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Full text of "On rest and pain: a course of lects., ed. by W.H.A. Jacobson"

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BEST AND PAIN: 



2 (ZDourse of 'Eectutes 



ON THE INFLUENCE OF MECHANICAL 

AND PHYSIOLOGICAL REST IN THE TREATMENT OF 

ACCIDENTS AND 8URGICAI. DISEASES, 

AND THE 

DIAGNOSTIC VALUE OF PAIN, 



BT THE LATE 

JOHN HILTON, F.R.S., F.R.C.S., 

aUSGEOSr EXTRAORDDfABY TO UER MAJESTT THE QUEEN, CONSULTING SURGEON TO 

CUT*« HOfrPITAL, MEMBER OP THE COLLEGE COUNCIL, PRESIDENT OR TIIK 

ROYAL COLLEGE OF SURGEONS OF ENGLAND, MEMBER OP THE 

COURT OP FJCAMINERiS AND PROFESSOR OF ANATOMY 

AND SURGERY, ETC., ETC., ETC. 



EDITED BY 

W. H. A. JACOBSON, B.A., M.B. Oxon., F.R.C.S., 

ASSISTANT SURGEON TO GUY*S HOSPITAL 
AND DEMONSTRATOR OF MORBID HISTOLOGY IN THE MEMCAL "i^HOor., 



TIIIED EDITIOM 



^<y 



^g^^o"^ 



^UG 



! « 



v<9. 



$LOLE\^ 



v> 



LONDON : 

GEOEGE BELL AND SONS, YORK STREET, 

COVENT GARDEN. 

1880. 

[Tke riff At of Translation it rttervtd.] 



LONDON : 

PBIMTXD BT WILLIAM CLOWIS AND SONS, 
STAMFOHD VIXKET AXD CBABIKO CB068. 



AUTHOR'S PREFACE 



TO THE SECOND EDITION. 



-•O*- 



The First Edition of these Lectures was published, soon 
after their delivery,* 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. Durham, at that time Demonstrator of 
Anatomy at Guy*s Hospital, was soon out of print. It 
wae 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 pur- 
pose in view — namely, to show how largely wo are 
indebted for our professional success in surgical practice 
to the recuperative power of Nature, especially when 
helped by the suggestions of a thoughtful surgeon. But, 
on carefully scrutinising the materials, I foresaw what 
appeared to be insuperable difficulties; and since then, 
from one cause or another, I have allowed the reappear- 
ance of these Lectures to be from time to time deferred. 

* At the Boyal College of Surgeons of England, 18C0, 1861, and 1862. 



w-f 



iv 



AXJTHOB*B PBEFAOE. 



As, however, I have lately been aasnrod, on repeated 
occasions, that a Second Edition would be welcome and 
useful to many, I have submitted the Lectures to the care- 
ful and judicious editorial guidance of Mr. Jacobson, who 
has conferred on me a great obligation for the work he 
has now so well accompliBhed, with the slight aid of my 
own occasional assistance and supervision. 

It will give me great pleasure and satisfaction to know 
that the republication 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 value of mechanical and physio- 
logical rest in surgery. 



10, New Bboad Street, 

September Ut, 187C. 



EDITOR'S PREFACE 



TO THE THIBD EDITION. 



-O^ 



In the preparation of this Edition, the only changes made 
in ^Ir. Hilton's text have been a few abbreviations and the 
omission of two or three illustrations. 

This work, whilst acknowledged to be one of our few 
surgical classics, was formerly too much regarded as a 
monograph, a book which dealt with 8i>ecial subjects, and, 
by students in particular, as one which took them over 
fields far remote from those covered by the ordinary 
text-books, and which accordingly treated of subjects not 
noticed in the course of ordinary examinations. 

Mr. Hilton's ingenious way of reasoning from anatomical 
facts, and his application of those facts to the needs of 
daily practice, have done much to lighten the labour cf 
students, junior and senior alike. To the former, while 
ei^g^g^ ^ ^^^ drudgery of Dissection, this book shows 
how useful the dry facts of anatomy will surely be here- 
after, and it encourages the latter, while busy in the wards, 
to keep up their knowledge of anatomy, by applying 
to their practice the thoughtful lessons which abound 
throughout these pages. 



vi EDITOB*B PBEFAOE. 

To those who, in friendly oritioifim, have BUggested to 
me that somo of Mr. Hilton's yiews are fancifdl and speeu- 
lative, I would reply, that such speoulating enoourages 
anatomical investigation, and gives fresh interest and zest 
to it. 

As bearing on the value of snoh leotnres as these, I may 
quote the following from Professor BiUroth's * Pathologie 
und Therapie,' 7th ed. p. 849 : *' Es liegt in der Strdmnng 
unserer Zeit, dass solche sogenannten theoretischen Re- 
flexionen, mit denen ich vielleicht Manchen von Ihnen 
ermudet habe, nngebtihrlich in ihrer Bedentung und 
Wirkung auf die Praxis unterschatzt werdon, und diese 
Stromung reisst auch Viele von Ihnen mit sich, und 
bohindert Manche, sich mit dom Erlemen und Nachdeuken 
uber diese Dinge zu befasson. Doch ich versichere Sie, 
dass Sie spater, wenn Sie erst einige Jahre in dor Praxis 
sind, kaum im Stande sein werden, ein medicinisches Work 
zu lesen und zu vorstehen, wenn Sie nicht wahrend Ihrer 
Studionzeit die Basis gewonnon haben, auf welcher von 
nun an weiter und weiter gebaut wird. Ich bin iiberzcugt, 
dass sich nach einigen Jahren der Praxis Maucher von 
Ihnen, der heute iibersattigt von Vorlesungen ist, gar 
sehr damach sehen wird, einmal wieder einen zusammen- 
hangenden wissenschaftlichen Yortrag iiber wichtige 

Krankheitsprocessen zu horen " The drift of the 

above I perhaps may render thus : " A strong tendency has 
set in, in our day, to undervalue, as regards their import- 
ance and influence on practice, the so-called theoretical 
observations with which I have, perhaps, wearied many 
of you : this tendency carries many of you with it, and 
prevents many from applying themselves to these subjects 



editor's pbefaoe. 



Vll 



with due reading and consideration. But I assure you 
that in later days, when you have been some years in 
practice, you will scarcely be able to read and understand 
any work on medicine, if you have not, during your 
student years, secured a firm foundation, on which you 
may continue to build. I am convinced that after a few 
years of practice, many of you, who at present are surfeited 
with lectures, will long to hear once more a weH-arranged 
and scientific discourse on important morbid processes." 



41, FmsBUBT Squabe, 

February 1880. 



CONTENTS. 



PAOS 



The Inflaence of Nataral Therapeotios — Beet the chief Natural 
Therapentio— Object of Pain — B&et the Fosterer of Bcpair — 
Rest necessary for the Healthy Action of any Organ — Means 
adopted by Nature to secure a State of Qniescenoe to the 
yorions Viscera 1 

LECTURE n. 

Distribntion of the Dora Mater — External and Internal Arach- 
noid in the Cranium and Vertebral Canal — Wapt of Corre- 
spondence between certain Parts of Base of Sknll and Brain — 
Physiology of the Cerebro-spinal Fluid — Relation of Spina 
Bifida to the Cerebro-spinal Fluid — Danger of drawing off all 
the Fluid—Clot of Blood giving a Cast of the Third and 
Fourth Ventricles and Intervening Spaces — Case of Occlusion 
of the Cerebro-spinal Opening accompanying Internal Hydro- 
cephalus treated by tapping one of the Lateral Ventricles . . 20 

LECTURE HL 

Function of the Cerebro-spinal Fluid in the Foetal Brain — Case of 
Occlusion of the Cerebro-spinal Aperture — Condition of the 
Brain during Sleep— The Brain after Concussion a Bruised 
Organ — Comparison between a Bruise of the Brain and that of 
other Organs — ^Long Rest essential after Concussion of the 
Brain— Neglect of this a Fertile Cause of Permanent Brain 
Disease — Symptoms of Concussion of the Spinal Cord, and 
Treatment by Rest — ^Most of the Graver Operations of Surgery 
performed for the purpose of allowing Nature Rest to restore 
Injured Parts — Case of Tracheotomy Twenty-eight Years after 
the Operation 44 



OONTBKTS. 



LECTUEE IV. 

FAGE 

CoaguTablo Lymph a Means for seooring Best to Inflamed Seroos 
and Mucous Membranes — ^Pain with Increase of Temperature 
a Sign of Inflammation in the part where it is felt — ^Diagnostic 
Value of ** Sympathetic " Pain — Area of Hyperesthesia after 
Fracture of Spine— Disease of the Yertebrso indicated by Pain 
over the Lower Part of the Abdomen and Pnbes — ^Knowledge 
of the Accurate Distribution of the various Nerves to the 
Head and Ear, leading to a Diagnosis of the distant Diseased 
Organs wliich may cause ''Sympathetic" Pain in those Parts 
— Pain between the Shoulders an indication of Visceral 
Disease — Pain over the Stomach, in the Region of the 
Cutaneous Distribution of the Sixth and Seventh Dorsal 
Nerves, a sign of Vertebral Disease* 67 



LECTUEE V. 

Synmietrical Sui)erficial Pains indicate a Central, or Bilateral, 
and Unilateral Pains a Ono-sided, Cause — Cases of Diseased 
Spine with Symmetrical Abdominal Pains — With Pain in the 
Back of the Head — Pain over the Left Shoulder and in Left 
Arm — With Loss of Power and Sensation in the Limbs — With 
imi>endiDg Death from Pressure on Spinal Marrow cured by 
Rest — Fatal Cases — Portions of Atlas and Axis expelled by 
Post-pharyugeal Abcess — Anchylosis of both Temporo-maxil- 
lary Articulations — Patient surviving Fourteen Years after 
Injury to the Cervical Vertebra) producing Paralysis of Upper 
and Lower Extremities 91 



LECTURE VI. 

Abscesses opened to secure Coaptation to their Intomal Surfiices, 
and to permit their Union by giving them Rest — Principle 
exemplified in Sub-mammary, Knee-joint, Axillary, Orbital, 
Cervical, Post-pharyngeal, Iliac, Sub-gluteal, Sub-fascial, and 
Sub-muscular Abscesses, together with the Best Method of 
Opening an Abscess — Sinuses ciu-ed by Rest — Treatment of 
Sub-occipital, Cervical, Carbuncular, Popliteal, and Facial 
Sina8e8---Cau8e and Treatment of Irritable Ulcers . .122 



CONTENTS. XI 



LECTUEE VII. 

FAGB 

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 — Headache and 
Intolerance of Light cured by Physiological Rest — Design 
manifested by the same Nerves being distributed to a Joint, to 
the Muscular Apparatus used for its Motion, and to the Skin 
over the Insertion of the Muscles — Application of this to explain 
the Involuntary Flexure of an Inflamed Joint .... 153 



LECTURE VIII. 

Cutaneous Branch of the Muaoulo-spiral Nerve — Precision of 
Nervous Supply to Muscles — Symptoms of Inflamed Joints 
and Treatment by Rest and External AnsBsthetics — Examples 
of Physiological Rest — Musculo-cutaneous Nerve of Upper 
Extremity — Bent Arm after Venesection — Cases of Injury to 
Musculo-cutaneous Nerve — Nerves of Fingers, Toes, and 
Thumb — Effect of Pressure upon Spinal Nerves — Gangrene of 
Third and Fourth Fingers from Pressure on Ulnar Nerve. . 177 



LECTUEE IX. 

Pressure on Ulnar Nerve producing Gangrene of the Third and 
Fourth Fingers — Furred Tongue on one side depending on a 
Decayed Tooth, Disease within the Cranium and Fractured 
Base of the Skull — Effects of Disturbance of Nerve Force upon 
Nutrition — Decayed Molar Tooth producing Grey Hair on 
the Temple — Excoriation of Auditory Canal and Enlarged 
Lymphatic Gland — Nervous Supply of the Wrist and Lower 
Extremities — Cause of Ulcers on the Legs being frequently 
just above the Ankle— Distribution of Obturator Nerve — Usual 
Origin of Hip-joint Disease — Cutaneous Nerves of the Knee — 
Explanation of Hysterical Pains in the Hip- or Knee-joint . 203 

LECTUEE X. 

MoBcnlar and Cutaneous Distribution of the Nerves of the Knee 
— ^Dislocation and Contraction in Diseases of Knee-joint— 



XU CONTENTS. 

PA6B 

Treatment — Muscular and Gataneoua Diatribation of the Gluteal 
Nerves — Order of Supply in the Distribation of Nenres to Dif- 
ferent Muscles — Course of Spinal Aooessory and Laryngeal 
Nerves — Pnin on one side of Penis depending on Disease of 
the Perineal Branch of the Ini^or Gluteal Nerve — ^Enlarged 
Bursa on Tuberosity of Isohinm — ^Relation of the Peritoneum 
to Cutaneous and ICuBCular Distribution of Nerves — Applica- 
tion to Practice — ^Latent or Masked Peritonitis — ^Bolation, by 
Nervous Distribution, of the Perioaidium to the Diaphragm . 229 

LECTUEE XI. 

Cutaneous and Muscular Nerve Distribution in relation to the 
Pleura — Application to the Treatment of Inflamed Pleura — 
Mechanical and Physiological Best as applied to the Treatment 
of Pericarditis — ^Analogy between the Effusion of Lymph by a 
Serous Membrane and the Production of OiUua in a Fracture — 
Swollen Joint a Means token by Nature to procure Rest for 
the Part — Rest illustrated in the Treatment, Natural and 
Artificial, of Injury to the Eye — Nerve Distribution to the 
Mucous Membranes — Practical Application — Chronic Cystitis 
relieved by Opium inducing Physiological Rest — Other 
Examples— Cure for Onanism 256 

LECTURE XII. 

Irritation of Mucous Membrane of Urethra and Vagina — Corapa- 
xative Insensibility of Upper Portion of the Mucous Membrano 
of the Rectiun, illustrated by Cases of Cancer, Vascular 
Growth and Overloaded Colon — Great Sensibility, Difficult 
Dilatation, and Enduring Power of Contractioti, the Charac- 
teristics of Lower Portion of Rectum — Ulcers of the Rectum 
cured by Mechanical and Physiological Rest — Anatomical Rela- 
tions of the Nerves, Muscles, and Mucous Membrane of ^Vnus 
— Arterial Supply of the Rectum — Arterial Association of 
various Parts of the Body — Enlarged Lymphatic Glands near 
the Rectum — " Sympathetic " Pains produced by Anal Ulcera- 
tion — Division of Nerves and Muscular Fibre in tlicso Cases — 
Anal Ulcer producing Retention of Urine and Symptoms of 
Pregnancy cured by dividing the Sphincter — Anal Ulceration 
treated by Division of Sphincter — Ca»*e of Arterial Hoimorrhago 
from an Anal Ulcer cured by Division of the Ulcer — Intestinal 
Obstruction treated by Mechanical and Physiological Rest . . 270 



CONTENTS, XIU 



LECTUKE XIII. 

PAOI 

Many Diseases of Joints attributed to Scrofula the Besnlt of 
Accident — Oeae of Disease of the Knee- and Hip-joints on the 
same Side — Knee amputated — ^Pja)mic Joint Inflammations 
after Fevers — Hip-joint cured by Rest — Diseased Joints require 
a Long Time for Cure — Joints protected from Injury by Over- 
exertion generally free from Disease — The Costo- Vertebral 
Articulations an Example of this — Pelvic Articulations — 
Diseased Joints more frequent in the Lower than the Upper 
Extremities — Disease of Outer Side of Foot more frequent than 
Inner — Healthy Joints not likely to deteriorate from Best — 
Foot of a Chinese Lady — Diseases of Joints modified by Age — 
Grating Sensation in a Joint before Cure by Anchylosis — 
Peculiar Course followed by Diseases of the Joints in Children . 306 



LECTUKE XIV. 

Hip-joint Disease not necessarily Scrofulous — Importance of 
Diagnosing Hip-joint Disease in an early Stage — Distribution 
of Nerves of the Hip-joint — Earliest Symptoms of Hip-joint 
Disease — Disease of Shoulder-joint not kept at Best, Joint 
destroyed ; Hip-joint Disease in the same Patient cured by 
Best — Dwarfed Pelvis as a Besult of Hip-joint Disease — 
Diseased Hip-joint cured by Five Months' Best^— Another Case 
of Twelve Months' standing cured by Seven Months' Best — 
Hip Disease in a Scrofulous Patient cured by Best — Diseased 
Hip-joint, Limb bent, straightened under Influence of Chloro- 
form, and cured by Best^Dislocation on Dorsum Ilii from 
Disease reduced. Anchylosis proceeding — Similar Case, Disloca- 
tion twice reduced 330 



LECTUKE XV. 

Dislocation of Bight Femur; reduced Two Months afterwards; 
Deatii from Pysomia — Hip Disease supposed to be Scrofulous 
cured by Anchylosis after Best; no Distinct Abscess — Hip 
Disease in a Phthisical Patient cured by Anchylosis ; Abscess 
absorbed — Discussion of the Propriety of opening Abscesses 
connected with Diseased Joints — Hip Disease; Bony Anchy- 
losis ; opening of Abscess deferred ; Becovery — Chronio Abeoess 



XIY CONTENTS. 

PAOI 

absorbed — Absoefls in DorBal Begion absorbed — Disease of Hip- 
joint ; AnchylosiB and Large Absoess absorbed — ^Best Method 
of measuring Lower Limbs — Diseased Hi]>-joint, with Sappnra- 
tion of tlie Left Side, cured by Fonr Ifontbs' Best; Abscess 
absorbed— Diseased Hip-joint, supposed to be Gonorrhoea!; 
Abscess opened by Nature; PortioDS of Bone extruded by 
Granulations ; cured by Best, with Permanent Anchylosis . . 865 

LECTUEE XVI. 

Hip-joint Disease; no known Accident; Sequel to Scarlet Fever; 
cured by Anchylosis, after a few Months of Best — ^Looal 
Affections after such Diseases as Scarlatina, Measles, ftc., arise 
from previously Unhealthy Structures suffering Bapid Deterio* 
ration from the Effect of the Oonstitutional Disturbance — Two 
Cases in Illustration— Diseased Hip-joint, with Necrosis of 
Acetabulum, cured by Rest — Hip-joint Disease; Anchylosis, 
with Thigh somewhat bent — Cases simu luting Hip-joint 
Disease due to deficient Nervous Influence; Treatment — 
Hip-joint Disease suspected, real Cause being Cerebral — 
Curved Sacrum, causing Outlying Symptoms of Hip-joint 
Disease — Congenital Malposition of both Hip-joints — Con- 
genital Deficiency of Development of one Lower Extremity 
resulting in its being Shorter than its Fellow ; Effect of this — 
Diseases of Sacro-iliac Joints — Disease of the Last Lumbar 
Vertebra simulating that of the Hip-joint— Severe Disease of 
Spine close to Pelvis cured by Rest — Disease between Sacrum 
and Iliimi, with Intense Pnin in the Leg of the same Side . 39G 

LECTUEE XVIL 

Sacro-iliac 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 ; Suppu- 
ration within the Pelvis, Abscess absorbed, cured by Rest — 
Disease of the Sacro-coccygeal Joint, from Injury, cured by 
Rest — Inflammation of the Coccygeal Joints, from Injury, 
cured by Rest — Pain in the Posterior Portion of the Coccyx in 
Hysterical Cases, Explanation of — Case of Non-development of 
both PatellsB up to the Age of Three and a Half Years — 
Disease of Knee-joint (Scrofulous?) treated by Mechanical 
Best cured by Firm Bony Consolidation — Diseased Knee-joint, 



CONTENTS. XV 

PAOI 

from Injury, with partial Caries or Neorosis of the Patella, 
cured by Best — Traomatio Dislocation of the Tibia, treated by 
Beat and Application of Cold — ^Wound 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 in Knee-joint, 
Flexors divided — Treatment of Loose Cartilage of Knee-joint 
by Be«t 431 

LECTUEE XVIII. 

StnuDons Disease of both Elbow Joints ; Joints well Anchylosed, 
but in bad Positions — ^Disease of the Wrist cured by Best — 
Oaae of Bupture of the Ligamentum Patellse at the Junction of 
the Ligament with the Patella — ^Disease of the Cuboid and Os 
Colds; Diseased Bone removed; New Bone formed; Cure 
aided by '* Mechanical Best ** — Disease of the Os Calcis ; Bone 
removed ; Bone renewed — Disease of the Epiphysis of the Os 
Calcis — ^Distribution of Third and Fourth Cervical and First 
Dorsal Nerves to Upper Portion of the Chest — Disease of 
Bight Stemo-clavicular Joint, cured by Rest — Suppuration 
in Left Stemo-clavicular Joint opened by Ulceration, cured by 
Best — ^Disease of Bight Sterno-clavicular Joint, produced by 
Forcible Traction; Death probably from Pyajmia — Disease 
between First and Second Portions of the Sternum, cured by 
Best — Effect of Muscular Exhaustion on the Joints of the Foot 
— Inflammation of Bight Ankle-joint and Foot ; Suppuration ; 
Dislocation of the Foot; cured by rest — Injury to soft 
Structures uniting Shaft of the Tibia to its Lower Epiphysis ; 
Ostitis; Sub-penosteal Suppuration; Death in Twelve Days, 
probably from Pyaemia — Conclusion 466 



iKDiJC 499 



4<^i 



ON THE 



THERAPEUTIC INFLUENCE OF REST 



AND TBB 



DUGNOSTIC VALUE OF PAIN 

IN ACCrOENTS AND SUEGICAL DISEASES. 



LECTUEE I. 

THE UfFLCBNCB OF NATURAL THERAPEUTIOS — BEST THE CHIEF NATUBAL 
THERAPEUTZO — OBJECT OF PAIN — BEST THE F06TEBEB OF BEPAIB — 
BEST NBCR88ABT FOB THE HEALTHY ACTION OF ANY OBOAN — MEANS 
ADOPTED BY NATCBB TO SE0X7BE A STATE OF QUIESCENCE TO THE 
YABIOUB YIBCSBA. 

Mr. President Mn> Gentlemen, — There are duties which 
are difficult of fulfilmeut pertaining to every position in 
life ; and there are duties attached to public professional 
life, £rom which no man can assume to himself the right to 
shrink, with whatever diffidence and feeling of incapacity 
they may be undertaken. In this duteous but self-mis- 
trustful spirit I have ventured to accept, at the request of 
my colleagues in the Council of this College, this Profes- 
sorial appointment — this, in my estimation, highly honour- 
able appointment— the requirements of which I must now 
proceed to carry out as best I can. To this end it is 
desirable to set out with a clear conception of its objects 
and intentions. I conceive that the institution of these 
lectures was based — firstly, on the wise recognition of the 
fact, that there is much in surgery which cannot be 



2 THE THKRAPSUnO ZHVLUBHOB OF BEST OLdeor. 

systematized — t .e. which oannot be oon^OTed firom mind to 
mind in books, in systematio treatises — ^I had almost said, 
which cannot be given clinically, because the necessary 
grouping of like cases rarely accompanies clinical oppor- 
tunities ; secondly, on a natural anticipation of the pro- 
gressive steps which might be foreseen in a scientific art 
cultivated with such inteUigeooe, such laborious activity, 
and such an abundant supply of husbandmen as the present 
centuzy has produced ; uia thirdly, on tiie opinion that 
among those who had been actiyely engaged for a long 
period in extensive hospital practice would be found a 
fitting exi)onent of surgical progress. 

This, ^ntlemen, is the oonoeptioB I hsvB adopted of the 
original intention 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 short of re- 
sponding to that intention I need not 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 
facilis deBcensM by wnich an habitual lecturer to students, 
whom he can presume to instruct, may be betrayed into 
treating an audience, whose high reputation and whose pro- 
fessional knowledge far exceed his own, as if he presumed 
to instruct them also. Nar is it neoessary 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 Deque chorda soinim reddit, quern volt, manns, et mens, 
Poflotatiqne gnvem penaape lemittit actttnm ; 
Neo lemper feriet quedjcunque minabitar aimii.*' 

Hob. Ar8 Poet. 848 et aeg. 

But, gentlemen, phraseology and diction have been to 
me minor considerations 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 Hstened with admiration to my predecessors in this 
ohair, as thqy ei:pouBded to you tlM more veoent advaKoes 



I.] AND THE BIAONOSTIO VALUE OF PAIN. 3 

in the pathology and diagnosis of the most important 
surgical diseases. Histology, general anatomy, and physio- 
logy have been so perfectly elaborated here as to bring 
under your attention their most recent discoveries ; and it 
appeared to me that my forerunners had left to me, for the 
present, but <me unoccupied department — namely, that of 
Therapeutics. By Therapeutics, however, I do not mean 
to imply the action of drugs, which more especially belongs 
to the department of the physician ; but rather the influ- 
ence of what I may venture to call " Natural Therapeutics " 
in the cure of surgical diseases. The chief of these is one 
so apparently simple as to make me almost apologize to 
you for selecting it. It is Best — Physiological as well as 
Mechanical Best — ^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. 

Begarding this subject of Best 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 faoe," as a punishment for his disobedience, 
it pleased Him, in the plenitude of His unspeakable 
benevolence, to permit man's fatigue and temporary ex- 
haustion 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 
labour. 

Entertaining, as I do, the most exalted admiration of 
Nature's powers of repair, the thought has not unfre- 
quently ooourred 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 a$ a curative agent, 
my mind naturally rev^i^ed to that period of man's exist- 
ence when it was the sole curative means of which he could 
avail hintHelf- 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 parents sudd^y thrust out of the garden of Eden, 

B 2 



ii^%6 



4 THE THSBAFBUTXU ZHFLUJUMCUB OF BB8T CLdeor. 

and doomed to toil for their daily bread; with hands 
unused to labour, inexperienced in the sabstitatee for 
unnecessary exertion and in the avoidanoe of looal injury, 
and exposed to all the aoGidenta of a precarious existence. 
Let us try to realise the awe-stricken dismay which must 
have oppressed man's mind on the infliction of his first 
wound, his first experience of pain ; — ^the breach of surface 
disclosing to his sight his blood flowing unceasingly, or 
leaping, at sustained interrals, from its opened chambers, 
his sense of fainting, and his ultimately sinking on the 
earth under the foretaste of death; tlus, too, with the 
recent denunciation, **Thou shalt surely die,** still ringing 
in his ears. Can words depict the hopeless anguish which 
he must have endured? But what foUows? See him 
awakening to life again, the stream of blood stayed, the 
chasm plugged, his strength reviyed, and day by day that 
wound — ^waich he regarded as the badge of death, the 
yongeance of the Creator's wrath— narrowing and healing 
till it could hardly be seen. 

I haye made these obseryations for the purpose of 
showing the original promptings of Nature to man, for 
the alleyiation of what must haye necessarily befallen him 
in his altered condition. Pain wAs made the prime agent. 
Under injury, pain suggested the necessity of, and, indeed, 
compelled him to se^ for, rest. Eyery 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 enabled 
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 endowments which enable him to sustain his 
existence under the punishment of labour and the vicissi- 
tudes of his daily Ufe, a recuperative power from the 
accidents and mischances of nis precarious existence, 
appears to me to supply an evidence of His merciful and 
unspeakable love, too lightly considered. 



L] AND THE DIAGNOSTIC VALUE OF PAIN. 5 

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

Growth is the antitype of repair, prefiguring the physio- 
logical capabilities of existing structures to repair ^em- 
selves. 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 
relation of cause and efifect. Accurate observation of the 
animal and vegetable world certainly reveals their per- 
petual co-existence ; and growth, as a rule, seems to pro- 
ceed, pari passu, with physiological rest. 

Mr. Ward * says : — " All plants require rest, and obtain 
it, in some countries, by the rigour of winter ; in others, 
by the scorching heat of summer. 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. 

*' The winter of 1850-51 was ushered in by some heavy 
falls of snow, with which I filled my Alpine case, giving 
the plants a perfect rest of three or four months, and with 
a most satisfactory result ; the Primula marginata, Linncea 
barealis, and other species, flowering much finer than usual. 
Many of these beautiful plants would, I am convinced, 
succeed well if kept for five or six months in an ice- 
house. 

** Plants, in hot countries, have their periods of rest in 
the dry season. In Egypt, 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 as hard as bricks by the action of the sun, are 
then used as carriage roads. When the water is again 
admitted, the plant resumes its growth with redoubled 
vigour." 

Our great master in physiology, John Hunter, has not 
left this field unexplored, for we find, not only in his 
published works, but in others which remain in manu- 

* On tiiA Growth of Plants in Closely Glazed Gases, p. 11. 



6 THX THSBAFEOnD VKWLOMBICB OV JXSBT [Lmt. 

script, that the fabjeot of rest oooopied no inoonaidenible 
portion of his attention. **Mo6t plttnt%*' iajB he, ''hare 
their periods of growth and periods of rest 

** Some plants dose their leaTes, others their flowers, at 
particular hours of the day or night; and with snch 
regularity does this period of rest take place that more 
than one vegetable physiologist has proposed to constmot 
from them a floral otooL*' 

We all know how eagerljr rest is sought for by the lower 
animals, especially in penods of sujflfering from injury or 
disease — how they endeavour 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 largo a 
portion of our staple food is well known to the stock- 
keeper and grazier. A homely illustration may be found 
in the fact that in infancy the child who sleeps much 
mostly thrives. Mutatia mutandis, the observation is 
equally true, that the wakeful, restless child seldom 
displays the evidence of active nutrition. Doubtless all 
will admit that in infancy development is in its highest 
state of activity, 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 develop- 
ment of others — seems thus to claim sleep and rest as its 
helpmates. 

Thus far I have endeavoured 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, 

Eopair is but the repetition of growth. The same 
elements, the same kindred conditions, are necessary to 
the same results. Best is the necessary antecedent to the 
healthy accomplishment of both repair and growth. I'his 
surely is the natural suggestion of a means towards an 
end which should never be lost sight of by the physician 
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 
subsides, and rest asserts its power, the recovery or rejmir 
becomes extremely active, aocompanied by an increased 



L] AKD THE BIAOKOSTIO VALUB OF PAIK. 7 

tendency to sleep ; sleep supplying the gxeat desidenttnm 
previously required. 

Take, for example, the case of a child suffering greatly 
from the irritation of stone in the bladder, which prevents 
sleep, induces sometimes extreme emaciation, and urges the 
child even to the verge of death. How marked, how almost 
immediate is the change on the removal of the stone ! On 
giving rest to the bladder, and consequent constitutional 
rest to the general system, the child falls into a profound 
and prolonged sleep** 

In principle, the same remarks and the same reasons 
would apply to cases of extreme dyspnoea relieved by the 
operation of tracheotomy, of strangulated hernia after the 
reduction by taxis or the knife, or to the removal of an 
extraneous 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 sleep. 

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 constitu- 
tion has to sustain the stress of repair only — not of both 
development and repair, as in the child. Their recovery 
is slower ; their subsequent sleep is not so profound nor so 

* In calcalatiDg the ruks of an operation, especially one entailing 
much shook or prolonged repair, the ca^city for long refreshing sleep 
is of the ntmoBt importance. 8ir J. Vaget, Clin. Loot and Assays, 
p. 44, writes : — ** If a patient can always sleep long at a spin, that is a gCMxi 
patient In one of tne most periloas operations for hernia with which I 
have had to do, a case in which the hernia had heen reduced en hlocy 
and in which its return was effected with considerable force and 
disturbance of parts, I believe the patient owed his recovery more to his 
capacity for sleep than to anything else. He was a yoang bargeman, 
dull-witted ana over-worked; and in his ordinary lue sleeping 
whenever he was neither working nor feeding. Shortly after the 
operation he went to sleep ; and ho slept sixteen hours out of the first 
twenty-four, and in a scarcely less proportion of his time for two or three 
days afterwards ; and he recovered, although he had acute peritonitis, 
for which I thought it necessary to put on nearly a hundred leeches." 

To secure sleep after operations of any severity the plan of giving a 
subcutaoeous injection of morphia, before the patient has thoroughly 
come round from the effects of the ether, seems to me of great 
value. — [Ed.] 



8 THE THBBAFEUnO INFLUEKCOB OF BEST [Lbct. 

prolonged, nor their rest so complete. The 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 endeavoured to inculcate is, that 
growth and repair bear an exact relation to due physio- 
logical rest, local and general. 

Let me emplov a familiar example to illustrate the effect 
on the brain of rest, Inr referring to any overworked 
member of our own promssion at me end of the London 
season. Free from structural disease, but worn, and 
appearing prematurely old from exhaustion by mental 
labour, not physical exertion, he 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 fact, calling into activity the 
latent or suspended function of the cerebral centres, 
leaving the higher, the intellectual part of the bi"ain to 
work out its own recovery from over-fatigue or exhaustion 
by rest — that is, by freedom from its own peculiar func- 
tion or occupation. After a time he returns completely 
invigorated, improved in general appearance, active, and 
full of mental vigour, and equal to the resumption of 
almost any amount of renewed professional exertion 
without fatigue to his brain. 

I may adduce this additional remark regarding the bene- 
ficial influence of rest, that those persons who drop off to 
sleep quickly, anyhow or anywhere, and sleep soundly, 
undisturbed by active dreaming, are, cceteris paribus ^ cajwible 
of sustaining a greater amount of mental and corporeal 
exertion than those who find it difficult **to get off to 
sleep," who sleep lightly, and, dreaming much, awake 
but little refreshed. 

Bearing on this subject, I, like others of our profession, 
have had repeated occasion to observe the effect of over- 
work on gentlemen who use their brains with an expendi- 
ture of energy inconceivable to the heedless or thoughtless 



I.] AKD THE DIAONOSTIO VALUE OF PAIN. 9 

multitude — men of widenspread mercantile affairs — men 
occupied with important calculations, engaged in money 
transactions on a large and anxious scale. The condition 
of such patients attested the applicability of these remarks 
by their mental and physical exhaustion, by their de- 
pression of spirits, and by their want of self-confidence. 
Yet, with such men, the restoration to health has been 
made complete by mental 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 reference to cases of more decided mental dis- 
turbance from overwork of the brain, 1 may be permitted 
to read this note from my friend, the late Dr. Hood, of 
Bethlehem Hospital : — 

•* March 22, 1860. 

" My dear Sib, — In reply to your inquiries, I may state 
that I am frequently applied to for the admission of luna- 
tics into this hospital, whose insanity is caused by over 
mental work, anxiety, or exertion, and for whose cases 
nothing is required to restore the mental equilibrium but 
rest. Therapeutical measures are not necessary ; all the 
mind seems to need is entire repose. I do not by this mean 
to imply that the patient reduced to a state 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 over- 
work so mentally fatigued that he is incapable of working 
out with accuracy the most simple sum in arithmetic. 
Sensible of his incapacity, which perhaps 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. His physical functions are healthy ; no medicine 
is required or taken, but a holiday from the counting-house, 
freedom from all thought and anxiety, the substitution of 
amusement for labour, restores his mind to a healthy state, 
and he returns to business as competent as he ever was. 



10 THE THBRiraUTIO nfUJBHRSB OV XKBI [Licr. 

I have now under Biy ofsn a man who far aome yean past 
has been snbjeot to oeoaakmal attabka of melanoholia. He 
ifl occupied as a oomponior, and, being both a derer and 
trustworthy man, ia constantly employed. He works early 
and late for many conaeoatiTe hoamyand far some montlui 
all goes on well ; but the stretch on the mind nltimately 
causes a break-down, from which he cannot rally, unless 
he leayes his bosineas fara month or six weeks, uid takea 
a oomplete holiday. He tells me that the oaose of his 
mental suffering is firom concentration of thoodbt, and that 
rest removes the weight and aaxmy of melancholia^ In a 
word, he takea a months holma^, engjaffes in no oocnpa- 
tion requiring thought or faringing wiw it anxiety, and 
returns to his duties with the mind of a^ounff man. Some 
people may reply, ' This is not rest; it is only a change of 
employment.' I maintain it is perfect rest to the faculty 
which has been overworked. Of course we do not propose 
that the whole mind should remain fallow, but that the 
pressure should be removed from the particular part which 
IS fatigued. 

'' I could ffive you many illustrations from the wards of 
this hospital, where we are called upon to treat mental 
symptoms in the cases of governesses, students, clerks, and 
clergymen ; and rest is all they require, and with that the 
most aggravated cases are restored." 

Having thus very briefly and very imperfectly reviewed 
the subj^ of rest m relation to the body genenJly, let us 
inquire into some of the expedients which Nature adopts 
to secure the same end in its individual organs. 

All viscera (as in the case of the brain, to which I have 
already aUuded) require the alternate condition of activity 
and rest to keep them vigorous and in health. If this 
condition be not observed or attended to, structural 
changes and deterioration of function are sure to follow. 
Indeed, in reference to the etiology of the diseases of 
individual organs, it may be asserted that a large pro- 
portion of these diseases originates in circumstanoes 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 exercises, and thus deprived 



L] ASD THE DIAONOSne TALUB OF PAIK. 11 

of its appropriate rest, beoomee prone to the TariotiB altera- 
tions in its structures, which post-mortem 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 disoi^anization for the same reason. The 
kidney, too, if its function be disturbed by the abuse of 
alcoholic and other fermented drinks, which entails an 
unnatural and continued stress either upon its Malpighian 
or tubular portion, obeys the same tendency to structural 
decay as a consequence of its loss of due rest.* 

It is, I believe, an admitted phvsiological axiom, that 
each structure or or^n, whilst actively employed, is in a 
state of vascular excitement or turgescence, and therefore 
enlarged during that time. 

So it is noticeable that each oi^an of the body, which is 
liable to the rapid supervention of activity in its proper 
function, is so placed in relation to surrounding structures 
as to permit of temporary enlargement during the persist- 
ence of that activity. 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 

* Dr. Milner Fothergill (The Practitioner's Handbook, p. 388) has 
pointed oat another fertile soorce of disturbed rest in the case of the 
kidney, and how to mitigate it. ** This knowledge [that urea is largely 
derived from the splitting up of albuminous material in the liver, as well 
as from disintegrating tissues] has enabled us to relieve impaired 
kidneys by dimhaisbiug the amount of work they have to do. A large 
amount of the nitrogenized food we take is unnecessary, and is not 
required for tissue building; a comparatively small amount only of 
nitrogenized matter daily is sufiBcieut for that purpose. We take it 
because we like thia form of food, and beoause the stimulating 
properties of nitrogenized substances render them agreeable. The 
energy of the meat-fed man as compared with tiie vegetable eater is 
distinct and marked, but gout and other troubles are the inseparable 
alloy. There is a Nemesis behind the force-manifesting animal food. 
The presence of large quantities of waste nitrogen in the blood maintains 
the Indneys in a state of high functional activity, and the h^pencmia 
of aetive function leads in time to the production of connective tissue 
in excess. 6ueh is the origin of many cases of chronic renal disease ; 
such indeed is the natural history of interstitial nephritis, of the 
contracting, granular, dzrhotie, or gouty kidney.'' — [Ed.] 



12 THE THEBAFEUnO INFLUEHOE OF BEST [Lbct. 

oongestion by their tubular oatlets. The elasticity of the 
enclosing capsule exerts its beneficial effect towards the 
same end by inducing centripetal pressure, and this tends 
to diminish the sise of the organ as soon as, its function 
performed, its state of physiological excitement begins to 
diminish. The elastic capsule uius maintains the healthy 
quiescent size of the organ. 

The liyer is endosed within a strong elastic peritoneum, 
and it has also its proper elastic but thin capsule ; and I 
may add, as probable, that the tissue found in Qlisson's 
capsule, surrounding the portal vessels, &c^ in their dis- 
tribution within the liver, may influence their condition by 
its elasticity. These forces, aided by the contractile power 
of the blood-vessels themselves, bnng the liver back to 
and maintain it in its condition of rest ; thus allowing the 
individual minute secreting parts to recover their physio- 
logical strength and their tone. 

