, the patella may be broUeO, perhaps, or the whole bodv 
receives a momentary shock from the rapid transit of the vibration througn 
it. The Influence of the shock is felt even in the brain, inducing tempo- 
rary confusion, and causing sometimes a slight stinging, electric-like Ben- 
sation upon the face throughout the distribution of the sensitive part 
the fifth nerve — sometimes, indeed, the tongue is bitten. 

Whence this sudden discord in the action of the various struotum', 
hitherto employed in harmonious co-operation, which permits this rud^T 
and harsh concussion of the whole frame from so small an error in progrea-. 
sion ? The bones, the synovial membranes, the articular cartilage, the Tig4- 
nients, are all in a state of integrity. The only peculiarity is, that the mus- 
cles have been taken by surprise, and have not had the opportunity of 
giving that aid in the fall which they would otherwise have donc^,! 
and so preserved the person from the concussion from which he haaj 
suffered, but which he would have escaped had he been aware of th<i 



1 



k 



JFLUENOE OF RE9T. 

sudden descent, or had he been alive to the correot meaaurement ot the 
distance. 

Allow me to put before you another illuBtratton of the same atate. 
You may see a man, full of confidence in himself, jump from a height of 
two or three yards, alight upon bis feet, and walk away unhurt; wbile 
another person, or thn same person at another period, tiinid and afraid, 
or without a fixed purpose, falls suddenly and unexpectedly, or jumps, 
under the influenue of fear or doubt, a comparatively short distance, not 
maintaining his mental equilibrium, " loses his head," as it is called, and 
comes down upon his feet, confuses his brain by the shock, and perhaps 
sustains a fracture or dislocation at bis ankle, a broken leg or thigh. 

What has been the cause of these different results? Simply that the 
one who had his mind " always about him," his nervous centres alive to 
his impending necessities or requirements, has had the advantage of keeping 
up and controlling bis muscular adjustment, so as to prevent any ahaketo 
the brain or serious injury to any of the bones or j'oints. This seems to 
me to be the result of instinctive muscular adjustment. 

Now, to go back to the application of this rather long digression. 
The pedestrian who walked on at the time when his friends stayed behind 
for the purpose of repose, procHeded on his journey in a state of fati^e 
and muscular exhaustion, so that the joints had not, during the period of 
their prolonged exercise in walking, the advantage of muscular adjustment 
to modify the effects of concussion upon the joints and ligaments. Under 
such circumstances, the joints become the subjects of violent conoussion 
or vibration, vascular congestion, and then infiammation. There is no 
apparent or recognizable lesion of structure; butthe pliability or elasticity 
of the foot is gone, and the joint is stLS, and will not bear concussion. 
The elasticity of the artiimlar cartilage, however, is only temporarily 
diminished, for the renewed capability of bearing weight and concussion 
in a few hours indicates structural recovery. Carry this inquiry one step 
further. Instead of taking his onward course on the following day, the 
person whose foot or ankle-joint is inflamed lies up during a day or two, 
resting and elevating his leg and foot, and using a bandage and cold 
water. Now the foot and leg are to be raised. What is the object of 
this elevation of the foot ? What does it mean ? It simply means 
emptying the capillaries — giving them rest, freeing them from their state 
of congestion, and thus allowing them by " rest " to return to their natu- 
ral and vigorous condition. Ought not this typical expression of Nature's 
high appreciation of rest to fonn a safe guide and direction for the sur- 
geon in many of the cases to which his attention may be called ? I say, 
Yes 1 Is it BO regarded, or is such a physiological line of thought and 
action manifested so often as it ought to be by the surgeon in his rsoom- 
mendations or bis practice ? I say decidedly. No t 

I have indicated to you that accidents and diseases of joints occur 
from over-walking and over- straining, from rude progression, from some 
twist, muscular fatigue, or some other casualty. The throe drawings 
(Figs, 106, lOr, 108, and 109) have reference to this point. 



C'ifie of severe L\flammation of Rifiht Ankle-joint and Foot, follmced 
by Suppuration; complete Dislocation of the Fbot ; cured hy Rest. 

This drawing (Fig. 106) represents the right foot of H. B , who at 

sixteen years of age was admitted under my care at Guy's Hospital on 



384 ON THE TIIKHAPEUTIO 

March 20th, 1855. He was previously quite weli, but fatigued, wb«na 
dotermiaed to walk £rom Soutfaw&rk to Enfield ou the morning of Mu? 
21at, 1855, although \ 
hud pain in his fo^ 
when ho reached Gn 
church Street on his w 
When he arrived at L 
field hia foot and arilq 
were awolleu. He I 
indoors alt day, and 1 
the evening went to ti' 
railway station 8upp< 
ed by two men. 
□ight he could not I 
the slightest weight q 
on his foot, and 
ankle was much swollt 
Cold lotions were applii 
to the painful and swi 
len parts, and somi 
cine given. Hec 
Guy's Hospital ( 

ot the attack, suffering mc 
rlkot^ severely with acute i 
flammation within 
ankle-joint, and at ' 
id cuboid bone. Leeches w 
ntationa. The legwaselevated uponi 
ind-bngs. Extensive suppuration tocn 
This was opened in a fortnight froB 
disposed 




e applied. 



outer side of the foot over the oa calcis s 
applied abundantly, and poppy fomentatii 
pillow, and supported laterally by e 
place near the external malleolus. 
the accident. The integuments wert 
to slough. Hemlock poultices wen 
A week after this opening was m, 
ulceration of the skin occurred, and the foot 
becanie completely dislocated inwards from 
the tibia, so as to expose to view the top of 
the astragalus, as well as the articular sur- 
faces of the tibia and fibula. 

Here I might add, as a matter of inter- 
est, that this boy's ankle-joint being com- 
pletely exposed to view, 1 took occasion to 
touch with my finger the exposed, inflamed, 
and partially ulcerated articular cartilage. 
He felt no pain; but when I pressed bard 
upon either the articular surface of the as- 
tragalus or the tibia, it gave him a. great deal of pain; clearly indicating 
that the pain was not associated with simple ulceration of the cartilaf 
but had reference to the deep pressure upon the subjacent parts;. 

Chloroform was inhaled, and I reduced the di.slocAtion ; but thinking 
it safer for the patient, I divided his tendo Achiliis, for the purpose of 
preventing any displucemcnt by the aelion of the gastrocnemii, whioh 
were frequently in a slate of spasm. Splints were then applied, and the 
diseased leg was swung. He remained in Guy's nearly eleven month^l 




I 

I 



aad then went out for six weeke, wlieu be retunied because his foot bad 
become swollen, red, and puinfu], trom iinpruperly using it; in f&ct, the 
new or repairing young bone was not a.t that time equal to the claims and 
exigencies which had been thrown upon it. Subsequently he had fre- 
quently alight attacks of inflammation in his foot from over-exertion in 
standing or walking. He used to say, " I only come to the hospital to 
lie up;" and he availed himself of the privilege rather frequently. Hia 
mother, getting quite tired of these repeated hospital visits, wished me 
to'take (iS bis Teg; but 1 preferred to wait and see the result of Nature's 
efforts at repair. 

Well, here is the result (Fig. 1U6). Three or four pieces of dead bone 
came away from the os calcis, and proba-bly the cuboid. T saw him in May, 
1861. He considers that his font and leg have been well for three years. 
He can walk any reasonable distance, and stands at his work — hat and 
cap making — not unfrequcntly for fifteen hours a day. This is a good 
cose, fairly representing bloodless conservative surgery, and indicating 
that although a great amount of local injury may occur as the result of 
over-fatigue, it is capable of being entirely recovered from. 

The next case is one of great later&st. 

Iiyury to the soft Structure uniting t1\e Shaft of the Tibia to its Imoer 
^piphyais, fuUoteied by Ostitis and Suft-periosteal Suppuration ; 
Death in Tweloe Days. 