Again, the liver is so placed as to have the additional 
advantage of pressure from without, by its subjection to 
the contractile power of the muscular walls of the abdo- 
minal parietes and the diaphragm, especially during exer- 
cise and active respiration. This no doubt explains the 
benefit of walking exercise, in cases of congested or torj)id 
liver, at which time the liver is compressed between the dia- 
phragm and the respiratory part or upper half of the abdo- 
minal parietes.* I would here ask you to observe the eftect 
of forced rest, or the absence of this pressure upon the 
liver, in cases of accident which necessitate the recumbent 
position, and induce congestion of the liver and jaundice. 
For example : we see a patient in good health suddenly 
placed upon his back by the fracture of a leg, the local 

• Oliver Wendell Holmes (Autocrat of tlie Brtakfaet Table, p. 66), 
treatiDg of the value of walking, rowing, and riding, writes thus of tlie 
influence of the last upon the hver: — •* Saddle-leather is in some respects 
even preferable to eole-leather. The principal objection to it is of a 
financial character. But you may be sure that Bacon and Sydenham 
did not.recommend it for nothing. One's hepar^ or, in vulgar language, 
liver — a ponderous organ, weighing some tnree or four pounds — goes 
up and down like the dasher of a chum in the midst of the other vitul 
arrangements, at every step of a trotting horse." It is obvious that every 
squeeze upwards of the liver in any of the above exercises must send a 
squirt of venous blood through the inferior vena cava into the closely 
contiguous right auricle, whUe every downward movement draws open 
the same vein slightly in leadinen for the next upward jei^Eo.] 



I.] AND THE DIAGKOSTIO VALUE OF PAIN. 13 

injury being confined entirely to the leg. The fracture 
goes on well, but the patient in a few days is jaundiced, 
without much constitutional disturbance. A moderate diet 
and a few doses of blue-pill with saline purgatives soon 
dispose of the jaundice, and thenceforward everything pro- 
ceeds healthily. I believe the congested liver, which leads 
to the jaundice, results from the forced rest to which the 
liver is subjected by the recumbent position ; the circula- 
tion through the organ up to the period of the accident 
having been aided by active respiration and ordinary exer- 
cise. The withdrawal of these aids leads to congestion of 
the liver, and thence to jaundice. The same kind of con- 
gestion of the lungs at their bases and posterior obtuse 
margins may, and ft'equently does, take place under the 
influence of difficxdt and inefficient respiration, dependent 
upon the difficulty of moving the posterior parietes of the 
chest while the patient is in the horizontal posture. The 
circTilation through those parts of the lungs is not com- 
pleted ; and as the quantity of blood circulating, up to the 
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 and 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 liave repeatedly observed this one- 
sided pneumonia disclosed at the post-mortem table, 
associated 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 prac- 
ticable, and to allow the patient to sit, so that the chest 
may be as little as possible encumbered by position.* No 
doubt it was the fatal effects upon the lungs and liver, 

* Kr. Eriohsen (Med. Ghr. Tra. yol. xxyI.) PointB out how prone 
asthenic, hypostatic pneumonia iBtoraperrene after Borgical opemtions 
and iDJnriea, especially where a recumbent position long continued, 
giving rise to a congested state of the Inngs, is combined with any 
canse that diminiehes the functional activity of the nervous system, 
e.g. profuse suppuration, long confinement in hospitals, and irritative 
fevers, more particularly when afisnming a typhoid type, and when 
occurring in individuals advanced in life. The writer then draws 
attention to the ohscurity of the onset, the frequency with which Vh^ 



14 THE THEBAraunO XHVLUBVOE Off BB8T [LaOT. 

which local and remote aoddentB leaned to produce, which 
induced our forefathers to *'let blood'* in almost every 
kind of accident whioh compelled the patient to keep quiet, 
or confined him to bed. 

The spleen has a strong elastic capsule, and also aa 
internal network of highly elastic* tissuOt so tiiAi the 



symptoms are rendered latent bj the low condition of flie mtient, or 
masked by the existeiioe of aome Miere ii^arj that ohiefly attmote 
the suigeon's attention. la ipeekfaig of the treatment. Mr. Eriehsen 
writes as follows: — ^^Tha nqdnepodtion thoiild ako be ooeasiouaUy 
changed for the lateral one, or, ii the patient have sufficient stsength, 
lie may be seated partly nprisht. And the stazdied bandage may here 
be of most essential aorrioe, or enabUng the aargeon to pkee patienta 
with injuries of the lower Umba ia aaoh a poakion and aaeh an 
atmospheiie as shall remove two of the moat aotnre piediapoeing caosea 
of the form of pneiunoaia now under oonsidoratlon, namoly, the 
recumbent position, and the comparatively impure air of a hospital 
ward or sick room.** 

Dr. Milner Fothergill (ho, 9upr. dL p. 140) speaks thus of the 
value of position in adynamio congestions of the lun^ : — " When the 
patient lies upon his bock, as he does in the typhoid condition, the 
posterior portions of the lungs are among the most dependent parts of 
the body. The blood collects in tliem, from lack of tone in the vessels 
to prevent such stagnation. It becomes at once apparent that under 
these drcnmstanoes stimulants must be administered, and fooely too, in 
order to maintain the ^wer of the circulation. But more than that, 
mere position is not without its importance. As lon^ as tho patient 
can turn over on either side, the lung of the other side is to some extent 
unloaded, and so relieved. Old practitioners aie always hopeful of fever 
patients as long as they etn turn over. The same species of hyposttitic 
congestion is &und under similar circumstances in the kidneys ; and 
when the power to turn over is lost» it is a good practice to roll the 
patient first on one side for an hour or two^ and tiien on to the other, in 
order to mechanically unload the congested viscera of each side 
alternately, especially ia advanced typhoid statea." — [En.] 

* In edition to the elastic fibres spoken of above, the presence of 
involuntary muscular fibres in the capsule of this organ, which, from 
its close relation to the digestive function, is constantly liable to con- 
siderable variations in size, shows an especial provision for providing 
tlie spleen with rest The existence of these fibres, though disputed 
in man (W. Milller and Harloss affirming, while others, as Gray and 
Kolliker, deny or doubt their presence), has been demonstrated in the 
capsule and trabeculte of the spleen of many of the mammalia, nottbly 
the ruminants and the pig. Their abundance in the spleen of these 
animals may, I think, be explained b^r the frequent and sudden inter- 
ruptions to which the digestive function must of necessity, from their 
mode of lil^ be aoiyect m thorn animala— [Ed.] 



I] ABTD THE DIAGNOSTIO VALUE OF PAnT. 15 

interior of the organ may, when necessary, be ocmipressed, 
and its gorged condition reduced to comparative emptiness. 

The lodneysalso possess a strong elastic capsnle for the 
same pnrposo, and are also subjected to pressure by the 
weight of the superimposed colon. 

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

The 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 distension, to the surrounding structures, without 
encroaching upon any of them. Thus we find the lung 
especially grooved or hollowed out, to allow the cavse, 
descending aorta, arteria innominata, and left subclavian 
artery to pursue their courses without hindrance. 

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 is, that the right 
auricle, thus distended, exerts its mechanical influence 
upon a small portion of lung, which yields, and permits 
its distension.* It is probable that this fact constitutes one 

^ In t^ heart two proTisioDB may be met with for gmnff zest and 
sparing diftreas to that part of it whieh is most liable to over-diftenaion : 
one the naperteoi doaare of the tricnapid valyet, by which some reflux 
is penaitted into the rig^t anriele and the adjaoent^avn ; the other the 
existeooe in many animals of tl>e ^ moderator band of distension,*' a 
mnscalar band passing fnm the sepital or fixed waU of the right 
TCDtiiele to the opposite or yielding one. Both of these provisions were 
described by Kr. T. Wilkinson King (Gny's Hosp. Bep. 1887). Prof. 
BoUestOQ (Harreian Oration, 1873X having pointed out that this band, 
present in many of the Ungnlata^ is met with in birds also, apeaks thus 
of its nae: — ^ The advantage which^ in ^ atruicgle for existeDoe, and 
aspaoiaUy in that ?aiy emmman phase of 'it which lakes the fosm of a 



16 THE THEBAFBUnO INFLI7EH0B 01* BEST [hmn. 

of the reasons for the existence of a third lobe in the right 
lung ; and it is worthy of this additional remark, that tikis 
third lobe is wedgenshaped, a meehanical form seldom 
employed in the oonstmotion of the hnman body. This 
wedge-force is the most powerful meehanioal foroe whioh 
can be employed ; and, b^g interposed between the upper 
and lower lobe, is competent to separate them from each 
other, and from the middle mediastinum containing the 
heart, &c.* 

laoe for food or from an eater, an animal with anoh a mnacolar band 
passing directly acroBs the caTity of its right ventiiole moat pooBeas 
is not a difficult thing for any man to underatand who has e?er either 
watched in another or experienced in himadf the distreas canaed by the 
over-distension of any mnaonlar aao.**— J^Sd.I 

* Prof.BoUeston, in his addreas to the Brit. Med Aasooiation at Oxford 
in the Long Vacation of 1868, wrote of the ** Law of Parsimony '' or 
"Economy ' (N'ewton's enunciation of this law runs in part as 
follows : — '* Natura nihil agit frustra ; et frustra fit per plura quod fieri 
potest per pauciora. Natura enim simplex est, et rerum cauf<is 
8U|>erfluis non luxuriat — "): — " Where does Nahire bind herself to the 
observance of a * Law of raraimony ' ? In, as I think, three distinct 
linos of her operations. 

** Where an organ can be diverted from one and set to discharge another 
function, there Nature wQl spare herself the expense of forming a new 
organ, and will adopt the old one to a new use. She is prodigal in the 
variety of her adaptations. She is nigp^ard in the invention of new 
structures (Milne-Edwards, cit in Darwm's Origin of Species, p. 282). 
The complicated arrangement of co-operating muscles, whereby the 
bird s third eyelid is drawn across to moisten and wipe its eye-ball with- 
out undue pressure on the optic nerve, is manufactured, if we may so 
express ourselves, out of the suspensorius muscle, which in other animals 
has but the function of slinging up the eye. The scarcely less complex 
and beautiful arrangement of the bird's levator humeri is the result of 
a moilification of a subclavius muscle. 

** Secondly, where, by availing herself of the inorganic forces always at 
work, or where by the employment of— as in what is called * Histological 
Substitution * — a lowly organized or vitalized tissue, such as eUistic tissue, 
she can spare herself the manufacture of such expensive structures as 
muscle, there Nature adopts a lino of practice which we call a Law of 
Parsimony. Where a suspensory muscle for the eye can be dispensed 
with altogether, as where there is a more or less closed bony orbit, as 
in ourselves, and an air-tight cavity formed by it, together with the 
soft tisanes lining it, there atmospheric pressure is trusted to steady 
the eye in the socket, as it refixes the tooth loosened by inflammation, 
and holds the hoiid of the femur in the acetabulum. The eye of the 
burrowing mole, on the other hand, loses its recti and obliqui before it 
verges itself into total extinction ; but this very Buspenaoriua it retaina. 



L] AND THE DIAGNOSTIC VALUE OP PAIN. 17 

Quitting this digression regarding the surface anatomy 
of the lungs, I would observe, that if the views which I 
have advanc»ed in relation to Nature's expedients to pro- 
cure mechanical rest be true in their anatomy and sound 
in their physiology, as applied to the thoracic and abdo- 
minal viscera, they must also be true of the brain. This 
suggests the intention of the interstices between the con- 
volutions and other sinuosities and spaces on the surface 
of the cerebrum, and assigns 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 the accumulation of venous blood in the plexus 
choroides during a state of general cerebral congestion, as 
in sustained inspiration. The cerebro-spinal fluid within 
the ventricle supports the blood-vessels, and so prevents 
their rupture. Mr. Quekett tells me that any attempt to 
inject the plexus choroides, except in 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 us consider the 
relation of some uf the deep, enclosed, and internal parts 
of the brain. 

For instance, the corpus striatum and thalamus opticus 

after the wreck of ltd other property, as itd guardian in the undivided 
nndliferentiated teinporo- orbital fossa. 

** Thirdly, wliere matter that would otherwise be wholly refuse, and 
to be rejected, can be utilised, tliere Nature exemplides this law by her 
utUisation of waste substances. The transverse colon with its various 
contents, aids and ekes out the elastic recoil of the lungs in expira- 
tion ; and by its near approximation to the stomach, has, as Duverney 
long ago pointed out, the shock of the inge^ition of fresh food propa- 
gated directly to it as a warning against sluggishness in the discharge 
of iti own function." I have appended the above words of my old 
teacher, that any student after reading them may be enable<i to think 
of numerous instances by which nature gives rest to or lightens the 
labour of her structures or organs. Thus the ilio-tibial band which 
saves so much work to the muscles which maintain the erect poeitiun, 
and the arrangement in the kidney by which tiie watery part of the 
nrine is formed above, and is thus enabled to scour down tne solids so 
us to save the need of any special apparatus for carrying oft' the latter, 
will readily occur as examples of Prof. Bollestou's second and tliird 
divisions.— CEd.] 

C 



18 THE THERAPIDTIO JUrLCBBOS OT BS8T [Lmr. 

are placed within the oerebmm, and project into the lateral 
ventricles. Theee parta saperintend the morement and 
sensibility of the upper and lower extremities. 

The completed Iffain, being enolooed within a solid oase 
with unyielding walls, admits of no poesibility of eooentrio 
enlargement. If parts or organs liable to sadden or pro- 
longed calls upon their function were placed within and 
surrounded by solid brain, they oonld not enlarge, exoept 
by pressure or enorosohment npon aome other parts, with* 
out creating misohief; they oonld not, in &ot, be obedient 
to that general piinoiple in physiology which I have men- 
tioned. 

This increase in dimension of the parts forming the floor 
of the lateral ventriolefl is permitted, however, towards the 
interior of th6ventriole8,bythooerebro-«pinal fluid receding 
through the foramina of Monro, third ventricle, aqueiluct 
uf Sylvius, and fourth ventricle, and thence through the 
cerebro-spinal openiug in the lower part of the fourth 




a. P«(«rior And Ihl , -,. — 

^. UppfT uid poMerior p4rt of (h? 
t Cenlwo-iirlniil Bptnlng '— •' 



L] 



AND THE DIAOKOSTIO VALUE OF PAIN. 



19 



ventricle (Figs. 1 and 2) to the base of the brain or sub- 
oerebral spaces, and so into the vertebral canal. As the 
local hyperaemia of the blood-vessels in the thalamus, 
eorpns striatum, &c., subsides, the cerebro-spinal fluid rises 
into the ventricles, 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 cerebroHspinal fluid in this respect serving the 
analogous purpose of the elastic capstde of the liver, kidney, 
and spleen. 



c '2 



THE THBBAPECTIC INFLrENCE OF KEST. 



XECTURE II. 



i 



la my last lecture I endeaTonrcd to illuatrate tiu> 
mechanical means employed by Nature to reduce organs 
after they have been in a Btate of physiological excitement 
or turgcBcence, while performing their appropriate fnnc- 
tions, to the proportions natural to their state of rest. The 
examples to which I particularly referred were selected 
from the livor, the spleen, 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 
brain itself I purpose in this lecture to place befoi^ you 
the facts which seem to sustain that opinion. I shall 
endeavour to prOTe that the cerebro-spinal fluid performs, 
in relatiim to the circulation of the brain, the same func- 
tions that the elastic capsules referred to perform in 
regard to their visceia. 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 anatomical details with which 
you are familiar, but my so doing constitutes a necessary 
6t«p in my attempt to show how this action of the cerebro- 
spinal fluid is produced. 



22 THE THESUlSWJTIQ TSVLXJESOM OT BEST [Lbot. 

The letter a indioates the dma mater, whioh» yoa will 
observe, lines the whole interiar of the oraniiUBt end, after 
forming the tentorium, pitnmeB its oouzse down to the 
lower part of the Teitebrtu oanal, terminating in a conioal 
l)oint nearly opposite the seoond bone of the sacmm, A 
considerable space exists between the vertebm and the 
dura mater, so that this interval allows expansion or eooen- 
trical dilatation. I must direct joar attention to certain 
lines (^letter h) which are intzodnced for the purpose of 
localizing a piece of anatomy which, I think, has not 
hitherto received its proper attention. These lines repre- 
sent natural ligaments, which proceed from the anterior 
inferior part of the dura mater, oecome fixed to the bodies 
of the sacrum seriatim, and pass downwards nearly as fietr 
as the first bone of the coccyx. So much for the dura 
mater. You will notice that the letter h 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 
coiTesponds to the space between the interior of the cranial 

J)ortion of the dura mater and the surfeoe of the cerebrum. 
S'ow, the external arachnoid, which is a complete serous 
membrane in itself, is formed of two layers: one layer 
lines the internal portion of the dura mater, and gives it 
itH smooth character, and in the cranium the other rests 
upon the pia mater of the brain. 

Let us now trace the continuity of this external arach- 
noid downwards into the vertebral canal. Here you may 
notice its linear continuity lining the internal portion of 
the dura mater, and proceeding downwards to the lower 
part of the dura mater, which contains the spinal marrow. 
This external arachnoid is here again seen to be composed 
of two layers : its external layer, which lines the internal 
portion of the dura mater ; and the internal layer, which is 
blended with the external layer of what I should denomi- 
nate the internal arachnoid, to which I will presently direct 
3'our attention. This external arachnoid in ^ normal state 
contains only a very small quantity of serous or albumin- 
ous 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 BUxhooB of the external arach- 



n.] AND THE DIAGNOSTIC VALUE OF PAIN. 23 

noid during the movements of the brain. The ill efifects of 
any undue friction are prevented by the small quantity of 
fluid which exists between the surfaces of the external 
arachnoid. The letter c points to what I should denominate 
the internal arachnoid. It is this internal arachnoid 
which contains the cerebro>spinal fluid, which proceeds to 
the interior of the brain through the cerebro-spinal opening, 
and then lines all the ventricles of the brain, and their 
different intermediate passages — with the exception of the 
fifth ventricle. 

The existence of this cerebro-spinal aperture underneath 
the cerebellum, and between the cerebellum and the me- 
dulla oblongata, is not perhaps universally admitted ; but 
I believe, beyond all doubt, that it is the normal arrange- 
ment of structure, that there should be such an aperture 
(Figs. 1 and 2).* Some years ago I took a great deal of 
trouble for the purpose of ascertaining this point in a 
very exact manner ; and in no one instance, except where 
there were abnormal collections 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 disease (Figs. 8 and 9), 1 found there was such an 
aperture, freely allowing fluid to pass inwards and out- 
wards from the interior of the brain. I shall hereafter 
have the opportunity of laying before you some cases in 
which this aperture was 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 trace the outer layer of the 
internal arachnoid upwards and forwards, as far as nearly 
opposite to the fissure of Sylvius, it there becomes reflected 
upon itself, and lines the under surface of the brain, crura 
cerebri, pons Varolii, medulla oblongata, &c. Tracing 
this membrane (the internal arachnoid) posteriorly, its pos- 
terior layer passes underneath the cerebellum, joined to 

• The normal existence of this aperture, not allowed l>y Arnold, 
admitted, but doubtfully by Cruveilhier, was described in France by 
M. Alagcndie ; its pliyfiiological and pathological importance was first 
pointed out in this country by Mr. Hilton. — [Ed.] 



24 THE THEBAPECTIO mTLGKNOE or REST CLkoI. 

the iiitornnl layer of the eit^mal arachnoid : it then quits 
the external aVftchnoiil, and foUows the under surface of 
the oerebellum until it rcwches the cerebro-apinal opening, 
which it enters. You notioo, therefore, that tliie large 
Bpaoe (rf), which I now term the internal arachnoid cavity, 
»nd which contains the cerebro-spina! fluid, not only passes 
down the whole length of the vertebral canal (the relative 
position is indicated in tliis diagram), but the fluid lice 
under and supports the cerebellum, as well aa the most 
important parts of the base of the brain ; and it further 
passes upwards into the interior of the brain, and is tha 
fluid which wo generally find, after death, occupying mora 
or less the various ventricles of the brain, lo fact, the 
central parts of the base of the brain, instead of resting 

Fig.*. 




Tills tUunm bu been Lntndiioed to ihow tbe trranxcmflil of Iba (Uffermt in 
Ennu And sp«cce u they w bvLtered lo «xl»( In Uh "pluL coIudid. 

1, % L»jtr» of UKhDrtS fanning. S, aTllj of u-4chnokl. 

ft, ft, LlEunttitum dFDlicuUtiuQ. 

«, ilmnulrer ofipliuj conl. 

I, DrllcUe (TWlir tlHua found in Uh ■ub-u*clinold •;•« betmen Ifae UKh 

0, Anterlur ud uiMdlCT. fl. poMRhir And larger. ruoM of iplul Derre. 
It, 10, SIbUu Ubh to I. 



IL] AND THE DIAGNOSTIC VALUE OF PAIN. 25 

upon the bones of the skull at its base, rest upon this 
collection of cerebro-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 venous circulation — as I will prove to you 
presently — and also by the elasticity of the dura mater in 
the vertebral canal.t 

• M. Magendie (Reclierches Physiolopjiques ct Cliniques sur lo 
Liquide Ce'phalo-Bachidien ou Cere'bro-Spina', 1842), describes the 
followini? oollec'tions of fluid at the base of the brain : the hirgest 
below the cerebellam ; another in front of the poim and between the 
crura and lodging the basilar artery, and one more anteriorly below 
the lamina cinerea which closes tlie third ventricle below and in front. 
Very similar collections (Cistemen) are de8cril*ed and figured by Key 
and Retzins, loc. infr. cU, — [Ku.] 

t In the second edition this passage was left unaltered nt Mr Hilton's 
wish. No change has of course been made in the present edition. The 
reader will see at once that the space between the two layers of the 
*' external araciinoid ** corresponds to the cavity of the arachnoid and 
that the interval between the two layers of the '* internal arachnoid *' 
is the sab-arachnoid space between the arachnoid and the pia mtttcr. 
yii. Hilton believes that the cerebro-spinal fluid is contained between 
two epithelial surfincea, i e. that one such surface not only exists, aa 
nsnally described, upon the arachnoid, but also upon the pia muter as 
well, and that thus the otherwise inevitable infiltration of the pia mater 
U prevented. With all due deference to Mr. Hilton, I cannot quite 
accept this view. In the first place, as far as I am able to make out 
microscopically and with thfl use of such reagents as silver nitrate, no 
layer of epithelial cells exists upon the pia mater. I am further in- 
clined to believe that a slight infiltration of the suporfieial part of the 
pia mater does take place, as the cerebro-spinal fluid passes backwards 
and forwards over its surface. I am indebted to Mr. Davie^-CoUey for the 
knowledjce of the fact that Uenle applies to the sub-arachnoid tissue 
the epithet ** wasaerauchtig," oadematons. More than very slight 
infiltration is prevented, partly by the fact that the cerebro-spinal fluid 
is broken up into a number of little lakes and pools by tiie very delicate 
bands which are found in the sub-arachnoid space (the tissue forming 
theee bands being alao infiltrate<l by the fluid), and partly by the deeper 
layers being most closely united to the brain substance by the 
innumerable vessels entering it. 

It is only a pleasant act of justice to the memory of Mr. Hilt')n to 
state that the most recent and withal the most exact and elaborate 
researches into the anatomy of the nervous system tend to conflnn, in 
part at least, the accuracy of Mr. Hilton's belief that the cerebro-spinal 
fluid is contained between two epithelial surfaces. Thus in the * Studien 
der Anatomie des Nervensystems und des Bindegewebes,' by the two 
Stockholm anatomists Axel Key and Gustaf Botzius, a layer of scattered 
cells is described as lying on and amongst the more superficial wavy 



26 



THE THSBAFBCnO I MWWSS OK Or BBST [Lkt. 



For the purpose of pointuigont the practioal applioation 
of these anatomioal suita Tegarding the ftmotion of the 
cerebro'Bpinal fluid in its relatiOTi to the base of the br&in, 
I might Bay that almoat the only part of the base of the 
brain which fits in close coaptation with the bones ol the 
akull is the inferior part of Hm anterior lobe of the oer»- 
brum, wbero it rests upon the orbital plates of the frontal 
bones. So accantt« is tiiis coaptation, that if yon were to 




make a cast of the intorior of this portion of the skull, and 
compare the model from it with the under Hurface of that 
part of the brain vrliich naturally occupies this position, 
you would find them in exact correspondence. This is not 

(wellenrtinnig'i ani] Uie drcpcr, tuft-like (bilschelioriiiig) aod ntifler 
fibres of Hbicli the pu muter in figiueil w ooQwating. HUfte 1. 
Tftfel ivi. fig. 1-10.— [!-:[>.] 



IL] 



AND THE DIAGNOSTIC VALUE OF PAIN. 



27 



the case with the other portions of the base of the brain. 
If foo examine these two models which I have plaoed 
before you, you will find that one of them is an exact 
outline aud configuration of the various parts which form 
the base of the brain ; the other model is simply a wax 
oaat of the iuterior of the same skull, deprived of the 
brain. Now, if the base of the brain rested upon the 




urulBputsallb 



H oT Uie gkull uid at [be bnin. 



base of the skull, the wax model which is taken from 
the interior of the skull ought to give a cast exactly cor- 
responding to the baseof the brain. But wo see that this 
is not so, and the great difference marks the extent of the 
iat«rval occupied by the cerebro-spinal fluid. Wo have 
here a complete demonstration that there is not a coapta- 
tion or exact fitting between the under surface, or base of 



28 THE THEBAPEUTIC INFLUESCK OP REBT [Lect. 

the brain, and tlir>BQ bones which form the biiBG of the 
Hkiill. This eustiins tfao opinion, that the two poBt(>rior 
thinls of the base of the brain do not rest upon the bonee, 
iniieed do not touch the bones at all, but rest ii]>oa this 
»x)llection of cerebro-spinal fluid, which 1 have ventured 
to call the perfect wat«r-bed of the brain. Hence a person 
may fracture the base of the skuU, and yet show no 
evidence of injury to the brain itself; a fact which every 
obBerving surgeon knows to be true. I well remember a 
man walking into Guy's Hospital, sitting upon his bedside, 
undreBsing himself, and lying down oorapoaedly in his bed : 
this patient, on his admission, had bleeding from both his 
ears, and subsequently died &om the injury to his head, 
it being shown at the post-mortem examination that he 
hod a vf.'ry severu fnii'turc of the Ijase of tho skull. Yet 
this man walked into the hospital, and showed no mani- 
festation of loss of power or sensation in his legs, and no 
evidence of any encroachment upon those parts of the 
brain which form its base. 

Some time since 1 was requested Ia see a gentleman in 
the country, who, cominff home from hunting, was thrown 
from his horse, and got nis foot entangled in the stirrup. 
In his fall he 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 his horse again, and rode several miles home. 
This gentleman occupied himself as usual during thirteen 
days, occasionally riding, sometimes walking, but more 
frequently driving about the country in the pursuit of his 
business, and attending one of the county markets. He 
then became the patient of the surgeon who requcBt«d me 
to see him. At the time I saw him he was suffering from 
some indications of paralysis dependent on injury at the 
base 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 subject of a fracture of its 
base i yet he pursued his ordinary avocations for thirteen 
days without the slightest evidence of any cerebral 
lesiou, complaining only of headache and some febrile con- 
dition. Now this fracture traversed that portion of the 
skull where the oerebro-spiual Suid is interposed between 



IL] AND THE DIAGNOSTIC VALUE OP PAIN. 29 

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, manifesting 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, we 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 bones of the 
skulL When the blow is received at the posterior part of 
the skull, and the whole mass of the brain is driven for- 
wards from the momentum given to it by the blow upon 
the bones of the skull, the under surface of the anterior 
part of the brain rubs over the irregular 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 sub- 
jacent 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 ccrebro-8pinal fluid. 

The cerebro-spinal fluid has a specific gravity of about 
1007. It contains 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, 

* Mr Hilton has shown elsewhere (Lectures on the Cranium) that 
many of Uie ridges on the inner surface of the base of tlie bkuU serve 



30 TlIE THERAPEUTIC INFLUENCE OF BEST [Lbct. 

at itfl base Ooea not rest upon tlie bonee, but npon the fluid ; 
Beooudly. thJB fluid ieotatea tbe various uerrcepiiBBing near 
each other towards the same foramina ; and. lastly, sup- 
ported by tho cerebral circulittioii. it tiMi'ls tn i'ring back 
the internal organe «f thi3 briiiti tn a hi^iti' uf i.'im|jaratiT6 | 
emptiness or quieMeaos after their state of acbTitf .* 

1 have already ssid that th« tbalamaB nerri optief HBd- 
the corpus stnatom, whitb oocnpy the htm of tin 
lateral Tentricles, aapermtend ths noremeata and aeiNi- 
bility of the upper aad lower ezinmitiea. I praamM Ibmt 
when these fuuotiona are aotiTely employed, tiieaa two 
parts especially are ia a state ct tto'Keaoence, and that if 
they were imbedded in Ota wcAU brain, it wonld Ite 
impoesible for them to enlarga without eneroocAiit^ npoD 
some of the adjoining stniotureB, and thai inflioting, at 
any rate, temporary injury. But the oorpnB striatum and 
optic thalamus have a large extent of surface, which 
projects towards the interior of the lateral ventriclea, and 
in proportion as they become enlarged by congestion they 
displace the cerefaro-spinal fluid through the foramen of 
Monro, through the third ventricle, iter a tertio ad quartum 
ventriciilum, into the fourth ventricle, and thence through 
the cerobro-spinal opening, and thus proviBion is made for 
hypersemta of the thalamus and corpus striatum. When 
the activity of the corpus striatum and optic thalamua 
ceases, then the cerebio- 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 " tho ventricles of the brain " communicate with 

to oondnct Tibrationa to the olinoid processes which lie surronQded 
bjr cerebro-Bpiual Hnid, and that the viEi»tiau« &rreBted and lost in tbU 
fluid are tbua prevented from damaging the base of tho bruin. — [Ei>.] 

• In addition to the above the ccrebro-apinal fluid plajs two other 
important purls in the cranial circulation. B; the ahove'mentioned 
collectioni ut tho base (p. 25) it prevents the large trunki wliich there 
break up into braui-bes from being pressed upon. Also rb it follows the 



n.] AND THE DIAGNOSTIC VALUE OP PAIN. 31 

each other through the medium of very narrow passages ; 
and I most 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 narrowed parts very dense and strong 
for the purpose of resistance. At the margins of the 
foramen of Monro the structure of the brain is very dense, 
and the whole length of the iter a teii;io 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 partn 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 d^ree through these various ventricles and 
ccHitracted passages. 

I must now place before you a few facts which show the 
exact relation between the venous circulation and the 
cerebro-spinal fluid, in order to prove that they efjuipoise 
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 abdominal viscera, and divide 
transversely and neatly the various veins which escape 
from the vertebral canal through the intervertebral 
foramina, and lie upon the sides of the bodies of the verte- 
brae, taking care to leave these veins full of blood. Then 
take away the bodies of the third and fourth lumbar verte- 
brae, so as to expose the vertebral canal, with the dura 
mater, containing the spinal marrow, arachnoid mem- 
branes, and the cerebro-spinal fluid. With a body so 
prepared, if the blood within the veins of the neck be 
pressed upwards through the internal jugulars towards 
the interior of the head, it will be seen that, just in pro- 
portion 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 vertebree ; thus show- 
ing that as you push the venous blood into the interior 
of the unyielding cranium, you displace the cerebro-spinal 



32 THE TllER,U'EirTIC INFLUENCE OP BEST [Lect. 

fluid ; the evideuco of thai displacomeiit being this, that 
ytm Bee the dura mater lifted up by the fluid at the 
part where you have removed the two lumbar vertebna. 
So again, confining your attention to those veins which 
are in section on the side of the spine, and filled with 
blood coming from veine 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 vertebrre, and 
make pressure upon it bo as to displace the cerebro-Bpinal 
fluid, you will observe that just in proportion as you dis- 
place the cerebro-spinal fluid will the blood rise within 
and then overBow the various divided veins to which I 
have alluded ; thus showing that as you make pressure 
upon the cerebro-spinal fluid you displace blood from the 
veins which occupy the vertebral caual. 

And here let me introduce an esperimeiit bearing upon 
this subject, made upon a living body. 1 would not, 
however, advise a repetition of the experiment, because, 
probably, it involves a slight degree of risk to the patient. 
Some years i^o 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 thot if I 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 
established an easy communication between the auditory 
caual and the cerebro-spinal fluid in the interior of the 
sknll, I should be able to force out of the ear some of the 
cerebro-spinal fluid. I accordingly went to his bedside, 
and told him to take a very full breath ; I then held his 
nose and lips, and put my fingers so as to compress his 
jugular veins on each side of his neck. His face became 
exceedingly congested and discoloured ,1 and he commenced 
struggling to get rid of the pressureof my hands upon his 
nose and mouth. This had scarcely taken place before a 
quantity of thin fluid came running out of the auditory 
oanal, and I succeeded in collecting neaily half an ounce 
of it. The experiment was now completed; I removed my 
hands from the nose and mouth of the patient, and he* 
quickly recovered hie condition of repose. Thus, then, i 
Had succeeded in displacing from the interior of the 



U] AHD THE DIAQHOffnC YALUS OF PADT. 33 

Granimn a quantity of cerebro-flpinal fluid (for bo it was 
afterwards proved to be by microsoopio and chemical 
examination) by propelling to the interior of the Bknll an 
increased qnantity of venous blood. 

It may be a little wide of my proper subject, but while 
your attention is 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 the anatomical 
relations of the disease termed spina bifida. This will 
enable me to express the fact that the fluid contained in 
the interior of the cavity of a spina bifida is oerebro-spinal 
fluid.* 

The spina bifida is essentially the projection backwards, 
through the imperfect vertebral canal, of the membranes 
oi the oord, and the thin fluid which occupies the spina 
bifida is in truth the cerebro-spinal fluid (see Fig. 3, /). 
Thus the interior of the spina bifida actually communi- 
cates with the interior of the brain through the medium of 
the cerebroHSipinal opening between the medulla oblongata 
and the cerebellum. I have no intention of dwelling on 
the subject of spina bifida beyond pointing out the danger 
that is associated with the operations for this disease, 
especially those of injecting it with any irritating fluid. 
It is obvious that if any irritating fluid be injected into 
the cavity of the spina biflda, we are injecting a fluid into 
a cavity extending the whole length of the spine, and 
onrnTnTmififtting directly with the interior of the brain. 
Hence, although we may wish to limit 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 mem- 
branes of the spinal marrow, that inflammation is mani- 

* Tboagh this is the usual arrangement in snina bifida, that the sao 
oofmmimicates with the sub-arachnoid space ana contains oerebro-spinal 
fluid, there is no doubt that in a small number of cases the commu- 
nication is with the cavity of the arachnoid. See Preecott Hewett, 
Med. Gas., vol. xxxiv. p. i6i, and the Surnoal Treatment of Ohildrens' 
DiseaK8» ^ T. Holmes, pp. 79-81.— [^^.J 

D 



34 TBE THEBAPEUTIO INFLUENCE OF BEST [Lxor. 

feated almoet 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 exemplified by 
the diagram (Fig. 3), suggests the impropriety of at any 
one time drawing off the whole of the fluid from the spina 
bifida. Sureeons know very well that it has happened 
that when me fluid has been drawn off from the spina 
bifida as long as it would flow, it cecused only by the 
patient having a fit — a sort of general epileptic fit — and of 
that fit perhaps the patient has died. That occurrence 
receives an explanation when we trace a communication 
between the interior of the brain and skull and the spina 
bifida, for it is plain that as you draw off the fluid m)m 
the spina bifida, so vou withdraw the whole of the oerebro- 
spincd fluid from the interior of the brain, and from the 
base of the brain. All the veins become congested and 
distended with blood, the deeper parts of the brain encroach 
and make pressure upon each other, the various nerves at 
the base of the brain, including the pneumogastrio, are 
compressed, and the patient dies from defective respiration, 
or in a 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 so much fluid 
as will relieve the 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 bifida enables those walls to recover themselves, and 
to produce in time good and healthy skin, which forms the 
best natural defence of this unnatural projection of the 
membranes backwards through the defective vertebral 
canal. After this tapping operation, the skin ought to be 
supported by the local ap^cation of a thick layer of 
collodion and by a bandage. 

The diagram (Fig. 7) to which I am now directing your 
attention is made from a drawing representing a clot of 
blood which I found in a patient's brain, in the year 1842. 



n.3 



AND THE DIAGNOSTIC YALUB OF PAIN. 



35 



Yon know that sndden deaths used to be most frequently 
attributed, erroneously no doubt, to apoplexy, but it hai3 
rarely occurred to any person 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. 



Fig. 7. 




Cki of blood oocnpying And distending the third and fonrth ventriclefl and inter- 
v«iiiiic canal, and rqireeenting, therefore, a cast of the interior of those spaces. 

This patient dropped down dead upon the floor of the room 
of a public-house in which she had been drinking, and, on 
subsequently examining the body, I found that the cause 
of the sndden 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 corpus 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 pneumogastric nerves. Bunning 
the eye along the upper part of the clot, from before back- 
wards, we notice a semicircular notch (e), which corre- 
sponded exactly with the anterior commissure of the 
cerebrum in the third ventricle. A little further back is 
a peculiarly configurated depression (d), which is the im- 
pression of the oommissura mollis. And at the anterior 
and inferior part is a nipple-like projection downwards (/), 

D 2 



36 THE THEBArEDTlC INFLUENCE OP BEST [Lbct. 

which fitted into the tuber oinereTiin of the third ventricle. 
Behind thia (a) oorresponds to the interval betweijn the 
two optic thalami. The narrow prolongation backwards (b) 
is a cast of the iter a tertio ad qiuirtnm ventriculiun paw- 
ing under the corpora quadrigemiua ; and joined to thin ut a 
lozenge-shaped mass (c), having a prolongation downwarda, 
which pufised through the cerebro-spinal opening, and two 
lateral wing-like expanaiona, which were adapted to the 
lateral rcoessea of the fourth ventricle, which contain the 
deep and support the auperficial origins of the vagi ; it is, 
ia truth, a perfect cast of the fourth ventricle. There must 
therefore have been, in this case, great preaeure upon tho 
floor of the fourth ventricle at the origins of the vagi, which 
superintend the process of respiration. The sudden death 
was produced by the blood which bad been oxtravaaatod 
into the lateral ventrielea having pursued the course of the 
cerebro-spinal fluid, aud rested in the fourth ventricle, and 
there made so much pressure upon the roots of tho puen- 
mogastric nerves as to completely paralyze them ; and if 
the process of reroiration could not be continued, as it cer- 
tainly oonld not dtiriug the time the pnenmr^astrice were 
thus pressed upon by uie clot of blood, the patient would 
necessarily die quickly. This then, I apprehend, is the 
explanation of the sudden death of the patient. The clot 
of blood, which was quite entire, will also establish the 
fitct of the continuily of these various parts, through which, 
am I have undertaken to suggest to you, the cerebro-spinal 
fluid passes to and &o, accc^ding to the state of oongeation 
of the iatcrioT of the brain. 

I might here remark, that it appears to me impossible 
that any patient can live with what is called a diffased 
external hydrocephalus, assuming that the external hydro- 
oephalio fluid is placed within the external arachnoid. As 
the brain is of a greater speoifio gravity than the hydro- 
cephalic 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 thus pressing the 
brain upon the base of the sknlL You will remember that 
the arteries of the brain contain the blood, through the 
medium of which the brain is nonrished and manifests ita 



IL] AHD THE DIAGNOSTIC VALUE OF PAIK. 37 

fonctionB ; th&t tHose arteries lie between the under sorflBkoe 
of the brain and the bones of the skull, and if this hydro- 
cephalic fluid press the brain downwards, it must compress 
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 brain were thus 
pressed downwards, the pneumogastric 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 hydrocephalus, and, therefore, I 
presume the cases must be rare.* I apprehend that the 
examples recorded must have resulted from rupture of the 
internal arachnoid membrane, which allowed 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 cerebroHspinal fluid 
and the cerebronspinal aperture, I must call your attention to 
the drawing, Fig. 8, which represents a specimen of the 
closure of this cerebro-spinal opening. In such instances 
the cerebro-spinal fluid could not escape from the interior 

* The only condition to which this term can rightly be applied, is 
where a g:Tadual passive exudation of fluid takes place into the sub- 
araehnoid space, accompanying and telling of the atrophy of the brain 
beneath, the hydrocephalus ex vacuo of older writers, met with after long 
wasting diseases, or in senile decay, whether timely or premature as in 
the caee of Dean Swift ; this form of hydrocephalus, having been met 
with in the case of the great satirist, and forming one of the causes of 
that death which he so much dreaded, viz. a decay of the mind 
preceding that of the body. Prof. Bindfleisch (Path. Hist. Vol. ii. p. 
313) spcAks of a form of external hydrocephalus due to some pro- 
tractea irritative hypersmia of the brain, e.g. Alcoholism, which leads 
to permanent dilatation of the vessels of the pia mater, and so to com- 
prenion of the brain with gradual effusion into the sub-arachnoid space. 
Dr Mozon (Wilks* and Moxon's Path. Anat. p. 204) controverts this 
view, and points out that in the atrophy of the brain which accompanies 
old age or long-continued dnmkenness ** the pia mater fastened to the 
brain by its dose vascular connection with it follows the brain, so 
that thus the eabnarachnoid space enlarges and fills with fluid." 

For further information see a paper by Dr. Amdt, Ueber den 
Hydrocephalus eztemus, Virohow's Archives, Vol. 52, p. 42. The writer 
discusses the opposing views of Yirchow and Geist, gives cases and 
their autopedes in detail, and would appear to look upon this form of 
hydroeephftlus not so much as a serous effusion of the arachnoid but 
as the result of inflammatozy pzooesses connected with the dura 
[Bd.] 



38 THE THEBAPEUnO UfFLUEHOE OF, BSBT JXmer. 

of the brom ; and th&B the ooUectioii of ftoid within the 
brain woald constitute internal hTdrooephalna. And here 
I may add that the drawings m>m which the dit^nuns 
were copied represent specimena of morbid anatomy which 
I removed from little ohildren who had been the aa1:i)ects 




Dniriai atn ipedmsi of ocdailcin of Ifas etnbBUfintX opmliig, U 

wba dtod In 1N4 ttota iataaal bjdrocapbiUai. 
m, OBebrllum, b, Holallii iib)on»u. opper ud pi 



of internal bjdrooephaiuB ; and the occlusion of the open- 
ing was the only canse of the internal hydrocephalns that 
I could discover. 

The other drawing. Fig. 9, it taken from the same pre- 
paration, but represents a longitudinal section of it, which 
enables aa to see the extremely dilated state of the oom- 
munication between the third and fourth ventricles, and 
thepoint of closure of the cerebro-spinal opening. 

These drawings have been in my poBSeaaion a long time 
— ever sinoe I8&. At that period of my profiaaBional life 
I was examining the disesses of the brain in children. 
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 oerebro-spinal 
fluid could escape from the interior of the brain ; and as 



II] 



ASD THE DIAQITOSnO TALDE OF PAIK. 



the fluid wm being oonstantly secreted, it neceBsarily 
accomolated there, and the ooclusloa formed, to my 
mind, the essential pathological element of internal 
hydrocephalns. 

Internal hydrooephaltis is not an nnfrequent companion 
of spina bifida. In many of the cases of that disease that 
I have examined after death, the cerebro-spinal opening 
was closed, thus explaining how it happened that althongh 
the spina bifida had been tapped during Ufe, and no limit 




Thb nffnTlDE r t pw wnto % tonffilwtinai HctloD of Uw B* 
•. CCntella. b. Upper iwit of tbt nwdnlli. ablonsiu. 
n to longlliidlMl -— — 



^"T^wTfc 



% CBRbm-^ul Dpai[i 



opailni. 



tj hjdrocepJuUc fliikl 



pnt to the flow of the fluid at the operation, yet the little 
patient did not sufler &om cerebral congestion. Indeed, 
it was a case of this Idnd which first made me acquainted 
with the pathological fact of cloeure of the oerebro-spinal 
opening in the fourth ventricle.* 



* Other fautuwM of diatentioa of the Tentricles with flnid owiiiK to 
clomm otttie apaiiaie in tbe tbartb Teotricle, will be foand recorded in 
the TranMotfOD* of the Palhologicsl Bociet]'. The following »8cb are 
giren in Dr. WiUn'a and Dr. Moion's Pathological Ajiatomy, p. 215 : — 
"In me eawi the taain wu flnnlT adherent lonnd the fommeo tnagnam, 
and the membranes ^nd obomid pleins at the openimi' of the fourth 
Tmtriole were Tei7 fluok, almost clodng the apertnie. But the moat re- 
■natkaMe eaw we bare Men was one m whioh on openbig the ahiU 
ttunv tppoutA t, large bladder like an hydatid separating the left oere- 
btal oaanlntiona. This piOTed to be the inmiBnael? dilated laterel 



40 THE THBKAPEOTIO INFLUENCE OP REST tLarc. 

I will now detail to you the eliort particulars of a case of 
internal hydrooephalua in wMch the oerebro-epimil canal 
■waa closed at the iter a tsrtio ad quartnm vEmtriculain. 
Thia cMr> I flaw in the year 1847, with Mr. Otway, ft 
eurgeou at Kennington : — 

A. H. was a child of unhealthy parents, rery thin, 

feeble and sickly from birth, uttering constantly a pecu- 
liarly diatreaaing cry, and having a remarkable rotary 
movement of the head. When four mouths old, the head 
bugan to enlarge rapidly ; and after this had been noticed 
a week, the infant became comatoae, lying perfectly quiet, 
almost paralytic, with strabismua and dilated pupils ; her 
skin was of a dingy yellow tint ; pulse scarcely to bo felt ; 
respiration extremely imperfect, both as regari frequency 
ami extent. After the ojma had continued twenty-four 
JiourB, us death appeareil immini-nt, the anteriijr ftinttinello 
was punctured by a trocar and cannla, and eight ounces of 
colourless fluid escaped. While the fluid was being drawn 
off, the infant began to kick vigorously, the eyelids opened, 
the etrabismOB ceased, and the pupils contracted. So 
that the withdrawal of the cerebro- spinal fluid removed 
the pressure from the third nerve, which had produced 
strabismus and dilatation of the pupils ; it removed the 
pressure also from the thalamus and corpus striatum : and 
thia freedom &om pressure was manifested by the (diild 
moving its limbs vigorously. The lips began to move 
constantly, especially the lower lip, which had been drawn 
inwards between the gums. When the finger was intro- 
duced into the month of the infant, an attempt to suck was 
made, and a little warm milk and water was swallowed 



TentrfolB — which bad thnut its waj through to the sar&oe. The oanee 
orthu «» Found lo be a papillose tamour in the ftoor of the fourUi 
veothde, eompoted of ependymal Btruoture. It was of the size of a 
small baiel-nDt, and complHtel; cut off the cevitf of the ventricle. 
Two remarkably similar oaaaa are siven bj Virchow. Again, we have 
known the Tentriolea of the brain diBtcndod macb in a oase of pressure 
on the spinal canal through disease of the cervical spine, thus cerebral 
symptoou became added to the spinal. Another certain cause of 
expannoQ of the ventricles is tnmour or tnberde under the tentorium ; 
whether it pov in the pons or the oerebellum, it compresMS the 
fourth veobnele, and disulows the free eMape of (he cerebio-sidikal 
fliiid."-[EB.] 



IJ.j AND THE DIAGNOSTIC VALUE ()F TAIN. 41 

witliout difficulty. The pulse was about 140, very small 
and feeble ; Teepiiation reiy irregular ; the surface was 
cold and clammy, but warm applications soon restored its 
temperature. Moderate pressure was applied to the head. 
A week after the first operation, after some slight fits, the 
child became comatose again, and unable to swallow. 
Eight 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 (inflam- 
matory effusion, not cerebro-spinal fluid), was again 
evacuated under similar circumstances. During the next 
two months, the child took merctiry and chalk, in small 
doses, with some benefit. The bones of the head were 
gradually becoming approximated, and the anterior fonta- 
nelle was diminished. The child was emaciated, although 
it took the breast freely. The thumbs were turned in upon 
the palms of the hands, and the peculiar movement of the 
lips continued. The child died on the dOth of October, 
having had convulsions of increasing severity during four 
days ; but it continued to suck, and took notice of sur- 
rounding objects, till the day before its death, which was 
nearly ti^ree months after the first tapping. I did not see 
this patient alive, but I suspected, from Mr. Otway's 
description of the case to myself, that we should fiiid 
<2lo0ure of the cerebro-spinal opening. 

Pc9^-mortem eooamination.-^liody much emaciated. The 
bones of the head overlapped each other considerably ; 
the anterior fontanelle was imperfectly felt. There were 
cellular adhesions between the two layers of the external 
arachnoid; this membrane was much thickened, and in 
0ome places opaque. There was no appeare^nce of cica- 
trices in the position of the trocar punctures, but some firm 
adhesions existed at that spot. The veins on the surface 
of the brain were distended, and a dirty brownish-red 
discoloration, from altered blood, was noticed between the 
lobes of the cerebrum. Within the right lateral ventricle 
three distinct cicatrices were clearly seen, corresponding 
with the punctures made during life with the trocar. Each 
lateral ventricle was divided in an exactly similar manner 
by an opaque structure (resembling its lining membrane), 
in whicm there was on each side an aperture of about a 



42 THE THBBAPEUnO INFLUENCE OP BEST [LiOT. 

quarter of an incli in diameter. This was either a new 
false membrane developed within the ventricular cavity, 
or the lining of the roof of the ventricle, thickened and 
snbseqnently ruptured, so as to allow the fluid to make its 
way between it and the ventricular wall : most probably 
the former of these conjectures is the correct one. The 
lateral ventricles were distended, and contained four ounces 
of fluid. The plexus choroides was not to be recognised. 
The septum lucidum was elongated, its ventricle was 
enlarged, and contained fluid. The cavity of the tuber 
oinereum was dilated, and thus compressed the optic com- 
missure, explaining the impairment of vision. The iter a 
tertio ad quartum ventriculum was dilated nearly as far as 
the entrance into the fourth ventricle, where it was closed 
by old and firm adhesion. This occlusion necessarily 
preserved the fourth ventricle from dilatation, and it was 
accordingly natural in form. The olfactory nerves, as far 
as their bulbs, were hollow, and communicated with the 
anterior comua of the lateral ventricles — this persistence 
of a condition normal to about the fourth month of intra- 
uterine life suggested that the hydrocephalus, with its 
pathological cause, had commenced during the period of 
intra-uterine life.* 

* Dr. West (Med. Gazette, YoL xzx. p. 127) tabulates fiftj-eix cases 
of hydrocephalus treated by paracentesis, in sixteen of which reooTery 
was said to have taken place : he points out with regard to most 
of these reooveries that the evidence as to the time that had elapsed 
since the operation, and as to the patient's health before and after, is 
insufficient and funsatisfactory. Dr. West then, in proceeding to 
discuss the reported success (ten out of nineteen) of Dr. Oonquest in 
this operation, shows that in fifteen out of the above nineteen cases, ** no 
data are given beyond the mere number of punctures and the quantity 
of fluid removed. The age of the patient, the duration of the disease, 
the size of the head, the condition of the intellectual faculties before 
and after the operation are not noticed. We are left in perfect 
ignorance as to the time which elapsed before each patient was 
reported cured. 

" If the symptoms observed during life yield little encouragement 
to resort to the operation, the appearances disclosed after death 
afford a powerful argument against it An account is given of 
the post-mortem examination of twenty-six cases. In every instance, 
fluid, sometimes in considerable quantity, was contained within the 
ventricles, or in the cavity of the cranium, and the substance of the 
brain was softened and attenuated. But in addition, there existed in 



ABD THE DIAOKOSnO YALUE OF PAIN. 



48 



Beriooi organio disease or mAlfcnmation of tbe bfain 
(^ tiioogh no lymptom during life had betrayed the existence ot a 
Utkn which mechanical interference oonld only aggiaTate." Dr. 
ks (DisL of the Neryoos System, p. 145) expresses an equally 
.vomable opinion. ** I ha^e myself tried it in two cases, hut should 
r p sopoae it again — ^not on aoooont of the severity of tbe operation, 
from the want of possible success — when the fluid is drawn off it 
again fonn, and in order to prevent this, if a bandage be applied 
pioais of compression follow. Our difficulty was so to regulate an 
le bandage as to exert pressure sufficient to prevent expansion, 
yet not to cause undue compression.'* — [Ed.] 



^^HE3l^^^H 


44: 






•t 




^^m 




r^^ 




LECTUEE IIL "h 


FCBCT 


nOS or THB OBaEBBMPINiL TLOll IN TUB raTAL BAUH— OUM 












! BnAm AND TSAT OF OTHKB OHOAHE— LONO SKST EHSKNTUt Aimifl 




iocaeiON or the brain— meqlktt or th» a reara-E cauus or ■ 


rw 








srs 





A DIFFERENCE of Opinion exieta among anatomistB as to 
the presenoe of a well-defined membrane within the lateral 
and other Tentriclee of the human brain. I do not wish to 
expreBB an authoritative opinion, but I will adduce this 
model of the fcetal brain in support of the fact that there 
must be a firm and compact membrane lining the interior 
of the ventricles during the eariy period of intra-uterine 
life, when the brain itself is in a semi-liquid or diffluent 
state. This diagram, Fig. 10, was made from a model of 
the brain of a foetus at about the fourth mouth ; it shows 
the relative position and size of the lateral ventricles and 
their walla accurately. The diffluent rudimentary brain- 
structure is placed between the pia mater extem^y, and 
the ependyma containing the cerebro-spinal fluid m the 
ventricles internally. It appears to me that if a well- 
defined membranous wall did not exist on each side of the 
semi-fluid braia-mattor, it would be impossible for the brain 
to grow and to suBtain itself in anything like a definite 
form. The cerebro-spinal fluid contained within the 
ependyma seems to perform the very important office of 
supporiiing the membrane, and thus constitutes a scaf- 
folding or internal arch upon which rests the diffluent 
brain-matter, which is ultimately formed into firm brain- 
structure. 



HL] AHB THX DIAGNOBTIO YALUS OF PAIK. 45 

I will not dwell longer on this sabjeot, bnt I felt it 
necessary to advance these facts in confinnation of the 
belief of the existence of a lining membrane to the ven- 
tricles, even at a very early period of foetal life.* 

I said previously that I should be prepared to detail 
another case of occlusion of the cerebro-spinal aperture of 
considerable interest. I think that the case will be more 
instructive, and its value better exemplified, if I first read 
the post-mortem examination, and then allude to the 
symptoms observed during life. 

The gentleman who was the subject of this disease died 
at the age of thirty-four. On the day of his death he had 
visited ue Crystal Palace. He had been seized with vomit- 
ing in the morning, and again about two hours before he 
reached home. He walked from the Crystal Palace (a mile 
or so), and when he entered the house he stag^red, and 
said he felt giddy and oppressed. He was plac^ on a bed, 
and cold was applied to jus forehead^but he died in a very 
short time, with stertorous bieathing — ^remaining sensible, 
however, almost to the last moment. I examined the body 
assisted by Dr. Wilks, and this is the report of the post- 
mortem examination : — 

'* Cadaveric decomposition was advanced, except within 
the bndn, which presented in this respect a remarkable 
contrast to the other parts of the body. The convolutions 

* This ingenious reasoning of Mr. Hilton has appeared fitnoifal to 
■ome and incorrect to others, from the fact that tlie pia mater (the 
mpipomd ■oorce of the oerebro-tpinal fluid) has not been detected till 
the eighth week of liostal lifb, and no trace of the arachnoid till much 
later. Somewhat similar reasoning aeems to hare pcissed through the 
mind of H Magendie, hoc, atm. eit. p. 54. '* The conseauences of this 
prewore (of the sub-antehnoid fluid) influence the general conformation 
of the head, and doubtless also of the spinal column from the earliest 
period of embryosdo ezistenoe, during which the parietes of the cranium 
and fertebral eolunm are not yet solid. To what other cause are we 
to refer the spherical fonn of the head at a time when the brain is not 
yet in ezistenoe ? The cerebro-spinal fluid protects the formation of 
the oerebro-sphial nerrous axis, fust as the fluids of the ovum, and 
eipedally the Uqnor amnii, defena and protect the whole fcstus in the 
eavity of the uterus. There must even exist a kind of antagonism 
between the oerebro-spinal fluid, which tends to distend the parietes 
of the cranium and the spine, and the fluid of the amnios, which com- 
presses them on eyeryside, and tends to make them assume the smallest 
poasiUe ▼olmne."— (^.} 



46 THE THEHAPETJTIC mPLUENCB OF HK8T [Lbct, 

of tho cerebrum were largo, and their surfacea flattened by 
pressure from within." 

And these convolutione were few, auggesting, perbapa, 
that the conditioa of the brain was a persistent state ol a 
very early development of the oonvolutiona ; for althongli 




a, Latenl vntTlclca, of i 






itbapUi 



C/] extenullj bud fependynu (t) Ln' 



the person was full grown, and thirty-four years of age, 
the convolutions were large and few. 

" The brain-structure was healthy, neither it nor the 
membranes oontaining any tubercular deposit. On care- 
fully opening the lateral Tentricles, they were found to 
contain at least four ounces of clear corobro-spinal fluid." 

Regarding the character of this fluid there can be no 
doubt. It was carefully eiinnined. Its specifio gravity 
was 1 008, and it posseased all the microBcopio and chemical 
characteTB of oerebro-spinsl fluid. 

"The Tentricles were greatly enlarged, and all the 



in] AND THE DIAGNOSTIC VALUK OF TAIN. 4 7 

rccoilitig and projecting angles of the boundaries and comua 
were lost or subdued. The foramina of Monro were 
rounded^ and capable of admitting a large quill 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 inflammatory deposit or 
softening. The fourth ventricle was greatly dilated in all 
its directions, showing well its lateral comua which sup- 
port the pnetimogastnc, auditory, and other accompanying 
nerves. The cerebro-spinal opening between the under 
surface of the cerebelltim and the upper surface of the 
medulla oblongata was completely closed by a tolerably 
dense membranous structure, which formed a kind of pouch 
projecting downwards, and showed the direction of the 
fluid tension upon it to have been 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 neighbourhood, 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 heart was healthy, both as regards its 
muscular tissue and 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 opening found in this gentleman's brain 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 appa- 
rently perfect fltting-in of the symptoms to the pathological 
anatomy. But 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 
stated, but was drawn up by the brother of the gentleman 
himself, who is not a professional man. I asked him to 
oblige me with a detail of the symptoms which his brother 
presented during life, and this is his account of them : — 

*' This gentleman always had delicate health. The nails 



48 THE THEBJlPEUTIC ISTLUENCE OF REST [Lmt. 

of his fingers were peenliar in form, the laet phaUmget 
being very short, and the nails iiiBorted like two eeeds into 
the ciitick^."' 

I stop at this point to remark that here apparently ve 
have evidence of a congenital error in the deTelopment of 
the enda of the fingere ; and this inclines me ti> the concln- 
aion that probably the cerebral error, the occlusion of tb» 
cerebro-spinal aperture, was also congenital. 

" As a child, he was active and wiry, but ve^ irascible 
in temper. As a man he was very spare and delicftte- 
looking. [AU indications of a something which impeded 
healthy development.] He had always some colour in his 
cheeks, which he retained till within a year of his death. 
He had a fondness for intellectual pursuits ; also for tani- 
ing light fancy work, and gardening; and a great dislifee ^ 
to the excitement, and especially the noise, of LoudoiL ^ 
Indeed, at the ago of siiteen he had a severe ner\-onfl 
illDess, with great depression, bronght on by appUcatira to 
basineflfl in the City ; it ought, however, to be mentioQed 
that his occupation waa not «t all intense, and nothing 
would have been thonght of it by ordinary men," 

Now this is worthy of note, beoanse in this instanoe 
there waa no possibility of ihe oerebro-^inal fluid eecaping 
ft-om the interior of the brain. Whatever pressure might 
be made, by mental occupation or physical exertion, upoD 
the internal parts of the brain or uie medulla oblongata, 
would be morbidly manifested, in consequence of tiiere 
being no possibility of escape for the cerebro-spinal fluid. 
Or to put it in another way : Suppose over-exertion or any 
moral influenoe to produce an excessive accumulation of 
blood in tiie head, (here was no possibility, in this instanoe, 
of insuring a proportionate escape of oerebro-spinal floid, 
because there was no aperture to allow of it. 

" His fixid was always of the simplest kind. Even tea, 

* The atudeot will remember that tbe tno itractrnvs whidi ta this 
can picaeiited abnormalitie*, vit. tbe bnm and tbe t^jpeud^gea of the 
outiole, are developed tiom uii« and tbe rntae bLutodeinuc lajer, i.«. 
the epibloat. So uleo is some cases of apina bifida, not odIj u thcae 
an atmoi'mal coDditian of tbe spinal oord, bnt the Bkin over the 
tumour {■ «otiictimei oong^nitalh' deSoteiit or eotirel; abcent, ths 
■piiuhl dura mater or uaotmoid takmg itt plaoe. — [En.] 



m.] Ain) THE DIAGNOSTIC VALUE OP PAIN. 49 

coffee, and ooooa seemed to affect 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 ho only half lived in the 
winter; he seemed torpid, and would drop into a deep 
sleep after a meal, from which it was often difficult to rouse 
him at bed-time, when he seemed scarcely to know where 
he was. Excitement frequently brought on an impediment 
in his speech. For many years he was subject to head- 
ache, derangement of stomach, and occasional deafness." 

We have here, if we may so term it, a most important 
and valuable living experiment. Here is a man who can- 
not bear any accumulation of blood in his brain, because 
there is no possibility for the compensatory fluid to escape 
from the pressure or state of congestion of the organs in 
the interior oi the skull. I conclude that we find the caiise 
of the stomach affection and the deafness in the great dis- 
tension of the fourth ventricle, and the consequent pressure 
upon the pneumogastric and auditory nerves on its floor. 
If the fourth ventricle be filled with fluid, it must for the 
time exert some pressure upon the auditory nerve, thus 
explaining the temporary dea&ess. 

" His pulse was usually extremely weak, irregular, and 
slow, firom 50 to 60 beats per minute. He was thought to 
be suffering from heart disease. A peculiar restless, 
uneasy look of the eyes and stare, with dilated pupils, and 
a muddiness of the conjunctivae, afforded a ready indica- 
tion of any temporary derangement of his health. For 
the last year of his life, he was gradually losing flesh ; he 
became more feeble, too, and acquired a slight stoop in his 
gait. He also carried his head peculiarly, as if affected 
with slight sti£fness 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 prepara- 
tion for a scientiffo meeting; and this was followed by 

E 



CO THE THEBAPEDTIO raPLUEMCE OF REST [LlCT. 

great proBtratioa and collapse. On the day of his death 
hu had been to the Cryetal Palace. He had had aum« 
Tomitin^ in the morning, and a^ain about two houit 
before ho reached home. He walked from the Crystal, 
Palace, and when he entered the room he etaggered, smi 
eaid he felt giddy and oppressed. He waa placed on k 
bed, and cold was applied to hia forehead ; but he Aied 'a., 
a short time with stertorous breathing [indicating pn'Sfiurti 
upon the mednlla oblongata], but was sensible almoat tO' 
the laet moment." 

If I were to Belect this opportanity to enlarge upon thai 
appoaite circumstance* of tixia caae, perhaps I might do so 
at too great length. I will merely observe that I think it 
an important and interesting experiment in referenci- to 
the cirtulafioTi throiigh tho brain, the admiiiistrntion of 
fu.)d H).d Btiiiiiilaiits. and various othor iiiatU'iB. His 
brain could bear no falness of blood, no increaae of size, 
because the cerebro-spinal fluid could not escape from the 
interior of the brain. Ho could not take wine, beer, or 
Bpirita; and could bear no muBCulaj exertion. Theoonges- 
tion of the brain produced Tumiting by pressure upon the 
mednlla oblongata, exerting its influence upon the pneumo- 
gastric nerve. He died from pressure upon the medulla 
oblongata, with atertorous breathing — that pressure which 
could not be obviated. I shall dwell no longer either upon 
this case, or this kind of case, but I think that occlusion of 
the oerebro-apin&l opening is a pathological condition which 
has not received due attention from the profession. 

Before quitting the subject of the 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 state of repose or cerebral quietude. Hr, Durham, one 
of our demonstrators 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 abould call its state of 
quiescenoe, or rest. The facts are very few, and they 
■hall be allowed to speak for themselvea. 



Jll] AND THE DIAGNOSTIC VALCK OF PAIN. r>l 

'" A dog having l)een chloroformed, a portion of bone, 
about as large as a sixpence, was remoyed from the parietal 
region of the skull by means of the trephine ; the sub- 
jacent dura mater was cut away, and the surface of the 
brain exposed. As long as the animal continued under 
the influence of ihe chloroform, the smaller vessels of the 
pia mater were turgid with dark-coloured blood, and the 
larger veins were considerably distended.* No dififerenoe 
in colour between the arteries and veins could be recog- 
nised. The exposed portion of the brain manifested a 
tendency to rise into the opening through the skull. By- 
and-by the immediate effects of the chloroform 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. As sleep supervened, the vessels gradually 
emptied tiiemselves ; the veins ceased to attract notice by 
their distension; the exposed surface of the brain sank 
down to, or below, the level of the opening, and became 
pale in colour. In the course of a short time the animal 
waa roused, and irritated. A blush seemed to start on the 
surfiGkoe of the brain ; the vessels of the pia mater became 
fuller and fuller, and of a bright arterial hue. The con- 
trast between the appecurance of the brain during this state 
of functional excitement and the previous state of qui- 
escence was most striking. The more the animal was 
excited, the fiiller 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 re- 
assumed its pale aspect."t 

* Further experiments of Mr. Durham showed that this Mness of 
the veiiis was caused by the temporary interference with respiration 
doe to the administration of the chloroform ; as soon as the dog was 
perfectly under the influence of the annethetic, the brain became pale, 
very much as during sleep. — [Ed.] 

t A full account of these and other confirmatory experiments and 
obeervatkxis was read at the British Association Meeting at Oxford in 
1860, aod was subsequently published in the Guy's Hospital Reports, 
Srd 8er. Toi vi p^ 149. As Mr. Power has remarked in the Principles 
of Human Physiology, of which he is the editor, 8th edit. p. 754, 
Mr. Durham's facts OKve been corroborated by some observations 
made by Dr. Hughlings Jackson, Boyal Lend. Ophth. Hosp. Bep., on 

E 2 



52 THE THERAPEUTIC INFLCEKCE OF BEST [LKCT. 

I have dwelt thus fur upon tho subject of rest ooDBidered. 
ft8 a phjBiolo^oal agent almost exdusivel y, and attempted 
to show liow important a feature its production appearB M 
occupy in Nature's plan of development and for sustaining 
health. This I have felt to be necessary as an introducticK 
to the consideration of rest as a therapeutic agent. 

Mr. Prescott Hewett, who procodod me here, has d 
BO largely and so comprehensively on injuries to the head;^ 
that 1 am almost ashamed even to approach the subject 
esoGpt as an admirer of the monument which he has rMaai 
to himself. I would, however, solicit the attention of 
profession to what observation has taught mo— that rec ^ 
nised lesions of tho brain and its membranOB, associated 
with blows upon the head (whether the cranium be frao- 
tured or not), do not generally, or as a principle of treat- 
ment, obtain that extent of meehauical rest which is 
consistent with the expectation of perfect and complete 
structural repair. This error in the treatment of Bucli 
cases is one of the chief sources of the diseases 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 coacaasioii 
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 symptoms of compression of the brain, we at 



the oplithalmoMopio oonditioa of the retina during; sleep. Id these the 
optio diao ma (bund to be irbitei, and the neighbouriug p«rt of the 
retina more anmnic, than in the waking stale. Dr. Fleming (Brit. 
and For. Ued. Cbr. fiev. Ap. 1855J bad poiuted out that the theory of 
the oireulatioQ of the bntia being languid during otdioary sleep 
teoeived mipporl from aome experiments, in vhich be found that 
preemire on the oommon carotida vsa followed hj temponu; bat 
oomplete inaeniibilitj and unconMlousoeas. That this did not result 
from obatruotion to the retani of blood by the inlemal jugular 
Tsin (whioh most of oonne be more or leu oompreased at the same 
time) Dr. Fleming oonudered proved from the fact that the insemi- 
bilil; was most decided and rapid when, the arterj being distinetlj 
controlled, the faoe became pale, oud that on the other hand the effect 
waa deUyed and imperfeot when the preaaure caused oongeilion <^ the 
tMe.—i&u.-] 



m] AND THE DIAGNOSTIC TALUE OF PAIK. 53 

onoe admit that the cause ia safficient to produce the 
symptomB ; and as long as these symptoms remain, we are 
disposed to think that the cause or its effects continue. 
Let us apply the same kind of reasoning to the subject of 
concussion of the brain. There are one or two cases to 
which I have before alluded, showing clearly that a patient 
may die with symptoms only of concussion of the brain ; 
while the real cause of death may be laceration of the 
brain. Another cause of death with symptoms of con- 
cussion will occasionally be found. For instance, a patient 
has had a severe blow upon the top of his head, and dies ; 
and yet no structural lesion or cause of death is found at 
the post-mortem examination. But I suspect that, if in 
such cases the base of the brain be carefully examined, the 
cause of death may be discovered in injury to the filaments 
of the pneumogastric nerve, near their origin from the 
medulla oblongata. Some years ago I clearly made out 
this lesion in a case of concussion which caused the 

rktient^s death ; the only indication of local mischief which 
could discover was the laceration of some of the filaments 
of the pneumogastric nerve.* 

In ooncufision of the brain, as soon as the blow which 
strikes the skull has caused the symptoms of concussion, 
the physical disturbance of the brain, whatever it may be, 
has been produced. The continuance of the symptoms 
must depend on the continuance of the structural or mole- 
cular disturbance. But the actual condition of the brain is 
not known, and, as far as I am aware, has received no 

* Dr. Moxon (foe, mpr. ciL p. 221) has pointed out that this 
relation of the vagi to the foarth ventriole may have a very important 
bearing in fmotiires of the baae. "If the fracture ia through the 
petfona bone and tympanum, the {lagments drag upon the pneumo- 
gaatrio nerve; we have observed that this nerve has a close union with 
the lateral coarse of the fourth ventricle, so that a pull on the nerve 
alwaya immediately tears open the ventricle. Thus, if the petrous 
bone be broken into the tympanum, with a slight laceration of the 
dora-mater, and the nerve tear the ventricle, there is at once a road 
opened from the ventricle to the external ear, by which the ventricular 
fluid escapes. You will not fail to notice that sometimes the jugular 
fossa is ao elose to the tympanum, that the septimi is most easily burdt ; 
a oommoQ pin will go through it with scarce any effort This 
Bdatioii baa been scanely sofflciently noticed, perhaps because it is 
not •ooatentL'*— [Ed J 



S4 THE THERAPEUTIC INFLCENCE OP BEST [Lmt. 

clear explanation. Experience shows that the symptoms 
may laat a long ot n short time, vairing from days to 
weeks. If you ask what is the pathotopcal condition of 
the brain in a state of conoiiflsion, I believe there is no 
satisfactory answer to be given ; but the generally received 
opinion is that it results from disturbance of the vascnlar 
system of the brain. I cannot conceive it possible that a 
long oontinnance of the symptoms of concussion can depend 
upon any temporary error of this land ; I think it must 
depend upon something more intimately associated with 
the structure of the brain itself. One of the moat impor- 
tant results of ooncussion of the brain is " collapse," or 
" shock."* employing that term aa we employ it in cases 

capeoinlly in clolicutc penoiu. proTe immnliiitelT fntal. mich enges ara 
Tery mv. Carefully coiiduntKi post-nioitpuie jiroyp without cireption 
that Botiul i^juTy of (he bisio bIwbjb coeiutB with Bjmptoma of 
oODCiueion. Wbelbei the natiiro of the injury, vdriable ai this nraet 
be, conBBt of specks of ecchymosis. patches of eitrevasation or ronta- 
doii, or, SB montioned by Dr. Moxon (loe. mpr. eil. p. 216), bruising of 
a port apparently ao well protected al tbe aeptum lucidmn, this at least 
can be foretold that in cases where deuth has been moat speedy, 
hntnorrbage will very likely be found in tlie pons, medulla, or in the 
vetitrioles. One of the most recent wrilers on ooncagiion (Etudea 
eip^meotnles et climques snr les TreiimatismrB C^r^braui. Pnr le 
Dr. H. Doret, Tome i. Paris, 1878.) explains death after symptoniB of 
ooncuasion by a theory which is of gteet interest when oonaidered in 
the light of what Mr. Hilton has written above (p. 31) on the oerebro- 
apinu flttid and the tniok by which it flows, M. Duret's views aro tbaa 
snedDctly put In a review of his work in the Edin. Med. Joiim. 
Ap. 1879. "It is evident that the tension of the o!rebn>«i>iniil fluid 
most be the same at different parti — at tbe base of the brain, in the 
ventricles, and in the apinal cord. If a severe blow, therefore, he 
inflicted on the oreDium a certain amount of depression is piodnc«d 
which is salBdent to drive Home of tlie cerehrn-spinal fluid out of Ibe 
ventricles. If the blow is slight, the energy conveyed to the fluid may 
be dissipated on the elastic ligaments of the spinal mnl ; but if greater, 
he shows oonclosively from bis experiments Ibat the most deleterious 
resnlts are produced on the msdnlla oblongata and neighbonrhood. 
The fluid leaves the cerebral ventricles, traverses the aqnednct of 
Bylvins, and than emerges on the fourth ventricle. Here it meets with 
some redstanoe, and giva rise to rupture of tbe aqueduct of Bylvias.or 
laceration of some of tbe paris in tbe vicinity, accompanied by hemor- 
rhage. The injury whicli U^e medulla oblonpita suffers ftom this 
pressure is the immediate cause of the symptoms charaoteristie of 
" is here that ao many Important centres lie, and itlshua 



m.] AJSTD THB DIAONOSnO VALUE OF PAIK. 55 

of local injury to tlie exterior of the body in whicli the 
Btractures are not destroyed, but braised or conciiBsed. 
That the function of the part is rendered very imperfect, is 
evidenced by the insensibility of the braised skin, and its 
coldneBB or diminished temperature. These conditions of 
the integament may continue for some time, but ulti- 
mately, without loss of structure or function, the recovery 
is completed, although it may be deferred to a considerable 
period after the accident. In the latter case of external 
bruise, before and until the recovery is complete, the sur- 
geon secures as much rest as possible for the injured parts, 
not allowing them to be moved or stretched. Eelying 
chiefly upon Nature'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 func- 
tion, and to anticipate the occurrence, or resist the effects, 
of inflammation. 

Now, with all due deference, I venture to think that the 
considerations applicable to external injury ought to indi- 
cate the principles of treatment to be adopted in cases of 
concussion of the brain. No doubt our duty should lie in 
this : to give the brain absolute rest ; to rely on natural reac- 
tion, or Nature's power to repair the injury or disturbance ; 
to avoid 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 concussion of the brain 
than to hurry on reaction by excessive stimulation. What- 
ever the derangement of structure may be which coexists 
with this condition of concussion of the brain, the struc- 
ture itself is undoubtedly deteriorated. If that be over- 
stimulated through the medium of excitants, such as brandy 
and ammonia (sometimes given in unmeasured quantities), 



that the fluid in its passage outwards seems to meet with most resistance. 
The tension of the cerebro-spinal fluid being the same throughout the 
whole oerebro-spinal system, a ready explanation is also afforded of 
how it is that an injury to the head may produce a lesion of the cord. 
The energy propagated from the cranial cavity downwards, if greater 
than the oounteracting elasticity of the ligaments of the cord, will, and 
does produce injuries in the cord similar to those seen in the fourth 
▼cntricle.**— [En.] 



56 THE THESAPEUTIC INFLUENCE OP REST [Lect. 

the wholo tendency must be to do harm at the period of reac- 
tion. Shunld we employ stiiuulautB in that reiikless wsy 
in the caae of external bniiscs? If not, then I see every 
reason why we should Dot adopt such a plan in the case of 
the more delicate and highly vascular atructnro of the 
brain. Lot ns keep down any eseesuive temperature by 
the local application of ice, avoiding animal food, except 
milk in a definite quantity. 

I make no pretensions to anything new in this etatemeut. 
It IB only a simple mode of considering such caeea, and is, 
I believe, the true interpretation of what may be required 
to guide ua in our principles of treatment of concussion of 
the brain. Suoh a disturbed brain is defective, if not in 
Btructure, certainly in its vital endowments, and is there- 
fore unequal to even its ordinary duties. ItrecoverB itself 
slowly ; it then BOon becomes fatigued from use ; and if 
claims are made upon it too soon after the injnry — that 
is, before the structural and physiological integrity is re- 
acquired — the patient is very likely to suffer from serious 
disease of the brain. Cerebral cxerciBO or mental occupa- 
tion should always in such cases be short of fatigue. The 
brain requires absence from occupation, or rest, for its 
complete recovery, and tiiis should be in proportion to the 
severity and duration of the symptoms of concussion ; in 
fact, the length of time which has been reqtured 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 dne and con- 
tinued 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 chronic lesions, such 
aa failure of mental powers, softening, chronio inflamma- 
tion, extravasation of blood, &c. All I have stated is 
analogous to what is observed in collapsed or bruised parts 
QpoQ the exterior of the body. Thus, when those external 
parts have apparently recovered from the immediate effect 
of local injury, they are Ukely, 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 ulceration. The surgeon ought most 
ciicumBpectly to guard the brain iu this state of ooncnssioQ, 



m.] AND THE DIAGNOSTIC YALUE OF PAIN. 57 

keeping it most carefolly under liis professional surreil- 
lance and protection during its prolonged convalesoence. 

Every experienced surgeon will support the opinion that 
a great many of the chronic brain afifections which he 
meets with in practice are the result of local injury. A 
transient shake of the brain, slight or severe blows, a fall 
upon the head, the immediate effects of which having 
passed off quickly, may have been almost forgotten ; or a 
sudden rebound or recoil of the brain, as in railway col- 
lisions, produce a condition of confusion for a short time, 
and are then thought of no more. Again, we often hear 
of sudden deaths occurring a long time after concussion of 
the brain. I would suggest, then, that we ought to con- 
sider 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 exquisite delicate struc- 
ture. 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 eflSciently performed. Such soft parts 
having simple functions require weeks or months, or longer, 
for their complete repair ; surely, then, we ought not to 
deny the necessary and proportionately much longer time 
for the repair of the more delicate brain tissues : a repair, 
be it remembered, which ccmnot be accomplished by any 
direct aid from the surgeon, but only by Nature herself 
employing her chief agent — Rest. I believe that if this 
principle be adopted by surgeons generally, and the plan 
carried out, we shall not witness so many chronic diseases 
of the brain. 

I have thought it right to make these brief observations 
in reference to concussion of the brain. I will now add a 
few words respecting concussion of the spinal marrow, in 
which a patient may experience slight and temporary 
numbness or inability to control his legs and arms — a 
condition, I think, more frequently met with than formerly, 
probably on account of the prevailing kind of railway 
accident. I will state a case of concussion of the spinal 
marrow thus : — 

A gentleman falls, without violence, with his back upon 



58 THE THERAPEDTia INFXUENCE OF REST [I.scr. 

ihe hard ground or soft turf. There is no mental confuaion, 
no corobrft! diBtnrbance. He feels a transient, i>eculiar 
Bcnaution — " pina-ftnii-neeilleB " — in hU hands and feet ; 
he get8 up ; walks or rides home ; feels little or no incon- 
venience ; makes arrangements for the morrow ; but iu the 
morning is unable to get up, becauee he saye. he is in paia 
all over ; he feels sore and stiff, just as if he had been 
bruined, making it painful for hiin to move his limhe. 