A young gentleman, eighteen years of age, tolerably healthy, and liv- 
ing at Islington, was always active and fleet of foot. On Friday, Jan. lUtb, 
18«i, he ran two miles right off to a friend's house, and, after resting for 
a short time, he ran back two miles home, but suffered no known incon- 
venience from that exertion. On the Sunday evening following, return- 
ing from chapel, wearing a very narrow, high-heeled boot, and walkingflt 
the edge of the pavement, his loft foot turned inwards with a eudden jerk 
or twiatiug sensation, and he exclaimed to his sister, who was with him, 
"Oh ! I have twisted my foot; I never had such a dreadful wrench be- 
fore." He walked home, and, excepting at the time of the strain, he felt 
but little of the injury during that evening or night. He walked to his 
business — ten minutes' walk from his own home— on Monday morning, 
when the pain in hia leg near the ankle became so great that be could not 
remain, and he returned home; he limped, and could scarcely bear any 
weight on his foot. His mother fomented his ankle, used hartshorn and 
oil to it, applied vinegar, and gave him an aperient. She nursed him 
through Tuesday, Wednesday, and Thursday, when his surgeon was 
called in about mid-day. The patient could not then bear any handling 
of his ankle; he cried with pain, which he referred to about two inches 
above the intenial malleolus and across the tibia in a straight line; there 
was some swelling at that part, but no ecchymosis or other discoloration. 
The pain on pressure, witii a doubtful crepitus, made it appear prob ' 
that it might be a simple fracture of the tibia. The pain conlinuini 
Friday, his surgeon ordered four leeches to the part. Soon after this a 
severe rigor came on. I saw him on the Sunday, with Dr. Billinghurst, 
and I then came to the conclusion thttt he had sustained some injury to 
the epiphysis; for upon close examination I found the ankle-joint free 
from mischief. A little careful manipulation enabled me to isolate the 
injury to the tibia, and I told Dr. Billinghurst that I believed the soft parts 
between the shaft and the lower epiphysis of the tibia were injured. At 







286 ON THE THBKAPBUTIO 

that time tbe p&tient waa suftenng extreme pain, and he had a small a 
lection of pus deep in the leg at the inner and back part of the tibia, 
did not again see this patient alive. Five or six days afterwards h« diH 
with what was thought to be typhoid fever. 

By chance, on the tiny before the funeral, I heard of his death, 
mediately wrote to his relations, and obtained permission to make a 
aminatlon of the leg. I went to the house early on the following [ 
ing; the hearse was at the door, so that I had only time to unscrei 
coffin and examine the leg. I found tbe soft parts around the injun 
bone, external to the periosteum, infiltrated with serum, but tiiere was ■ 
evidence of any laceration of these structures; no bruised appearance, I 
extravasation of blood. The periosteum was separated from the ir 

anterior, and pos- 
terior parts of the 
lower portion 
the tibia by a consii 
erable collection 
pus, which was 
fined in its pout 
by the periost«unL' 
The lowest part of 
this collection of paa 
corresponded with 
the injury to the 
epiphysis depicted 
at rf, f'ig. 109. Tbe 
fibula wag not injur- 
ed, nor was the in- 
terosseons ligament 
between it and the 
tibia. No suppura- 
tion nor any evi- 
dence of intianuna- 
tory condition with- 
in the ankie-joiut ex- 
isted. 1 took away 
this bit of the tibia, 
and it fairly remune- 
rated me for my 
trouble. These draw- 
ings (Figs. 108 and 
109), were made from 
the preparation 
the same day that 
piece of bone 
obtained. Thia _ 
aration is a lonj 
tudinal section 
the tibia, showing 
the inflammatop;-^ 
condition of the whole interior of the shaft of the bone, and alfio of tJ 
epiphysis, There is, as you may see, a distinct gap from lullamniatoi 
softening and absorption, or laceration, between the shaft of the tibj 
and its lower epiphysis, This is precisely the spot where the lioy had t' 



INFLUENCE OF REST. 



first sense of injury on the Sui 
he complained of pain when Dr. 
we have distinct evidence of ; 
the soft structures between the 
by death— I believe from pyier 



iday evening; it was near to that spot that 
Bi)linf(hurst first saw him. In this instance 
in injury having occurred from violence to 
! shaft and epipTiysia of the tibia, followed 
nia — twelve days after the accident. 



These lectures, from the mode of their delivery, have been of necessity 
fragmentaJy. Their object hfis been to establish a principle; and how 
difficult a. matter of attainment this is iii medical science we need not be 
reminded. 

I have herein endeavored to show that " Rest is a most important 
therapeutic agent in the cure of accidents and surgical diseases.'' To il- 
lustrate the varied applications of this principle, 1 first Bur%'eyed, as fully 
as my limits permitted, the marvellous contrivances which Nature has 
employed for securing rest to the different organs of the body when in 
health. I then depicted the instinctive promptings of Nature to secure 
Rest on the occurrence of accident or disease. Lastly, I attempted to 
shadow forth the different appliances for the attainment of Rest with 
which that surgeon only will become familiar who has an accurate knowl- 
edge of the anatomy and physiology of the different parts which he may 
be called upon to treat. 

I have also endeavored to impress upon you the fact, " that every pain 
has its disfiiiet ami preffnajU siyuificitiuii, if we will but carefully search 
fftr it." To the extent of ray present opportunity I have striven, by the 
agency of a more precise nervous anatamy, to unravel and render patent 
the meaning of pains which have been ao often described a,s anomalviis or 
obscure. From the pain which follows the intrusion of a particle of dust 
on to the conjunctiva, and the closure of theeyehd for the security of rest, 
up to the most formidable diseases we have to treat — pain the monitor, 
and rest the cure, are starting-points for contemplation which should ever 
be present to the mind of the surgeon in reference to his treatment. Feel- 
ing that I have, at most, advanced but one short step towards the object 
of every acientifio surgeon, 1 trust I have neither dogmatized nor spolcen 

rresuraptuouslv, A like idea was doiibtleaa present to the mind of Dr. 
)arwin when (ie wrote the preface to his "Zoonomia." "A theory," he 
says, " founded on Nature, that should bind together the scattered facts 
of medical knowledge, and converge into one point of view the laws of 
organic life, would thus on many accounts contribute to the interests of 
society. It would capacitate men of moderate abilities to practise the art 
of healing with real advantage to the public, it would enable every man of 
literaty attainments to distinguish the genuine disciples of medicine from 
those of boastful effrontery or of wily address, and would teach mankind 
in some important situations the knowledge of themselves." I may also 
adopt bis quotation from Cicero, changed into the past tense, because it 
so exactly expresses myfeehngs; — '■ Hwc, ut potui, eiplicavi: nee tamen, 
ut Pythius Apollo, certa ut sint, et fixa qute dixi; sed ut Lomunculus 
unus'ex muitis, probabiliora conjectura sequena." 




APPENDIX. 



Caw of Disloeation of both Thigh-bones from Disease of the I7tp-Jointa; 

OTie J-'emur being displaced on to the Dorsum Dii, near to tlte Tschi- 

atic NaU'h ; the other dislocated downwards, below the lead of the 

Acet<ibulum, and close to the Foranien Ovale. 
K. S., a girl aged fourteen, was admitted into Charity ward, under my 
care, in July, 18Gi. The child was greatly emaciated, and daily growing 
weaker from a large amount of thin puruleut discharge, which came from 
numerous sinuses communieatiiig with the hip-joints. The head of the 
left femur was distinctly felt and seen upon the dorsum ilii, the left leg 
lying serosa the right thigh just below the level of the pubes, and pressing 
the right thigh down into the bed, so that it became difficult to ascertain 
what had happened to the head of the right femur. This, after chloroform 
had been given, was found lying deep below the right acetabulum, in the 
neighborhood of the foramen ovale. In the hope of improving the general 
health, any attempt at reduction was deferred for about a fortnight, when, 
under the influence of chloroform, the reduction of the left femur was accom- 
plished without much difficulty. A straight splint was applied, extending 
from near the axilla, along the outer side of the thigh, to the foot. Owing 
to the exhausted state of the patient, Bteps for restoring the position of the 
right thigh were deferred for nearly a. month more, when ehloroform was 
again given, and the limb having been rotated, the head of the bone was 
lifted up from its deep position, and then replaced in the acetabulum, A 
straight splint was applied as on the left side, and thin pillows placed be- 
tween the legs. The health of the patient was restored rapidly, the dis- 
charge from the sinuses becoming less and less until it almost ceased. The 
splints were removed occasioniilly for the purpose of cleanliness. After 
about four or five months of rest, comparative fixity of the joints became 
apparent, and ultimately the anchylosis was perfected in both limbs, and in , 
good positions. On being allowed to get up, the patient was able to stand 
without pain. Gradually she gained more and more power, and used to 
ahuflle about the ward swinging her trunk upon the pelvis, anobylosed to 
■ the femurs. 