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 vertebrse, and be itself 
cDncuseo<) in that way. Or the little filaments of the sen- 
sitive and motor nerves, which ai'e delicately attached to 
the spinal marrow, may, for a moment. Ik; put in a state of 
extreme tension, beetmsc, as thfy ]wish thmui^h thi; inter- 
rertebral foramina, they are fixed there by the dura mater ; 
and if the spinal marrow be dragged from them, the inter- 
mediate parts must necessarily be put upon the stretch, 
produoing at the time the " pins-and-needles sensation," 
and also explaining the symptoms felt on the following day. 
He has not caught cold ; he has no rheumatism ; nor has 
he been bruised The stiffness 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 when he fell. Has he stretched the trunks of the 
nerves, or the little filaments forming the roots of the 
nerves ? or haa the spinal marrow itself suffered molecular 
disturbance ? No doubt that sensitiveness of the surface, 
which creates pais on being touched, and the stifihess 
which he experiences, are the result of something which 
has disturbed the sensitive and motor nerves oonjointly 
or individually, according as the function of one and not 
the other has been disturbed ; or the ruisohief may have 
occurred in the interior of the spinal marrow. It is impos- 
sible that these symptoms oould be the result of anything 
but some such structural disturbance ; and they are, to my 
mind, the evidence of decided injury to the nerves or 
r, although what that injury may be is not ascertain- 
" ' the same when the spinal marrow has been 



m.] AJSTD THE DIAON06TIO VALUE OF PAIK. 59 

impaured by a blow, or direct force ; by a shake or a to-and- 
fro motion, mich as occurs in railway collisions, in which 
the marrow is least efficiently defended from external in- 
jury by the mechanical contrivance employed in the con- 
struction of the vertebral column. The deterioration of 
function which follows such accidents must be the efifect 
of some kind of structural disturbance, for it occurs im- 
mediately after the blow. 

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 endeavour to 
" walk off" his condition. There seems to be an impression 
in the minds of the non-professional public that if a man 
receives a concussion 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 £psom a few years since. The accident occurred from 
some scaffolding 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. Within a very short time he began to have spinal- 
marrow symptoms, which have resulted in complete and 
irremediable paraplegia. I firmly believe that if, upon 
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 marrow, which 
probably remains incurable. 

I h&ire seen many such cases of concussion of the spinal 
marrow, and some of the patients have been thought to be 
malingerers. A patient who has 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 walk- 
ing. In a few days, or a week or two, it is observed that 



60 THE THERAPECTIO INFLUENCE OF HEST [L«ct. 

the logs Ijccome feeble ; there is a little jumping of the 
legs at night on going off to sleep, some sense of coldnesB 
in the limbs, sligiit dulnesa of sensation in the surfooe of 
one or both limbs, or of partfi of one or both limbs. Then, 
perhaps, he is ordered by his surgeon to increase his exer- 
cise, BO as to oTercome the effect of disuse, especially if he 
is thought to be & malingerer. This increases the exhaus- 
tion of the s])inal marrow, and the plan, if persevered in, 
most probably leads to paraplegia. 

The oonfirmation of the accuracy and applicability of 
these viowH is, I think, nLade apparent when it is added, 
that all these morbid effeots of concussion of the epioal 
marrow are to be preyented, relieved, or cured by due and 
long- con tinned rest. 

The exjiLTimcnt to which I shall now allude proves our 
capability of (.-xhausting the uxi ito-inutory functions of the 
spinal cord. A person receives a fracture of the spine, 
which produces the destruction of continuity 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 excito-motory function which, is 
apparently dependent upon the grey matter 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 time, and you mention the patient's case to 
some other person, and aek him to go and see a specimen 
of excito-motory function. He goes immediately to the 
patient, tries the experiment, but fails ; he cannot excite 
motion. You see the patient again in a few hours, or on 
the following day, and perform the experiment successfolly. 
The movements are visible, continue for a short time, and 
then cease ; on the next day, perhaps, they reappear. Here, 
ihen we have evidence that by over-exoitation, which is 
equivalent to fatigue, we exhaust or destroy for a time the 
true function of the spinal marrow ; and I accept the res^Ut 
of the experiment as an indication that by over-exertion, 
after concussion of the spinal marrow, we may injure it by 
requiring it to do more uian it is competent to accompliw 
without fatigue. 

The obvious intention of theee lemarks is to suggest that 



m.] AND THE DIAGNOSnO VALUE OF PAIN. 61 

in cases of conooBsioii of the spinal marrow by accident, it 
should have more rest than is usually allotted to it, in 
order that it may not suffer physiological exhaustion by 

gremature and too vigorous exertion before its structures 
ave repaired themselves. Experience distinctly points to 
this recommendation ; since we observe that after many 
months, or a year or two, such patients may recover per* 
fectly. On the other hand, recovery is sometimes 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 spinal marrow or the nerves themselves. 

A surgeon from the country lately came to my house 
with a patient. He said, ** 1 want to consult you about a 
young lady who has a diseased toe." With her was a 
relative, an elderly gentleman, a very kind-hearted man, 
who thinks himself a good surgeon and goes about doctoring 
people, sometimes doing harm, and sometimes perhaps 
a great deal of good. He is very fond of animcJs, and has 
a number of pets. After 1 had examined, with the 
surgeon, the lady's toe, the elderly gentleman said, " Well, 
Mr. Hilton, what are you going to do to cure this young 
friend of mine ? " I said, " I think we shall put a splint 
on the foot and keep the toe very quiet, attend to her general 
health, and Nature, in all probability, will do the rest." I 
then said to him, " What led you to adopt the occupation 
of a philanthropic surgeon in addition to your other 
occupations ? " " Well, Mr. Hilton," he replied " I will tell 
you. You know I am very fond of animals. Some years 
ago I caught a live mouse in a trap. I took it in my hand, 
and I said to myself, *■ Poor thing I you must 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 having bone covering your 
brain^ou have now only a thick dense membrane defending 
it.' Then I thought to myself, ' This mouse must have had 
difficulties in the treatment of its injuries ; and ' " — inter- 
rupting his story, he said, " I hope you won't be offended 
at what I am going to say ? " '* No," said I, ** not in the 
least." "Well,** he continued, "I said to myself, * Surely 
this mouse, although it is cured, never had a physician or a 



62 THE THEBAPEUnO INFLUENCE OF BEST [Lki. 

Burgeon ! ' I qnite agree with jou, Mr. Hilton, that 
Nature is a very valuable surgeon." 

It would be well, I think, if the surgeon would fix 
upon his memory, as the first professional thought which 
should accompany him in the course of his daily occupation, 
this physiological truth — that Nature has a constant tend- 
ency to repair the injuries to which her structures may have 
been subjected, whether those injuries be the re«ilt of 
fatigue or exhaustion, of inflammation or accident. AIbo 
that this reparative power becomes at once most conspicnooB 
when the disturbing cause has been removed : thus pre- 
senting to the consideration of the physician and Burgeon 
a constantly recurring and sound principle for his guidance 
in his professional practice. 

As illustrations of this truth take the following : — ^An 
extraneous body falls upon the conjunctiva ; it is imme- 
diately pushed, by repeated involuntary cloBure of the ey^ 
lids, towards the angle of the eye, close to the puncta 
lachrymalia ; thence the lachrymal fluid floats it upon the 
caruncula lachrymalis, where it becomes entangled by the 
hairs with which this structure is provided. So long as 
the extraneous body remains upon the conjunctiva, the 
redness, pain, <fec., continue ; but after its removal by the 
surgeon or Nature, the whole of the inflammatory appear- 
ance 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 con- 
stant involuntary eflbrts of deglutition — as soon €U3 it is 
removed all the disturbance in the throat ceases. An in- 
growing toe-nail produces great pain and loocd inflamma- 
tion : if you take off the pressure of the edge of the nail, all 
these symptoms quickly vanish. Corns get well if pressure 
be taken u*om 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 ike 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 in practice, especially when looked at 



Ill : AND THE DIAGNOSTIC VALT'E OF TAIN. G3 

through the biassed vision of those who think that in the 
treatment of disease or accident everything is to be done 
by medical or snrgical aid. But I feel convinced that, 
under the most favourable oircumstanoes, 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 
that, by the use of appropriate mechanical applications, 
aided, if necessary, by soothing medicines, and by the use 
of properly adapted diet, we may facilitate her efforts to 
repair the injury she may have sustained. In fact, nearly 
all our best-considered operations are done for the purpose 
of making it possible to keep the structures at rest, or 
fi*eeing Nature from the disturbing cause which was ex- 
hausting 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 suc- 
cumbed to the exhausting influence of disease. In aneu- 
rism — ^I think I am not in 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 disease *bj 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 only not 
to disturb the intestine by purgatives, but we give opium 
to arrest peristaltic action. We know the gut has been 
damaged in its function and structure, and will not bear 
excitement ; that it requires rest and quiet to enable it to 
repair itself. Sometimes we carry this so far at Guy*s 
Hospital, that one of my colleagues, Mr. Birkett, mentioned 
to me that in a case of operation for strangulated hernia, 
the bowels had not been opened up to the twenty-first 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 chfonic laryngitis, cured by tracheo- 
tomy« the cuie is not effiscted by opening the larynx, but 



64 TUB THEBAPEUTIC INFLUENCE OF BEST CLwBl 

by giving the larynx rest. In tlie performance of tracheo- 
tomy for dieeaae of the tarynx, the Burgeon uever toiiches 
the disease at aU ; he merely enabloB the pntieut to breaths 
through the tracheal tube, and diverts the strenm of aii 
away from the larynx, thus giving the larynx the oppor- 
tunity of recovering itself. It ia marvellouB to see what 
hitppens in a few houra after the traoboa has been frce^ 
opened in cases of traumatic injury to the top of the laryu^ 
Huoh aB occurs from, the accidental local application o£' 
scalding water. 

And here I might remark upon the Btriking difference ia 
the BUccesBful roeults of tracheotomy in cases of tranmatia 
injury to the upper part of the larynx, as compared witt 
the want of suoocbs of the operation in cases of diphtheria 
or croup. In the latt«r coses the patient may have a tube 
introduced into the trachea, and may breathe through it 
for a. considerable time, yet the diBcaaed condition of the 
larynx remains, and is often fatal. It is not like the simple 
effects of a local injury : the seat of the local injury being 
kept quiet, the inflammation subsides, and the larynx 
rapidly recovers ; whilst in the other case, of diphtheria, 
the cause still persists. Hence tracheotomy has not been 
euocessful aa a curative operation in such cases. 

I may mention the case of a patient upon whom I per- 
formed the operation of tracheotomy nearly thirty years 
ago, to prevent suffocation from syphilitic ulceration of 
the larynx. She has lived by breatiiing through the tube 
ever ainoe, scarcely any respiration going on through the 
upper part of the larynx, the air which passes through 
^is not being sufficient to stir the flame of a candle. I 
need scarcely add, the voioe is totally lost, but she is not 
disposed to have any further operation performed in refer- 
ence to clearing the upper part of the larynx, and the tube 
is still worn in the trachea.* 

* In April, 1876, 1 mw this patient. Bhe was then mit^ jean of 
age, it being tveiit^.eigbt yeara nnoo tracheotomy was performed for 
the relief of larjneitia, probably of a ajpliilitio natiire. She bad worn 
a tube oontinDuuBl; ; her voioa as such wai quite lost, but by a boorsa 
whiapei and movements of her lipi she made herself intelligible. At 
Ut. Uillon ob«eiTcil, it h to her ver^ small sue, and tberefure small 
reapinttoiT needs, that her havina; liTed so long is to be attributed. 
On changu^ hei tube, the eslemaT ofienlog and hei rerj imall bsohea 



m.] AHD THE DIAOKOSTIG VALUE OF PAIN. 65 

So, again, if a portion of bone be presBed in upon the 
skull, you have only to remove it and give the brain rest, 
and ^e brain will repair itself. It is not the operation 
that cures the injury to the organ, but by removing the dis- 
turbing cause, the brain recovers itself. I might allude 
also, in the same spirit, to the operation of lithotomy. 
Stone is not the disease, although it is the cause of the 
symptoms. The patient does not complain of stone, but 
of the pain and irritation which the calculus induces within 
the bladder. If a patient has a stone in his bladder, it 
does 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 prostate, with all the indica- 
tions of stone. No surgeon can tell whether it is stone or 
not till he has explored the bladder. Those are the symp- 
toms 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 
observation 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 haemorrhage from the bladder. He is always relieved 
by maintaining 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, 



only admitted a tube of a child's size, and (showing the valne of good 
silver tubes) the patient informed me that the tube I removed had 
lasted six yean. The tape-holes were almost worn through, but the 
rettt of the tube scarcely affected.— [Ed.] 

* ** The behaviour of the bladder towairds a stone in it is most peculiar 
and puzzling. In one case it displays almost perfect indifference, Rud 
even acts the part of host witli an approach to hospitality, and allows 
the guest to grow and stay until it reaches enormous proportions. 
Some years ago I made a post-mortem examination on an old mnn 
dead of abdominal aortic aneurism, and discovered accidentally that 
tlie bladder contained a large lithic stone which weighed nearly nine 
otincea. The bladder was healthy and the mucous membrane pule. 
For yean I had occasionally attended this patient, but so little did 
this large stone trouble him, that neither he nor I were a^are of its 

F 



THE THEBAPBCTIC INFLCENCE OF REST [Lkot. 



is n disease requiring operation because 
derangenieut of ikti Btructiii-e which produoea certain fttiin- 
ful symptoms, and by removing the cause the part gete well 
— Erst, through theaasistanceof the Burgeou, hut ultimately 
through tho medium of Nature. 

pceeonce. In otljsr cuaea, no soouor does a stone eulec at oue [xntal 
than the couQict begius, and goes on aotil uitlier it ia tumtd out along 
the urethral passage at the other portal, or the bladder ii pernetnallj 
fretted, worried, aad inflamed, until eithet the aurgoon or deatli tvmai 
to end tho dispute." (Oadge on Lithotrit; at oue Hitting. Lanoel. 
Ap. 5. 1879,) Certain caaet of tviberootoda of the imoary tract prore 
the comHitnese of Mr. Hilton's remarks on symptoms which simulate 
those of stone in the bladder. In tubercular cystitis hlBms.tiitia. 
irregular and tycquont mieturilioa, an irritable, lender and conbsoted 
bladder, pains referred to the neck of the bhiddoT, — all these mav b* * 
met with in a young subject and simulate the presonoe of stone. — [Ed^I ^ 



nrj AND THE DIAGNOSTIC VALUE OF PAIN. 67 



LECTURE IV. 

OOAOfJLABLE LTMPH A MBAlTS FOR 8E0URIN0 BEST TO INPLAlffED SEROUS 
AMD MTJOOUS MBMBBANE8 — PAIN WITH INCREASE OF TEMPERAT17RE A 
nOH OF nrFLAlOfATIOK IN THE PART WHERE IT IS FELT — IJIAONOSTIG 
TALUS OF STXPATHETIO PAIN — DISEASE OF THE VERTEBRiE INDICATED 
BT PATH OYER THE LOWER PART OF THE ABDOMEN AND PUBES — 
KNOWLEDOB OF THE AOOURATE DISTRIBUTION OF THE VARIOUS NERVES 
TO THE HEAD AND BAB, LEADING TO A DIAGNOSIS OF THE DUTANT 
DISEASED ORGANS CAUSING STMPATHETrC PAIN IN THOSE PARTS — PAIN 
BETWEEN THE SHOULDERS AN INDICATION OF VISCERAL DISEASE — PAIN 
OTEB THE STOMACH IN THE REGION OF THE CUTANEOUS DISTRIBUTION 
OF THE SIXTH AND SEVENTH DORSAL NERVES A SIGN OF VERTEBRAL 
DUEASB. 

In my last lecture I said that I thought it would be well 
if every surgeon would fix this upon his memory, as his 
first daily professional thought, that Nature when undis- 
turbed has a constant tendency to repair her own injuries^ 
whether those injuries be the result of fatigue, of accident, 
or of inflammation. I had proposed to extend these ob- 
servations to the consideration of the means adopted by 
Nature to obtain a proper degree of rest where serous and 
mucous membranes have been the subjects of inflammation. 
Although time will not allow me to do justice to the subject, 
I cannot pass it over without a few remarks. 

Serous membranes are secreting and absorbing organs. 
If a serous membrane be wounded, coagulable lymph is 
poured out, and it forms a temporary spUnt thus securing 
a certain degree of rest to the original structures, and 
contributing 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 tissues is rendered complete, this 
temporary medium or splint employed by Nature com- 
pletely disappears. This is analogous to what we see in 

F 2 



H^ THE THERAPECTIC INFLUENCE OF BEST [LetT. 

the case of fractured bones. When a fracture is not nicely 
ailjustod, or much disturbance liaa taken place, Nature 
throwBoutalargequantityof new niatorial, termed ralloB, 
which keepB the fractured bones accurately in pofittion for 
a oonsidcrable length of time, until they have repaired 
thomselveB, and when they have achieved that object, the 
cuUuB entirely disappears. 

TluB subject, perhaps, receives its best and most practical 
illustratiou in cases of wounds of the viscera, and, no 
doubt, when looked at in this light, it suggests to every 
surgeon the great impropriety of doing anj-thing which at 
all tends to disturb the parts, in wounds of serous motn- 
branes. This subject, however, I cannot enlarge npon at 
the present time. I would ask you to Buppoee a serous 
membrane infiamed. What happens when this takes] 
place? When it is not traumatic, but dependent upon^ 
some internal cause (quite irrtjspeetive of any direct local ' 
leaion), almost immediately a considerable quantity of lympti 
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, the irritation must be considerably in- 
creased ; by the coagulation of the lymph upon the free 
Hurfaoee, they are protected against direct friction, in the 
apposed surfaces of the abdominal viscera and their parietes, 
OF in the heart and the opposed surfaces of the pericardium. 
As soon as the lymph is poared out, the serous membrane, 
as far as it can be, is put in a stat« of rest, or freedom ^m 
friction. When the original disturbing cause has become 
exhausted or removed, then I apprehend that, in conse- 
quence of the rest which the serous membrane has expe- 
rienced through the effused lymph, it is able to recover or 
resume its normal function of rapid absorption. Thus we 
see the eSusion apparently performing two purposes — pre- 
venting the friction between the two inflamed surfaces, 
and, that being accomplished, giving Nature a fair chance 
of removing the original disturbing cause. Here the reat 
has 80 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 Ihe first 



IV.] AND THE DIAGNOSTIC VALUE OF PAIN. 69 

act of its renewed health and vigour is to absorb that 
effusion which was the primary result, whatever the dis- 
turbing cause might have been. Thus, then, the lymph 
prevents friction, and aids absorption. In this way, I 
apprehend. Nature does her best to repair injuries, whether 
they be the result simply 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 is in- 
flamed. When a mucous membrane is very much inflamed, 
coagulable lymph is poured out upon its free surface, and 
from that moment the membrane is defended from the 
influence of external agents In the case of the larynx and 
trachea, it prevents 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 ; the latter is thus separated, pushed off from the 
internal surface, and becomes expectorated. This is seen 
in the little preparation before me. Here is a portion of 
lymph partially separated by Nature, as the result of the 
rest which the mucous membrane seems to have obtained 
by the effusion of the lymph. These glands and follicles, 

* In the healing of uloen of tho skin also, the valne of coagulable 
Irmph may be seen as a rest-giver, though in a different way. 
Oocasionallj, eyen in outpatient practice, much time may be gained in 
the treatment of a tedious ulcer, by taking advantage of any oppor- 
tmiely fotrming scab of lymph and pus or blood. Under such a 
scab the grancdations, now kept at rest and free from the disquieting in- 
floenoe of any external stimulus, develope from mere heaps of pyoid cells 
into the more stable spindle or fibre cells, just as granulations around the 
periphery of an ulcer, as soon as they are defended by epithelium, 
rapidly paas into fibrous tissue. Again, this fibrous tissue newly formed, 
whether under a scab or epidermis, gives itself fresh rest by its power 
of contraction. This obliterates superfluous capillaries, and by thus 
cutting off much of the water supply to the ulcer helps to dry up alike 
any graoulaticHiB that remain, and also tiie newly formed fibrocellular 
tiJBoe, diminishing the waatefnl cell proliferation or suppunition of the 
former and consolidating the aa yet gelatinous condition of the 
latter.— [Ed.] 



7n THE THEBAPEDTIC IKPLUENCE OF BEST ILlcT^ 

wheii inflamed, do not secrete their fluid normally, eithar 
in quality or quantity. By means of rest, liowevur, tliey 
have the opportunity of recovering themselves, and wheB' 
they have doue ho, their abundant and natural secretion iti 
interposed between the mucous membrane and the lymphs 
Tho lymph is thus pushed off, and becomes expectorated oP 
Bwullowwi, Sometimes, in the cJtee of acute inflammatioa'' 
attacking the mucous membrane of the intestines, you way 
see long tubular portion* of solid lymph discharged front 
the bowels, having at first sight the appearance of th0 
intestine itself ; but, upon post-mortem examination, it wili- 
be found that the originally inflamed portion of intestins 
has perfectly recovered itaelf. 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 larynx and trachea. 

As a preliminary to my observations on the beneficial 
influence of rest in the treatment of diseases of the spine, 
it will be instructive to remember that accurate diagnosis 
and early recognition of disease constitute two important 
steps towards sucbesBful treatment. It will be advisable, 
therefore, that I should preface the subject of spinal affec- 
tions with some few clinical remarks on pain as a symptom 
of disease. 

When a patient is suffering from pain in any part, he is 
instinctively inclined to believe that he must also be suffer- 
ing from iuflammation 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 these may co- 
exist 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 reference tu the diagnosis aa 
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 recognised at 
once. In the minds of some surgeons there may be con- 
siderable difficulty in distinguishing what is termed an 
inflamed ulcer from an irritable ulcer ; both look red and 
congested, and both are painful : bat by placing the hand 



IV.] AND THE DIAGNOSTIC VALUE OF PAIN. 71 

npon the snrfaoe of the former, and feeling the increase of 
temperatDre in it and its immediate neighbomrhood, its 
nature is rendered evident. The real and essential patho- 
k^cal condition of an irritable nicer I hope to prove to 
yon before I have finished these lectures. We must also 
admit that the employment of the hand for the purpose 
of recognising increased or diminished or normal tempera- 
ture is a matter of ^reat importauce in determining the 
state 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 know- 
ledge, and clearly indicates the precise points where 
leeches, blisters, or counter-irritants should be applied. 
Again, I would submit to you that if, in very young chil- 
dren, this little (but oftentimes repudiated) symptom of 
heat or increase of temperature had more credit given to 
it, and was more frequently observed, its diagnostic value 
would soon be appreciated. Suppose a little child to be 
lame : it may be very difficult for the surgeon to tell with 
precision the exact seat of the 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 inflammatory condition in any 
particular spot. It was in anticipation of what I 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 elementary observations. 

Pain in any part, when not associated with increase of 
temperature (the local symptom of local inflammation) 
must be looked upon as caused by an exalted sensitive- 
ness of the nerves of the part, and as a pain depending 
upon a cause situated remotely from the part where it is 
felt. In availing ourselves of these so-called sympathetic 
pains (and no doubt they are in certain sense " sympathetic" 
pains), I should like to displace, to throw aside, the term 
" sympathy " as something too ideal, and would ask you to 
consider such pains in their obvious, intelligible, and 
more natural relation. I would ask you to regard them 



THE THEBAPEUTrC INFLUENCE OF KEBT [LicT. 



lis rcBuIting from some direct norvons commuuicatioili 
pausing between the part where the paius are expressed' 
and the real and remotely situated cause of the pain. 

I admit that I formerly estimated this aubject too lightlv^ 
BO ihat if a patient complained of ]>ain between hiC 
Hhouldera, or anywhere else, I never asked myself, WhriT 
association of nerves will explain this pain ? Butt- 
beyond doubt, this is the proper way of regarding this 
rjuestion. If the bidden cause of pain be in any ddS' 
particular spot, it ia only by tracing the nerves of and from 
that spot that we can hope to arrive l(^catly at the ro^' ' 
cause of the symptoms, and so divest the cause of its obacQ- 
rity. Applying this method to practice, it is through the 
medium of the distribution of the ooiebro-spinal nerves of 
Hensation (the fifth nerve being the trae cranial »oiiBitiv8 
nerve) that we are enabled to explain those pains which are 
called " sympathetic," but which result from a continuity 
ijf nerves between the cause and the effect, the disease and 
the symptom. It is impoeaible, I believe, to overrate the 
]iractical significance, or over-estimate the value, of thia 
simple statement regarding the relation of pain as a 
Hymptom 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 toasargeon, 
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 favourite phantom). " Yoa 
have caught a cold ;" " you have been standing in a draught 
of air;" "it is the easterly wind, which has ^n 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 inherited it from yonr father 
or your great-grandmother ; or you must have had a blow 
upon the part some time ago, which you do not reoollect>— 
that is all," 

Now estemal pain, or pain upon the sur£u;e of the body, 
if properly appreciated, may be considered as an ezteraal 
sign of some distant derangement. If the pain persists — 
if it does not depend on any transient cause — it becomes 
necessary to seek the precise position of the pain ; and aa 
soon as we recognise the precise position of the pain, we 



IVJ AND THE DIAGNOSTIC VALUE OF PAIN. 73 

aie 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, be able to reach the 
original, the producing cause of pain, and, consequently, 
to adopt the correct diagnosis. 

Patients judge of the position of their own disease, moNt 
firequently, 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 anatomy. We know by experience that such 
symptoms may exhibit themselves at a spot far removed 
from the actual seat of the disease. This latter remark is 
peculiarly applicable and pertinent to diseases of the spine. 

In illustration of this, I may mention an instance that 
oocured to me some years ago in Guy's Hospital. A 
patient was admitted, under my care, with disease of the 
spine. He had lost the power of motion in liis lower ex- 
tremities, and his sensation was very much diminished 
below the pelvis; but he complained of excessive pain 
over the lower part of the abdomen and pubes. It was 
there he believed his complaint to be; and I failed to 
convince him that there was no disease at that spot. 

In this case I might incidentally remark on the close 
proximity of the two distinct nervous conditions of dimi- 
nished sensibility and pain. Below the pelvis sensibility 
was very much diminished, but just above that point he 
suffered excessive pain. This is in strict accordance with 
what is observed in injuries of the spinal marrow, where a 
person may be completely paralyhcd both as to sensation 
and motion ; but a little nigher up than the original seat 
of injury, there may be exquisite sensitiveness, causing the 
patient extreme pain. Let me illustrate the case in this 
way. Suppose a fracture of the spine, with complete loss 
of sensation, below a certain spot. A little higher than 
that spot the sensibility is not very distinct, and, a little 
higher still, the skin is exquisitely sensitive. If the patient 



74 THE THERAPEUTIC INPLDENCE OP HE9T [Lkct. 

(lies, we shall prohnbly find that the nerves that supply the 
aiin where the pain was experienced are attached to the 
upper portion of the injnred spinal marrow, near the neat 
of injury, which is in an iniiamed condition. This is the 
reason of the exalted excitability of that port immediately 
above the seat of the Iobb of Hensation.' 

I tried repeatedly to asaiire the man that there was no 
diseBBe where he felt the pain- — that that was not the seat 
of his disease ; but I failed to convince him. I ordered 
tartar-emetic ointment to be nibbed over the diseased 
portion of the spine ; but the patient would have it that 
the ointment 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 ol' the pubes. and 
upon the penis and scrotum ; and, I need not tell you. he* 
Buffered considerably for his scepticism and his obHtinflcy. 
Of course the twin was not in the slightest degree relieved. 
The pain in this case was situated at the lower part of the 
abdomen, over the pubes ; but the real cause was the 
disease of the vertebne. After a time the man got per- 
fectly well, although he had been i)araly>ed, and nearly 
lost sensation in the lower extremities, the treatment 

• As thU aren of hypfirffistbeBiu mnj cxiat very shortlv after the 
Bocident, when there lias been do time for iiiflannnBtlon to have snper- 
veuMl. there miut be some other eiplBnatiou for ttiij) symptom. I 
oannot do better than qoote in Mr. Hilton's ovn wocda unother 
explanatioD given by bimaelC in n olicical lerture (Gd;** Hosp. Bep. 
IH65) oil a case of TrBctureil epine, where this hypematbesia yiM 
found to exist nn sdmiBsion immediately after the accident. 

" This symptom may, I think, be explained tlms. You know that 
Die lower you get in Ibe spinal canal, the longer is the distance 
traveiaed by the necves which lutve some off (Void the spinal oord 
before they untcr the intervertebral foramina. Each puii of nervea is 
placed more obliquely tlian the pair above it, and, to epeak more pre- 
ei*eiy with regan) to the site or injury in this ouse, the lower dorsal 
nerves, after having left the cord, travel downwards an loch and a half 



li and three-gnnrlers before leiiving the spinnl oinnl. Now, 
I in leaving the canal be pressed upun, an alteration in the 
pprfomiBiice of its functions will, of ooarw, tak» place ; anil this altera- 



tion is manifested by pain or increeeed eenaibility, vhich is referred ti 
the peripheral distribution of the nerve on the akin." — The eiiatenoe 
or not of this line of bypenestliesia may be importnat in the disgtious 
between fnicture and dislocation of the spine ; its aheeQce makes the 
presence of the latter probBble. as there are then no sharp edges to fret 
the nerves at theii exit~[En.] 



rV.] AND THE DIAGNOSTIC VALUE OP PAIN. 75 

having been simply rest — nothing else — and attention to 
hisgeneral health whilst lying in bed. 

When this patient was nrst seen by a surgeon, he was 
thought to be labouring under some disease of the bladder 
and kidneys ; for he hsA a severe lumbago, pain over the 
bladder, and offensive urine. There had been no suspicion 
of anytliing wrong as regards the spine. He was a master- 
painter and house-decorator, and was monstrously con- 
ceited, thinking himself right and everybody else wrong. 
When I explained to him, after careful examination, that 
the spine was the cause of the symptoms, he was not 
satisfied with my opinion, and, without my knowledge, 
consulted Sir Benjamin Brodie, who also assured him that 
his spine was diseased, and told him that he must rest it 
by lying down. To this he then assented. 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 was 
very impatient, and would not remain long enough under 
my care to be quite cured. He returned home, gradually 
improved, and was getting quite well, when some pseudo- 
friend advised hydropathy and homceopathy, 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 homoeopathy, but, no doubt, by 
Nature. The man, however, feels convinced that hydro- 
pathy and homoeopathy cured him. It so happens, gentle- 
men, 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 a severe disease of the hip-joint. I 
gave myself a great deal of trouble about her, and I 
believe 1 placed her joint in a comparatively healthy 
condition. Her note to me was — her compliments, and she 
sent back the crutches, having got well after five months' 
treatment under a distinguished rubber at Brighton. 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. 

In elucidation of my conviction of the value of pain as a 
diagnostic symptom, let me put the subject in a plain and 



"Ij THE TIIEKAPECTIC INFLCE>*CE OF BEST [Leot^ 

jiractical way. You know that the upper and anterior 
part of the external ear and the auditory canal derive their , 
aeuBibility from the fifth cerebral nerve, whieb has ita i 
diroot nervouB associations with the interior of the hea«^ 
the forehead anteriorly, tbe temple, face, eyen, noeo, tectb^J 
and t^mguo ; whilst the poBterior part ami the anterior par^i - 
of the penduluHfl portion of the external ear derive their,' 
sensitive nervous supply from the spinal nerves isBuins-. 
from the spine between the second and third ccrvicat 
vertebrte. it may appear to some of my anatomical 
Mende rather remarkable that I should have depictod 
(Fig, 11) the precise distribution uf tba two Bonsitive 




Sketcb or txKinal pi 



, ahowli^ Ibt dIMtllnitlon ol tbe BRh f«nbni1 Btrrt, ud 
Mm upon IL c, TlK iippH pin of xbr nr. loppllcd b; 
-■I bnncli at the Bftb n«nF. d. Auditory urul. lUppllMl 
!rv(L b. The put ot ths «*r nppljnl by the grrit inrtcslir. 



nerves supplying the external auditory apparatus. A 
curious circumstance enabled me to do so. Some time ago 
I was anxious to depict this piece of anatomy from my 
own dissections, but I did not feel quite satisfied as to the 
exact line of demarcation separating the part where the 
cervical nerves supplied the skin of the ear Irom that where 



IV.] AND THE DIAGNOSTIC VALUE OF PAIN. 77 

the fifth nerve was diBtributed. A short time since, a 
man, who is now undergoing the punishment of penal 
servitude, attempted to cut his wife's throat. In drawing 
the razor across her neck, he divided the auricular branch 
of the second cervical nerve, and gave me the opportunity 
of ascertaining the distribution of that nerve. My dresser, 
as well as myself, pricked with a needle over the whole of 
the auricular surfetoe, and ascertained minutely the precise 
position of the loss of sensation consequent upon the divi- 
aion of the cervical nerve ; whilst the skin which retained 
its sensation indicated with equal precision the distribution 
of the fifth cerebral nerve upon the external ear. 

When a patient, then, tells us that he has earache, or 
pain in or upon his ear, we ought to ascertain whether it 
is pain upon the back part of the ear, or whether it is in 
the auditory canal, or upon the anterior and lower portion 
of the ear ; because it is obvious that the real cause must be 
widely different in the two cases. If the patient has pain 
in the auditory canals or the upper portion of the anterior 
part of the external ear, the pain must be, without 
question (I hope I shall not be considered as putting this 
too dogmatically), the result of some irritation or diseased 
condition associated with the fifth cerebral nerve ; and this 
gives precision to further inquiry.* 

* The importance of recollecting the nerves to the external ear. and 
the other neryes with which they loin, is shown by the cases (in 
addition to tho^e given above) which are occasionally met with, 
pointing to a nervous sympathy between the ear and other distant parts, 
e.g. the gum^, larynx, stomach, etc. 

Bmaberg, Lehrbuch der Ncrven Krankheiten der Mensoben, speaks of 
a praritns of the external auditory meatus from hypersesthesia of the 
anricolar branch of the vagus, andaooompanied by cough and vomiting. 
An interesting article on this subject by Dr. C. Fox will be found in 
the Lancet, A p. 28, 1866. The following are his conclusions : 

'^ 1. The sympathy between (he ear and the larynx, as well as the 

stomach, has been long known. 
'*2. This sympathy is not manifested in every individual, but in 
about seventeen per cent, and seems to depend on a stiite of 
hyperaethesia of the nerve which supplies the auditory canal. 
** 3. This nerve cannot be a branch of the vagus, but in all probability 

is a branch of the fifth." 
Dr. Fox's reason for denying that the vagus is the only nerve 
oonoemed is that the auricular branch of this nerve is distributed not 
to the canal, but to the back of the pinna. 



78 THE THEKAPEUTIC INFLUENCE OP REST [Leot. 

Now, we know yory well that there is often a simulta- 
ueoiie OL-Gurrence of toothache and earache. The same 
nerve that supplies the auditory caoal and the anterior 
portion of the ear supplies also the teeth ; hence, iu all 
probability, this associated \min. I think you may take 
a further step iu the other direction, and say that earache 
often acoompaaied with a atiffiieGe of the jawa. the fifth 
rve supplying the masticatory muscles which fix the 
jaw and also the articulation. So wo know perfectly well 
''.hat disease affecting any part of the anterior third of the 
;ungne is a very common cause of pain in the auditory 
canal, the tongue and the auditory canal being supplied 
by the fifth nerve. These auricular pains are pretty 

" i, TfiU BVinpathy is an enimplo of n reflected Bensation, in which 
file ciPiinoiiDLi bclwoea tlie uervcs touttriieJ lakua pLiCu in the 

■' 3. Ciiae» oocMionally occnr where a congh is solely depeadent <ui 
tlie existenoe of «otne source of irritation in the audilory 
cnnal. Too cases are quoted, one of a coitgli of eighteen 
months daratiim, vhich was ouly cared by the removal of a 
plug of cerumen and Ihe application of silver nitrate to a little 
uloer found beneath the plug; the ottier, a case quoted by 
Ihe late Mr. Toyobee, in wbick an intractBblu cough eeaged 
at once od the remoial of a atnall piece of dead bonu from the 
eilermd auditory meatus. The nriler goes on to state that 
the impreasioii produced by irritation of the auditory canal In 
these cases is probably oonveyed by the auriculo- temporal 
nerve to the deep origiTi of the sensoiy root of the flftli, which 
is in cloM pioxuaily to the deep arigin of the vagua In tlie 
floor of the fourth ventricle. Here a change lain all protia- 
bilitj effeoted in the grey matter, which results in the Htiau- 
Intion of the vagus. The irritation is referred to the laryoi 
because the medulla oblongata Is wont to receive impre«sioDS 
from ihet organ through this nerve. As a oonacqnenc«, the 
respiriLtor; muscles are set in action to free the larynx of the 
supposed irritation. Sometimes the ouiigb ia accompanied b; 
vomiting from excitation of the craniiU origlu of the vagus." 
Dr. 0. Fox also gives other ioslances of the ooQuecliou between the 
flftb and the vagus: e.g. the cough from teething, which it ia so 
important to diagnoHO from tliat of cough, bronchitis, etc., and which 
usually ceases as soon as the gum lancet has been judiciounly L-mployed. 
Again the sympathy between the ear and the stomach is shown by 
cases arising where a derangement of the digestive organs is the sole 
cause of deafness (cf. the amaurosis oooasiunally produced by dys- 
pepsia), or by the case quoted by Arnold where a oljild sufiered from 
obstinate chronic vomiting, which was at once removed by extracting 
from each eu a bean introduced ia pUj.— [Et>.} 



'V.j AND THE DlAli.NO.SriC VAl.L L Of TAIN 7;i 

ooDitant in caaes of malignant disease attacking the side 
of the bmgoe or the part towards the apex. Local morbid 
conditions are sometinies indnoed by irritatiuK seoretions 
which resnlt from the free nervous oommnnicstion between 
the different parts which derive their sensibility from the 
fiiUi nerve. 
A professional friend had an enlarged gland below the 




'». b'. RtgLun tappLitd by an 



external ear. The real cause of this was not quite appa- 
rent, and BO be requested me to look at it. There was a 
slight discharge of morbid secretion in the auditory canal. 
We disooBsed the question together, and I said, " Ver}- 
likely it may be the result of a decayed tooth. Irritation 
from it may be conveyed to the auditory canal, and induce 
this morbid secretion ; that morbid secretion may produce 
•Ught excoriation, and that excoriation, aided by lyniphatio 
' ' . the existence of the enlarged 



absorption, may explain 1 



80 THE TnERAPEOTIC INFLUENCE OF REST [Lect. ' 

gland." The tooth was eKtract«(5, all the other local 
morbid conditionB diBappoared, and there was no reimr- 
rencc of the local eymptoms. 

In order to show the practical application of the views I 
have just advanced, I may mention a case that occurred 
last year. A gentleman, aged eixty-three, came to con- 
sult me about an ulcer situated upon the left side of hit 
tongTio. On examination, I found an elongated, very ugly- 
looking ulcer, neafly as large eis a bitter almond, and of 
niuch the same enapo. The snrronndiug parte 'were 
swollen, hard, red, ana much inflamed, and a lymphatic 
glaud was enlarged below the horizontal ramus of the 
lower jaw on the flame side. I saw in the mouth a ruggod 
tooth, with several projecting points upon it, opposite the 
ulcer. This gentleman observed to me, " Having sufFered 
a good deal from earache on the left side for a long time, 
without experiencing any relief from medical treiitment. 
it was tlioiight thiit I must Ix- gouty, am! I went tii a 
surgeon who treato gouty affections of the ear. Thi« 
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 had for some time past some- 
thing the matter with my tongue. On seeing it, he imme- 
diately began to apply caustic vigorously ; moreover, not 
satisfied with applying it himself, he gave it to my wife, 
that she might apply it at home. I have gone on is 
this way from day to day until the pain in my ear is very 
considerably increased, and the ulcer on my tongue is 
enlarging ; so I have come to you for your opinion regard- 
ing my state ; for. to tell you the truth, 1 am afraid of a 
cancer in my tongue." I thought I saw the explanation of 
this patient's symptoms. The I'ain in the ear was expressed 
by tlie fifth nerve, and there was a nigged tooth with little 
projections upon it, some of which touched a small filament 
of the lingual- gustatory branch of the fifth nerve on the 
Burface of the ulcer. I detected this Kttle 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 caused the 
pain in the auditory canal which led the patient to go to the 
atirist, and the anrist, instead of confining himself to his 



IV.] 'AND THE DIAGNOSTIC VALUE OF PAIN. 81 

own department, seized the tongue, pnt nitrate of silver 
upon the whole of the nicer, and increased the mischief. 
I simply desired that the ulcer should be left at rest ; that 
the patient, to avoid touching the tooth, should neither 
talk nor move his tongue more than necessary; that he 
should wash his mouth with some poppy fomentation, and 
take a little soda and sarsaparilla twice a day. In three 
days about one-third of the ulcer was healed up, actually 
dcatriaed, the enlarged gland nearly gone, and the earache 
much diminished. 

This rapid improvement might appear something like 
exaggeration, but all surgeons know that the tongue ha^ 
those elements within it which contribute to the most rapid 
repair of injury. I do not know any tissue that repairs 
itself more rapidly. It is abundantly supplied with capil- 
laries filled with arterial blood, and has an enormous dis- 
tribution of nerves, and these are the two elements that 
contribute to rapid reparation. It was quite clear that tlie 
treatment was in the right direction — viz. that of givinj; 
rest to the tongue and ulcer. After a few more days T 
requested him to consult a dental surgeon with respect to 
the propriety of taking oflf the points of the tooth. This 
was afterwards done, and the patient soon lost his anxiety 
abont cancer, his earache, and his other severe symptoms. 

I mention this case to point out the value and importance 
of recognising the precise distribution of the nerves of any 
part where a patient is suffering pain. I thought I might 
take the surface of the external ear as a pretty accurate 
illustration of what I intended to convey. Last July a 
patient came to me with earache. The pain was on the 
lower part of the ear — not the upper part, nor in the 
auditory canal. Looking at the neck. 1 saw a little 
swelling there, and the patient said, '' Oh, that is only a 
kernel which comes down sometimes. I have been under 
my surgeon's care for some time for the ear, but am no 
better." It struck me that the '* kernel " or gland, lying 
close to the second cervical nerve, was the cause of the pain. 
Hemlock poultices were applied over the gland, and in 
a week or so the gland suppurated ; it was opened, and 
the painful symptoms disappeared. The patient had ear- 
ache, and the symptoms were precisely expressed. There 





fi3 THE THEKAPEDTIC INFLUENCE OP BEST iLtOM, 

was no pain in the auditory canul supplied by the fifA( 
nerve ; the part of th« ear implicated waa that oounectod 
with the auricular branch of tho second cervical nerve. U 
was the reoognition of this distribution of the nerves to 
ear which gave me the opportunity of detecting the roil 
cause of the painful symptoms. ^ 

These cases support the opinion that accurate infoi 

tion respecting the exact deat of jwin is a very importaafe 
step towards obtaining a correct diagnosis. 

Again, with respect to pain upon the head. Suppose 
person to complain of pain upon the scalp, is it not ver_ 
essential to kriow whether that pain is expressed by tlM| 
fifth nerve or by the great or small occipital ? Thus ) ' " 
in the anterior and lateral parts of the head which 
supplied by the fifth nerve, would suggoHt that the cause 
must be somewhere in the area of tlie distrilmtion of the 
other portions of the fifth nerve. So if the pain be ex- 
pressed behind, the cause must as assuredly be connected 
with the great or small occipital nerve, and in all proba- 
bility depends on disease of the spine between the first 
and second cervical vertebras. 

It is not enough to say that a patient has pain upon his 
ecalp ; we must know precisely on what part of the scalp. 
It is not enough to say that he has pain in hia ear, but 
upon what part of the ear; because there are distinct 
nerves connected with these two difierent parts. I ad- 
vance these local illustrations to indicate the proper 
method of exploration of the causes of pain, in whatever 
part of the body they may occur, although my remarks 
are here especially applied to the surface of the body, 

■' Sympathetic " pains ' on the surface of the body con- 



' Amongst otIiGr irall-knowD inatnDceB or pains fonnerl; cnlled 
" ejmpiithetic," but now readily oucuuntod for by tlje koowQ nuntiimj 
of ceiiaiu DerveB, are the pnin on the innei side of the knee in hip- 
disease, at tlje citrecait; of the urethra in certain ii&ectioDS of tho 
bladder, in the IcstiB tind thigh iu renal oilculvs, and that lesi 
clearly explained pain felt in the tip of (he ehonlder in certain afTMtions 
of tlie liver, e.g. congestion and canci^r of the liver, and in passage of gall- 
atones. In a paper ruad before the Brit. Med. Assoc, at NewcaBtle in 
1870, Dr. Emblelon reviews the different eiplanfttions of shouldpr-tip 
pain; amongst others that of Mr. Hilton him self (Hunt Orat. 1»675, 
tliitt this pain wm duo to the phienic nerve having oommuaicialiOD with 



IV.] AHD THE DIAGNOSTIC VALUE OP PAIN. 83 

nected with derangements of the internal viscera, are of 
great and pressing interest to us. I conceive that pains 
situated upon the surface of the body, and associated with 
some abnormal state of an internal viscus, must be looked 
upon as a beneficent provision, enabling us by external 
pain to receive the information and to appreciate slight 
organic changes or derangements of function of the internal 
viscera.* Otherwise, and without some such reference, it 
seems difficult to understand why there should be structural 
nervous communication, and thence pain, upon any part 
of the surface of the body, consequent upon the patholo- 
gical state of internal viscera or internal parts of the 
body. 

Perhaps one of the most frequent of the ** sympathetic " f 



the 3rd and 4th cervical and also teuding twigs to the porta of the 
liver and to the round ligament ; that again of Prof. Roileston, who 
explained (Address on Physiology 1868) this pain by the connection 
between the phrenic nerve and that to the subclavius. Dr. Embleton 
however, believes that this pain originates in the filaments of the vagus 
which reach the hepatic plexuses, and that then by the intimate connec- 
tion between the vagus and the spinal-accessory, it is expressed in the 
branches of the latter which supply the trapezius and which communicate 
beneath it with the third and fourth cervioti nerves. Dr. Embleton gives 
the following as his reasons for thinking that this liver pain is connected 
with the vagus rather than with the phrenic, viz. that its ordinary seat 
is not in the clavicle, but in the edge of the trapezius rather than in the 
clavicle, and that the trunks of the vagus and the outer division of tlte 
apinal aooessory, as far as they are amenable to examination, arc abnor- 
inally sensitive to pressure.— -[Ed.] 

• For two theories of the use of tnese '* sympathetic " pains see a paper 
by Dr. Hart (Pract. vol. xxi. p. 346) to which fuller reference is made. 
Lect. ix. note p. 210.— [Ed.] 

t The subject of dorso-interooetal pain, especially that variety known 
as infra-manunary, will be found discussed in the pages of the Brit. 
Hed. Joum. for 1858. Dr. Martyn (Brit. Med. Journ. vol. ii. 1864) 
gives the following explanation, which, like that of Mr. Hilton, is based 
on the connection between the sympathetic and spinal nerves. " The 
question was this : — Why is pain almost invariably confined to the 6th, 
7th, and 8th intercostal spaces of the left side ? The answer seems to 
be a relation to the heart .... The aortic arch impinges on the left 
•ide of the 3rd dorsal vertebra, and opposite the 4tn, 5tli, and 6th, it 
receives contributions to its plexus from the corresponding ganglia of 
the sympathetic, while its plexus again contributes to the heart. These 
sympathetic ganglia have, however, just received branches from the 
intercostal nerves themselves : and so it is that the heart and the inter- 

O 2 



1 '" 

.,..■. I iciK'c wr must c'<»n<-lu<l<' lh;it tlirs' 
iiniiirtliatt' scat nf the ]>aiii. It" wr trari 
'j,i«';U s]»laii('lniic nnvr tVoiu within tlictlio. 
an<l liiui it connected tit its abdominal end 
plexus, theuce trace its distribution to the 
donum, liver, and pancreas ; and if we fi. 
or upper end of the the same great splanch 
the fourth, fifth, and sixth dorsal nerve 
peripheral sensitive filaments to the integui 
angles of the scapulaB, to the interscapular 
adjoining skin, we can well imagine (withe 
the question of how the transmission is ma 
nerves carrying the influence upwards and b 
explain the occurrence of the pains sometime 
in those external parts associated with abdo: 
disturbance. I think it likely, then, that tl 
persons experience in disease of these vif 
explained by the Illative position of the gre 
nerve, communicating, on the one hand, w 
plexus, and thence with these digestive or( 



orwtal space (4th, 5th, 6th) are supplied by the san 
Now the 4th, 5th, and 6th intercostal nerves are thoi 
large, lateral, cutaneoiis branches, desoending over twi 
terminate in the skin over the 6th, 7tl), and 8th intorA^^ 
is the theonr tl»o* »»»^- - 



IVJ AND THE DIAQKOSnC VALUE OP PAIN. 85 

the other, distributing its branches to the fourth, ^fth, 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-defined 
disease of the spine. As in accidental injuries to joints, 
80 in accidental injuries to the spine — as in diseases of the 
jmnts, 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 majority of the cases of primary disease of the 
spine in children, and almost all those in adults, are the 
resnlts of exercise persevered in after fatigue — that is, 
ftfter moBColar exhaustion, or of accident, unacknowledged 
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. I trust I shall 
not be thought too sanguine when I assert it to be my 
firm conviction that if diseases of the spine were recognised 
sooner than they usually are (and I am confident they may 
be), most of the cases would be cured by properly applied 
rest. If the disorder is allowed to proceed until deformity 
is manifest, as in hip-joint disease, then assuredly the diffi- 
culties of the case are much increased, and the prospect of 
a favourable result much diminished, thougli not by any 
means destroyed. 

In the cases of inflamed joint, we can discover its actual 
condition through the existence of a single local symptom 
— ^viz. increase of temperature in the parts. So, in disease 
of the spine, there is one symptom which almost always 
stands out most prominently, I would almost say solicits 
onr right appreciation of it, and that is, local and fixed 
pain upon the surface of the body, with or without exacer- 
bations, local increase of temperature being absent at this 
mpot. I feel quite certain that through the medium of 
Uiis symptom, properly employed, we may be led to the 
recognition of morbid conditions of the spine long before 
there is any evidence of disease by palpable deformity. 

Diseases of the spine may begin in the vertebrse or in 



86 THE THEBAPEDTIC INFLUENCE OP REST [LiOTt 

the inten-crtcbral substance — I think, upon tha whole, 
most frequently in ihe intervortebrftl substance, or when- 
this JB joined to the vertebra." This rathor aupports the 
view that diHeaaes of the spine are veiy often the result oE 
aocident, because we know that in accidents, at least BO- 
far as I have been able to diacover. the inoBt frequent 
lesion in injury to the apiae is a partial eeverahce of the 
vertebra from the intervertebral substance : and I suapeot 
the sanie thing obtains with resficct to disease of the spine. 
The pain associated with diseased spine to which I now 
refer is found upon the skin Bupplied by the nerves which J 
escape from the vertebral canal through the intervertebrsl I 
foramina, close to the bones or inter^■ertebra! aubatanoea, ^ 
either of which, as I have said, may be the seat of the ' 
disease. It is upon the recognition and right interpreta- 
tion of the eauae of this pain upon tho surface of tlio body 
that we ought to place the best prospect of early and cor- 
rect diagnosis in spinal disease. 

In disease of tiie lower cervical, dorsal, and lumbar 
regions of the vertebral column, the pain is usually ex- 
pressed symmetrically — that is, on both sides alike. It is 
often, however, not so when the disease lies between the 
occiput and atlas, or between the first and second cervical 
vertebrss. In all cases of symmetrical pains the cause is 
central or double, both sides being in a like morbid con- 
dition, whatever the disease may be. I have had this 
sketch (Fig. 13)made for the purpose of reminding you of 
the method of proceeding in analysing the cause of ^m- 
metrical pains. I will select two of the dorsal nerves for 
the purpose of illustration. 

The positions of the sixth and seventh dorsal nerves are 
here indicated, as they are distributed to the skin just over 
the pit of the stomach. If pain be felt at that part alike 

* Thia view, tljat dieeBsu of the spine oommcnceB at the junrtioD of 
the vertebra with Uie JDtcrvertebral Bubotunces mora frequentlj thui 
in the inlerreitebral BubBtanoM or the Tert«bnD tbemBtlves, receiTes 
support from the fact that the janctiou of e, tuoie ti> a Itss elastic body 
is tliD weakest spot, and therefore rcceivea liio full effect of a, Ktrain. 

tlie junction of an atheramatoua with the hoalihy part of an arlerv ; 
Bucb a spot, with its sudden ditainution of elnstieity , being natundlj 

nnfitted to msM either a stnun or increesed blood-prcMuie.--{£d.] 



IT.} 



AlTD TEE DIAOKOSTIC VALUE OF PAIN. 



87 



oa l>oth eidee of the median line, these nerves become the 
only powible ezpreaaion of that oanse, for there is no other 
■trnctare there sitoated which could manifest the pain. 
By then tracing the nerves producing these surface-paina 
backwards to the posterior median line, and noting accu- 
rately the healthy or unhealthy condition of the various 




str qc tu rw near which these intercostal nerves would pass 
— such as the ribs, pleune, aorta, ceaophagus, and other 
Btmctnree in the posterior mediastinum, —we arrive at the 
vertebra and spinal marrow, and in that way, proceeding 
by the law of esolusion, we arrive at the diseased spine as 
the real cause of the pains experienced at the pit of the 
stomach (See Fig. 13.). ^ 

I would now point to the application of this method in 



SS THE THERAPEUTIC INFtCENCE OF BEST [Lew,; 

[jractioe, aa iUiiatrated hy a case whicli I saw in 18^1. Os' 
the 18th of Marcli of that year, Mr. Kay, of Xhilwialit. 
brought me a boy, eight years of age, who had beoK' 
suffering from severe paio during January and FcbruaiJiS 
1851, just above the pit of the stomauh. and who used iig 
walk about with his hdiids placed over that region, wift 
the body a little inclined forwards, as if suffering froift 
Home irritation or pain of the abdominal organs, in whic^' 
direction the treatment had hitherto been chiefly applied,) 
bnt without much benefit. It was noticed that the pai^ 
increased during the mainteaanco of the erect posture, aoS 
that it wns relieved by the recnimbent position. The chUa 
was old enough to express a little of what he felt, and' 
when asked where the pain was, he put both his bandl 
ijver the stomach, where he had previously complained of 
[Jain, and we observed that the pain was esproBsed on both 
Midee alike. I reijuentt'd 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 vertebrte, and 
pressure upon these vertebra produced the pain in front. 
The child could give us no explanation of the symptoms. 
Xo known accident had occurred. 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 nioiiths, he got quite 
well, without any local application to the spine. The 
improvement began immedjately on his lying 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. 

I mention this case for the purpose of showing that lapse 
of time, and the accidental casualties of life, have not 
induced the reappearance 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 circumstances. 

About two years ago Dr. Addison was requested to see a 
gentleman's son, who was then at the Westminster School, 
and who, it was thought, had been suffering from some- 
thing wrong in his aMomen, for he had pain at the pit of 



rVj AND THE DIAGNOSnC TALUE OF PAIN. 89 

the Btomach and occasional vomiting. Observing that the 
tongue and other circumstances did not indicate much 
leiious disturbance in the neighbourhood of the liver, 
stomach, duodenum, and other parts in that locality, he 
suegested that there might be something amiss with the 
qnne. I was therefore requested to see the lad with Dr. 
Addison. I found that he had precisely the same pains 
(as those observed in Mr. Ray*s C€ise to which I have been 
referring) over the pit of the stomach, and that ho was 
eaty when lying in bed. We believed we recognised disease 
of the spine exactly between the sixth and seventh dorsal 
▼ertebrse. All the stomach medicines were entirely put 
adde. He was made to lie down on a bed, sofa, or couch 
in the drawing-room for two or three months nearly un- 
interruptedly, and from that time he got perfectly well. 
No cause could be made out for the disease of tlie spine, 
except that as he was a tall, growing lad, it might have 
been induced by sitting daily too long, without any support 
to his back, upon a form at the Westminster School. The 
■onrce of the mischief was here accurately diagnosed by 
observing the precise position of the pain. Tli^re was no 
eyidence of a local inflammatory condition where the pain 
was expressed. It was clearly a pain dependent upon a 
cause giiuated remotely from the point of manifestation. 
Tracing the pains backwards, we came to the seat of th6 
disease, and then, by adopting rest as an agent, the boy 
was ultimately cured. 

Some time since I saw a gentleman, who was brought to 
me by a surgeon, complaining of something wrong in his 
back. I was not told what it was, but was recjuested 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 recognised 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 



-^^'■'' zj';:z::;:r -'' '-■ ''^"" ^ 



V.l AND THE DIAGNOSTIC VALUE Or PAIN. dl 



LECTURE V. 

STIORTSICAL SUPERFICIAL PAINS INDICATE A CENTRAL, OR BILATERAL 
Ain> UNILATERAL PAINS A ONE-SIDED, CAUSE— CASES OF DISEASED SPINE 
WITH SnOIETRIOAL ABDOMINAL PAINS — WITH PAIN ON THE BACK OF 
THE HEAD — ^PAIN OYER THE LEFT SHOULDER AND IN LEFT ARM — WITH 
IXMB OF POWER AND SENSATION IN THE LIMBS — ^WTTH IMPENDING 
DEATH FROM PREB8URE ON SPINAL MARROW CURED BT BEST — FATAL 
GASES — ^PORTIONS OF ATLAS AND AXIS EXPELLED BT POST-PHARTN- 
6BAL ABSCESS — ANCHYLOSIS OF BOTH TEMPORO-MAXILLART ARTICU- 
LATIONS — PATIENT SURVIVING FOURTEEN YEARS AFTER INJURY TO 
THE CERVICAL VERTEBRJE PBODUCINQ PARALYSIS OF UPPER AND LOWER 
EXTREMITIES. 

When referring to the subject of pain, in my previous 
lecture, I endeavoured to snow its value as a means of 
diagnosis, with especial reference to the detection of diseiwe 
situated remotely from the part where the pain is ex- 
pressed. 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 must 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 
mechanical rest; therefore, the point which I 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 
structural disturbance. I will now, however, confine my 
observations to the subject of 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, endeavour 
to reduce my views to the form of a proposition — a propo- 
sition admitting of qualification, it is true, but it may assist 
your apprehension of my meaning. I would state, then, — 
That superficial pains on both sides of the body, which are 
symmetrical, imply an origin or cause the seat of which is 



93 THE THKRAPEDTIC INFLUENOB OF BEST [LeOT. \ 

eentral or btlaUral ; and that unilateral pain tmptieg a trd 
of origin which it onesided, and, a* a rule, exigte on the. wiM 
aide of the hndy at Ike pain. 

Afisociatec! with disease in the lower cervical, or the 
lumbar or dorsHl vertebra, the pains ore almost alwayi 
HymmetricAl, whilst iu diseases betweeu the occiput ^nd 
atlas, or between the atlas and the second vertebra, it often 
[luppena that the pains are unilateral, or one-sided. The 
probable ground of this pocnliarity ia, that the diaease of 
the spine which oooiire between the oocipnt and first ver- 
tebra, or between the first and second vertebrse, may 
attack and confine it«elf to one of the joints between these 
bones ; whilst a disease of the other vertebrae general^ 
involves the whole of the body, or the whole of iha_ 
int«rvertebral subetiuice. 9 

I detailed in my last lecture two or three cases showinff 1 
that, notwitli standing the strikingly marked symmetry rf 
these spinal pains iin the surface of the body. esp<-cifil]y 
over the abdomen, tliey were not proptTly interpreted, and 
consequently that such cases were often treated erroneously 
by being thought to depend upon some abdominal dis- 
turbance. 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 attendance. I pur- 
posely abstain from mentioning the name or the locality. 

Caie of Diteaaed Spine, with Symvietrieal Ahdominal Paint. 

E. A , aged four years and a half, a moderately 

robust girl, with a rather strumous diathesis, always on- 
joyed 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 supposed abdominal 
affection without benefit. In consequence of the contina- 
ance of these symptoms, she was sent to the sea-side. 
The surgeon there in attendance assured the parents that 
she was sufiering from a slight stomach derangement, and 
physicked her accordingly. One month subsequently to 
this period the child returned home much reduced Id 



V\] AND THE DIAGHOSnC VALUE OF PAIK. 93 

itrength and flesh, and nnable to walk about, from 
ipasmodic pinching pain in the abdomen, which '* doubled 
ber up." In a short time, however, having been kept 
)iiiet in bed, she recovered her flesh and strength, so as 
to be enabled to walk about a little without pain. Quickly 
ftgain all the untoward symptoms supervened ; the abdo- 
oien became large and tumid, bowels irregular, with pain 
b the belly, as if a cord were tied around the abdomen. 
[Tbis sensation of a cord around the abdomen is very 
significant, and is usually suggestive of spinal mischief. * 
iL gentleman whom I saw from the neighbourhood of 
Korwich, with a disease of the spine, in detailing his case 
to me, said, " Did you ever see any of those Italian fellows, 
ndth monkeys on boards, dancing to music, with a cord 
Mr piece of leather strapped tight around their belly and 
loins ? That is just how I felt " — giving one an idea of 
the pinching and contracted condition of the abdomen 
nrhich he had experienced.) The advice of another 
mrgeon was obtained, who assured the parents that the 
Doeflenteric glands were affected. The urine was at that 
time phosphatic and ammoniacal. She was allowed to go 
hhont as usual. In a short time the alteration and un- 
iteadiness of gait became more marked, and the other 
lymptoms continuing, she was taken to London to see a 
mrgeon (not myself), who told the parents that the child 
vras suffering from angular curvature of the spine. The 
3hild was placed in a recumbent position, and I was 
xmsulted. I saw this patient on the 19th of March, 
I860, when there was evidence of disease of the eighth 
ind ninth dorsal vertebrae, with slight projection back- 
nrards. The urine was now healthy. Uninterrupted rest 
in the recumbent position was ordered, with no medicine 
%t all. It had recently been remembered (this is one of 
the important points) that the child, about a year ago, 
fell out of bed upon her back — a distance of about two 
feet — and that her abdominal symptoms began about three 

* Very siinilar senBatioDH — as pointed oat by Dr. Buzznrd, Lancet, 
lip. 5th, 1879, of sharp pains like knives around the trunk, increased 
by moveiDent, and a numbed feeling about the belly, may be produce*] 
by a gummatous meningitis making pressure upun the posterior roots 
n kome of the spiual neryes. — [Ed.] 



»B iuni'i^ J 

1 cural^ 



94 THE THERAPEDTIC INFLUENCE OP REST [Lect. 

months afterwards. TIub I take ae another illuBtration 
of what 1 have gonerally foiinil, that almost all these 
diseases of the spine are tbu result of slight accideutt 
overlooked. On the 15th of May the child was lying 
down, &nd was reported to be in excellent health and 
epirita, having do uutoward symptoms. It was then 
intended that the child should lie down two or tlira« m 
months longer, and wo assumed that, if < 
exercise it was gradual and oteady, she would be c 
and cured by rest. 

A little while ago, Mr. Sewell, a surgeon in Lambetb, 
reminded me of a like case that I had seen with him nine 
years ago. It was the case of a little girl, sis years of ago. 
with symptoms as nearly as posaiblo like those I haw 
just detailed. There waa disease in the lower dorsal ve^ J 
tebree, with slight projection backwards, and psoas absoon'l 
fluotuating just below Poupart's ligament. She got per* I 
fectly well by sis luoiiths' rest, iiiid the absccBS has never 
shuwu itself since. It graduEillv mwlfd ; I prcsuuie it 
has been absorbed. She is now at school, perfectly well 
in every respect, ejtcept a slight 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 jMjsition 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 jiain which he feels, and may, 
perhaps, be able to iudicate the de]>th of the pain, so as to 
enable us to giit at the real cause. 

No oases of diseased spine arc so immediately dangerous 
to life as those in the upper part of the cervical region, 
especially if situated between the first and second cervical 
vertebne. I believe if surgeons will examine carefully the 
pains of which such patients complain, and use them as a 
means towards the right interpretation of the probable seat 
of the real disease, and then ado]>t, iu a must positive and 
determined manner, the proper treatment by rest, the 
majority of these cases will do well. 

I shall now endeavour to sustain this opinion by detail- 
ing some cases. 



V; AND THE DIACtNOSTIC VALTK (iV TAIN*. N") 

Disease of the Spine, with Pains on the Back of the Head. 

About fourteen years ago I saw, in consultation with the 
late Dr. Bright, a gentleman, aged twenty-^ight, 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 
rarely sends any filaments to the skin beyond the muscles ; 
indeed, it is chiefly a motor nerve.* The great occipital 

* No doubt this statement is correct for most cases, and receives 
rapport from the fact that in the sub-occipitnl ucrve the relative size of 
the roots is exceptional, the anterior being larger than thu posterior. 
But in the absence of any cutaneous offset there is invariably a branch 
of communication between the posterior division of the sub-occipi- 
tai nerre and the great occipital, over the posterior surface of the 
inlinior c^lique. By this any irritation of the nerve, as it lies in relation 
to the verteoral artery, might reach the great occipital and so the 
•tsalp. Dr. Bright* B cases of diseased arteries of the brain with pain on 
the oociput will be found in the Ist vol. of the Guy's Hos. Bep. ; the 
following passage will he found at p. 12. *^The probability of such a 
change having taken place in the vessels is considerably increased in 
each of these cases, because the occipital pain has been a prominent 
symptom; and further, this pain would, of itself, chiefly direct our 
Bospicions to disease of the vertebral arteries ; for, if we turn our atten- 
tiofi to the position of the sub-occipital and two superior cervical nerves, 
rdatively to the vertebral artery, we shall perceive that the sub- 
occtpital nerve lies side by side with the artery where the latter makes 
itt torn in the groove of the upper edge of the atlas ; and that the 
second cervical nerve, on issuing from me spinal canul, passes close to 
the artery. When these circumstances are borne in miud, we shall find 
DO difficulty in admitting the high probability, that if the artery be- 
come diseaised, it may directly excite pain and irritation in parts to 
which the sub-occipital and second cervical nerves are distributed, and 
■imiiarly affect those supplied by the great occipital." . . . With these 
of Dr. Bright should be read a paper by Dr. Ramskill (Lend. 



96 THE THEKAPEUTIC IKFLUENCE OF BEST [L«M. ■ 

norvo Buppliod tte stin whoro the pain was felt by thin 
gentlemau (ride fig. 12, a'), anil (m tracing this nerve 
towards tbe spine, we came to the csuso— viz. diaeaep 
between the first and second ccrrical vertebrre. The 
ptktient 'was ultimately cured by continned rest in tbe 
nearly horizontal position ; the care, however, consisted in 
completo aiichylfieis of the bones, and a fixed neck, with 
tlie nead turned somewhat downwards and towarda the 
left side. This patient died from pulmonary consumption 
twelve years after his recovery from his disease of tito 
spine. J 

Diteaie of the Spint leilh Pain al tke Back of the Heofl 

and over the Left Shoulder and in Left Arm. I 

In the autumn of 1957 I was consulted by a lady &wtt^ 

one of the Midlaud Counties, respecting a pain she | 
espcrienccd on the Imck of her hoad mid ear, and upon the 
shoulder of the left side, acconipauied by lose of power, and 
pain in her left iirm. I was told that these symptoms had 
come 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 

Uoep. Iteo. lgG4) on nises of tlilatnliun of the left ventricle of the beMt, 
nuBOciated with diffiralty uC articulation, nnd with biib-occipitiU paiD. 
Id (hia paper Dr. Buoahill mukeg use of the Bame rtoaoitin^ na Dr. 
Bright lo »ugge»t how disease in llie vortebral ailtry mny prodooe 
dJfflcDlty of ai ticulation : for the hjixiglusHal n<-rve li^ !□ the eame 
relative positiun above the arti^ry tliat the eub-occipilal nerve dues 
below it. The paper enda Ihua : " Thtreare canea of disfased arteriea 
leading to hemiplegia, to apoplexy, atid In other cerebral lesions, \«hich 
first show themselves by uii altorcil ccnditiiin of the vertebral artery 
maniltvled by sub-ovcipiCal pain, and by difficult arliculatinn. Some 
disease of arteries may be eiperted at a cialuro age voiying irith tlie 
ouDBtitntional tendeucies and moile of tifu of Ilie individual, but the 
mischief arising ftvm snch diseaao in the arlerJBj tunics is fastened by 
certain funns of lieuitilisease, of Hbickweakrirsiior dilatation is s chief 
chaiarleriBtic In noiiie cases it may bo astwcloled with fntty de- 
ceni-mtiun, in others with simple dilatalinn, with or without Talmlar 
dieease. In such ciihih, rumediea should lie fiddrcsscd to tlie heaTt,and 
an improvenifnl in its nclion will be toUuwed by a corresponding 
Birc'st in the Bu1)-i<c<^ipili<l puin and diffii'ult articulation, and by A 
postponi-mpnt. st lenst. of the Coming api'pleiy, hemiplegia, or the 
eetebnl lesiou."^[Ed.} 



Vj~ AND THE DIAGNOSTIC VAI,( 11 OF TAIN. 1'7 

tlicii seut to Cromer, ou the Norfolk coast, to improve her 
general health, and with the hope of getting rid of these 
suppoeed hysterical or rheumatic symptomB. She remained 
at the sea-flide daring the whole of the summer without 
any benefit. When I saw this lady in the autumn of 
1867, her age was about thirty ; she had pains on the left 
side of the back of the head, and behind the ear ; pain 
over the clavicle and shoulder ; pain, with loss of power, 
in the left arm; pain deep in the neck on pressing the 
head directly downwards upon the spine, and on rotating 
the head ; some fulness and tenderness on pressure about 
the first, second, and third cervical vertebrce, especially 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 particular 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 injury of the spine 
affecting the occipital nerves (see Fig. 12, a', h'), the third 
cervical nerves, and the nerves forming the left axillury 
plexus. As far as I could interpret the case, rest appeared 
to be the proper remedy. The patient maintained almotrt 
uninterruptedl}' the recumbent position during nearly 
three months, two sand-bags being placed, one on each side 
of the head. You will excuse my bringing forward these 
sand-bags, but they are not sufficiently used. They aro 
useful in cases of fracture, for the purpose of sustaining 
the fractured parts in a right position. They are alfto 
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 recumbent 
position, when suffering from disease of the cervical portioii 
of the spine. I know of no simple mechanical means 
answering this purpose so well as sand-bags, made of bed- 
tick, and about three-fourths filled with dry sand. One is 
to be placed on each side, close to the head and neck, m 
as to be moulded to them, in order to keep the head 
straight, and to render lateral or rotatory movements 

u 



its THE THEBAPEnTlC INFXUENCK OF BEST [Lwr 

impossible. As I have said, two heavy eatid-bage wert 
placed, oue oil each eide, upon the pillow, supporting the 
head of this lady. The only medicine employed was one- 
sisteenth of a grain of Viiflilorido of mercury twice a day, 
during about two months. At the expiration of three 
months the patient had lost all pain and tendemeas, and 
had regained the use of the arm, neither did preesiire not 
rotation of the head induce pain. The fulnesB in the neck 
had also disappeared. 

I might here refer to what I have already alluded to, 
when fipealtiup of inflammatory effnsions, and endeavouring 
to show that the effusion of lymph, associated with local 
diseaee. roally acts as a splint to secure local rest to diseased 
parts, and so aids recovery. In the case now under oott' 
sideration this is the interpretation of the fulness of the 
neck during the perBistenco of the disease, and its dis- 
appearance when the orifcinnl disenfio was removed. It is 
the same with disease of the larger joints of the body 
when a cnre is effected with or without anchylosis : all the 
surrounding lymph that has been poured out for a gi«at 
length of time, and which seemed to promise to be very 
enduring, entirely disappears. Its object was to act »s a 
temporary splint, to Itecp the parts quiet ; that duty having 
been per/onaed, the splint of lymph is no longer required, 
and it is absorbed, just like the temporary efhsion, or 
callus, in the case of fracture. To conclude the case before 
us : this lady left town, and afterwards reported herself 
quite well. 

■ I may here add that this patient v-as 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 witii 
fear when she looked forward to the possibility of the 
death of the patient. The real cause of the patient's 
symptoms, and of this anxiety, was afterwards explained 
to me. The disease in the neck 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 ladiee 
had been reading with each other something about the 
intestine wars of the houses of York and Lancaster. One 



v.] AND THE DIAGNOSTIC VALUE OP PAIN. 99 

seized a red and the other a white rose, and they had a 
battle of the bolsters insteeul of the battle of the roses. 
My patient Tthe white rose) was struck down, and so York 
fell — upon tne carpet, and was unconscious for some little 
time. She had, as reported to herself, a sort of struggling 
fit. On recovery she was put to bed, and in a day or two 
nothing remained 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 considerable 
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 rest, so far as I could 
interpret it, was the sole important element employed to 
aid and secure her recovery. 

The next case 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 {vide Fig. 12, a\ 6'). 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 somewhat alarmed, and came to me. 
suffering from pains indicating disease of the second or 
third cervical vertebra. He was ultimately cured by 
Ijdng down — that is, by rest. On the 8th of Februarv^ 
last he came to me perfectly well, and he says that he was 
quite cured by re8i. 

The anatomical diagrams (Figs. 14 and 16) were taken 
from dissections 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 dentata, and 
the various ligaments associated with the upper cervical 

H 2 



100 THE THERAPEUTIO INFLUENCE OP REST [LeC» 1 

vortsbree. These ar« tL^ stroug uieaiiB oniployed by Natnn I 
t<) ttu]>port the head and uock, and at the same time tdr 1 
permit flexioD, extensioa. and rotatiuu of the head. 

Diteate of the Spine. Pain at the Back of the Head, mth Lorn 

nf Power and Scruatiim in the Linihs. 

On the 28th of February, ICbS, I was re<)ue«ted to see 

lire. S , agod forty-fivu. I fonnd her sitting in a largs 

high-backed arm-ahair, eupported by pillowB. with hw 
head regting upon the side of the chair, uaablo to riee from 
her soat. I aactirtaiiied the following facta from hor 
husband, aud partly from heraelf. Her voioo was very 
ftioble. and her breath estmmely short. During aovenu 
niouthe back, she hod been suffering from pains in bath 
arms aud weakness of both legs, atxumpanied by pains in 
the neck jiud eliiiuldcra. She had lieeu under medical 
treatment during the whole time, and bad oonsnlted a 
physician and an hospital eurgeou. Both, according to the 
patient's report. couBidered the ciise as one of rhenmatism 
or neuralgia, and ordered her to take walking exercise 
daily : one of thein said two hours daily ; the other, as 
much as possible. Iodide of potassium, colchioum, and 
opium to relieve the pains, had been freely administered. 
The pains were really terrific (that was her own descrip- 
tion) in the arms at night, generally commencing about 
twelve, and oontinuing until four in the morning, when 
she usually dropped off into a short sleep. The dropping 
off to sleep at any time induced iumpiuga and startings of 
the limbs. This is a pretty constant coucomitant symptom 
when the central portion of the spinal marrow is involved 
in the mischief, that being the very seat of the excito- 
motoi7 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, 
BO that the prick of a pin was not felt (this 1 examined 
carefully myself). Both anus were nearly paralysod. She 
oould move the fingers slightly, but could not lift either 
hand or arm, and was obliged to be fed by her daughter; 
thia ooudition had been onming on nearly four montlu. In 



VJ AND THE DIAGNOSTIC VALUE OP PAIN. 101 

both legH sensation was much diminished, and they were 
partly paralysed. She could neither walk nor stand, and 
was therefore carried from place to place. Both the upper 
and lower extremities were swollen from venous congestion, 
bat not oedematous ; this seemed to depend upon the 
difScnlty experienced 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 venae cavae. 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 
gradually more and more feeble, and deglutition was 
difficult —indeed, 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 movements 
of the tongue, that the hypoglossal nerve, which is attached 
to the medulla oblongata, must have been implicated in 
the mischief.) There was no paralysis of the face, no loss 
of power, no pain, no loss of sensation in the ilistribution 
of the fifth nerve. The movements of the eyes were 
normal. There was exquisite pain and some tenderness at 
the back of the head, extending to the vertex on both sides 
of the median line posteriorly (vide Fig. 12, a'). (This. 
you see, marks pretty accurately the distribution of the 
great occipital nerves ; therefore, if any pain be expressed 
in that neighbourhood, it must be referred to the great 
occipital nerves.) There were pains at the back of both 
ears (within the distribution of the small occipital nerve), 
but more especially upon the right ear {vide Fig. 12, h'). 
There was no pain in front of the ears, or in the external 
auditory canals. (This is in accordance with the fifth 
nerve being free from implication.) The head was inclined 
to fall forwards, and, indeed, she found it impossible to 
keep it up without 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 nearly pulseless and fainted, and 
the limbs tremulous and agitated. We immediately placed 
her upon the floor of the room. I thought she was dead, 



. ..V .. in'-iniH'rcd sIh' had lVt(puiitly rx] 
the iH'ck and lii-ad in tryiiii;' to take all^ 
tVoin liiLili shrives. J will not di-tain y 
details ot" the case. It is a very iinpurta 
iu regard to its actual character, but as h) 
looked by the physician and surgeon 
consulted. 

Believing the disease in this case to be i 
first and second cervical vertebree, that al. 
were explicable upon such a supposition 
only possible remedy was absolute and long 
to the spine, I directed her to be placed ii 
her back immediately ; and I did not leave 
it was done. A small, firm pillow was put i 
and, in the evening of the same day, two It 
bags of sand were placed, one on each si 
and neck, to prevent any lateral movemen 
She was not to be disturbed from the horis 
for any purpose whatever ; the bowels were 
by enemata, and the urine to be drawn oi 
As the exact and methodical arrangemen 
suffering from disease of the upper cervica 
matter of great importance, I have placed 
drawing (Fig. 14) of a vertical and nearly : 
of the head, brain, spine, and spinal mt 



104 THE THERAPEUTIC INrLLESCE OF REST [LlCT. 

the Bpitm. The sense of siiffooatioii became at once much 
dinkiniHlifd (I had observed tLe same cireumBtance bofore, 
iu another patient who had disease of the higheitt part of 
tJie Bjiine). and X had therefore a smaU firm pillow pnt 
luidemeath the neck, which aupported it very perfectly. 
This 18 a very important fact, becauee I think I hare 
known at least two persons who were destroyed in con- 
sequence of this little point not having been attended to. 

If the ligaments between the first and seoond yertebm 
and the occipital bone be destroyed, and yon have nothing 
to support tne great posterior concavity or hollow of the 
neck, this part of the spine gravitates ; the odontoid 
process sinks or falls, and presses uiwn the lower part 
of the medulla oblongata. (See Fig. 14.) By putting 
something (say a small firm pillow) underneath the neok, 
we lift lip the body of the second vertebra, and remove 
the odontoid process from the lower part of the medulla 
oblonjjata, and thus prevent the fatal rusnlts of preasure 
upon it. 