She left Guy's Hospital in April, 18fi5, to go to the Cripples' Home, 
getting about on crutches. She remained here two years, and left to go 
to a dressmaking establishment in Kilburn. At this time she walked very 
well, and without crutches. All inquiries at the present time (1876) to 
ascertain her whereabouts have ended in failure. 




cuttmeooB diatii- 
batiooof, 141, 144. 222, 22J. 

AB8CR8S. ttbaorptioQ of, 318, 220, 335; 
lowest: part ot, depeniht upon ixiiiilioii cf 
patient, TO; surf ace coaptntton ot. eqtiiv- 
otcut to rest, 70; not to bo diaturbeil 
bj duly squeezing, 70. 

, ftiUlnty, 7u ; oerricBl, 75, 61 ; 1 

facial, S3; aub-Cascial, 77; iliao. 7ll; 
OTbiUJ, 75 ; popliteal, 82 ; post-phaiyn- 
peal, 75 ; peoBs, u3 -, anb-glutaal, 77; 
Bub-mammary, 70 ; iub-oc>;ipiUil. 79, 
70, 80, bd; imiler temporal fuacia, 70. 

, OPUKtSG OK. miiflt bo at italow- 

eat part, Tl); to give rest to its walla, 
09; deferred in Up-joint diaeusG. 220; 
ill disrose of epiphysis of femur, 2(H ; 
propriety of, indisoBsed joints, 318, 831; 
ulterior object of, GO ; d.uigRr of, by 
knife, 73, 74 ; method of, by toroepsoiid 
director, 71. 

ABSOHFrcoN of callus after giriog rest to 
botw, 151) ; of lymph after peiicnrdiCla. 
151; by bstoub membranes, lUO; of 
abBoesses. 223, 22G. 

Acetabulum, necroaig of, 233. 

Ali^STllBTlcs, local cutoueouH application 
of, in abdominal disease, 14:2; to branch 
of fifth nervs. lai ; to intercostal 
nerves, 149 ; for diseased joints, 104, 
133; fur pleurisy, 14S ; Cortioricorditis, 
15Ui for diseased bladder, lUU. 

Anai. ULCBlt, p^nfut, mode of giving rest 
to, 173; bleuJing, cured by division of 
lipbiact«r, 175. 

Ahcbvluskd rBMUB, attempts to alter 
position of, 338. 

AncnTLosis of ankle-joint, 231 ; elbow- 
joint, 2(ia ; hip-joint, 21)5. 907, 312, 230, 
333. 3211, 23», 3:!3, ZiS, 331! ; kneo- 
joint, 180, 183, 381 ; Bterao-clavicolar 
joint, STfl, 279 ; scaphoid uid Bstiagalns, 
llilti ; tempore -maxtllaiy joint. 65. 

Anscribu cured by rest. 35; cuu sing pain 
iu Che cutnneoas distribution of fourth 
and fifth dorsal nerves. I'lO. 

ANum-JOiNT, anchylosis of, 331; inBam- 
mation of. with suppuration and dis- 
looadou, cured by rest, 2KJ, 381. 



Antebiob CRUiiAL KKBVE, distributloa 

of, 130, ISl, 123. 
Axce, artillcial, affording physiological 

rest, 175; distribution of nerves to, 

105, IG8, 171. 
AoHTA, disease of, Hssociated with cn- 

tnneons pain. GO, 148. 
AuACElKijlu, internal and external, de- 

soription of, 13. 13, 14 ; one of Quid be- 



I. U, 1 



170. 



distribntion, law of, 108, 169, 



AsTBAOALrs, injury to, from a jump, 1S4 ; 
anchylosis of, 187. 

AuDCTOicr CANAL, excorinliou of. depend- 
ing ou diseased molar toolh, 110. 

AjciLi.Aitv .mscKss, 73. 



Bbd-borb penetrating into vertebral ouial. 



Bent aru after venesection, reasou of, 
1U8. 

Bladder, irritable mucona membrane of, 
method of relieving, 157. 

Brain, anterior portion ot, must liable to 
injury from blow at back of head, 17 ; 
ohronio affections of, often the result of 
local injury, 31 ; lostw its oongested 
state when quiesosut, 38; not con- 
gested during sleep, 38; disease of, 
prodnoing symptoms of hip-joint dis- 
ease. 237 ; quiesuenoe of. and ciroulation 
iaflueaced by the cerebro -spinal fiuid, 
18 ; mecbanicid means for securing rent 
in, after congestion by work. 10; rest 
ot, exemplified, S ; use of the lateral ven- 
tricles of. 10, 18; hiceration of, 30; 
lesions of, treated by mechanica] rest, 
3U. 

, CONCIISSIIJN OP. ahoald be treated 

with long rest, 29, 30 ; sadden deaths a 
long time after, 31 ; analogoiinto bruist^s 
in otber parts of the body, 31 ; prodn- 
oing moteculor disturbonoe of its sub- 
stance. 30 1 rest absolutely neoessory to 
produue repair otter, 31 ; danger ot 
using stimulants after, 31 ; value of the 



J 



ikpplinstion of Ice. 31 ; inflnenoe of food 

Kniliiliiuulaiita on. 31. 
BUI.LKT INJUKV to tuOBoalo-otitaiieoiu 

nerve, cflciiU of, 109. 
BuilNS, cdDtiacUun aftar, one caane of, 

140. 
Bl-ii) 



CAl.LUSabsorbed ai(«r rest hod bcon given 
to a bono, Vii. 103; lueaiu of HuninDg 
rent to a fracture, 38, 158. 

Cancich iDVolvinj; saoral mid obtaratot 
iMcveB, 125. 

of rectum, puinloM, 102. 

Capillakieh, mode of giving rest to, 283. 

CAreULB, elattiu fiun-tions o(, 7 ; of kid- 
acy, D ; of liver, 7 ; o! spi«eii, 8 ; of les- 
tiolc, il. 

CAttntiKCLB followed b; slongbing, after- 
treiitmciiit of, 82. 

OAKTiLAdEe luone la joints, treatment of, 
by rest, MH. 

Civuf. ot CrequoQcj of uloeis jiut above 
•njcle, 1-2:(. 

Cbrbdrii. SPINAL Fluid in the veDtricles, 
11; phjaiolngy o[, II, 1,1. 17; formi a, 
wal«r-bud for buBo of the brain, 1(1; 
ndvaniago of dintinguishing the ]iortinn» 

[ o( the bruin separuted by this Quid 
from tbo bones, 17; apt'ci&o gravity of, 
17 ; influence of, on tbo corpus atriaCuin 
and thHlainuB nervi o|itioi, IB; oniilugy 
of. to oapsnlar apparatus ot viacem, IS; 
efFeot of. on circulQlion ot brain, 18 ; 
inlluenco on the olruulatiou of the brain. 
18, IB ; obtained from a jiatient after 
fraotnre of iikull, 19 ; rehiLion oC, tn 
spina biBda, 20; function of, in Che 
fcetal brain, 2S. 

orKNiNa, nso of, ami 

doBcripHon, 10; ocdosion of, 23. 33; 
oodusion of, OBSociated with spina bifi- 
da, 33 ; oculuHion of, oauaiog intemiJ 
hydrocephalus, 33 ; occlusion of. in It 
gentieman thirty-four years of aga, 35. 

Oervicai. AiisuEHa. 75. 81, 83. 

— BEUVRB. third and fourth, dis- 
tribution of, 370. 

TtttiTEBK.B, fifth, sixth, seventh, 

cane of injury t°. and reoovery from. 03. 