I have here another sketch (l^ig. 15) taken from the 
same dissection as Fig. 14 ; but iu 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 case I shall 
presently allude. In the sketch before you, all the before- 
mentioned lij'anients have been cut away. If a dead body, 
thus prepared, he placed in the recumlient jxmlion, without 
mechanical support to the hollow of the neck, the second 
vertebra, with its odontoid process, falls towards the 
medulla oblongata, and makes pressure upon it ; or if a 
dead body, so prepared, be placed in the sitting or erect 
posture, the head has an immediate tendency to fall 
forwards, and to impale the medulla oblongata upon the 
odontoid process, wluch, as you may see, strikes exactly 
upon the niednlla oblongata. This is the vital part 
of the ecrebro-spinal axis, because it superintends the 
respiratoiy process ; and thus it happens that patients so 
circumstanced are killed immediat«1y. 

In the patient's caae, to the details of which I have been 
directing your attention, a small pillow was placed under 



VJ AMD THE DIAONOfinO TALUB OF PAIN. 105 

Ihe nrrical portion of the Bpine, by vhich ve were enabled 
to Urt up tiie odontoid proceBa aw&y &om the medulla 
ublmgata, and maintain the latter in a state of compa- 




5HlA Hixm Uw odOTkti>td pror 



■. /, Alia, or aFaind urv [al Te 

rative secnrity from pressure. I repeat, that when thia 
patient waa lying flat upon the bed, she could scarcely 



Im; T|[K TIIEKAPEUTIC IXFLUESCE OP REST [LlCT. 

breathe, but as aooa as I put my hand behind the net^ 
and lifted up the odontoid procesB. she was nearly fno 
from dyspacBa. It was obvious that her condition iiecee- 
flitated her lying down upon her back for soma consider- 
able time, 

Thie patient was ordered one-sixteenth of a grain of 
bichlorido of mercury, and one draohm of tincture of bark, 
to be taken twice or thrice daily in a wineglassful of water, 
and suHieieut laudanum, when reijuired, to procure sleep. 
At the espiration wf a month she had regained her voice 
and her power of articulation and deglutition ; hor paini 
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 give her confidence, especially in going to 
sleep. She remained lying down, and in the same poBi- 
tion, almost without stirring, during seventeen weeks, . 
uninterruptedly. At the expiration of that time, all her 
symptoms were so much relieved, that it was thought aafe t 
to allow her to be raided 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 far 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 esercise, to be carefully and gradually increased, 
was therefore allowed. After some little time, gaining 
strength and confidence in herself, she extended her walk 
into her garden, and remained 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 other old symptoms, 
again manifested themselves slightly. She then deter- 
mined that she would not go out of 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 spriue 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 



VJ AND THB DIAGNOSTIC VALUE OP PAIN. 107 

quiet, comforting companioiiB, the sand-bags, relying on 

tie influence of rest for her recovery, which was slowly 

but progressively accomplished. 
I baw the patient myself on the 2nd of March, 1860. 

She told me she had been well during many months, and 
occupied, as usual, in her household duties. She rides in 
omnibuses, walks well, and has nothing to complain 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 
pontian. 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 appreciated or 
regarded in their proper diagnostic light. Had these pains 
been recognised, 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 suftering from 
disease of the spine, which compelled him to bo on his 
back during many months. He ultimately got well, and 
is now fully occupied in business. The ceiling of his 
capacious and comfortable room was, as usual, white. 
I had occasion to see him a few weeks after his first 
lying down, and on entering his room I was surprised to 
observe the ceiling 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 irksome to my eyes and brain, 
that I could bear it no longer. I knew, from experience, 
that I could look upon a green field all day long without 
tiring, and therefore I have had the ceiling covered with 
gieen gauze, and since then I have had no difficulty at 
alL" This was a slight, practical hint which I thought 
worth recording. 



108 THE THKBAPEIITIC INPLDENCE OP REST [Lect. 

Caie of D!gea»ed Spine, with sevfre Pain upon the SatJc of 
the Head ; impending Death from Pretture upon tie 
Spinal Marrow ; cured. 

I must now briefly refer to the partioulars of another 
case Bonidwhat like the faregoing. lu 1850, I was re- 
quested by Dr. AddiBon to see with him one of his hospital 
pationta, a young woman snflering; from diseise of the 
upper part of the spine, the result probably of accident. 
Tlua was subsequently aacertained to be the fact. 1 fimud 
her almost pulselexa. with great distrDse in breathing, los 
of voice, an. inability to swallow, and nearly complete 
paralyeis of the anus and legs. She had had from tlw 
early part of her illness severe paioB spread over the back 
of her head and neck, increased on preaeing the hoad 
downwards upon the spine, and on rotating it upon the 
spine. Her svmptoms had graduallv arrived at this stage 
of (laiiger witlnnit lirTi.^fit frnm ni^-dicul treittmeut. I 
might here say, that the difficulty of breathing and deglu- 
tition had so greatly increased of late, that it was thought 
necessary, or to her advantage, to lift her up more and 
more in the bed ; but the change of posture seemed only 
to add to her distress in breathing and swallowing. 
These were the difficulties for which my assistance wu 
requested. She was then propped up in bed by pillowi 
at her back, with her head iD(;lined somewhat forward, 
or dropping upon the chest. As the impediment to 
swallowing was almost an insurmountable difficulty, I 
was desired to examine the throat, but I could not disooTer 
anything wrong in it. It was our opinion that her life 
was in imminent or perhaps instant danger : she waa 
paralysed, and conld not swallow ; her voice was ez- 
oeesively feeble and the pulse scarcely perceptible ; she 
hardly breathed at all, and was not quite conscious. 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 He down immediately. On saying to 
her. " You must lie down in bed," she replied, in the 
smaJlest possible voice, " Then I shall certainly be killed; 



V.j AND THE DIAGNOSTIC VALUE OF PAIN. 109 

I can't get my breath.'* Seeing there was no time for 

ooDtention, I told her our opinion was, that if not placed 

liorizontaUy in bed she would in all probability die in a 

wy few minutes. Being paralysed, or nearly so, she 

ooald offer no resistance to my purpose ; and I shall never 

for^t 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 arms, 

ilowly placed her upon her back, 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 motion. 

Here was a patient in the greatest possible danger, and 
I do not hesitate to express the opinion, that if the head 
had £allen forward, say half an inch, she would have died 
in an instant. Her sense of suffocation was soon relieved 
by the horizontal position, and she remained lying down 
during six months uninterruptedly, at the end of which 
time all the serious symptoms had disapi)eared. She was 
then allowed to move about the ward with caution, and a 
few months afterwards, loft the hospital, well, with the 
exoeption 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 was the only element of success in the treat- 
ment, and I think it is a very striking example of its power 
to prolong life, by enabling Nature to repair her injuries 
undisturbed. 

Que of DUea9ed Spine, with severe Pain upon the Bach of the 
Head ; sudden Death of the Patient, 

I will now direct your attention to another case of 
diseased cervical vertebrae, which terminated in sudden 
death. It is that of a little child, five years 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 gradually stiff and swollen, 
gooompanied by pains in the head and neck. These pains 



110 THE THZBAPECTIC INFLUENCE OF EEST [UorJ 

■were believed to be rhenmatio, and the treatment employe 
had reference only to that irapreaaioii, which was BnppoM 
to l)e supported by some pain exporioncod in the limbfc^ 
with cramps and stiffness in walking. She fronnwitly 1 
suffered from fever and loss of appetite aud had been 
under medical treatment dnring many weeks, the Byruptonu 
slowly increasing in severity. The mother told me after- 
wards that she had thought her an obstinate child, and 
that she sometimes threatened to pnnish or to shakt* her 
well, because she would not take her food. I have no 
doubt if she had done bo she would have killed the child. 
Upon careful examination, I thought I made out the case 
to lie one of disease between the first and second cervical 
vertebrEB, or tiiereabouts. I say thereabouts liecause the 
parts were too mucb swollen and too painful to admit of a 
more aoourato local investigation. There was pain at the 
back part of the bead, in the course of tho great occipital 
nerve; pnin IHiindthf cut. in l!n- mnrBc i if the great an ri- 
cular, and of the small occipital ; pain in the higher part 
of the neck, on rotation of the vertebrie upon each other ; 
and pain in the same vertebrte. probably the first, second, 
and third, by pressing the bones upon each other. She 
had some difficulty in deglutition, and the voice had lately 
changed its character and become more feeble, indicating 
that the pneumogastric nerves, and possibly the spinal 
accessory, were involved in the mischief. Thus having, in 
common with the surgeon in attendance, recognised the real 
nature of the case, I gave directions that tbc child should 
be placed upon her back, with her head resting upon a thin 
pillow, and some additional support to the nape of the neck, 
each side of the head to be supported by aand-bags. so as 
to prevent any lateral or rotary movement in the neck. It 
was plain that if the life of the child was to be prolonged 
or saved, it could only be accomplished by long-continued 
rest to the spine ; and for the purpose of securing easy 
rest to the littlepatient, a water-bed was sent from London, 
and the child was safely placed upon it, with the rand-bags 
extending from the shoulders to beyond the head. In 
about a fortnight, the nurse specially appointed to attend 
the child, finding that her rest at night was now so calm 
and quiet, that she was so &ee from pain and fever, that 



\. AM) Tin: DIAGNOSTIC VAI.TE OK I'MX. 1|] 

iicr apjx^titii and j)ower of {swallowing were so niiich im- 
prove, as well as her temper, and thinking she was alto- 
gether so much better, and willing no doubt to mark her 
own penetration, as well as to please the mother by telling 
ier in the morning what had been done by her little charge 
—this meddling and officious woman, instead of giving the 
cliild her breakfast, as usual, without disturbing her head 
or neck in the least degree, desired the child to sit up to 
breakfast. The child did so : the head foil forwards, and 
she was dead. The post-mortem examination proved that 
disease existed in the articulations between the first and 
second cervical vertebrae, that the bones 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 surgeon and Nature were 
completely thwarted. The local disease was considered at 
one time to be dependent upon a constitutional or scrofulous 
cause, but I have since underatood that it was the result of 
a blow given to the little girl by her brother, who struck 
her with something ho had picked up in the room. It was 
not constitutional : there was no visceral disease of any 
kind. 

Case of Diseased Spine ; sudden Death of the Patient. 

I have here a preparation from Guy's Museum, which 
has no special history attached to it. It marks the great 
features of the cause of the fatal accident which happened 
in the previous case. There is disease between the occiput 
and the atlas, and also between the atlas and the axis ; the 
transverse ligament has been forcibly ruptured, or has 
given way by structural disintegration, so that the odontoid 
process was free and able to mnke pressure upon the 
medulla oblongata, and thus to kill the patient. The late 
Mr. Mackmurdo informed me, that when attending the 
surgical lectures of Sir Astley Cooper, he well remembered 
seeing a preparation exactly like this, to which Sir Astley 
appended the facts, that the man to whom it had belonged 
had been long the subject of syphilis, had suffered great 
pain in the neck, and that, after eating his dinner, his 



112 THE TIIEBAl'EUTIO INFLUESCE OF REST [Leo 
head full I'orwiirdB upon the tahle, and he died toetantli 




He added that the cause of death was preasure made by 
the odontoid proc.-fie of the axis upon the spinal ii 



Case of Duea*ed Spine, leilh Pott-pharyn^fal Abteett, from 
which were expelled porlione of the Alias and Axis. 

Here (t'ig- IV) is another interesting preparation, coii- 
HiBtiug of two portions of houe : the larger one appears tu 

• A Eimilnr rase U rec.irded bj the lute Dr, A. Collta (Pmcl. 
Ob«orv. on tlie Venereul IJieeose, p. 139.) In this ciisb the exfoliation 
coDtisted of "a ling of thn hIIus with on one side tlie half, end on the 
other one third of Ihe articulating proceBBBB." Tbe patient hme wm 
syphilitic, ba recovered and anrvived eix yoaj^ Another oaw of 
exfoliation of " tlie fcrmter putt of tlic anterior arch of tlie atlas with the 
entire artioolating surface " will be found recorded by Dr. Wude in tlie 
Med. Chir. Tri. vol. ixxii. This alio ovcurred in a syphilitic siibjoi't 
— CSd,] 



Ij ASD THE DIAGNOSTIC VALUE OF PAIN. 113 

be the Artioalar surfare of &e anterior part of the atUs, 
wbicl) orticulatefl with the anterior Borfkoe of the odontoid 
pncen of the axia ; the other portion, a part of the articular 




surface probablyof the odontoid process. I will now rtad 
to yon a short record of this case from the Guy'a Museum 
book:— 

"Un. Q , a patient of Mr. Babiugtoti in 1834. a 

married woman, who bad worked hard at washing, and 
been much expoeed to cold. Five years before, she had 
an attack of plewrisy, but was not aware of having taken 
mercury, at least not to salivation, and she never had 

rbilia. Four months previously to her seeking advice, 
b^an to find her neck stiff, with a pain on the liiick nf 
her hrad. These symptoms increased, until one day, on 
oougtaing, she brought from her mouth a piece of bone, and 
sabeequently some smaller fragments, and a portion of the 
atlaa, or first vertebra, seen in the specimen. She was 
visited for some months afterwards, when the head was 
nearly fixed, and there was a discharging ulcer at tbe back 
of the phaiynx. The patient was last seen in October. 



114 THE THESAPEUTIO INFLUENCE OF REST [l.ofl. 

1838. when she was in tolerable health, and serving at the 
bar of a publio-honae." 

TIkjio are in the anntomical Mnsouma of thiB metropolis 
manv jiuthulogical Bpeciinens of uumplote bony anchyloaia 
of tiie occipital boue, atltis, and asia. Sucb preparations 
show clearly that very important and dangerous disease of 
the articulations between these bones must have exiBted, 
and thiit the patienta must have lived some long time after 
the disease had been so far remedied by anchylosis.' I have 
here upon the table before me several preparations illus- 
trative of perfect recovery from dieoase of this upper part 
of the epine by bony anchylosis, but I seleot fur your atten- 
tion this example, partly because the local repair of the 
spine vraa only in progress at the time of death, but espe- 
cially from its displaying also a rare pathological fact — viz. 
perfect union between the inferior maxilla and temjKiru] 
bones on both udeg. 

Cote of Diteated Spine ; Death ; ATichyloais of both Tentporo- 
maxillary A.rticulationg. 
This head and spine belonged to Charles Davis, a black 
from Jamaica. He was admitted into Guy'a Hospital, 
October 12th, 1825, under Dr. Bright. Three years pre- 
viously he slipped down three or four steps into the cabin 
of a sloop, and in the fall a fork penetrated to a very small 
depth into the back of his neck. He felt no inconvenience 
afterwards. Sixteen months before admission he com- 
plained of pain in various parts of his limbs, and frequent 
inability to move his arms and legs freely. " The head is 
always bout forwards, so that the cliin approaches the top 
of the sternum. He can nod bia head a little, but cannot 
turn it. December 6th.— More pain in the shoulder and 
neck. 22nd. — Was seized with stiffness and pain in his 
feet. 29th. — Fain in his neck increases ; he is unable to 
walk, and almost to use his arms. He has occasional 
cramp in his legs ; says he fails in every part of his body, 

■ For CttM's in uLich dklocation of the atlas, eilhor from disease or 
iriun-, wns tbllowetl by anchylosiB tec papers by SirW. Ijiwrenee, Mr. 
PhilfipB, and Sir Jemea Fagei in the lleii. Clir. 'i'n, vola, xiii., xi., iist. 



T,] AKD THE DIAGNOSTIC VALUE OF PAIN. 115 

Jannary 2nd. — Speaks less distinctly ; haa pain about the 
masoleB of the neck and Bhouldere, and is scarcely able to 
wJk. 6th. — Complains of pain in the hips on motion. 




t Bona Sinnlnf Oi- 
■llapLay tiwlr pfttecl o 

20tb. — TendemeBsabontthe neck and ahonldera, increased 
on pressure ; no loss of sensation in any part ; bowels 
regular; urine natural; pulse 100, rather weak. March 
4th.— Only very slight motion in the iaw. 7th. — -Tncrcas- 
ing fixity of the lower jaw. His inability to move the jaw 
oontinned to increase, until it liecame totally locked, bo 
that he could take no nourishment biit what he sucked in 
between his teeth, or through the space produced by the 
removal of his iirst molar tootli." He gradtially sank, and 
died March 23rd, 1826, about three years after the punc- 
I 2 



116 THE THERAFEUTIO INFLUENCE OF REST {Ltdt. • 

tured wound io Iho neok, which might or might not have 
been the starting- point of the (liBeasc^ in the cervical ver- 
tebr«6. The jwst-morteiii esamination was as foUowB: 
" Bixly emaci&ted and rigid ; neck immovable ; the jaws 
inneparably locked ; cranium remarkably thick ; arttchnoid 
opitqiiB and thickened ; a more than natural quantity of 
fluid external to the bntin, which was generally firm and 
i>f healthy appearance. The medulla oblongata was leas 
toiigb than usual, and broke off short when the brain was 
being rumoved from the cranium. The membranes adhered 
to this part with remarknhle firmnese. There was nn 
motion between the occipital bone and the atlas ; the 
urticulatiiig surfaces had ulcerated, and bony union had 
commenced. The articular eurfaces between the tmnsvene 
procesnes of the atlas and axis did not appear to be diseased, 
bnt there was a considerable quantity of bony matter 
thrown out On the dentiform proceaa of the second vcrtebni. 
not merely impeding the motion of the joint, but encroach- 
ing on the spinal canal. Anchylosis had also taken 
pla«e between some of the succeeding cervical vertebrse. 
A very compact and hard bony deposit was formed im- 
mediately under the anterior ligament of the spine, upon 
the bodies of the upper cervical vei tebne, and at that part 
concealed the intervertebral substance. On cutting the 
muscles of the temporo-maxillary articulation, it became 
obvious that bony union or anchylosis of the joint had' 
occurred to a considerable extent on both sides ; the aoft 
]Mrts did not appear to be at all diseased in the neighbour- 
hood of any of the aflected joints." 

Cate of Injary to fifth, sixth, and seventh Cereical Vertebra ; 
Partuygit and Loes of Seniation in the Upper and Lower 
Exlremilies ; the Patient lived fourteen years, and then 
died from another accident. 

In two or three respects the following case is one of 
great interest, John Carter, aged twenty-one, had an 
injury to the fifth, sixth, and seventh cervical vertebne, 
producing paralysis of both legs and both arms. He 
lived fourteen years, anil then died from the effects of 
another accident. The particulars of this case, so far as I 



v.] AND THE DIAGNOSTIC VALUE OP PAIN. 117 

know them, are these: The accident occurred in May, 
1836. The man's age was twenty-one. He fell from a 
tree, forty feet, upon his back, or probably his head. He 
was senseless, unconscious, and paralysed below his neck. 
Being carried home upon a hurdle, the late Mr. Whitmore, 
of C^geshall, Essex, saw him two hours after the acci- 
dent, and wrote me this note some years ago : — 

"It was in May, 1836, that 1 was called up, on a 
Smiday morning, between four and five o'clock, to John 
Carter, who had fallen from a tree, when in the pursuit of 
youig rooks. When T saw him he was perfectly insensible 
and motionless ; cold, and breathing imperfectly ; with a 
pulse weak in the extreme ; and he appeared to have sus- 
tained some fatal injury to the brain or spinal column, 
from which there was scarcely a hope of his recovery. 
The accident had occurred about two hours, I l>elieve. 
I ordered hot flannels and other means to bo used, to 
restore warmth to the body and to bring about reaction. 
In the course of the day reaction was ostablishod, and 
there were signs of returning consciousness, evidenced by 
a groan when aroused. Towards evening the pulse was so 
far re-established as to warrant venesection. In the course 
of the night he became more conscious, and was sufficiently 
sensible next 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 
throughout the body, except in the head and upper part of 
the neck. The muscular power of the neck was lost also 
for several days ; but after cupping the back of the tiock, 
and using proper remedies, a capability of moving thc^ 
head gradually returned. The bladder was paralysed and 
the catheter required. 

*' There was no appearance externally to indicate the 
precise situation of the injury as to the vertebrae — not the 
slightest irregularity ; but the general symptoms and cir- 
cumstances rendered it pretty certain that serious damage 
had been sustained by the firth 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 (as long as I attended the case) 
remained perfectly paralysed and insensible. 



118 THE THERAPEUTIC INFLUENCE OF BEST [Lect. 

" I left Coggeshall to go on the Continent, ami after five 
years' alisence, on my return I waa Biirpriaed to find the 
patient Carter atill living, and in much, tho aaiue ounditicn 
as when I loft England." 

This piiticnt used to amuse himself or earn liis living 
by making copies of engravings with liis mouth. 1 have 
one in my posaeesion, taken from a line engraving of 
Hewson, in the Sydenham Society's works, whidj ia 
certainly a moat extraordinary example of the man's 
tvouderful artistic capahilities. He employed a camelV 
hair hmsh, three or four inches in length; with which eveiy 
line waa made with the greatest HCciiracv and precision. 

I saw this man several times during tne latter period of 
ills life, and took these few notes of his case : — 

" Perfect loss of sensation in the lower and upper 
extremities, except indistinct sensibility on the left side as 
far as the elbow. Mnsclea of the left shoulder more 
dcvelojied thnn thi- right. FcpIh distinctly on the left 
shoulder, and indistinctly on the right shoulder. The left 
forearm is now flexed ; the thumb is turned into the palm 
of the hand, and the fingers are bent over it. Right arm 
nearly straight ; the little and fourth fingers flexed. The 
hands remained open until about sis months after the 
accident, when contraction commenced. No contraction in 
the feet, except that the right foot is a little flexed. Legs 
jump ,a little uuring the efibrta at defecation, and sometimes 
suddenly without obvious cause. Arms jump, especially 
the right, during micturition. BoweU not open without 
medicine (senna). On some days has peculiar sensations 
of chilliness, becomes pale, and then feels hot and flushed 
during defecation and micturition. The more constipated 
the bowels, the more these peculiar sensations are expe- 
rienced. Urine very offensive when he has caught cold ; 
at other times not so offensive, but always a little bo. 
Urine acid. Feels a distinct pain in the bowels occa- 
sionally, and now and then an aching in the loins. When 
sick, vomits with great difficulty. Erections of i)enis are 
frequent, and last a quarter of an hour, with slight escape 
of seminal fluid occasionally. Spine : nothing abnormal 
to bo felt. No costal movenients during respiration ; no 
hiccough. Chie good meal of meat daily." 



v.] AND THE DIAGNOSTIC VALUE OP PAIN. 110 

This case forms a great enoouragement to give every 
possible care and attention to the treatment of injuries of 
the spine, with the hope of obtaining the same happy 
result as occurred in this instance. According to statistics 
and the text-books, he ought to have died within a few days 
after the accident; but, repudiating any such duty, he 
lived during fourteen years, and then his death occurred 
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. Kott, of Coggeshall, to 
examine the body, and only upon a very special application, 
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 was made from the preparation 
itself, the bodies and arches of the fifth, sixth, and seventh 
cervical vertebrae are seen blended together by bone. 
The body of the sixth vertebra is displaced, and projects 
backwards into the vertebral canal, and no doubt was the 
cause of the paralysis. It is worthy of notice that the 
intervertebral substances have disappeared, but their 
outlines are still marked, and their places occupied by 
bone. The thin articular laminae of bone usually inter- 
posed between the intervertebral substances and the bodies 
of the vertebrae are still visible, although the intervertebral 
substance itself is gone. Every one must admire the 
perfect 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 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 



THE TttEBAPEUTIC INFLUENCE OF REST 



must be stated. The posture in which he drew was, lyiDg 
a little on tho side, with the head a little raisi-d by pillows. 




id tbclr •rdwi. 

A small, light deak of deal, made under Mb own directions, 



vj 



AND THE DIAGNOSTIC VALUE OF PAIN. 



121 



was adjusted for him. On this desk his drawing-paper was 
&stened in the usual way. The drawing to be copied, if 
of moderate size, was set np 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 
his 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 the most accurate 
and delicate strokes." 

I must apologise for detaining you so long with the 
details of these cases of disease of the cervical portion of 
<he 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 
situated in the immediate neighbourhood of the atlas and 
occiput, had intrinsic and rare merits of its own, which 
must be my excuse for devoting so much time to it. 



THE THBRAPEUTIO INFLUESTOE Of REST 




LECTURE VI. 



rOBT-FBimiiailAL. iliac. SlTEI-OLrrEAt., StJK-FAaUIAt., AKD 



Beuevino that even in public lectures aoiue little variety 
may add a slight degree of charm, X have taken the lib^T^ 
to break in upon the order of my subject, and to aak you 
for the present to divert your attt>iition from the considera- 
tion of pain, as associated with disease of the spine. 

As I contem]>Iate the subject of reel in its curative 
aspects, its application appears to me so widely extensive, 
and the variety of conditions in which we may derive 
important assistance from its use so great, that I am 
inclined to say there are few surgical diseases to which it 
may not be made to contribute relief. My present object, 
however, is to remind you of its beneficial influence in 
some of those familiar cases of diseases which the siirgeoti 
meets with so frequently m practice, I have therefore 
selected for out consideration in this lecture its agency in 
the cure of abscesses, sinuses, and certain forms of ulcer. 

I would now put the question — Why do surgeons open 
absoesBCB ? Various answers may ho given : to relieve 
patients from pain and constitutional disturbance ; to 
prevent the abscess enlarging, ur to limit the destruction 
of tissues ; to prevent further encroachment upon impor- 
tant organs ; to remove the accumulated extraneous fluid, 
&c. This is all true ; but still the question presents 
itself — What is the ulterior object in opening an abscess? 
It is to permit and to secure coaptation of the internal 



VI.] AKD THE DIAGNOSTIC VALUE OP PAIN. 123 

Burface6 of the abscess — ^to give its internal surfaces rest,* 
80 as to permit of their union, and further rest, for the 
purpose of consolidating the medium of union. This 
Tilterior object haa, or ought 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, ^'ithout disturbing the pail, we 
should make a hole at the bottom of it; or as if we 
desired to remove the whole of the fluid contents of a soft 
bladder, and induce collapse of its pliant walls, the aperture 
of exit must be made at the lowest part of the bladder. 
In the treatment of abscess, it must be borne in mind, that 
it is only by the evacuation of the whole of the fluid of an 
abscess that we can render coaptation of the two surfaces 
of its walls possible.! 

* An abscess left without rest, whatever be the cause of disquitt, 
whedier it be an ahsress in the ischio-rectiil fossa constantly liahle to 
moscnlffr disturbance — an abscess in the neck from the imperfect 
breakinfi^ down of some scrofulous gland— or an abscess in bono of 
which the walls cannot yield — is always liable to give future trouble. 
This may be the worry of a sinus gradually and steiiltliily followed by 
lardaceooB disease after an empyema that has never entirely healed ; or 
fresh attacks of inflammation in the site of a glandular abscess in 
the neck may be lit up after long years of quiet by some caseous or 
cretaceoua residue; and a long standing sinus or imperfectly healed 
afasceM abont the rectum, or, in a bone, may eventually be fretted into 
a condition of epithelioma.— [Ed.] 

t The late Mr. Oallender (Brit. Med. Jour., Nov. 4, 1876) showed 
the value of thoroughly washing out with carbolized water large abscess- 
sacs, especially those which are ** divided by septa, or have extended 
amongEt tinues so as to form several chambers communicating by narrow 
passages." The original title of the paper — ^* The treatment of abscesses 
by h3rpeidisten8ion with carbolized water *' would seem to lead students, 
froai their questions in the wards, to believe that the essence of this 
operation consists in inducing some immediate change in the state of 
tensioti of the abscess walls. The excellent results which it gives renlly 
follow from the abscess obtaining antiseptic rest throughout. The 
carbolixed solution driven thoroughly over all parts of the abscess 
suiface (for this purpose the usual pewter syringe is al>out as futile 
an inatrament as can be imagined, cither it should be fitted by a link 
of tubing to half of a No. 12 catheter, or a large brass syringe with 
a long nose-piece should be used) washes out all the contents, pus, 
coaeoas lymph, and, in the case of a psoas abscess, fragments of cancel- 
loos bone. Free from these irritants the pyogenic membrane shows its 
appreciation of the rest given it, and, itself a low form of granulation 



124 THE THERAPECTIC INFLUENCE OF ItEST [Lk». 

It is worthy of remark, that an abscess, under many 
oircamfitances, experienoes s great difficulty in getting rid 
of its jjurulent cuotonts. We see what a great len}^ of 
time an abscess requires to push out any solid estraneoiu 
body, such as a portion of wood or clothing, or of necroMd 
bone ; or a wound to rid itself of a portion of linen thnut 
into it. A considerable time may elapse before the grann- 
latiyns can ostrudo these solid liodies. But in the t*se of 
a simple abscess the collection of fluid naturally sinks to 
the bottom, and eompels the abscess 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 organised lymph, may ultimately succetil in forcing 
the fluid oontente out of the abscess, but it is a long time 
before the two surfaoes can be brought into aocniste 
apposition, and in general the abscess is a very long time 
healing. Abscesses, then, ought to be opened at their most 
dejieiiding or lowest ]jart. It is tho only wny t<i promote 
surfaco coaptation ; and it is the first step towards cure. It 
is also the best preventive against the necessity for daily 
squeezing an abscess for the purpose of emptying it. This 
continuous interference with Nature by the surgeon or 
patient might fairly be called very " meddlesome sundry." 
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 oi 
granulation, but almost sure by such friction to induce an 
inflammatory condition in structures which, for the pur- 
pose of repair, ought to bo in a comparatively healthy 
state, and quietly taking their own steps towards filling up 
the whole interior of the abscess in a sound o 



tissae, rapidly derel^ipea inta n higher stractnre ; a weepintC bidus U til 
that remains after tlie Brat few dressings, and ultimalely tbil is en- 
tirely oloseiL—TEd.] 

* It is meddleBome because it g;iTi>a tlie patient nnnecesnUT pBin, it 
il necdleBs bucausc tlie elnaticitv of tijo parU about the tbacen is 
Bufflcient to expel t)ie pua. Any student wlio renienibers the stractars 
of an absoess, nill see at once what harm this squeezing uf an abvnal 
will do to each of tlie cnostitueDtB of the abBoess wall : the newly formed, 
dilated and varioose vessel-loops of the pyogenio membrane, which an 
only snppgrted by the flaky lymph and thin flbrinoua pi'llicle whioh 
ronstitnte this membrane, lendily give way, the btEmorrhBge repro- 
ducing a harmful state of tension in the abscess sao; while the heftling 



VI.] AND THE DIAGNOSTIC VALUE OF PAIN. 125 

The lowest part of the abscess necessarily depends on 
the position of the patient. Thns, in the case of a patient 
in bed having a sub-fascial abscess of tbc thigh, the lowest 
part of the abBcess may be the upper part of the thigh. 

I may remind you that, in a case of suppuration under 
the temporal aponeurosis, we sometimes experience great 
difficulty in caring it. This difficulty arises partly from 
the neoeesary movement of the surrounding structures 
(temporal muscles especially), and from our inability to 
reach 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 abscess is extremely 
tediouB in closing, and the surgeon fails in his object. 
By-and-by, Nature herself makes a hole by ulceration 
into the mouth, at the lowest point of the abscess, near 
the ooronoid process of the lower jaw, and then tlie abscess 
or siniiB closes. Under these circumstances, 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 
small aperture opposite the point of the probe, and in that 
way obtain an outlet at the bottom of the abscess. Surface 
coaptation, equivalent to rest, then quickly takes place, 
and the abscess, instead of being tedious, is brought by 
" rest " to a rather speedy termination. 

Svb-Mammary Abscess, 

In marked illustration of the advantage of this principle, 
I may mention a case detailed to me by Mr. Luke. 

The patient had a very large abscess, extending under 
both mammae across the front of the chest, from which Mr. 
Luke let out the whole of its contents — more than three 
pints of pus. He took care to open the lowest part of this 
abscess, and to coapt the dome and floor of the abscess by 



of theabfloess is further delayed by the damage inflicted by the squeezing 
upoo the layers of plastic inflammatory material and condensed tissue 
wnieh, like a salutary harrier, limit the abscess on all bides ; the conver- 
sioD of the damased pyogenic membrane into granulation tissue which 
fchttU fill op the abscess cavity being, of course, also retarded. — [Ed.] 



126 TUB THEBAI'EUTIC INFLUENCE OP REST [LaCT. 

preBBuro with padB of lint, plaster, and bandag^a. The 
result of this accurate coaptation wae that the absoees was 
completely cured in a few days. 

This patient wBs thus cured by giving "rest "to thewdla 
of the abBceas. and enabling them to become united and 
cotiaolidated by adhesion. This case eipresses an impOT- 
taut fact, for there can hardly be a doubt that, if this 
large abscesB had been opened at tho npper part, and the 

(lUB incompletely evacuated, it would have required a very 
ong time on the part of Nature to extrude the fluid." 

* To Hbow Uiti vitlao of the trestmcnf of nbsoeneB by reet, the thiea 
fnlloving cnaea luive been oddail, two tre&ted by mechiinical. the oilier 
bj' pliyaiotogirul, Teit. Tlie Hist, for which 1 am mdebl«d to the kind- 
ness o'r Mr. Ckx^r Poratw, ii of eapeeiKl intenat on acooont of the 
previous pnilonMd and inefiWrClve treatment. The nutei of thii eatu 
are fmm the report of the ward-clerk. Sir. Plummer. 

W. S., rPt, 30, WBB Hdmilted into Luke wnrd under the cmb of Mr. C. 
Forsler. Dec. 0, ISTri. Abiiut eighlei'O months ngo he noticed a alight 
swelliug on tlie iiii]ier pait of the rislit ohtsl. This proval tij he a sub- 
ptctoral abMC-is, which " name to a hend ami broko " Nnv. 1874. Ai 
the plaue continued to ditcharge occaiiionali]', he waa under the can 
of his club doi^r till June. 1875, vhcn he went to University College 
HoBpitnl. Hero the awelliiig was " Innoed " three timed, iind poaltic«d. 
He left in Seplemher. and attended as an out-patient for a month 
lonKer, and then was nnderhie dub doctor agoin till his admiaaion Into 
Guy's in December, 1875. On admiaaion there was an abaroaB over the 
second right rib. No dead bone could be detected after laying the 
abscess freely open. Dec, 13, — Tjie arm was Sxed with bandages, bo ■« 
to keep the pvcloralea quiet. Jan. 31. — Tlie arm has been keptSxed: 
the place is almost entirely healed, discliarKe very slight, the akin around 
the wound is now tlrm and healthy. Har. 3. — Nudiacbaige. Mar. 23. 
— Tlie patient went out cured, 

In Sir C. Bt-ll's Institutes of Surgery (p. 31} will be found a case 
of flslula from a euh-pectnrel abaceas. which had not yielded to injeo- 
tions, aetons, compresses, etc., but which was cured by the neoeasaiy 
bandaging on the patient's breaking his arm, 

Tlio details of the third case, in which phvsinlogical rest waa anc- 
cessfully used, have been giveu me by Mr. UiltoD, in who^e practtoe 
tlie case occurreil. 

In ISSi Mr. Hilton was roneulted by a lady who luul a large abaoen 
in her right brcaat soon after a confluement. The atraeess had ood- 
tinued to diacbargo from aevornl ainuses during many weeks, nutwitb- 
■tanding tlio application of well-ndjusted preaaure anil many other local 
means. Since lier ciiuflnement the patient liad continued to suckle the 
child from the left brensl. the supply from which seemed Bufflciont for it. 
Mr. Hilton, flailing on inquiry of the patient that the bresstaaympathiaed 
physiologically bntli before and during the feeding of ttie child, adviaed 
that tbi* functional and associated sympathj Mould be daatioyed bjr 



VL] AND THE DIAGNOSTIC VALUE OF PAIN. 127 

Ah$ce88 aver the Knee-joint, 

I have had this diagram (Fig 20) made for the purpose 
of illustrating the position of one kind of abscess which 
oocurs in the neighbourhood 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 
interior of the articulation. In this sketch from nature I 
have endeavoured to indicate the position of an abscess 
underneath a layer of fieiscia lata which is prolonged over 
the patella. Such an abscess may be the result of an 
inflammation beginning within the bursa m^n the patella. 
or tempervening upon any accidental inflammation at that 
part. This abscess extends laterally on both sides, spread- 
mg over the joint, so that if pressure with the finger be 
made on one side, fluctuation will be felt on the other side, 
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 the supposition that it is an 
inflammatory effusion, it may create a groat deal of un- 
necessary alarm. Upon careful examination, however, it 
will be found that a thin layer of fluid is conveyed over 
the patella from one side to the other, thus marking the 
eztia-articular position of the abscess. I would not place 
such a rudimentary case before you, except to controvert 
an error which not unfrequently occurs, and which I know 
has led to the death of two persons by giving time and 
opportunity for the abscess to find its way into the interior 
of the knee-joint. In cases of this kind of abscess, 
whether they originate in a bursa or some other structure, 
it is of little use to open the abscess at its top — tliat is, 
over the patella. I have seen many examples, and it has 



weaning the chilrl, in order to secure physiological rest to the right 
breast The onlinary meana were adopted, and within 'a day or two 
the right breast lessened both in size and hardness, and the diBcharge 
froox the sinuses quickly ceased. In a few days the local abscess 
ftymptODiB disappeared, and secretion of milk in the left breast soon 
cea«ed after the withdrawal of the child. Since tlie above date this 
lady haa had several children, and ha^ experienced no arrest of function 
in the right breast. In April, 1876, Mr. Hilton hud ftn opportunity of 
examining the right breast, and found it presenting the condition no4mal 
to this organ in pregnancy. — [Ed.] 



128 THE THEBAPEUTIC INPLDENCE OP HEST [IjBt I 

been aliaoBt Jnvdriably aeoesHarr ultimately to "pen iti I 
lower part on ijach side. In one case, in wlii<:li this wH J 




put or knH Joint, a'. Ontr Ude <if Jolnl- b, PoMeriar put of Mm. 
V, Innei •ld>' of Jotnt. e, ru«Ll> In oHtlon. with » Ibia Uffr of JUdi 
' " " . <. Iniertor of joint. boDodid by ■jno'lil 



not done early enough, the absccBB found ita escape nnder 
the fascia of the thigh, and became a very large sub-faBcial 
abscesa. This might have been obviated if one aperture 
on each aide had been made, so as to prevent extension - 
upwards. 



VL] AND THE DIAGNOSTIC VALUE OP PAIN. 129 

It is true of this kind of abscess, that after opening the 
top of it, if the knee-joint can be carefully strapped on 
each side, so as to secure accurate coaptation of the walls 
of the abscess, we may now and then succeed in closing it. 
Bat in this prooeeding there is some little risk of the whole 
of the matter not being evacuated. 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 sur- 
geon in Finsbury Circus who is now dead) in which too 
long delay in opening such an abscess allowed it to make 
its way into the knee-joint, and caused the death of the 
patient. 

Axillary Abscesses, 

A large abscess extending high into the axilla, under the 
pectoral muscles, should be opened from the axilla through 
the floor of the abscess. If you open the abscess at the 
npper and anterior part of the axilla, you open the top of 
the abscess, and the tediousness of the case annoys both 
patient and surgeon. Many years ago, I saw, with Mr. 
Blenkame, a case of this kind, in which this difficulty and 
annoyance occurred to us. I stupidly opened the abscess 
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 
abeoesB ; we could not keep its walls quiet, 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 at its most depend- 
ing part is not always a very easy and safe proceeding ; 
henoe it becomes important to ascertain, as far as we can, 
what is the safest and best method of opening a deep 
abscess. Here I must take the opportunity of mentioning 
to you a method that I 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 haemorrhage con- 
sequent upon opening a deep abscess b}' the lancet or 

K 



130 THE THERAPECTIC INFLUENCE OF KEST [Lect 

bistoury. Within the last twelve months I have known 
twu liveB placed in great jeopardy by the use of the lancet 
iu opetiiug deep aliscesfles. Thcat) ciroumetancce alone 
will, 1 hope, Ijo a Hiifficient excnso for my bringing; tbia 
subject lioforo your notice. My own long experience 
of its value justifiea the high opinion I entertain of the 
inethixl of opening a deep absceaB which I am about to 
recommend to your notice as the safest and beet. It is 
safest, because it is scarcely possible to inflict W it any 
injury on blood-veeeels or nerves. I think, too, it k the 
b^t plan; for if the deep opening into an abscess be 
lacerated and I.ruiBed, it ia not at all likely to close by 
adhesion ; and undoubtedly, when we have opened a deep 
abscess, we are desirous that the deep opening should not 
close immediately. In principle, all will admit that if a 
lacerated opening bo made instead of an incised one, it' 
will le under ctrcuiust'iiicca udvcreu to ita quickl}' i^euuitiug. 
Nay, more : supposing a lacerated wound, for example, to 
be made deep into the thigh, and a blood-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 confidence, " 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 Itcen 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 cellular tissue and 
fascia of the asilla 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-vessel. There is 
only a small branch of one of the external thoracic arteries, 
which sometimes runs along the edge of the axilla ; ex- 
cluding that, which if wounded can be easily ligatured or 
twisted, so far as I can see, we run no other risk. Then 



VL] 



AND THE DIAGNOSTIC VALUE OF PAIN. 