Cnii.DiiKN when ill waste more rapidly 
than adults, 4. 

CutNlt9K tody's foot, showing that toroed 
rest does not deteriorate the structure 
of jolDta, 187. 
Cbosubb. origin of different, at different 

times, lOt. 
CmcliwvLKX NERVE, distribnttoii of, 06- 
Clock. PLoa&L, 



di.tached af l«r perfonniiig it* oSoa, W ; 
aiiaorption of. after "■<*— "— iiiiii_ it ; 
ditnger of disturbing, in wooada of ••■ 
rous membranes, 39. 
loLuK, pressure of. on kidney. 9 ; diMaM 
of. associated with pain in knea-jaiBt, 
1^; obstructed, treated \ij aruSoal 
anus, 17S. 



CONJUNCTI 


VA, inj« 


red, cured by pbyaio- 


logical ra 


t, 154. 

KBTER, 






COUI'L'B H'r 


IIATUM, 




mil fluid 


IL. 17. 




COBTO-VKH 




•lOlNTB, diaCMO at. 


very rare 


lHl;n. 




and rest 


r. laa. 




CnrciAL LioASiEJJTH. action ot 188. 


ConoiD HOME, disease of, cured by Mat, 



Cl'hved BAcncK, causing; oatlyins, 

Bf luiitome of bip disease. 2M. 
CvHTiTis, obioaio, means o[ j 

{ihysiological rest in cases of, Iu7. 

David. M., observations on rest, 87. 



L 






tal. of one lower extremity mistaken for 
spinal disease, 340 ; a cause of early 
hip -joint disease. Cll. 

~Ei.AT IS orF.NiNfi on abscess about knee- 
joint, danger of, 72. 

Lkltoip, wasting o(, after injury to cii- 
cumBex nerve, IGO. 

DKVKMJP.yKNT OK PKLVia may bo dwarf- 
ed in long-btonding coses of hip-joint 
disease, 201. 

DiAi'liiiAOU. influence of, on the liver, ' 
nervous distribution to. 103, 14n ; ani^ 
peiicaidimn, nervous distribution ln>l 
DualognuB to that of n joint, 140. T 

Dislocation ot hi p-ioiula, congenital, S!^8,] 

Distribution or &ERVBa. See Nerret^ j 
Distribntion at. 

DoKsAL NBitvE, Brat, distribution of, 87fl- 

UoHsliu iLii, dislooatiun ot femur on ti 
reduced, anchylosiB, 207, 211. 

DunliAM, HR- a., oonditiou of 
lug deep, 39. 

Ear, external, distribution of nervM to, 

Bahaciib, assorinted with tootbaohe. 44; 
associated with disoasod tonfnie. 44 ; aa- 
Bocifttcd with stiflneBs of jnw, 44 ; pro- •m 
duoed by enlarged oervicjtl g^and new ^ 
auricular briuidi of sccoud and thiid'f 
oerviool nerves, 46. 




Earliest STMrroMS of hip diiiejiae, 128. 
Elbow joint, mnmralo- cutaneous oerve, 

dixtribatioa to, IDS; auchjIoBis of. 369; 

■crodlloUH disease of, 3(iO, 
EfiPUirBis, diaeose of, femur, l!)!i, 190 ; oa 

oalcis, 374. 375. 37(1; tihia, 28S. 
EaUiVRCB. PiidFttesoa, on tbe use of coJd 

In Burser7, 201 ; on a case of sacro-illiui 

disease after oliildbirth, 350. 
ExcoRrATiON of auditory oonol front dis- 

eaned molar tooth, 119. 
EsposuRB of iutercxiatel nervee by on ab- 

ioesM, cane of, 148. 
Etslid, DOTve distribntion to, oompared 

with Chat of a joint, 154. 

Facial auscbbb, 83. 

Fbht, dilference in development of, 

231, SSe. ^68; after discjiso of the lower 

extreoiitj, \'-li>. 
Fbmuk, ani'hylo^is of. to pelvic, 304, 307, 

3!3 ; di«lo<:;tUon of, 21)7, 308, 313 ; dia- 

saae of epipbjniB of. 304 
PlNQRlt. dixtribntion of nerres to. 110, 
Furred tonouk on oue side, 110, 117. 

IIS. 

Qakobkite, a oase of, bom pressure on 

tbe nlniu nerve, 113. 
Olisuom's CAPSdi.B, function of, 7. 



Olui 



KRHTEs. distribution 
of, 134. 1:I7; paiD along inferior piidi 
dal braooh of, produced by bursa on ; 
borosity of ischinm, 138, 139. 

QiiNORRiKEA, ohordee after, canse of, 
lUI ; joint-tronbleB (pyEBmic?j after, 
178. 238. 

GBAHIII.ATIOIIB, pafutul, mofie of treat- 
ios, HI. 

GitAHPiNO, nerrouB supply to muBOleii 
gaged in, 07 ; intluen'je of musculo- 
tmneons asaooiation on. 07. 

Qrati.no beard and fell iu diseased jointa, 
reiuion of, 189. 

OuAY tiAiR on t«Diple, dopending on a 
liecajed molar tooth, 110. 

Growtd the antityjie of repair. 3 ; insep- 
arably connected with rest. 3 ; of plants 
tbe result of rest. 3; of plant's Hnnter's 
Tiews respecting, 4 ; repair, a repetition 
of, 3. 

Ha5db. difference in development of, 201. 

Hkart, tight auricle of, raeiihanical in- 
UnencB on tbe third lobe of Che luug, 9 ; 
effects of overwork on, 7 ; diseases of. 
nasociaCeJ wiCh onCaneous pains. 147, 
151) ; value of local application of anies- 
theCioi in diseases of, 150^ 

HSAT, true sign of local inflammation, 
40 ; value ot, in diagoosiitg inflamed 
jointa. 40; a means of distinguishing 
between an initable and inflamed nicer, 
40. I 



EX. 293 

Henlb, PROFRsaon, epithet used by, to 

gnb-orochnoid tissue, 13. 
Hernia, danger of por;gattves after, BBj 

value of rest in cases of. 85. 
HiP-J<HNT, anchylosis of, 204, 307, 213; 
congenital raalposition of, 33S ; distribu- 
tion of nerves to, 133, H>;t. 

, ursiCA3& or, eesaciated with pain 

in knee-joint, 194; aot neoeftsaiily sorof- 
nloua, !0I ; has nothing npeviol in iU 
character, 193 ; oharacteristio Bymptoms 
do not show themselves till tbe diseoas 
has advaaced, 193 ; importance ot early 
diognoais of. 193; diagnosis of, 105, 
190 ; value of rest in uosea of, 107 ; 
method of distinguUhing iiymptoins of, 
bom thofie of sacro-Uiao disease, 198; 
cured by rest in same patient where the 
shonlder- joint was destroyed for wanii 
of rest, 109; splint for, 200, 2U5, 306; 
case of, I'ured by Bve montbs' rest. 203 ; 
of twelve months' duration, cured by 
seven months' rest, 303; in ncTotulous, 
patient cured by rest, 204 ; limb straight- 
ened and splint applied, cured by rest, 
200 ; with dislocation of right femur, 
death from pyemia, 213' scrofnlooH 
treated by rest, 214 ; In phthislotl pa- 
tient, cured by anchylosis, 216; bony 
anchylosis, opening of abscess deferred, 
recovery, 330; scrofulous, cured by an- 
obyloeis. absoess absorbed, Zi'3 ; with 
suppuration o( left side, cured by (our 
months' rest, 33.5 ; supposed to be gon- 
orrhiEal, cnred by rest, 230 ; sequel to 
scarlet fever, cured by rest, with onohy- 
losia, 228; with necrosis of aoetaboliun, 
cured by rest, KKt ; cases simulating, 
230, 337, 3S8, 340, 242 ; symptoms of, 
produced by curved sacrum, 338; aymii- 
toms of. onusei by cerebral disease, 237 ; 
simulated by dbease of Che last lambur 
vertebra, 343. 
HobMRH. Mr. T., on spina bifida, 20 ; on 
a cose of early hip dieease, 120; on the 
diognonis between infantile paralysis of 
lover limb and hip disease. 237. 
HoMOWPATHT and hydropathy often gel 
the credit where rest effects tbe cure, 43, 
Hood. Dr., letter on the effcota ot over- 
work produciog inwuiitj, which is cured 
by rest, 6. 
HuoHumofl jArKBOK. Dr.. on th« opb- 
tholmoacopic condition of tbe retina 
daring sleep. 2SI. 
HuMTKR, JoHH, views of, on growth and 

rest in plants. 4. 
Htprooefhalds. difTased and e(t«niBl, 
32 ; internal, caused by closure ot the 
iter a tertio od quartam ventriciilnm, 2!! ; 
Internal, fluid of. drawn oS by puncture 
of anCerior fontanelle, 23. 
HYoro BONK. ortcrieB to. 108. 
HvPBHA'jTHiau, area of, after fractured 
■pine, 42. 



I 
J 



294 I N D 

Bybtbrical PAIN9 In h'p- or knee-joint, 
explanation of, 120 j ailecUoiui of ra^ro- 
oooaygeal joint, bow to diHCinguish, 2!)i>; 
oonlraction of abdotuinnl muscles, how 
to dUtin^fiiuih from Uiat of peribomtia, 

IcB. uppliotttioD of, to tranmatio dialooa- 
tjon of tibm. 2(iU ; applicution of. to la^ 
cerated wound, iuto knee-joint, SUl, 

Iliac ABscfuis. 70. 

Ilium and Kacmm. diBeaeebctweGU, cured 
by rest, 240. B4H, 340. SSO. 

biFANilLB rAllAl.vala effecting 1o»-er 
limb, diagnoaia of, from Mp disease, 
837. 

In FLAUMATION, locol lieAt ft true indica- 
tion of, 40. 

iNTEHCOflTAL KERVES, dietiibntioii of, 
143. 147. 

Internal ktAsiLLARr artekt, dietribn- 
tioQ of. 1G9. 

Intkrkal bapfirnotib kerte, distribn- 
"nof, ];" "" "" 



1. 127. 



jAidiDtrn prndnced by congested liver, 
af tei forced rest. 8. 

Jaw. lower, diaeoae of, following Bcorlt- 
tJniL.232. 

Joints, inflamed, wliy thej become flexed 
and fiiail. 95, B6 ; flexed knee, cause of, 
07; inllamiuiition of, by cutaneous ap- 
plication of aniestbetics. Ill4, lUQ, 110- 
■welling' oF, analogoua to callus in a case 
of fracture, 153. l^tS • cause of gratiui 
sensation in, IHl) ; those least subject b 
overwork least liable to disease, 181. 

. disxlahru, explanation of Qexnre 

in, 07, 08 ; more frequently the result of 
overwork or nvcideut tban of serofula, 
177; of kip and knee on saine side, 
treatment of, 178; necessarily ooc-npy a 
long time in their cure, 180; ooBto-TCrte- 
bml, »ery rare. 181 ; tarsal. ISS ; course 
of, in children, 189 ; absceaEOB connect- 
ed with, propriety of opening', £18, 222. 

JrMPrNn, inltuence of muBcuio-cntaneoua 
■ * 1, 07. 



KiDNET, effects of overwork on, 7 ; elastio 
oapsnlu of, ; effect of pressure of the 
oolun on. 0. 

Knke-Juint. abBcesH over the, 71 ; anchy- 
losis of, ISt, 180. 3(!1 ; flexed. OS. 00; 
' grouping of muHClen of , by their nerrona 

distribotlon, 12i'<, 1^; lacerated won od 
into, treated by cold and rest. 261 ; 
local applioatioQ of omestheticii to, 132; 
nerve distribution to. VIT. IH'i; pain in, 
jutsociated witli disease of the sacro-iliac 
ortdculntion. 125; paia in, associated 
with spiunl disease. 125 ; pain in, asso< 
oiated witb diaeiae *>( colon, I2i>; pain 



in, associated with disease of hip-joint. , 
125. 
KkkE'JDINT, disease of, producing dis- 
location, 133 ; treated by diriaioa of 
tendons, 133; scrofulous, cured by reat, 
■J57 ; with necrosis of patella, cored by 
re.'tt. 258 ; with flexed joint, tendon* 
divided, cured by rest, 2Q5, 2(t6. 

Lauekehs in cntLDREN due to deficient 

nerve influence, 230. 

Larvhx. disease of jointa of, 190 ; phyal»- 
logical rest afforded to mncons membrane 
of, by nitrate of silver. 100 ; I«w of 
nervous distribution to, 13-^ ; onae of 
syphilitio disease of twenty-eight ye&ti 
niter tracheotomy, 36. 

Latent feritunitib, 143. 

LitiAUENTL'u TRKEB often the aarlieat 
seat of hip disease, 120 ; disappeaia fr^ 
qnently after a slight injuty ' "* 
people, 104. 

LiTHUTOMT ^ives rest to bladder by re* 
moving cause of irritation, 30. 

Liver, effects of overwork on. 7; eaa> 
gestion of. produced by f oreed rest, 8 ; 
clastic oapsule of, 7 ; influence of di»> 
phragm on, U. 

LuMDAit KtR^EB, distribution of. 148 1 
vcrtebne. disease of, simulating diaeaaed 
knee-joint, 125. 

iTKGS, elasUcily of, ; third lobe ot, 
influence on the right auricle. ; matll- 
od of preparing, so aa to show their 
normal dimensions, ; congestion of, 
produced by recumbent position, S. 

Lvuru, value of the effusion of. asaapliat 
to secure rest. 38, 55 ; effusion of. la 
perioanlitta, cause of, 151 : Knttira's in- 
tention in the effusion of, in pcrieardida 
and croup. 151 ; absorption of, oftW 
periaardiUB, IGl, 1G2. 

Lymphatics, abBorption by, may explain 
enlarged gland and pain. 44, 40. 

HARsn, Mr. H., on two cawTs of lithotomy] 
in very exhausted chi!drpn, 5. 1 

Median nerve, i-ffect of praarare on, I 
113. I 

Measurino lower likiib, method ol^ j 

Monro, foramen of, 11. 1'', 

MrciiL'SMuuBHANEs. ncrvona anodotton ] 
of. with muscles acting upon tbei . 
uervouB association of. in sore throat, I 
155. ISO ; influence of purgative med- ' 
ioincs on, 150; of irritabta bladder, I 
method of relieving, 150 ; of tectum, * 
nerve distribution to, 10-1, lUS; * ' 
nrethra, 101 ; of vagiun, IGl. 

MURCLEB, grouping ot, according to tbejr ' 
nervous Hupply, 103 ; precision of ner- 
vous supply to, 102; supply to muaolM 
of leg, 127. 

Mdscui^R kdjostment described, iSi, 



I 



283 ; contraction of, after burns, oame 
o(, 140. 
Uuecui'O'ariKAL hrrvb, disCribntioii of , 

102, 103. 

Nature, power of, in aeK-repnration, 2 ; 
eruploya rest aa acarntive agent. 3 ; the 
rppnriLtive power of, a principle of 
guidontie fortba Burgeon, 3S ; trentment 
of, for Hevere injuries, H'l ; treaCn>ent of, 
(or B foreign boij in the oonjimctiva, 
85 i conatanb tendency of, to repair in- 

I'ariea, <t5, 39 ; intention of. in etfnsing 
ymph in periaardltis and oroup, 151. 

MKCROdis of ocetsbulnm. 23^ ; of tibia, 
231 ; of patella. 3.'>8. 

IfiiHvRB, fitch cerebral, irritation of, pro- 
ducing pain in the anili^ory canal. 44; 
GIbh pair, irrttotiun of, by diseased 
tooth, 44 ; p«in in the cutaneous diatri- 
bation of fourth and fifth dorsal, caused 
by Bnenmm, 50; the same that supply 
the joinM Hopply alao the inn^clea moving 
the joint and the aldn over the iuHertions 
of the mnscles, M ; precL-ion of sapply 
of, to the mnsoles, 1112; meilian. effect 
of preasureon, 113 ; ulnar, effect of prea- 
■ure on. Hi) ; obturator, effect of pressure 
on, 125; of inucoiis membranes, their 
AaEKwiBtion with muscles Boting upon 
them, 140, Ifll ; glutoal, diHe.-ute of. 
producing pain in penis, 137 ; gluteal, 
pitin along, produued by buna on tubei- 
osiQT ol ischium. 1.19. 