131 



push a grooved probe or grooved director upwards into the 
Bwelling in the axilla ; and if you will watch the groove in 
the probe or director as it is being passed up throiigh the 
comparatively healthy tissues into the axilla, a little stream 
of opaque serum or pus will show itself. Take a blunt 
(not a sharp) instnunent, such as a pcdr of " dressing 
forceps," and run the closed blades along the groove in 
the probe or director into the swelling. Now opening tlie 
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 with- 
drawal of the instrument, you leave a lacerated track or 

Fig. 21. 





a. Director. b, Drvsaing furuipii. 

The free end of the director should he made blunt and rounded; the last quarter o( an 
Inch of the groove ought to be increasingly shallow, until it emerges upon the 
rounded end of the director. 

Tbe end of the cloeed blades of the forceps should be of a size adapted to run easily in 
tiie groove of the director. 

canal, communicating with thocoUectionof 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 

K 2 



132 THE THEBA-PEL'TIC INFLUENCE OF BEST [LiCT. 

axilla, or in other important parts of the body, withont 
fear of inflicting any injnrj- upou the patient. Having 
been connected many yeare with a large hoapital, I have 
neceHsarily had good opportunitiee of trying this method. 
Diiiing tliat time I have not opened a deep abecoas in any 
other ivay, and I can say, honeatly and truly, that it ha< 
never faUod, and that 1 have never obaerred any inoon- 
venience from it. 

With respect to this method of proceeding, a curious cir- 
cumstance happened to mo. I was requested some yean 
ago to see a surgooa in London, who -mas snEfering from t 
largo 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. HiB 
pulse waa very feeble, and there were other ciroumstanoei 
indicating that &tal miachief waa impending. I opened the 
ahsoeas in the axilla in the way which I have pointed out. 
pasaiiigthe grooved director but ween twnunl thnx' inchep 
up into the axilla, and opening the abscess by a pair of 
di-ossing forceps. The patient got weli. the starting-point 
of his recovcrj- being the opening of the abscess. Aboal 
ton years aftenvards, this same surgeon 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 
mo that on the previous afternoon he had opened an abeceas 
in the anupit. " I did it," he said, " as well as possible, 
without any difficulty, for I used Listen's knife" (blaming 
the knife for what had happened). " I opened the abscesB 
yesterday, and let out the matter, and this morning I find 
the armpit fuller than before it was opened, and blood 
is comine out of the hole I made. The man is nearly 
dead, ana his arm is as big as two." We went directly, 
and found the man nearly at the point of death from Iobb 
of blood. I had to enlarge the aperture in the axilla, so as 
to enable me to introduce my hand, scoop out the whole 
of the blood, and esiwae the cavity to the external air. 
No further haemorrhage 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 



VL] AND THE DIAGNOSTIC VALUE OF PAIN. 133 

blood-vessel in the armpit with " Liston's knife," and 
nearly killed his patient. 

Orbited 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 side, 
and was suffering very severely locally as well as consti- 
tntionally. With the hope and probability of finding a 
ooUection 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 of dressing forceps, and opened an alJ8ce^s 
by separating the handles of the forceps; the matter 
escaped freely, the patient was relieved of his distress, the 
pressure upon the optic nerve was removed, the amaurosis 
disappeared, and he ultimately recovered without need of 
further aid. 

Deep Cervical Abscess. 

About four or five years ago I was sent for by a surgeon 
in my neighbourhood to see his wife. She was a delicate 
woman, in about the middle period of pregnancy, and it 
was feared that she would miscarry in consequence of 
her having a large inflammatory swelling deep in the 
right side 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 question was, how to reach 
the seat of the disease. I should not have dared to put a 
knife in, because, with all the anatomical accuracy which 
a surgeon may possess, it must be admitted that moveable 
parts get very much displaced by the enlargement of an 
abscess, so that it is not possible for the best anatomists to 
tell with accuracy the exact position of those blood-vessels 
and nerves which it is important to avoid. I cut through 



....,.|.uini,uni. 1. (•irciiinscril)o<l, cither 
rtsnltiiijj^ from ex|>«>.-suro to cold, constitutional cav 
ol iiifrctivo niatt'iiiil In* the lynij)luiticsof the face > 
U'.sultiii^ lioni aculo celhiUtis complicating erysi^ 
coiiseciiieuce of bitoi, 8tin;;8^ or any poisoned woiu 
fa8ciai suppuration, this too may M — 1. Difftiaed 
2. Circumioribed, depending on the abeoiptkm < 
from the mnpoos membnuie of the foean and aim 
mbath, ihiioei, pharynx and lairnxt or fimm niaU a 
thote parts, fouionlar or dentaL Bometimea the a 
with the pos beneath extends ohi^y above the hj 
the lower jaw, eometimea ttiey deacend below ; the 
mined by the attaohment of the teoia to the hyoi 
given off behind that bone towardi the etylo-hyoid a 
as by the fiuoia separating the snbmaxillarT and pai 
between the ramus of the jaw and the styloid prooc 
side of the pharynx and the auditory meatns gmded 
of the parotid. Whether making its way abm or b 
brawny exudation fimns a kind of odlar, puahing i 
upwards or laterally, or more deeidy poshing up agai 
mouth, or tongue, and lower down on me mn 
oMophagus, lanmx, tnushea, and the great Uood-ve 
purative process oommsooe in or extend to the inteil 
mrotid gland, the nressure and imtation may afltet tl 
distend the naroHa fiMoia, aa^ even temporarily pai 
bianohes of the fhoial nerfo. Thus are explain 
dUBonltj ofmastinstion, swallowing, Ineathing, and s| 
of straiigulatioo, the deafiiosa, the prominenoeof thi 
turbanoes of vision, the symptoms of oerebral oi 
ocwasional paralysis of fhdal muscles. IVom tht 
peripharyngeal s uppura tion or strangulatinir 
bo dtstinffni«h^ ^ "" '" 



VL] AND THE DIAGNOSTIC VALUE OF PAIN. 135 

Post'pharyngeal Ahacess, 

Some time ago, while going round my wards at Guy's 
Hospital, a little child was brought in ; and tlie cireuin- 
stanoee 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 vertebra?. 
She had a large deep swelling in the upper part of the 
neck, on the left side, extending to the angle of the jaw. 
The carotid artery was pulsating upon the anterior surface 
of the swelling, close to the anterior edge of tlie stern o- 
deido-mastoid. The trachea was pushed forward and to 
the right side, and the tongue was protruded. My finger 
detected in the pharynx a swelling, which prevented deglu- 
tition. Be«piration was extremely difficult, and tlic sj)ino 
and neck were curved forward. Large superficial veins 
were crossing the left stemo-cleido-mastoid, and occupying 
the space between it and the trapezius muscle. Examina- 
tion of the throat through the mouth brought on extreme 
djBpnoda, so that the child was nearly suffocated, the face 
becoming quite livid. On the previous evening a surgeon 
was called to the case, for the purpose of performing 
tracheotomy, but it was thought better to send the child to 
the hospital. When the patient was sent up into my ward 
she could not swallow anything, and it was exi)ected that 
the child would die of suffocation if tracheotomy were not 
immediately performed. The post-pharyngeal collection of 
pus was the cause of all the urgent symptoms, but how to 
get at it without danger to the little patient was the ques- 
tion. In this case it seemed to me that if I made an aper- 
ture through the mouth, the child might bo liable to suf- 
focation by a large quantity of matter escaping into the 
larynx. I determined, therefore, to adopt the following 
expedient: — I carefully made an incision, about half an 
inch in length, with a lancet, throTigh the stemo-cloido- 
mastoid, thus exposing the fascia underneath it ; I then 
thmst a grooved probe or director through the faiucia, to- 
wards the back part of the pharynx, when a little stream 
of opaque fluid came trickling down the director. I then 
ran the dressing forceps along the grooved director, made 
an opening into the deep abscess, and let out three or four 



i-':'' THE THERATEUTIC INFLUENCE OF REST [Lec( 

ouncee of pue. The exit of the puB was aided by pawiog 

my finger into the olilld's mouth, and preeaing upon tlii! 
posterior wall of her pharynx. The carotid arterj' eubeideJ 
to its proper positioD, the lireathing waa immediately 
relieved, the patient lost all Beueo of suffocation, and some 
wine and water was quickly swallowed. The child left 
the hospital after six or seven woflks in a comparativelr 
healthy condition, 

I helieve it would have been unsafe to have attempted 
to open this abeoeBB in the nock, and close upon the spine, 
by any cutting or perforating instrument. 

Oct. If*e0, — This patient was seen three months after- 
wards ; she was quite well aa regards the abeecss, and the 
spine was consolidating. 

Hiac Abseegs. 

A man came under my care at Guy's Hospital, having 
receiveii a kick from ahorse over the left hip, wliich broke 
the OS innominatum, and drove a large piece of it inwards 
towordB the abdomen. Subsequently an absceHs occurred 
under the iliaans intemus and thence it descended into the 
thigh, behind the femoral blood-vcsaelB in Irtmt of tlic liip- 
joint, towards the inner side of the thigh. He was suffer- 
ing great conBtitutional distresB, and it became necessary to 
open the deep and obscure absceBS. Believing that it could 
not be safely reached by a knife or bistoury, I made an 
aperture on the inner side of the upper part of the thigh 
by cutting through the Bkin and fascia lata, and exposed 
the gracilis muscle. I then ran the grooved director 
through the gracilis into the deep and painful swelling, 
and opened the abscoas with the dressing forceps. The 
patient was relieved at once, and there was thenceforward 
neither difficulty nor danger associated with the case.' 

* Absoeu in the neigbbonrbood <>r the Miiic fodsa should, na si rule. 
bi> opeopj EHily. If conoecteil with the JliiioDa muscle or faacia the; 
ufteti travel up into thu abdomen, perhaps opening the onoarn, or into 
(be pelvia. or thty burrow down along the tendon on far as the leaser 
troohanter, and lW« meeting tetistance. paw back into the gluUal 
region. Again, tboy may innide tbo periiwteum and so give rise to 
tioubleaome Biuusea rmin deep-senled oeoroeiB of the ilinm, or, if ttie 
suppuration have started in the bursa under the p«oae and iliecus, 



VI ; AND THi: niA(rN().STI(' VAUK OF TAIN. I'.T 

Svh-gluteal Ahaceas, 

A few years ago I saw, with a physician and a surgeon, 
& young gentleman, in St. John's Wood, who had acute 
disease of the hip-joint, with deep fluctuation (abscess) 
under the gluteal muscles. The lad was very feeble, and 
dangerofoaly ill, and it became necessary to relieve him. I 
made a small cut down to the gluteus maximus, not 
through it. I then ran a director through the gluteal 
muscles, and opened the abscess with the forceps without 
the slightest difficulty to myself, and without any important 
bleeding or danger to the patient. 

Sub-fascial and Sub-muacular Abscesses. 

I have over and over again pursued this same safe plan 
in sub-fascial or sub-muscular abscess or abscesses formed 
upon or under the periosteum in the thigh. It has occurred 
to me many tunes in such cases, after dividing tlio fascia 
lata, to see the healthy muscles project boldly and clearly 
in tJie wound ; and, instead of cutting through them, I 
have reached the abscess by running a director right 
through the muscles into the collection of fluid, and then 
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 the perforating branches 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 if the 
plan which I have recommended be pursued, it is hardly 
possible that any such mischief or accident can occur ; and 
I can add this satisfactory assurance, that I have not yet 
had a single case in which this method of opening deep 
abscesses has been followed by important heemorrhage. 

I have 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 



to necrosii of the peMo brim ; this variety of abscess being also liable, if 
left unopened, to bring about even worse mischief by bursting into thu 
rabjacent hip-joint— [Ed.] 



138 THE THERAPEUTIC INFLDENCE OF BEST [IjCT. 

the alieceBB by some cutting instrument. Pus and arterial 
bluod eacui>ed itota tlie o])«niDg, but tbo bleediag wu 
Btuppud for A time by plugging the wound. A recurrenoe 
of Huddon and profuse arterial htemorrhago took plaoe hi 
a fuw days, which nearly destroyed the patient. It wm 
then thought right to ligature the femoral artery at th* 
upjwr third of the thigh, and the bloediug ceased fiwn 
that time. 

In the case of a patient having an abscess close npOD 
the interosseous ligament in the forearm, if the attempt to 
reach it be made by cutting down upon it, it is extremely 
difficTilt, next to impossible, to ascertain previously the 
exact position and direction of displaced nerves, veins, or 
arteries ; so it must be e^inatly impossible to avoid, with 
certainty, wounding some of these important parts. Bat if 
you simply out through the fascia so eis to expose the 
muscle at the most prominent point of the swelling (taking 
care to avoid the cinii-se of the lurp^T Uood-veKsels, ivhieE 
may bo felt with the finger), and then thrust the grooved 
director through them down to the interosseous ligament, 
the matter will 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 showing in what manner 
deep abscesses may be opened with the greatest safety. 

Simues cured by Best. 

If a sinus remains a long time after an aliscess, we are 
very apt to think that it depends on the bad health of the 
patient, and the custom is to send him to the sea-side, away 
from his ordinary occupation, and to leave the sinus alone; 
and certainly the sinus gets well. This result is, perhaps, 
not so much the consequence of improved health aa of rest 
at the sea-side. 

I will now place before you a short series of cases where 
abscesses, or sinuses after abscesses, are disturbed by 
muscles, and are, therefore, very difficult to heal. With 
regard to many such abscesses or sinuses, if the surgeon 



L] AND THE DIAONOSTIG VALUE OF PAIN. 139 

'ill only take the tronble to asoortain whether the ana- 
imioal associations are such that muscular disturbance of 
lie walls of the abscess can take place, and will adopt the 
ight moans to secure rest to the base of the abscess, or 
nek of the sinus, I think he will discover that this kind 
r abscess or sinus, which seems to defy almost every kind 
r remedial agent, will be found amenable to a very simple 
lethod of treatment, i.e. by rest. Walls of a])8cesBes, 
iflnencefl by muscular force, are to be treated by rest — 
lAt is, by preventing motion, and by the use of gentle 
ressure; or, when necessary, by the division of the 
.ucle or fascia. The fascia may be considered as a 
ntioii of the insertion of muscle ; for I apprehend there is 
) fascia in the body which is not influenced by muscle. 
Iiyriologically and surgically considered, fascia is one of 
le insertions of muscle — a jwint to which I may have 
oasion to refer in more detail at some future tiiiio. 

Sub-occipital Abscesses, 

An abscess under the occipito-frontalis muscle is some- 
aies very large, and resists surgical treatment for a vary 
Qg period. Why is this ? Let me remind you that the 
eolar tissue in which this abscess exists is abundant, and 
at the whole superficies or dome of the abscess is un<lor 
e influence of the occipito-frontalis muscle. Hence 
ere is no rest to the abscess ; it never has a chance of 
liet, or of accurate and persistent coaptation of its sur- 
oes from the disturbance produced by the movements 
this muscle. That such abscesses are difficult to heal 
Ql be admitted when I mention the particulars of some 
see ; and I will endeavour to demonstrate to you that in 
e surgical treatment of such cases the great object 
oald bo to keep the occipito-frontalis perfectly quiet by 
rapping. 

In illustration I may mention this case. Last spring 1 
us requested to see a stout gentleman aged fifty, who had 
Uen down the hold of a ship. He had been taken to the 
mdon Hospital, where his wound was well dressed. The 
Lterior half of the scalp was injured ; it had been turned 
rwards and downwards, quite over his face, by the acci- 



140 THE TltERAPEUTIC INFLUENCE OF BEST [I.«l. 

dont. This flap was replaced in ticcurate position, bandaged. 
strapped, and the patient was sent home. No primanr 
adbc«ion took place in the wound, and in a few days his 
eurgeon thought it right to take off the dressing, when it 
was found that the scalp itself was much swollen, and that 
the whole of it was lifted up or raised from the Ixinea by 
sub-occipital suppuration. The patient eubsequently hu 
two attacks of aevero hsBmorrfaage, from sloughing and 
ulceration of the temporal arteries, which required ligaturve. 
It is 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 &om the blood supplied by the arteries « 
the dura mater. The wound was dressed dally with tint 
and warm water, and tbo pus squeezed out from under the 
whole of the occipito-fri>ntalia ; but the abscess would not 
heal, and the question was, how to get the pus from under 
the posterior part of the scalp — for there was no outlet for 
it in that direction — and how to secure rest to the moveable 
domeof the abscess. The hair ujion his scalp was shaved 
off, and long strips of plaster were so arranged 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 being done simply for the 
purpose of giving rest to the parts. The rapidity with 
which the abscess then healed was very remarkable in con- 
trast with the tardy results of the previous daily dressing 
and emptying of the abscess. He got quickly well, without 
any necrosis of bone. 

SiA-occipital Abgceis and Sinuieg. 

The next instance I have to mention is of a patient who 
had suffered during a whole year from sub-occipital abscess 
and sinuses — sequelee 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 occi- 
pito-fron talis and the swollen scalp. This abscess and the 



AND THE DIAGNOSnO VALUE OF PAIN. 141 

I were originally the resnlt of a blow, and she had 
lore than a year under surgical treatment. Sinuses 
izTOwed under the swollen oedematous scalp, tra- 
{ it in dilTerent directions, and communicating with 
ther. The cranial bones were found denuded of 
oinm at two or three points, and profuse suppura- 
ok place from the openings of the sinuses. (Here I 
bcidentally remark that profuse suppuration is tanta- 
to daily venesection — and this is the way in which I 
a mirgeon should regard excessive suppuration. 
min must necessarily keep the person in a reduced 
km of health.) Poultices and stimulating injections 
en used, with ointments to the scalp, and these had 
iMiduously employed during a twelvemonth. The 
rtm now shaved, and numerous long strips of plaster, 
alf an inch to an inch wide, were arranged around 
sro0B the scalp, so as to keep the muscles perfectly 
whUe allowing the apertures of the sinuses to remain 
nred, thus permitting the escape of any discharge. 
•trips of plaster wore applied as soon as the others 
d loose from the graducd diminution of the size of 
lip, and the patient was well in three weeks, 
r this patient had suffered from abscesses and subse- 
flinuses during a whole twelvemonth, the sinuses 
communicating with e€U!h other, with here and there 
3d bone. Perfect rest was given to the walls of the 
I, by accurate adaptation with plaster, and the 
t was well in three weeks. There was no exfoliation 
e, the chief nutrition to the bones of the head being 
1, as 1 before remarked, from the dura mater, and 
im the pericranium. 

B years ago, 1 saw, with the late Dr. Marshall Hall, 
ng gentleman in Westboume Terrace, who had 
Bias of the scalp, followed by a similar abscess. We 
not succeed in healing it until the head had been 
L and plasters applied, so as to keep the occipito- 
lis at rest, when he got perfectly and quickly well. 
tay mention another case of the same kind. H. 
, aged twenty, general health good. Ten weeks 
my visit he had received a blow upon the top of his 
leluch was followed by an abscess of considerable 



142 THE THEBAFEUnO INFLUENOE OF BBgT [L» 



8izo under the tendon of the occipito-fixmtalia. It 
opened by a surgeon, and had been discharging freely ei« 
since ; but when I saw him the discharge had ceased !■ 
a day, from temporary closure of the artificial opemif 
On passing a probe into this closed opening, between tin 
and three ounces of thin sero-purulent fluid, tinged will 
blood, escaped from under the occipito-fron talis, leaviiigi 
large loose wall of scalp covering the seat of the ahsoMi 
The head was shaved, a pad of lint was placed upon tk 
loose portion of the scalp, and there strapped down will 
moderate pressure, leaving the opening froe so as to alkii 
of the escape of any discharge of pus or serum. On Ji^ 
14th, eighteen days from the beginning of the treatmMI 
by rest, this was the state of the patient : — WaUs of absoM 
have almost entirely united; little or no diachaifp 
strapping applied to-day for the third time. On the 21s 
of Jiily the patient was quite well, having been cured b 
local rest. 

StUhoccipitcU Abscess udth Ulcer on the Forehead. 

About the end of September, 1848, Edward L , age 

twenty-seven, applied to mo with a large, deep uloeratia 
of the integument of his forehead, and suppuration tw 
inches above the ulceration. He had been under tli 
treatment of an hospital surgeon, uninterruptedly, duzm 
seven months, without benefit, the means used having bes 
poultices^ stimulating injections, ointments, and vaiioi 
medicines. This ulceration, influenced by the oorrugaton 
and occipito-frontalis, was situated near the middle of til 
forehead, chiefly over the left frontal sinus : the ulcer an 
the walls of the abscess or sinus being freely moveable b 
both tliese muscles. Two long strips of adhesive plasii 
were applied transversely across the forehead, eztendia 
laterally to each temple ; and one long piece was applie 
vertically, extending upwards from just above the nO0 
and near the median line, along and over the verteiz i 
the head to the occiput, a path having been previond 
made by cutting the hair along the intended course of tl 
plaster ; a bandage was then passed several times firm] 
around the head. All this adjustment was made for tl 



.] ASD THE DIAGNOfinO TALUE OF PAIN. 143 

zpose of opposing the disturbance of the parts influenced 
rectly by the muscles to which I have alluded. Nothing 
B was done. The ulceration began to improve, and on 
ivember 9th, 1848, my notes report him well, so that in 
or or five weeks it was healed ; but as the cicatricial 
nictares were yet feeble, one transverse slip of plaster 
IB worn, BO as to steady the base of the ulcer, until 
ibmary, 1849. I saw this patient during the summer of 
49; he continued perfectly well. He was cured by 
ring rett to the base of the ulcer, the muscles l)eing kept 
let by strapping. I happen to know that this patient 
d had the advantage of very good professional advice ; 
1 1 think that his professional adviser did not recognise 
» flimple cause which interfered with Nature's healing 
xsess. It was only by the recognition of the fact that 
) abscess was so placed as to be under the direct influence 
Tarions antagonizing muscles which were contending 
sdnst each other, and making traction upon and dis- 
rbing the base of the sinuous abscess in various direc- 
118, never allowing the ulcerated surface to have any 
rt, that the method of cure was pointed out. 

Cervical Abscess under the Platysma Myoides. 

Abflcesses in the neck, under the platysma myoides, are 
dl worthy of your attention. When these abscesses are 
ened either by the surgeon or by Nature, they are some- 
aes yery difficult to heal. I believe the great difficulty 
pendfl upon the fact that they are under the influence of 
B plat3rsma myoides. Some time ago, my friend. Dr. 
ildy, brought to me the son of a clergyman, who was 
ffeiing from a large ulceration, the sequel of an abscess, 
iiuf deep in the neck. He had had the advantage of 
od professional attendance and general treatment ; but 
B ulceration not only did not heal, but was slowly 
tending. We determined to see the effect of rest to the 
3er. Strips of plaster were placed across the neck, and 
ayer of cotton wool over the plaster and the ulcer, upon 
d side of the neck ; these means, aided by gentle band- 
ing, kept the platysma myoides quiet. The ulceration 
d existed a considerable period before I saw the patient. 



Di'pp Cvrvlcal Ahscfss, foUow 

I have here the notes of anothei 
existed in the neck, which was ourei 
was of two years' dnration and was < 
I am almost afraid yon may be induce 
the language of exaggeration in th 
really am not. 

In 1849, Elizabeth H , aged 

Lambeth, had had a large abscess exte 
the platysma myoides and the stemo-dt 
had continued as a long sinus, dischar, 
many months. She had been an hoepd 
two years. Iodine, &o.<, had been injec 
and a seton passed through it and reti 
some time without any benefit. Strips • 
were drawn tightly over and across th< 
the sinus, and the head was steadied 
splint, cut rudely into a form which oc 
the body along uie back of the should 
the head, and tiien laterally on each side 
the whole of the head in a circle of 
splint was made o£F-hand with wet, soft, 
covered by linen, pressed "*— 

ftfl f/fc "Vt^ — 



YL] AND THE DIAONOSTIO VALUE OF PAIK. 145 

Small Superficial Cervical Abscess, 

We are often troubled how to deal satiBfaetorily with 
the results of small superficial abscesses in the neck. 
Snch open abscesses under the skin are mostly said to be 
scrofulous; but I suspect their persistence depends not 
onfrequently upon their close relation to the platysma 
mjoides. I believe — and I am speaking here from ex- 
perience — that by placing a pad of cotton wool, twice as 
large as the area of the disease, over the part, and by 
fixing it there so as to keep the platysma myoides and all 
the surrounding parts at rest, many of those cases that 
seem to defy almost every kind of treatment may bo suc- 
oeBsfully dealt with. I have had opportunities in verj' 
many such cases of observing the success of this treatment. 

Case* of Carbuncle, follotoed by Sloughing. 

We all know that it is not easy to manage successfully 
the treatment of a patient who has had a large carbuncle 
on the back of the neck near the scalp, wliich, by destroy- 
ing the subcutaneous areolar and fascial structures has 
left large portions of loose overlapping skin, blue, dark- 
oolourea, and congested, showing a very feeble power, and, 
in addition to this, exposed the trapezii muscles to view. 
Now I wish to show the therapeutical value of local rest 
in the treatment of such a case. 

Some years ago I saw the wife of a physician, whose 
condition accurately resembled that wliich I have just 
delineated. She had been previously attended by a very 
eminent London surgeon. The case was not proceeding 
satisfactorily ; there was no local evidence of repair ; and 
the wound had remained stationary some time before my 
visit. On looking at the patient's neck, it appeared to me 
that there were two additional requisites in tbe treatment 
wliich might help the cure: one was to arrange some 
simple mechanism which would keep the trapezii muscles 
quiet ; and the other, to support in their proper positions, 
and to maintain in a state or perfect rest, tlio loose feeble 
flaps of skin. I hoped by such means to facilitate adhesion 
of the two granulating surfaces. The loose flaps of skin 



HI oi'dci' tt» iix tlK; hn 

and cMiiliol tlic tiapr/ii. In tufiitA 
(.'('iiiiiH'nciMl, aii<l jirtMTLMlrd, iindcr 
niriit. to tlie most Batisfactory and 
Nut long after that time I saw a j 
Boad, with Mr. Wright, where just t 
occurred, with exactly similar treatn 
same result. Here the parts were ke] 
thick pad of cotton wool pressing uj 
means of a bandage to keep the h 
muscles in a state of rest. Cases of t 
same result from similar treatment, ha 
me in Guy's Hospital. 

Popliteal Abscess and Sk 

Sinuses in the popliteal region, in i 
are very difficult to cure, except by lo< 
will take' the liberty of reading part 
received from a surgeon in Essex, wh< 
back of his knee-joint : — 

** Jan. 9th, 1863. — My sinuses occun 
in the popliteal space, which left a 
healthy ulcer, the size of a walnut, ai 
deep sinuses extending from it, amonge 
hamstring muscles. Not bein^r ablo 
this ulcer, I conwii^'^'' 



us uicer, x com*""^"'- 



.] AND THE DIAGNOSnO VALUE OF PAIN. 147 

Small Facial Abscess. 

In Bome small abscesses sometimes occurring in the face, 
leek, or neck, which have opened by a minute uleerati(»n 
iDogh the skin, the aperture communicating with the sac 
the abfloesB, I have found the happiest results from 
ziying ont this principle of rest to the part. I have 
Brely passed a small probe into the aperture in the skin 
r the purpose of keeping it open whilst collodion was 
ing applied upon the dome of the abscess, so as to press 
e dome upon the floor of the abscess. In this way 
emiTe and rest are secured, and by cr)aptation the 
rta are kept undisturbed. The process of healing 
sn commences, and I think the patient gets well more 
jokly by this than by any other local method of 
Atment. 

Binnsea, then, are cured by the adoption of local rest ; 
d I think that if surgeons, instead of affixing t<:) ovurj'- 
ins the opprobrium of bad general health, wtmld take 
bo consideration the possibility of there being sonic 
Boial local disturbing cause associated with it, such as 
iflcular or other movements, more hucjcobs would result 
km the very simple plan of treatment by rest. 

Painful and Irritable Ulcers. 

I promised, before concluding these lectures, to refer to 
me surgical cases which show the good effect of ** phy- 
>logical rest." As yet I have scarcely liad an opportunity 

aUnding to the subject. The only example of the 
inciple of "physiological rest" as a curative agent 
liich time will admit of my using is tliat of tlic painful 
citable ulcer. An irritable ulcer is to be distinguished, 
> doubt, from an inflamed ulcer, by the quantity oi 
mph which is poured out upon the inflamed ulcer, and 
high degree of its temperature. Irritable ulcers, 

we know, are exceedingly painful, and sometimes verj- 
flScnlt to cure. As far as I have been able to detect their 
il essential pathological character, it depends upon the 
posure of a nerve on the surface of the ulcer. Of course 
IS quite clear that every uloer must have nerves more or 

L 2 



148 THE THERAPEUTIC INFLUENCE OF REST [LtCT. 

leas espoBod on the snrfBce; but in the case of an irritable 
ulcer, it seemB prolmblo that the eheatli of the nerve is 
dcBtroyeii, and that the end of the true nerve-fibre c« 
tubule reinaina denuded, and bo causes the exquisitelj 
Beusitive and painful character of the ulcer. Upon thu 
expoBurc uf nerve dependB. I believe, the chief feature oC 
what we term au irritable ulcer, and the method of 
dotecting the precise Beat of the exposed nerve is ver? 
simple. You must underetaud that niy remarks on thu 
subject arc founded on a twelve or fourteen yeatB* expe- 
rience of such cases. Having a very painful umoflamod 
ulcoT before you, you apply the blunt end of a common 
probe Hpon the Bore, and, as you move it about, the patient 
presently exclaims, " Oh, there you hurt me dreadfully ! " 
You thun go a little further ou with the same method of 
examination, and scarcely any pain is felt ; but on oomii^ 
back to the same spot, the patient is again " dreadfully 
hurt." At that painful spot some sniiiU nerve is osptieed 
un thfi Hurfaoe of the ulcer. Tht' tirnt time I obwrvoii this 
fact, and arrived at what I believed to be the right inter- 
pretation of it, was in the case of a patient %riio had a 
thecal bursa extending from the palm of the hand, undu 
tho annular ligament, t« above the wrist. I made an 
aperture into the biiraa above the wrist large enough to 
let out aU the fluid and solid contents. The bursal 
swelling gave mo no special trouble, and was speedily 
cured ; but at the seat of the opening a very irritable 
painful ulcer remained which I could not heal by anj 
local application. On examining tho ulcor with a prob& 
I discovered a point of exquisite tenderness. Tho norma! 
position of the small palmar branch of the median nem 
corresponded with the site of the local sensitiveness, anc 
seemed to explain tho pain. I then passed a small poiutec 
bistoury under the track of tho nerve above tho tendei 
spot, so as to divide the nerve between tho spinal marrov 
and the irritable ]ioint of tho ulcer ; from that time the 
pain ceased, and the ulcer rapidly healed. It was curec 
by the "physiological rest" resulting from the division o 
that little nerve. 



VL] AND THE DIAGKOSTIO VALUE OF PAIK. 149 



Painful Granulations following Injury, 

Some long time after the occTirrenee of this case, I had a 
patient in Gny's Hospital suffering greatly from an ulcer 
at the end of the finger, in which, as the original injury 
wag a cut from breaking a window, it was supposed, there 
was a piece of broken glass. She had been under the 
observation of a surgeon, who had tried repeatedly to get 
out the suspected piece of glass, and had severely but 
imintentionally pumshed her. 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 8urfiBW» of my finger, however, was not a sufficiently 
aocxiTate localizer of the pain. I then employed the round^ 
end of a probe, and with great care examined the whole 
surface of the lAfcer by pressure, until I came upon a spot 
that was exquisitely tender, and produced dreadful pain to 
the patient. With a pair of scissors I cut out the painful 
granulations. Explaining to Dr. Halxjrshon, then De- 
monstrator of Anatomy at Guy's Hospital, the views I 
entertained regarding the cause of the painful granidations, 
I requested him to examine them by the aid of the micro- 
Boope, and he found in them, and near the surface, as I 
had expected, looped filaments of nerves, thus completing 
the demonstration of the cause of the pain. From the 
time of my cutting away those sensitive granulations the 
pain ceased and the sore began to heal ; there was no more 
trouble or difficulty as regards the treatment of the ulcer, 
it got well by giving it ''''physiological rest" 

Exquisitely painful Ulcer after Injury, 

About a year and a half ago, I was requested to see a 
gentleman's coachman, who, on getting off his box seat, 
slipped his fingers between the lower bar and the seat, and 
thus had two of his fingers broken off at the second pha- 
langes. One of them went on rapidly towards healing, 
and did so very well. The other remained swollen, irri- 
table, very painful to the touch or on exposure to the air. 



150 THE THKRAPEUTIO IJiPirENOE OP BEST [\JKl I 

preventiug al<;i>p, and producing great constitutional di*- 1 
turbauco. We failed to relieve those eyniptoras hy the j 
local and internal employment of opiam. This unhealthy j 
condition could not be from any conetitutioiitti defect 
because one finger did well ; nor could it be from t' 
result of uny diHaimilarity of the original injury, for tb 
were precisely alike. With the eurgeun in attendancM, X_ 
made a careful examination of the part ; and when Tl 
platicd the end of a probe towards the edge of the n' " 
u]xju the finger, it detected a sfiot which was oxqui 
tender, and the patient screamed out — " Oh. pray, I 
God's sake, cover it over ! I can't stand it." The pontii . 
of this pain was in tlie cciurse of one of the laceratei4 
digital nerves. I passed a pointed biBtoury under tbe ' 
nerve, about one-fourth of an inch above its espoeed 
portion upon tbe wound, and so divided it. Tbe lutin in 
the ulcer ceased immediately, and the touch of the jirobo 
caused no uneasincsa. From that tii*t' all the local 
BjTuptoms rajiidly improved, anil the case fjave no | 
further trouble, being quickly cured by " physiological 
rest." 

These cases prove distinctly that an ulcer may be veiy 
much modified in its character from the exposure of a 
nerve in the wound. 

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

Painful Irritahle Ulcer of the Leg. 

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

John J , aged twenty-aeven. a sailor ; admitted on 

the 9th of Noveniher, 1859, suffering from a syphilitic sore 
on the fnenum and penis, with secondary eruption and 
a very painful ulcer on the inner malleolus of his left leg. 



VL] AND THE DTAGNOSTIC VALUE OF PAIN. 151 

The syphilis was treated and cured by Plummer's pill, 
five grains, twicje a day ; but the painful ulcer remained 
uninfluenced 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 ulcer formed on the inner malleolus of the 
left leg. It had made frequent efforts at healing, but 
nerer eioatrized completely. It now looked irritable, with 
DO inclination to heal, and was very painful, with intense 
oenrcms sensibility localized at its upper margin, which 
was ascertained by examining it with a probe. 

** Jan. 24th, 18(50. — Mr. Hilton passed a j)ointed bistoury 
a little distance above the tender spot, under, and then 
throagh, the granulations, thereby severing the filaments 
of the nerves supplying the morbidly sensitive granula- 
tions ; and although the patient made much ado about the 
operation, yet he immediately acknowledged himself re- 
heved by it. The ulcer 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 
pamleut exudation, cicatrization daily advanced, and the 
ulcer was closed in a fortnight, and remained so until lie 
left the hospital, on the 8th of March, 1860." 

This was 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 sj-jot of an old irritable 
nicer was examined 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 accu- 
rately the therapeutic value of what we may fairly term 



152 THE THERAPEUTIC INPLDENCK OF BEST [Lwr. 

" phyBJological rest." by removing the abnormal Benaibilitj 
of tho Biii't'ftce of the sore." 

I trust I may have snooeeded in thns briefly poioting 

oat tho time pathological feature of what is tenned t 
" painful irritable ulcer." 

* Sir. Hilton famished me with the fbUowiD| notes, which ibo* 
thnt " phyeiologioul r««t" in in this clasaof caseofneiiiDahiuiporlaiicA 
in prirnto at in hmpital pinctice : — 

"Soon after tho delivcrf of iUeae leoturea, Mr. Qoain, who vm *i 
that time called away ttom Londoo, placed under my care a patieol 
who hitd for many months heea suffering eitremeN from a nuicl 
imiiiful irritablu ulcoi on tho lower third of oau of her legii. Tttil 
ulcor bud resibt^d WEll■dire(^tod trcntment of the luiuJ kiod. Wbep 
Mr. Quaiii und I saw tbc ulcer it was rircaUr in shape, about an iaali 
and a half in diomeler, and bq letuitiTB that my blowing a brtiaUi d 
air upon it caused the patient exquisite pain. We then examined t^ 
gurhce of tlie uloer by the aid of a blont probe, so a« to tndioate ^ 
exact position of the moat aenaitiTe points, of which there were Mvenl 
Opposite to each of them, and about one-eiKhlh of an inch from the 
cdKi) nf the ulcer, I pasadl ii abarp-finiLitcd histiiiiry throuixh (lie sbin, 
and divided in each case the auboutaneous tissue containing the teanota 
of the nerve, the end of which was exposed upon the nicer. This 
divieiuD of the nerves rendered tho ulcer almost painleae. and the 
patient eiprcsseit herself as much relierod. No epecia! treatment was 
roquired; tljo patieDt, freed from the pain by wiiich her liealth had 
bi.<eii mui^b impaired, was enabU'd to take her food and enjoy pleatjr at 
sleep. Healthy pua soon appeared upon tlie surface of tbe ulcer, the 
healing process waa quickly established, and the lady returned to btt 
liome cured." — [Ed.] 



Vn.] AND THE DIAON08TI0 VALUE OF PAIK. 153 



LECTURE VII. 

cue SHOWING TUS DANGER OF OPENING AN ABSCESS IN THE THIGH 
BT A LANCET— CASE OF SLOUGHING OF THE SCALP — SINUSES CUBED 
BT APPLICATION OF A TRUSS — IBBITABLE EXTBEMITIES OF A NEBYB 
or A WOUND BKLIETED BY DIVISION OF THE NEBTE — HEADACHE AND 
arrOLXBANGE of UGHT CURED BY PHYSIOLOGICAL BEST — DESIGN 
MANIFUTED BT THE SAME NERVRS BEING DISTRIBUTED TO A JOINT 
AND TO THE MUSCULAR APPARATUS USED FOR THE MOTION OF THE 
JOINT — APPIJCATION OF THIS TO EXPLAIN THE INVOLUNTARY FLEXURE 
OF AM INFLAMED JOINT. 