NsRVi^e, DiBTiiinuTioK OP, to ear. a 
means of diagnosing; disease, 43 ; fifth 
pair, causing osHooiatrion of di^eo-ied 
tongue with aurieulur pains, 44 ; necoud 
cervical to the external ear, 4^; fifth to 
the exterual ear, 44; Hfth to soalp, 44 ; 
occipital to scalp, 44; to the elbow. , 
lllfl; to the fingers. 11(1) to the toes, 
111; to the thumb. 111; to ihe wrint, 
120 ; of Ulterior orursl to the hip^joint, I 
i3'Z; from saaral plenus to hip-j.iint, 
iO'i ; of the obturator, to the bip- joint, 
132, 1118; to the knee, 137, 128. IHl ; 
to the larynx. 135; to the diaphntjjm. ! 

103, 146; to the pericardinm, 14,~>; to 
the Bnua. loy ; of the anterior crural to 
the hip-joint, U'H; ablominal, 141 -, 
■ecoad cerricol, 43. 44 ; third oerricol. 
43, 2711; fifth oranUI. 43. 44. 115 ; oir- 
cnmlleic. UD; anterior crural. 120; 
foarth and fifth dorsal. 47. 5.) ; first dor- 
iol, 270; aUtbond seventh doraal, 4S, 
40 ; superior gluteal, 134 ; inferior 
glateal. 137; intercostal, 143, 147; 
InmbBT, 141. 144: recurrent laiyngeal. 
138: obturator, 124; ovarian. liK ; ex- 
ternal popliteal. 132 ; phrenic. 10:1, 
154; pudic, 13B, l.ia, l«a, 107; inna- 
culo-spinil, loa; social. 10,^ ^ socro 
coccygeal, 2.53: saphi 



Bdotio, 127, 'ltl7; solar plexii^ 



295 



spinal aoceBBorr, 13a; splBnohnie, 47; 
aynipathelic. ISO ; uterine, 13B ; 
NlTKATB o» HILVBR. means of affording 
phyaiologicol rest to mucous membrane 
of larynx, 150 ; applicatioa of, to anal 
ulcerations for procuring phyaiolocricol 
reut, 171, 172. 



Obturatob hbbve, distribntion of, 124, 
127. 183. 

Omanibm, snccessftil method of treating, 
ISS ; case of, with pecoliar symptoms, 
158. 

OriOM injections in oyatitiB a means of af- 
fording physiological rest, 157 ; use of, 
in chordee, 101. 

ORBITAI. ABftCBSS, 73. 

OitioiN of bip-joint diseaso, 136 ; of apiiuJ 

disease, 48, 
Ob CALCiS. disease of, cured by rest, 272, 

274 ; removed, renewed liy Nature, 273 ; 

disease of epiphysis of, 274; spontane- 

ona separation of epiphysis of. 275, 270. 
OvARiAK nKBVES, distribution of, \29, 

130, 



Paget. Sih J., on the inSnetice of tha 



47; I 



the mimicry of bip- and knee-joint dis- 
ease, \29 ; on the presence of odhesiona 
in joints long kepi ut rest, IW; on tho 
value of temperature in diagnoais of 
joint disease, 104, 

PArn suggcBiE rest to injnred parts, 3 ; 
value of, as a symptom of dtacase, 40, 
41 ; by itself not an evidence of inllain- 
mation, 40; external, unaccompanied by 
liHEil inflamination. a sign of distant de- 
rangement. 42 ; over lower part of abdo- 
men and pubes, resulting from diseased 
spioe, 42 ; cutsneoDS, over the soapnla. 
Guimesof. 4C, 14H ; Bryminetricol, anolysiB 
of, ol; Hymmetriual. over stomach, in- 
dicating disease of sixth and wventh 
doisal vertebne, 48, 4Q ; difference to 
the indications of unilateral and bilat- 
eral. 51. 

— . '■BTMPATriETrc," moans of dis- 
tinguishing. 40. 41 ; cauKe of. 41 : often 
mistaken tor rheumatism, 41; throi 
the medium of the distribution of I 
oerehro-spinnl nerves, value of, m a 
means of diagnoxia, 41. 

pARAT.ysis OP LRPT LKO following typbos, 
237. 

PATBLL.B. non -development of. treated 
by teat. 255 ; nenrosia of. 25S ; rupture 
of ligaments of. treated by rest. S7t. 

Pri.vic bunes. artioulation of. 183. 

PERI-ARTIOULAHBblweBa. 218, 

pEKrcAitDiTi^ conHidered in relation to 

physiological rest. ISO. 
Pbbioaroiob. dirtribution of nerves 

143, 140; nervous assoolotion of, with 



I 



pit SC IB ION 

caes, 1U3. 



k 



tlie diaphTBgm analogous to JUtiibution 

of tcrveH to a joint, 145. 
kept tense bj cervical faacift 

above and diaphra^nii below reiuon of 

this, 145. 
PBHITOSlTia, why it prodaceB contraotion 

of abdominal masoleH, 142 ; latent fomi 

of, 143. 

PunOKBAI. OR EXTGHNA.!. PUI>Lm:A.L 

NK&vil, distribution of. 131. 

PUJtESJCNKIlVE. distribution of. 1C3, 140. 

Plants, grontli of. a le^ult of rest, 3 ; 
pbysiolo^ioiU rest of. in hot couutiics, 3. 

Plbukisi, why aaaoouited with cntoneoan 
pofna, 147 ; Talue of lucal application of 
anteathetHM in, 148, 149; nuccsEit/ fuc 
rest lu the treatment of, 1.50 ; c^tutuog 
Bj'Rimetiioal cutnneous piun;i. 144. 

PSKVUOiiABTSlC HEnvR, laceralion of, 
<10 ; preBsure od, Iij blood dot, 31. 

PorLiTBAJ, ABBCHaa, 83. 

L AJisCEse, G3, 7^. 

, symptoma of, prodaoed by 

anal ulcer, ITS. 
Pbost.itk tUAND, nlcoFBtion of, prodvi- 

(ang symptouiB ot Btono, it!, 
PuROATivii:)), danger of, after hernia, !II>; 

oooalantuae of, injiidicjooa, I5U, 
PuDic NBRVua, diaUibuLion of, 139, ICS, 

105, 107. 
Pyemia and pj'cemio joint- ttoablea after 

fevera, IBO. 



1»8; 

RucTCU, canoer of, painlem, 103 ; inaoD- 
ribilitr of, 1112 ; diatribuliou of nerrea 
toinuconaioembnme of. lUT, USS ; art«- 
liol diatribution to, lOrt; nloetof. I'llt, 
l(i7 : nlcet ot, aaaoaiated with eolai^ed 
glaodg, 170. 

RiiCL'SBKNT LAitmoEAL NBRVB, distri- 
butioD of, 135. 

Rsi'.tllt, primordial powsrot atmctniea to 
repair themaelvea, 1! ; a repetition ot 
growth, 4 ; maiimnm of, oo-equal »il.h 
luiniinum of dinturbauoe, 6; iLuociatcd 
with d'^feotive aleep in the old. 5. 

Brst the first curabire agent of Natore, 3 ; 
to injured porta aoggeatBd bj pain, 3 ; 
and (^owth inseparably oonnouted, It ; 
and growth iu plants, John Huuter'a 
views regarding, 4 : ve^tnble, the Qorol 
clock an instance of, 4; phjaiological, 
of plante in hot conutriea, 4 ; neoeaaary 
for ibe produotiou of animal food, 4 ; 
and sleep the nornisl ounditioa of 
healthy infants. 4 ; of the brain, ex- 
eiDplifioatiou of, S ; effect of, in cnriag 
inFmotty prodnced by overwork, ; onil 
work, altemntiou of. necessary to so- 
onio tha bealtb of tha visoera, 7 ; Na- 



ture's plan (or auatainins health, 2t^1 
1 of the brain treated by, 81 j'' 
IS of the Bpiue ueated by, 83 ; 
1 cored by, £> ; value of, in bir- 
Dia, 33; given to the larynxin laiyofptii 
l:y trachea tont]-, iSli ; to Injared luain 
by trephiuiv^g, S1I ; nloer of longua onnd 
I"/' *■> 1 given to eyea by painting a orfl- 
ing green wbcn the patient moat be is 
tbe tecnmbeiit position. 00 ; atMoeasea 
opened to sccnre, to their walls, 60 : 
stnuaea cured by, 76 ; physiologieM 
method of treating iir'-table nlcen W, 
US ; observations on, by M. David, 97; 
physiological, case of intolenace ot 
light curerl by, B4; phjaiologioal, pro- 
dnced by the cutaneous appUcaltoa of 
aomatheticE, 104 ; necpEnity for, in plen- 
riny, 140 ; phyvoiogical, in rdation to 
peiicarditis, 153 ; awelling of jointa a 
nieaOB for secDtlng, to3, 153 ; to a ftao- 
tured boue secured by callus, 153 ; IJiex- 
apeutic influenoe of, indicated by Na- 
ture in injuries of the eye, 1G4 ; phyno- 
logicnl. injury to the conjunctiTa cuivd 
by, 155 ; phyaiolf^cal, in treatment of 
spasm ot the throat, 155; to mnoooa 
membrane of the larynx by appllcatii» 
of nitrato of silver, HAi; physiological, 
in cases of eystitia, 157 ; pbynologioal, 
means of proauriog In vsginiBm.iis, lfl9; 
physiological applioaljon of. to rata m 
ulDsr in the reetum, lti3, 184; mod* of 
giving, to a painful anal nloer, IIH, 171 ; 
phy Biological, to irritable ulcer of tbe 
anus . 173 ; to obstructed ooloa by oni- 
flcial anua, 175; compulaoty, notinjori- 
ona to health, IBU; of joints, doea not 
deteriorate their atrueture, 180 ; valne 
ot, in hip-joint disease, 341 ; hip-iojnl 
disease cured by, in five months, -KtS; 
hip- joint disease of twelve mon^ cnrcd 
by, in seven months, 303 ; hip-joint dla- 
ease in aerofuloua patient cured by, S04; 
hip-joint disease cured by, 20d ■ svrofn- 
lous hip-joiut cured by, S14 ; bip-jolst 
disease cured by, in tonr moDths, 2S& ; 
hip-joint disease, with necrosis of acetab- 
ulam, cored by, SS'J ; disease of si^na 
close to tbe pelvis cured by, 344; laogo- 
iliac diaeoae cured by. MB,34D; aaoro-iliao 
disease after parturition, cored by, 1190; 
diaease of aacro-coccrgeal joint cored bj 
S53 ; BBoro -coccygeal joint, inflsmmatiaii 
of, cored by, 254; vuloe of, in a case of 
non-development of the patelln, IQ6: 
eorofuloua disease of knee-jt^t, treated 
by. 3.77 : diseased fcoee-joiDl, witli ne- 
crosis of patella, cured by, 358; Inn- 
niatia dislocation of tibia treated Ig', 
disease of epiphysis of feninT 



i of wrist cond by, 870; 
dioesBe of cuboid bone cared by. 272 ; 
diseaae of o» calois cured by. X7'i, 2T4 ; 
meads of Bocatiag. to diseased eprphj-Kk 
of 08 oalcla. 375 ; Tslae of. in treSituieal 
of disease of ateno-claTiculu joint, 
278 1 disease of st«iuo-cl aT-cul.tr joiiit 
cured bj,S70; disease of Btetnam cured 
bf , 279 ; v&lQe of, to joints ia cases of 
DTer-fatigne, 383; mode of giving, to 
c:ipillariea, 3S3 ; diseased ankle- joint, 
witb dislocation, cured b;. S^^. 

RlEtOEd on inner surface of base of akoll, 
one use of, 17. 

CiTfKiiTON, Mb. W., on the forms of joLat 
met with between Gut two pieces of 



Sacrai. hzrveb. distribution of, 1G5, 252. . 

Sacbu-oocctqeial nbrtrb. distribulJoa 
of, 2r>2; joint, disease of. cured by lest. 
2^; joinc, hysterical aSeotions of, how 
to dististrnlah, 255. I 

Sacho-ii.iac joint, disease ia, may be 
BBsociated with pain in kneejoint. 125 ; ' 
disease in. may be confounded with hip- 
joint disaisL', lUB ; disease of. after pnr- 
tariuoQ, cured by rest, 2.')0 ; disease of. 
oared by rest, 24.1, 24lj, 2^. 

Saoruk. curved, firoducm^ aymptoms of 
hip-joint disease, 2i!8. 

Sakd-b.^ub, mode of conatmcUng, and 
Talus of. Hi. 

SCALi', distribution of fifth and occipittd 
nerves to, 44, 4li. 

Scaphoid bose, anchyloaia uf, 168. 

BvARi.ivT FBVRK, hip-joinc ilist^ose, aeqnet 
to. 228 ; necrosis of tibia and anuhylosis 
of ankle -j lint lolluwiiiK. ^tl ■ disease uf 
lower jaw following, 2.'!:^. 

Sciatic kbhveh, distribution of, 110, 
l£j. 128, 144, 204. 

ScKOt-iTLoUH or tubercular disease seldom 
the cause of spiaai disease, 47 ; less fre- 
quently the cause uf diaeused joints than 
aocident or overwork. 177; hip-joint 
OQied by rest, 204, 214, 2i>3 ; of knee- 
joint. treated by rest, 4B : of both elbow- 
jtauts. 2U9 ; of wrist, 27U. 

8b LP- nici'A RATION, Nature's power of, 3. 

S&Bova NEHBiiANBB, doueeT of disturb- 
ing coi^fulable Ivmpb in wounds of, 3U ; 
nervous tusociatioQ of, 141, 142; Ab- 
sorption by, 152. 

, their relation to onta^ 

neooa and muscular distribution of 
nervea. 147, 148. 

Snat'i.tiKR-.i(iiNT, diseive of, joint de- 
stroyed for want of rest, I'Ji). 

SisuB cured by rest, 7«; treated by a 
trus?, Dl ; deep in the groin, 92 ; under 
tendons of the muscles of the foot. S2. 

Skull, tractnro of base of, without evi- 
dence of lesion of the bn«n. 1(1 ; frac- 
tured base of, associated with lutrcd 



39? 



tongne on one aide. 118; oeitain parte 
of base of, do not correspond with over- 
lying braiu. lU ; use of ridges on inner 
surface of. 17. 

ScEEr necessary for repair of the body, 
2 ; after operations, 3 ; want of, in 
children, connected with imperfect nu- 
trition, 4; defective, assooiuted with 
slow repnir in the old. 5; persons of 
middle age bear loss of, aCler iujurles. 
better tl^ children, 6; those who do 
BO well, and soundly, bear great mental 
labor cosily. 5. 

Sphincter asi, line of demarcation be- 
tween intemiJ and external sphincter. 
ItHS ; reason for dividing, in coses ul 
anal ulcer, 171, 17:1. 

8t'iNA Bifida. rBlation of, to cerebro- 
spinal duid, 10; danger uf injecting. 20; 
danger of drawing off all the fluid from, 
30; ligatnre of, producing inllnmmalioa 
of the araohnoid, 2tt ; mode ot treating, 
2i) ; nBBOciated with occlnaion of spinal 
opening, 23. 

Spinal accemort nerve, disti'ibuUon 
of, 13S. 

disease seldom produced by acrof- 

olo, 47 ; often the result of exercise 
after mnsciilor exhaustion uud over- 
looked BcddcntB, 47 ; fretjucctly oom- 
mencts in the intervertebral aubatance, 
47; indicated by &Ked cutaneous pain 
before deformity takes place, ii; be- 
tween, occiput uod atlas, cutaneous pain 
not Hymiuetriuat, 51 ; in the oei'vical, 
dorsal, and luinhar regions, the cutane- 
ous pain i^mmetrioal. 51 ; of sixth and 
seventh dorsal vcrtebrm indicated by 
pain over the stomach. 49 ; of sixth ftnd 
seventh darutl vartebrco treated by rest, 
49 ; symptoms of, between occiput and 
upper cervical vertebrro, 54, 50, ^7 ; 
with ay Tu metrical abdominal pains, 
cured by rest, 52 ; nith psoas aluoeaa, 
cured by rest. 53; between first uud 
second cervical vertebrtj, cured by rest, 
with anchylosis, Sii, 58 ; between first 
and second cervical vertebras cured by 
rest and the use of sand-bags. 60 ; of 
cervical vertebra caused by a blow from 
a bolster. .'i3 ; bctweeu first and second 
cervical vertebral, oauaiog loss of sensa- 
tion in the limbs, cured by rest, nit ; 
diagram showing proper position for a 
patient with diseaGo of cervical vurle- 
brse. 57; diagram showing eSi^ct of de- 
struction of ligament of the atlas, axis, 
and occipital bones. 58; valne ot amitll 
pillow in cases of . 58; ot Urst and sko- 
ond cervical veri^bne. death oau-ied by 
ignorance of nurse, (11, 62; ulceration 
of articular cartilage and laceration oC 
tiaosTOrse ligament. resnltJng fromsjiih- 
ilia, 5:] ; portion of atlas ei[ielled lru:n 
poat-pharjUa-enl abitceas, til ; aiicbylosls 



298 IND 

of oooipitol bone, utlu, and aiiB, 34 ; | 
Ol Rest auil second cerricai vertebne, , 
uichyIo*iB, death of patieat thtee years 
after the injury which produced tiia 
diHenae. 04 ; of littli. sixth, and Keventb 
cetvical vertebne, pnrolyHis, death of 
^ patient fourteen yean afterwaids from 
an aaudent, fifi; sBsocinted with pain in 
knee-joint. 13S; oloBe to pelvu, oured 
by rest, 342. 

Bpt.NAi. HAKKow, coaooiuioii □(. 32, 3,1 1 
paraplegfia produced by nmuing, after 
receimng tujury. 'J3 ; exuiteiiient of, pro- 
duoes exhaustion and destruction of its 
exnito-inutor funotions, 'S-i; fructare of 
the spine.area of hyperiEathesia after, 42. 

SPLUbK, elastic capsule of, H. 

SfLiNT for Up-ioiat dlseaee, 300, SUO, 
229. 

Btbrno-clavicolak joint, omitomy of, 
270 i onchyloms of, STG ; ditiease of, 
cured by rest, 277, 878; diaoaBe of, 
death from pyiemia, 370. 

BT£ltNl:u. di.-wuBe of. cured by rest, 280. 

Stitck, eiplanation of, 148. 

8TOKE IN BLAUDKR, irritation prodaced 
by, causing extreme attenuation in a 
child, 4 ; does not always produce irri- 
tation, do ; symptoma of, produced by 
ulceration of bladder or prostute, 37. 

BcBCLAViAK ASTBRV, ilistribution of, 1(!S. 

SnB-FASCtAL AMCRPB, 70, 77. 

Si-n-MAMHABT ABSCE8B, treatment of, 70. 

St)B-i«ciPiTAL AB3CEBS, 78, 70, 80, 80, e«. 

Bt'DDEN OBATB in spinal diseaso, cases of, 
«l. 03. 

STMPATnETic SEaVB, bronchos to mmieX 
plexus, 120. 

" SifMPATSETic " pains, 46, 

Byhtatht between structures both In 
growth and in disease, mat with in obLl- 
dren, inittancea of, 1»() ; torei in adults 
ta regaida diacase, 19U. 

Stphilis m JUiNTB rare, 180. 



Tabbal joiftb, disease of, 184. 

Tbnotomv of ham-strings, 200. 

Testicls, elastic capsule of, 8. 

Thalauub nurvi optkt, effect of oera- 
bro-Hpinol fluid uu, 18. 

Thkrapeutich, natnral, definition of, 3. 

Thro.at. spasm of, tjreated by physiologri- 
oal rest, IW, 150. 

TaruB. distribution of nerves to. 111. 

Tibia, necroais of, 331 ; traumatic dial oca- 
tion of. treaf«d by rest and B|)plicatioQ 
of ice. 200; injury to lower epipbyaia 
of, death of patient, 285. 

ToBS, distribution of nerves to. 111. 

TosauB. injuries of, rapid repair of, 4.'i ; 
nicer of, cured by rest, 45 ; furred, 
depending on disease within the croai- 
urn, 117; furred on one side, produced 
by decayed t*>oth, 110, 118; (urred on 



one Hide, depending on fracture » 

base of the skull. 118. 

TooTti, Acayed. producing earache, i 
40; pio.iuui.igirrilutiouof filth p ' 
nervea, 40 ; ptodUPing nicer on la „ . 
43; produoing enlarged glund betiiu. 
the ear, 44 ; producing furred ton^s 
on one eide. 110, 118; producing gray 
hair on the temple, 110 ; prodocing 
excoriation of auditory canal, and eo- 
larged lymphatic gland. 119. 

Tracheotomy a means of Bi»ing rest to 
the larynx in chronic laryngitii '" 



s'-fu] i 

tu dise 



coses of 






TRErniNiKa gives rest to an injured bntin, 

30. 
Trubb sometimes useful far moking prea- 

TuKOKSdESCB of the brain, means for 
diminiabing, after exercise of tbdt 
organ, 1(1. 



Ulcers, irritable, means of du-tlngniidung, 
40;methodof treating, ta, 84; JiritkUc, 
of finger, 84. 8.') ; irritable, of Ic^, 8S; 
irritable, after amputation, S3 ; irritable, 
of legs, treatment of. 123 ; of lens, why 
so frequently near the ankle, 133 ; at 
rectum. lOa ; of rectum, aiwodoted with 
enlarged glands, 17(J; anal, painful, 173; 
oual, treatment of, by physiological 
rest,17-t; anal, producing retention of 
urine and symptoms of pregnancy, cured 
by dividing the sphincter, 17;l ; anal, 
producing patn along the edadc nerve, 
cured b.r division of sphincter, ITS. 

Ulnar serve, effect of pressure on, 113. 

Unhealthit htbuctithes, rapid deCeriw- 
ationof. 230. 

Uretuiia, spasmodic stricture of, due to 
inpply to it« muscles and muoooa 



Urine, 
ulcer. 178. 

Utbkinb s. 



of, produced by uul' 



, distribution of, 



TAomA, oontraetjon of, c 

treatment, 101. 

Taqinismiib, cause o^ and tretttiaen^ 



103. 






a distribution of 



Van d 

and motor nerves. 11)1, 
Yabci'lar ti uQKacENCB produoed bjr 

exercine of an organ. 7. 
VKiK^of lower extremity, 123; just abortt 

ankle, 12.S. 
Tenesbction, bent arm ofter, eatise of, 



131. 
Vemtbicleboi 



IK, ceiebro-spuuiH 



INDXZ. 



299 



fluid in, 10 ; use of, 10, 18 ; oommunica- 
tion between, 18 ; case of their coxnmn- 
nioation formed by a clot of blood, 
21 ; cause of death when blood tt ponred 
oat in, 21 ; dilatation of, by internal 
hydrooephalos, treated by tapping, 23, 
24. 
Vertebral canal, bed-sore penetrating 
into, 218. 



Ward, Mr., on the osteology of the foot, 

185. 
Work, over, effects of, on men of bosi- 

ness. 6 ; viscera require alternations of, 

with rest, to keep them in health, 7; 

over, effects of, on the heart, liver, and 

kidney, 7. 
Wrist, distribution of nerves to, 120; 

joint, disease of, cored k^ zest, 270, 271. 






J 



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LANE MEDICAL LIBRARY 



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APR J35 1933 



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