While I endeavour to illustrate still further the principles 
on which I have insisted in my previous lectures, it seems 
to me but right that I should 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 importance which Nature seemed to have attached 
to the attainment of " physiological rest," as exemplified 
in the marvellous provisions which she had made for it 
in the vegetable and animal kingdoms. After a somewhat 
minute review of the equally wondrous and efficient, yet 
ample, expedients, 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 

Principles to the treatment of various forms of disease, 
remarked that the subject grew with contemplation; 
that, narrow as it appeared when adopted as a mere 
platitude, or in its axiomatic form — " Best is an important 
agent in the cure of disease," when employed in relation 
to the countless forms of disease presented to the ob- 
servation of the surgeon — it expanded and enlarged in its 
proportions, like the series of circles extending 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 



154 THE THERAPEUTIC INtLljENCE OF BEST [Ucr. j 

thereby excite in othera. more capnblu than myself, a s[niit \ 
of research into those deepcir recesses of the existence of 1 
which I am convinced. ' 

This 18 no new subject of inquiry. Perhaps there are 
few thoughtful members of our profession tu n-bom it hu 
not suggested itself; aud my reason for disc-oursiug upon 
it is rather for the purpose of gathering together in a con- 
nected form uotions which had long been floating vaguely 
in tbe minds of others as well as my own. and which 
required to bo collected that they might produce predso 
Tesnlte. As tar as my knowledge extends, this has nut been 
done, even in the meagre degree in which I now present 
it to j-on. 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 priae essay 
on the subject of" Hest," by a French surgeon, M. David, 
presented totheKoyol Academy of Surgery of Paris so long 
sinoe as 1778. The subject proposed by the Academy for 
the prize essay of that year was " to esplsin the e&eots ot 
motion and rest, and the indication according to whieh 
either should be prescribed in surgical diseases.' M, David, 
the «uc-('CHBfnl conipetitrir, iu acctirdance with the phrase- 
ology of his day, speaks of man as the epitome of the 
universe, and of fire as tho great moving principle; and 
proceeds to lay down the following converse propositions: 
"If it be required to resist or prevent the inspissation of 
the fluids in the cure of these disorders, it will bo necessary 
to call in the assistance of motion, provided there be no 

Srticular circumstance that renders the use of it improper. 
. on the contrary, the plan of cure require to give a better 
ooneisteiice to the fluids, and if the eETects of motion should 
counteract this plan, we must have recourse to rest." 
Pursuing these propositions, he dilates freely on the sub- 
ject of motion as applied to rheumatism, gout, anchylosis, 
and so forth ; rather as if for the purpose of creating & 
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 verte- 
bral disease which had been benefited by rest, and dwelling 
upon such ob\-iouBly necessitous cases for its adoption as 
dislocations, rupture of tendons or muscles, conlnsione of 



VII.] AND THi: MAONOSTIC VALIK OK TAIN. l.".:. 

joints, ifec, he suggests its applicatiuii to tlie treatment of 
sinnses and fistula of the anus. 

Eenoe I believe I am only arranging, in an approach to 
a svBtematic form, the fragmentary atoms of a great prin- 
ciple, which has occurred to the minds of very many 
mag^ons. Fortunately, from my position, I am enable<l 
to illustrate that principle by cases deduced from my indi- 
vidual experience, and thus, I trust, to impress it on the 
minds of others, who will extend its a])plication. At any 

late, I can say, 

*^ fangar vioe ootis, acutam 
Beddcre qosD ferrum valet, exson ipsa Becandi/* 

Horace, Ara Ptictica, line 304. 

Before proceeding to a further and wider examination of 
the therapeutic value of Kest, I would solicit your atten- 
tion to three or four additional cases, illustrative of some of 
the points which I have had the satisfaction of previously 
placing before you. These few cases are good examples, 
perhaps, but form only a small portion of the numerous 
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 exemplifying the value 
of Best as a curative agent, 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 of the danger which so 
frequently attends their professional mismanagement. 

I also endeavoured to call your attention to what I 
deemed to be the safest and best method of opening deep 
abscesses; namely, by a lancet, grooved director, and 
ordinary dressing forceps. As I have hcul a case before 
me, full of point with respect to this subject, I will detain 
you by relating one or two facts regarding it : — 

A young lady, aged thirteen, had a deep abscess in the 
lower third of tne left thigh. As far as I can judge of the 
case by the history which I have received, the abscess was 
associated with periosteal or sub-periosteal inflammation, 
for the abscess was deep under the muscles. It was 
opened at the lower and inner part of the thigh with a 
lancet or bistoury, by one puncture or clean incision, which 



156 THE THERAPEUTIC rNTLITENCE OF EEST [LboT. 

reached the abHceea. Fua eecapod. mixed with a cooHidec- 
able quantity of arterial blood ; and nfter all the ptinilKit 
fluid had been evaoiiated, arterial blood still flowed from 
the aperture. The aperture was then plugged. On the 
third day, the plug beiug removed, a little haemorrhage 
took place, and it was plugged again. On the seveuih 
day after the opening of the abecesa, a most profuse and 
sudden arterial hfemorrhago occurred, bringiiigthe patient 
really to the very brink of the grave. At that time a ood- 
sultatiou of surgeons took place, when it was determined 
to tie the femoral artery. This was well done, just above 
the middle of the thigh, and there waa no subsequent 
heemorrhage. I saw this younglady in London last October. 
She waa then in an extremely emaciated and depressed 
condition, with a slouglt upon the back. The aperture 
made by the lancet wm still there, and pouring out daily* 
small quantity of aero-purulent fluid. I need not trouble 
you with any further particulars of this case, except to 
express ray opinion, not in opposition to the gentleman 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, dividing the fascia 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 intcmus muscle, and 
open the abscess by the dressing forceps, guided into it by 
the groove in the director, 

I took occasion also to refer to the treatment of abscesaes 
by " rest," and I brought before your notice some cases of 
ahscoHS under the occipito- frontalis muscle — abscesses mOBt 
difficult to manage, except upon one principle, the use of 
mechanical means to keep the parts in a state of quietude 
or " rest." 

Since then a most curious and remarkable case has been 
brought under my notice at Guy's Hospital; it Is hem 

depicted (Fig. 22):— A man(\V. 1) ), aged sixty-three, 

in January, 1860, felt from the rigging of a ship, hie head 



ra.] 



AJJD THE DIAQHOSTIO VALUE OF PAIN. 



167 



aoming in contact with a bar of iron in a barge, producing 
extensive laceration of his ecalp. He was professionally 
attended to immediately, adheeivo plaeters were applied, 
tnd the edges of the wound were adjusted ; but, from 
whaX caose I do not know, these plasters were allowed to 
nmain on the man's head eleven days undisturbed. He 
was not, I think, under professional oare during that time. 
The plastera were then pulled off by himeclf, and euli- 
Kquently he had BoveraJ attacks of erysipelas and aloughing 
o{ the Bcalp. In May, four months from tho time of the 
tccident, he and his surgeon began to notice that the scalp 
was falling, like a land-slip, gradually sliding down the 
nde of the head till it ultjmately attoincd the displaced 
podtion which you see in this portrait (Fig. 22). 'ITie 

FIB.M. 




■pace between the fallen scalp and the edge of the granu- 
lating surface is now occupied by newly formed skin, free 
from hair. A considerable portion of the parietal and 
adjoining bonos has been detached from the top of tho 
bind, so as to expose the pulsations of the brain near the 
centre of the lai^e and massive granulations, which are 
shown in the drawing. I adduce this caao for the purpose 
of supporting the opinion that tho whole of this mischief 
might have been avoided if attention had l)een paid to 



i.i.-^ iiii: ri]i:ii\i'Ki:Tic iNfrvESi/E of kemt tl 

the uao of boulu ni(K;hauical tneaoB, each as strips of plaster 
placed around and over the acalp, to maintKin the occipito- 
frontalie in its proper position. In this case the sabjaoent 
areolar tiaauo Hloughed ; there wfta nothing to hold the 
oocipi to frontalis, and it slid olf lh<? sid» of thu skall. f 



FtJ.M. 




might add another practical remark. I think it is prolitihli; 
that if the scalp had buen carefully rctainod tn gita on thi' 
top of tho head, tho loss of bone would not have been Bu 
eztenEive. The portions of detached bone, when put 
together, make a large piece, somewhat circular in form. 



VU] AKD THE DIAGNOSTIO YALUE OF PAIN. 159 

with, a diameter of about four inches. The exfoliation is 
Qonfined to the external plate of the cranium and diploe, 
except near the parietal foramina, where a piece of the 
internal plate or table is visible on its concave aspect, and 
it 18 at the corresponding part of the exposed dnra mater 
tittt the distinct pulsations of the brain may be seen. 
Althoagh I am aware that the chief nutrition of the bones 
of the head is obtained from the dura mater, yet no doubt 
Bonie portion of it is derived from the periosteimi or peri- 
cranium. The pericranial membrane was destroyed by its 
exposure, and hence the sloughing that occurred. This 
picture (Fig. 23) represents the patient after the operation 
which I performed upon him. It is perhaps rather too 
flattering to the patient, and a little too complimentary to 
the success of the surgeon*s efforts. But I would ask you 
to remark one other point in this case with reference to the 
influence of rest'. The granulations in this drawing, 
Although not artistically well depicted, do exhibit a healthy 
character, and the area is much diminished, and is still 
dimishing. This improvement has occurred Bince the 
removal of the hanging mass of the scalp, which by its 
Weight was making constant traction upon the healing 
Bcalp, and so interfered with Nature's curative efforts. 
By taking away the depending portion of scalp, I gave 
" mechanical rest " to the margins of the ulceration, and 
thus enabled Nature to concentrate her attention more 
upon the healing of the exposed surface ; and now the 
condition is that which is here represented. 

The cure of sinuses by " rest " was another subject that 
I brought forward, and I may here mention an additional 
case or two bearing upon this point which have since 
occurred. 

On November the 2l8t, 1860, a gentleman, aged twenty- 
three, consulted me with regard to a sinus in his right 
groin, which was the sequel to an extensive suppuration 
which took place in a glandular swelling below Poupart's 
ligament, tkree or four months previously. The abscess 
had* been first punctured, and subsequently freely cut along 
its whole length, near its lower boundary. The sinus did 
not heal, and the gentleman was sent to Ramsgate, where ^ 



160 



THE THEBAPETJTIC INFLUENCE OF REST [LnjT 



he reraainod three mynthB, during which time he wore! 
pud of lint bafldaged over the parts, with the idea of 
making jireftsure upon them. Upon his return to town, 
there beiug scarcely any iniproverueut in the condition of 
the ulcer and sinus, he was ordered by his iturgeon to 
return to the Bea-eide for the winter, fur the further im- 
provement of his health. It was at this time that I wn 
consulted. The gentleman explained to me that he had 
made great saorifioes from the cumiueiicement of his illness, 
several months back, to the present time, by abaentiiig 
himself from businesa, without any benefit to ibo sore, uJ 
that he could not alfurd to lose more time, except as B 
matter of necessity. On examination, J fonnd a, short 
BiiiUB, about an inch in length, mniuug parttUd with 
Fou])art's ligament, on the right aide, and then cmnmnuii* 
eating with a cavity having granulating walls. One 
granulating surface jjassed underneath an overlapping 
piece of skin, aViout two iiichuH loup nuil thrut^-ijunrters of 
an inch wide, which rested iu part upon a long slip of 




exposed granulation, extending below the margin of over- 
lapping skin. Both surfaces wci-e covered with granula- 
tions, and the two wore moving freely upon each other. 
It appeared to me that this gentleman's liealth was pretty 
good, and all that was required would be to apply some- 
thing to make a steady pressure upon the flap of skin, so 
that these granulating surfaces might be brought in con- 
tact, and maintained in that state, for the purpose of aiding 
secondary adhesion. Just as when primary adhesion fails 



L] AHD THE DIAGK08TI0 VALUE OF PAIN. IGl 

the operation for hare-lip, by bringing the graniilationa 

gether they unite, and the reparation is tolerably perfect. 

or the purpose of securing this necessary adaptation of ^e 

imolating surface in this i>atient*s case, I recommended 

im to wear a truss of this kind (Fig. 24 V which was well 

idapted to relieve his condition. Towards the large end of 

die tnus is introduced a ratchet wheel, regulated by a key. 

This is capable of turning the pad inwards upon the sinus 

•Imoet to any extent ; and if the patient finds the pressure 

too g^reat, he can himself reduce it with facility and pre- 

dsion.* This truss was applied, and I advised the patient 

not to sacrifice more time, but to attend to his Imsiness, 

and not go into the country'. In a fortnight the sinus had 

* Bert, by carefully adjusti-d pressure, whirh a patient can ro^nlate 
for himself, will be R>una of very great service in tlie treatment uf a 
Tsricoc«:le by a truss. I refer to that degree of vancucele which is not 
miBeieiitly relieved by a suspensory bandage, and yet doi's not call fur 
tu operation. A rough but sufficiently reliable test as to tlie amount of 
benefit likely to accrue from the use of a truss consists in the application 
of temporary pressure, while the patient is recumbent, and at$ci;rtaining 
the amount of relief given when he stands U[». Whether a trusH of the 
abi>vc kind, or a rooc-main, or bag*truss be ma<te use of, HupjK)rt should 
be }?i\en not onlv at tlie external abdominal ring, Imt ulbo along 
tlu) inguinal canal. As long as, in one way or anotlier, the patient 
retains the power of regulating the amount of pn-bsuro, no fears need be 
entertained of atrophv of the testis from obstruction of the Hi)onnatic 
artery, or complete obliteration of the spermatic veins. Any one who 
has examined an injoited preparation of a varicocele will huve noticed 
the number of small veins which, under such pressure as. the 
alx>ve, will escape complete obstruction, and carry on the circulation. 
With reference to the spermatic artery a certain degree of o))8truction 
will give rest to the tettis and so be bonetieial. It niuht not ha forgotten 
tliat in many varicoceles, especially those complicated with murbiil 
oonditiona of the genitals, such as irritability, hyper-^enMitiveuess, 
neuralgia, there are two factors at work, not only is the eiferent current 
at fault from an altered condition of the vehis, but the utferent blood* 
supply is also altered, being often excessive or subject to fre<iutnt and 
mddHTi vuriations, from habitual exee^tses wliich need not l)e further 
spedfled. Aud where this irritability and hyper-senbitiveuess are 
esptcially complained of at night, gentle support and pressure with a 
truss will be found beneficial as well as in the daytime. Finally, the 
student vHU not forget how mnch rest can be given in this troublous 
oondition by removing any habitual sluggishness of the large intestine, 
and by restoring the tone of the cremaster and dartoe, the natural testis^ 
supporter and compressor, by sluicings with oold water, and the Iiabitual 
avoidanoe of heating clothing.— [£d.] 



162 THE THERAPEUTIC INFLUENCE OF BEST. 

nearly healed. Od the Sth of January, I8G1, it had o 
;>li?teiy heaktl, and the discharge had entirely ceased, 
ekjn over the wound being then thin and delicate, ] 
'lupBted him to wear the trass a few weeks longer, i 
he did, and then everything was perfectly well. I 
spring he went out hunting, and the friction of the tj 
led to a little excoriation, which required some teiupc 
attention. 

Thus we BOO that the simple ti-oatmeut by Rest— that M. 
by brioging the granulating Burfticee together, and keeplt^ I 
them quietly iu contact for a short time— did away with ^ifl 
necessity of this gentleman's quitting his buatneas an^'l 
making large personal and pecuniary sacrifices, for thifl 
purpose of doing what would not ultimately liave led'l 
to luuch, if any, improvement in his sinos and concealed ' 
ulcer. 

In the summer of 1859. my opinion was roqueeted 
regarding a gentleman, aged forty-two, who had jriat then 
sought advice in reference to some sinuses in hia groin, 
which had remained afttr glandular enlargement and snp- 
puration, associated with non-syphilitic ulceration upon 
the prepuce. The patient had been, during the three 
previous months, nn interruptedly under the care of a 
hospital surgeon, who had used many different local 
applications to the sinuses, and had given him mercury 
internally, with rest at his home, but all without any 
benefit. His surgeon had told him that nothing remained 
to bo done but to " lay the sinuses open, and make them 
heal from the bottom. ' This gentleman, who was in good 
health, refused to be cut, and sought the advice of Dr. 
Daldy, who suggested that my opinion might be taken as 
to what had best be done. I found five external openiuga 
of sinuses, margined by granulations, and communicating 
with each other deeply under a surface of about two Inches. 
The discharge from the sinuses was purulent, but thin, 
and the immediate neighbourhood of the sinuses was 
massive aud thickened. It appeared to me that a truss 
applied ujmn the skin overh'iug these deep sinuses, so as 
to force the granulating walls into contact, and to keep 
them in that state during a few weeks, might close these 
:, aud obviate the suggested " laj'ing them open." 



VIL] AWD THE DIAGNOSTIC VALUE OP PAIN. 163 

Such a trass as that I have sliown you was then applied, 
and the patient permitted to walk about. The truss was 
worn day and night, and in a fortnight all the sinuses 
were finnly closed. After that time tbe patient wore the 
tross during the daytime only for several weeks longer, 
until all the thickening and hardening of the soft parts 
had entirely disappeared. 

The merits of " mechanical rest " are sufficiently obvious 
in this case. I may add that this patient had, a few 
months afterwards, a most severe and dangerous attack of 
double pneumonia, which invalided him for a long time, 
bat the sinuses did not re-open. 

The next case to which I will refer is that of a sinus 
nnder the tendons of the extensor muscles on the dorsum 
of the foot. This was the case of a young gentleman aged 
thirteen, who was brought to my house on the 11th of 
July, 1860. The sinus occurred after an abscess suspected 
to be associated with disease of the tarsal bones ; it had 
existed oflf and on during four years, and he had been under 
the surgical treatment of a hospital surgeon irregularly 
during the whole time. Sometimes the sinus was discharg- 
ing ; then it would heal up ; soon again become swollen ; 
then break and discharge for a time, and so on. A probe 
passed easily along the sinus under the tendons of the long 
extensor for alx)ut two inches, the course of the sinus being 
indicated by considerable thickening of the areolar tissue. 
I ooold 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 tarsus. This latter method 
enables the surgeon to asceiiiain with precision which of 
the tarsal bones or articulations, if any, are diseased. The 
patienVs 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 bandage over the whole of the foot, so 
as to coapt tne sides of the sinus, a small aperture being 
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 adhering partly to the tendons and 
partly to the subjacent tissues, llere, 1 suspect, was Ihe 

M 2 



164 THE THERAPEUTIC INFLUENCE OF REST [Lbct. 

Btarting-point of defect in the troatmont by the Burgeon 
who {itvoedcd mo. The new tiBBuos fiUiug up the einoB. 
ur uniting the oppoeod grauulatiouB, were not etrong 
enough and healthy enough to reaiBt the traction of tlu 
tendons of the extenBore or the movements of the ftxA. 
Looking on the ease with this interpretation of the previona 
failure, I deBirod Mm to continue wearing the pad of lint 
and bandage for three or four mouths. The last time 1 
Baw bim was on Docembor 10th, 1860. The akiu and 
Bubjauent tissues iu the course of the old ainus werv soft, 
and the areolar tissue was pliajit and moveable, allowing 
of the movemeDts of the exl«nHors. and apparently eom- 
petont tothe performance of itn ^-ioldingand elastic duties. 
So the Binua remained perfectly well. Anjcioua tii»t I 
might state nothing but the truth relating to tliie case, I 
wrote a note to this patient's father, who thus replied to 
me. May 7th, 1861 :— "I have mnoh pleasure in saying 
that my sou's font contiiiiicB sound." 

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 rosnlts. I think it also illustrates this wide but 
frequently lUsregarded principle, that new tissues are not 
competent to the same eiucrgeudeB as those which are 
more thoroughly organised or advanced in life. The 
uniting medium of this freshly closed bIuub was young at 
first, and I have no doubt, if I had allowed it to cootinns 
nndcr the influence of those cstensor tcndouB. it would 
have given way, and I should have had a repetition of ths 
conditions which occurred to the other Biirgeous who had 
attended the case previously. 

I chall be excused if 1 mention one more case, and then 
proceed to the other part of my subject, I adilucxxl in my 
previous lecture some instances of ulcers and wounds whiwi 
were very painful in consequence of the exjiOBure of the 
ends of the nerves in the wounds— cases in which the pain 
was stopped by division of the uerve just below the suriaoe 
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 tbe nerve exposed in the 
wound. One case, that of a man aged twenty-eight, who 
had his finger crushed by accident, presented itself very 



AJTD THE DIAOKOSnO YALTTE OF PAIN. 165 

He was admitted last March, with a Beverely 

and lacerated index finger. An attempt was made 
he finger, but it was ultimately thought right to 
a it, just above the head of the first phalanx, by 
rml flaps of soft parts. The flaps assumed an un- 
oharacter, and the man was brought into the hos- 
Phe sntnreB were removed, and the flaps fell widely 
They were extremely painful, the agony of the 
lelingfl being expressed by his features in the 
manner. He was scarcely ever free from pain, 
nder the narcotizing influence of large doses of 

Upon the exposure of the flaps I detected the 
Mmtion of the exquisitely sensitive points in the 
doiiB, and I passed a pointed bistoury uiider the 
f the nerve within the flap and divided it, and my 
livided the other nerve in the same way in the 
p. It is not too much to say that the man was 
ktely freed from pain. From that time he suffcTcd 

and required no opium. The flaps became less 
and inflamed, and in ten days, the granulations 
en healthy, they were nicely adjusted, and the uian 
ectly and quickly well. 
mot avoid encroaching upon your time for a 

in order to relate another case, which comes from 
donal friend, Mr. May, of Reading, who wrote to 
be 12th of December, 1860, as follows: — 

DEAR Sir, — I cannot resist the temptation to tell 
caae which offers a striking illustration of the 
e 80 admirably explained and enforced in your 

at the College of Surgeons, and for which our 
on is deeply indebted. 

rly twenty years since, I attended a lady, who, for 
• nine years, had been afflicted with intense head- 
d intolerance of light, commencing on first awaking 
doming, and persisting more or less all day, totally 
g her, and, during many months, confining her 

to her house. 

imed that she had consulted several medical gentle- 
th in London and the provinces. Under an im- 
i of inflammatory mischief in the brain, Dr. 



ItiS THE THERAPECTIC INFLL'EKCE OF BEST [l.irt. 

Marshall Hall ordered her a soalp issue with twenty !*«». 
which was piiilonged for acme weeks ; tthe nnderweut * 
loug cuiinso of mercury, m'us cupped mauy times, blietereiL 
&(:., &!:. Under other aiivice, she took tonic medicines of 
THrioiis kitidB, and made a, journey on the Bhine, &o. Al 
soemed iisclbsa, and she had rcBtgned herself to despair. 

" At my first examination of the cuMe, I learned that « 
eevero frown was caused by the firet influx of light in the 
morning ; then followed headache, &o. My imprefiBJon 
was, that if I could arrest this Bpasniodio action (by phy- 
Biological rest?), and break tho habit of return by mechn- 
uical means, I should prevent the other symptoms; and so 
it happened. ' I merely covered one eye with a card, about 
the size of a orown pieoe, and attached an elastic tape to it. 
BO that it pasBed around the head, across the forehead, and 
over ono eye, slightly oompresBing the oocipito-frontalil 
and comigators. This aimplo device effeot'ially prevented 
tht- fnraii, and thorc wan iit ojice an tiid to the niiHohief. 

" The only further treatment required was to gradually 
accustom the eyes to light and action ; and this was readily 
done by using one at a time for two honrs, and th^ 
changing the card to tho other eye, regulating the admiB- 
sion of light. In other, but still more expressive words. I 
gave ' rest to parts ' morbidly excited ; and so this mort 
terrible malady vanished aB a charm. 

" The patient continued free from the complaint during 
the remainder of her life, and died about two years ago." 
" Believe me, dear Sir, yours most faithfully, 

"George May." 

Here was an important recognition of the principle of 
" Physiological Rest," which seems to have been applied 
very delicately and neatly to the relief of the persistent 
and painful symptoms experienced by this lady. 

I shall now venture to direct your attention to an 
arrangement of nervous distribution, wliich has supplied, 
to my mind, during more than a quarter of a century, and 
still supplies, a noticeable instance of design, which has 
not been, so far as I know, generally recognised or properly 
appreciated. 

it is my purpose to devote a part of these lectures to the 



VII.; A\D THE DIACINOSTIC VAIJi: OF PAIN'. !'7 

consideration of tlie influence of Kest in the tivutnient of 
digeased joints. In anticipation of thoeo facts which will 
make manifest the importance of rest in treating diseased 
junta, and for the purpose of showing the physiological 
tnd fnndamental principles on which it is based, I am dc- 
niauB of placing before you some details of healthy human 
anatomy, regarding the general distribution of the nerves 
tothe joints, and the associated muscular apparatus moving 
those joints, which bespeak special design. 

I may remind you that when a joint becomes inflamed, 
h is painful and difficult of movement; it Ix^conies 
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. 
Xow, what is the key to the explanation of the flexed 
position and rigid state of an inflamed 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 not 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 liope to 
have the opportunity of showing you distinctly that, when 
the hip-joint is diseased, it is flexed, and is often in a ver^^ 
painfrd state ; but that when the femur is put straight, 
the patient from that time is free from pain. Here is an 
instance in direct contradiction to the idea that the flexed 
oondition is the easiest for the patient. When the joint is 
made straight, the patient experiences, almost immediately, 
a diminution of pain. It is true, however, that, in tlie 
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 coaptation 
than in any other position of the joint. This surface 
coaptation becomes more and more reduced, or lessened in 
extent, as the tibia is carried backwards away from the 
femur. Probably, it is this diminution in the extent of 
the articular surface contact, as well as the diminished 



168 THE TUEKAPEUTIC INFLCEKCE OF EE8T [LbI. ' 

preesiire, which eipltiinB tbo feeling of oomfort thlt 
patienta eometimes exptrieiioo when the inflamed bwc , 
joint is lit lowed to become flcx.ed. 

Still the question oomcs back to us. Why ie an infla 
Joint fixed and flexed? It appears to me to result from 
the circnniBtancea to which I shall preeently allude men 
in detail — vis, that the irritated or inflamed condition of ' 
the interior of the joint (say the fcneft-joint), involving the 
whole of the artintlar nnvea, excit«« a correepJiidiug' con- 
dition of irritation in the game nervous tninks which 
supply both sets of muecles. extensors and flexors ; but 
that the flexors, by virtue of their superior strength, compel 
the limb to obey ihem. aud so force the joint into ii»fifmA 
condition. The joint then becomes rigid and floxed, becailM i 
the same nerves which supply the interior of the jotBt 
supply the muscles also which move the joint. 

This unatoniical arraiigi^nient. phyaiiilopieally considered 
itiiil riglLfly iiitcrjiretL'd, luiiy lit' nuiik- thf iyh-uhh i>f ej;- 
plajning some of the most prominent symptoms of joint 
diseases, and of constituting a foundation for the required 
treatment of diseased joints by rest, which I 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, 
pi^-siological, and pathological grounds, I will state it thus: 
" The game trunkg of nervet, whose branchet tripply the gnmpt of 
mtuelei moving a joint, furnish aUo aditlributionofnenettolM 
ikin over the tnterliont of the lume mutclet ; and — what at IAm 
motnenl more etpeeiaJly meriia our ailentum—the interior o/tke 
joint receive* iU nervet _from the tame source." This impliea 
an accurate and consentaneous physiological harmony in 
these various co-operating structures. 

For instance, the circumflex nerve supplies the tens 
minor and the deltoid musclce, the skin over the del- 
toid, 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 sup- 
scapular trunk, which is derived from almost precisely the 
same part of the axillary plexus as the circumflex nerve. 
The suprascapular nerve after supplying the supraspinatiu 



TIL] AND THE DIAGNOSTIC VALUE OF PAIN. 16^ 

■nd infraspinatuB muBcles, sends littlo filaments to the 
interior of the same joint. Thus the saiiio circumflex 
Bare supplies these muscles, the joint which the muscles 
Dore, and the skin over the muscles, as well as the skin 
Offer the fascia, which is a part of the insertion of the 
Utoid muscles. But here I touch niKni a point, by which 
[ tm reminded to state that every fascia of the body has a 
niucle attached to it, and that ever^*^ fascia throughout 
the body must be partly considered as the insertion of a 
nraflde. I shall be able hereafter to trace nerves derived 
bom the same trunk supplying the joint and muscle, and 
nmetimes distributed over a large extent of fascia. That 
attent of nerve distribution, however, I shall show to have 
iTery exact relation to the projwrtionate attachment of the 
anfldes to the fascia, of which I shall be able to adduce 
ome well-marked examples. 

The object of such a distribution of nerves to the mus- 
olar and articular structures of a joint, in accurate asso- 
iation, is to insure mechanical and physiok>^ical consent 
etween the external muscular or moving force, and the 
ital endurance of the parts moved, namely, of the joints, 
11UB securing in health the true balance of force and fric- 
on nntil deterioration occurs. If this point of l)alance or 
ijnstment be overreached during exertion, pain. Nature's 
mming prompter, is induced witliin the joint, and suggests 
16 necesfidty of diminishing or arresting exertion. This 
Msation or this reduction of exercise, or friction and 
reesnre upon the articular structures, must he effected by 
le muscular apparatus of the joint, eitlier tlirough the 
ill, or immediately by its own instinctive efforts, called 
ito play by means of the nervous association. The 
nflcles, indeed, appear to be told, through the medium of 
be nerves of the interior of the joint, that its articular 
motures are overtasked; and the antagonistic muscular 
loeB of the joint being thus involun^rily excited, the 
int is at once rendered rigid and stiff, for the purpose of 
wping it at rest. Or it may be put in this way (only as 
oifirmatory, however) — that the synovial membrane itself, 
ider the influence of physiological exhaustion, contributes 
mething towards the same end, by failing to secrete the 
roper quantity of synovial fluid. The joint thus robbed 



170 THE THERATEUTIC INFLUENCE OP BEST iUO. | 

of its lubricating medium demandB of the exhatuled RM 
for itB niovomest, a atill greati^r effort than iu its nonnl 
state ; and their inability to respond to the extra dcmanl 
t:iecetjeit)tti.-H the rest of the joint. Still, in this mode d 
viewing the subject, the neceuaity for limiting exertion, in 
order that the interior of the joint may obtain the red 
requisite for the renewal of its physiological jwwer and 
atructural integrity, is intimated to the mo\'ing agents, bj 
the same Dorve interpreters, and the moving agents ill 
obedionue to the announcement, render the joint stiff «nd 
difficult of movement. 

Without this nervous association in the muscular aai 
articular structures, there coutd be no intimation by tbn '' 
internal parts, of their exhausted function. There cannnl 
be any doubt that it is when this period of functiomd 
exhaustion is the internal parts has been reached, and aiti- 
cular friction is nevertheless continued (notwithstanding the 
structural and functional prostration), that the mischief in 
the articular atructiiruH ooiiimciiees, (mil diseasi' of tlie joints, 
as we term it, starts into existence. 

Again, through the medium of this maienlar and eutaiuoM 
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 violence. Their in- 
voluntary contraction instinctively makes the Burronndiog 
structures tense and rigid, and thus brings about an im- 
proved defence for the subjacent joint structures. 

This same associated muscular and cutaneous nerve dis- 
tribution is obviously of the highest importance in refer- 
ence to the sense of touch. Thus in 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 holding or grasping. Hence the me<£aii 
nerves, with others, are employed in grasping, and also in 
the adaptation of the fingers to the palm of the hand. 
Whether the boilj' to bo grasped be great or small, there 
must be an instinctive limit to the grasping effort. This 
can only be indicated to the muscular apparatus employed 
by the sensitive nerves. 

In standing, walking, or jumping, the contact of the 



AND THE DIAGNOSTIC VALUE OF PAIN. 171 

r the foot with the ground intimates, in health, not 
lie degree of musoular force neceBsaiy to sustain the 
Oflture in standing, but gauges the use of the re<|uired 
r in walking, and moderates the concussion of jump- 
Without this normal, consentaneous muscular and 
.ye function, precision of action would Ix) lost, and 
iBored exercise of muscular force would l>e employed 
f the performance of any of these functions. The 
IjoBtment of muscular power must be an imi>ortant 
for we know that unexpected muscular force breaks 
tella. 

us now go to the bedside. Is it not indisputable 
r we allow an inflamed knee-joint to lie upon a soft 
, unconstrained by mechanical means, the muscles of 
int, stimulated to undue exertion, never allow the 
lar surfiAces to be kept quietly in apposition with each 
* This explains the fixed and flexed condition of the 
Thus the flexors — as I have before remarked, the 
powerful muscles — act unceasingly day and night, 
mtly without any rest, and especially declare their 
ievouB assiduity by the wakeful slumbers and dis- 
L deep of the patient. This persistent action of the 
I slowly alters the relation of tlio articular surfaces 
bones to each other — more slowly, indeed, but not 
irely, than the hour-hand of the clock, which does 
>pear to move, but yet, if I compare its present posi- 
ith that which it occupied some time since, I i)erceivo 
b has gone on marking the course of time. 
QB take for example the case of the knee-joint. The 
m sees an inflamed and swollen joint, lying on its 
■ide, and desires that it may be kept (^uiet upon the 
r on a soft pillow. Whether he sees it again in a few 
or days, or in a week, the first thing that strikes him 
regret, and perhaps surprise, is the changed position 
bones. He sees that the knee-joint is considerably 
flexed than when he last saw it. On inquiry, he 
ains that neither the patient nor the nurse has dis- 
L it, and then he recognises that the stealthy and 
ievous flexors have secretly effected this change in 
cm. It is merely flexion, under the influence of 
liar energy involuntarily exerted; for as soon as 



172 THE THEKAPKOTIO INFLnENCE 07 BEST [IJ*^ 

muscular contraction is dwtroyed by olilorofonn, the fiwd 1 
and flexed conditions of tbo joint are for the time entinlT 1 
lost. And here I may state, that over and over agucl 
have eeon the deatmctive effect of this increasing elAtcul 
flexion uf the joint ; resulting, not aoldoui, I may say. frwD 
procrastination, or inexoHBable want of courage on tht 
part of the surgeon to rectify it, or from his yielding t™ 




easily to the importunities of the patient or his friends, in 
order to avoid giving pain. From the time when the 
limb begins to be flexed starts the mischief, which by-ULd- 
by cannot be oontroUod. 



VII.; ANT) THE thaonostk; vali i: of pain. 17.) 

I luiYe here a dniwing lioiii uuture (Fig. 2,")) to show 
to what extent flexion is sometimes iuvoluntarily carried. 
Yon see the tibia flexed upon the femnr at a very acute 
tngle. This was originally a case of inflammation begin- 
ning in the interior of the knee-joint, and the contraction of 
the muscles was never resisted in the slightest degree, but 
wis allowed to take its own course, and you see tlie result. 
Fig. 26 represents another case of diseased knee-joint, 
in which the tibia and fibula were carried backwards, so 
that the heel touched the tuberosity of the ischium. 

These are extreme specimens of the results of the absence 

of mechanical constraint, and I feel convinced that the 

starting-point of the mischief which ultimately led to this 

condition, necessitating the amputation of these limbs, 

inight have been successfully combated by placing 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 mo that it is a great mistake 

On the part of professional men, when they see an inflamed 

knee or other joint beginning to be contracted or flexed, 

not to correct it at once, and so avert the condition which 

led to the 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 articulation. In cases 
of long-continued or chronic inflammation of joints, the 
contraction and fixed condition depend partly, no doubt, on 
the encumbrance of the joints by the new material. Hence 
the deformity of the joint at that period cannot l)e entirely 
removed even under the influence of chlorofonn. 

Permit me just again to refer to this constantly flexed 
state of an inflamed joint. Take, for example, that of the 
hip : I venture to say that no gentleman here ever saw an 
inflamed hip-joint with the leg extended. It is uniformly 
hent, and also, as a rule, slightly adducted, the cause of 
which I shall have occasion to refer to at another time. 
In the case of the knee-joint, when inflamed it is always 
flexed. Curiously enough, the malingerer, wishing to 
deceive and to impose, almost always endeavours to indi- 



174 THE THEKAPEUTia INFLUENCE OP REST [Un. 

cate his long-oantinned and extreme Rnfferin^ by AlUlfl 
extendiag the leg. But this extended position dilplljr^ 
the imposition, for an inflamed joint is never sttai^Ufll 
always flexed, the degree of that flexed condition depi^ 
ing upijn the intenaJty or the long duration of the luira . 
Did any person ever aeo aii inflamed ankle-joint, ])eniuM, 
to pursnu ita own course, remain nearly at a right U^l 




with the foot ? The heel is alwajrs raised by the gastro- 
cnemii. and the toes jwinted downward. An influmed elbow- 
joint is always flexed, never extended. But when we come 
to the wrist-joint, we find that, although the mnscular 
power associated with it is very great, yet in consequence 
of the extending and flexing forces being pretty equally 
balanced, we seldom have much flexiou of the hand when 



VII.] AND Til?: I)IA(;N()STIC VALrK OF PAIN. 175 

the wrist-joint is inflamed. This is in strict accordance 
with the law which I have endeavoured to place before yon 
—the equality of muscular force not causing much disturb- 
•006 of the bones, but simply maintaining the joint in a 
quiet but fixed condition. Again, with regard to the 
ungers. Who ever saw a finger with an inflamed joint of 
; tny duration in which the finger was perfectly straight ? 
Such a thing was never seen ; the inflamed ji:>int 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 nervoufi supply, on which I shall have occasion to 
dwell in my next lecture. The forefinger, 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 extremely flexed condition of some of the fingers, 
the slight degree of flexion of tlio forefinger, and tlie nearly 
straight condition frequently observed in an inflamed joint 
of the thumb.* 

* III ti.e Dublin Journ. Mod. Sci., vol. Ixii. p. 87, will be found a sliort 
ritume of obeervntiona and experiments which have been made of late 
years on the intra-articular pressure of the knee-joint uuder different 
ootiditiona, and which bear on the above question of its position during 
infliiroination. ** Amon^t the most important observations are those 
(if Doiinet, Rcyher, and Ranke. The principal factors which tliese 
obtenrers have taken into consideration, are — 1. the position of the 
limb ; 2. the condition of the peri-articular mu&cle^ ; 3. the amount of 
intrMrticular effusi(m ; and 4. the traction to which the limb has been 
Ribjected. The pottition of the maximum capacity of the joint, whicht 
uf ooune. corresponds to ti>at of minimum presaure, is the; subject of 
•muti diflferenoe of opinion. While Bonnet asserts it to be that of Hexion 
of the le/ at hr angle of 60"» the other two observers reduce tliu angle 
to SO'^. Ranke found that (taking the muscli-s into account) on 
ttarting with the attitude of complete extension, the pressure dimin- 
iahea with the flexion of the lej;, and attains its minimum at the angle 
naiucd (30°). Ou further increasing the flexion tiic pressure iucreosoa 



1 



170 THE THERAPEUTIC INFLnENCE OF WEST [Ud 

rapidly, and becomei coniidcrablj greater tiiui tlio primitiie preno 
correepandiDE to full extenBion, uwa bernrti the leg tiiu been ^led 
a right aiigb. The contractiun of the peri-artioalar inuwlu b 
cocsidcrnblo effi«t, secording to tlio measure luenta of Ranke (G 
fralbJ. f. Chir. ISTS) in angmoDtiDg ]ind modifymg the intrB-aitirai 
preseore. The effect of eoatiauouB traotioti of thi- limb is modiBcd 
the other faclorg, llj forcing neeillua inbi the condjloid estntnitT 
the funnr aad iiito the bend of tlia tibiiL, Reyher (Deul. Zeitseh 



!i triiction of 100 livrea producing an ehmgiitiuii of 3.S nun. Ha 1 
(\irther obserred that, in rwaod where llm quantity of sfnorik 
narmat or but very bliglitly augmemeJ, the cfleel of continnoiu tnct 
is tn dirriiniBh the preiBurf within the joint, Pasehon (iUd.> bu alni 
mndu the name obaerratiunii witli reforoiiiv to tlie hip-joint. The ei 
is the oome if the muulea be relaxed or immlyted, what^rer ba 1 
Buount of effusion. But it the quantity uf cmiaton bo ouiiaidenl 
and the musolej aotive^ the effect of extension hy mUbl iriU he- 
iticreuo of pregButo. Some of tlie spiiliuutions of theue obeervUiani 
surgeiy are suffloiently obvious. Ttat-y illuntrale the eljghtlj §m 
Dttitiide of (he limb in acute iyiiovitia; but, nbovr all, they indicate I 
rationnl employ nicnt of continuoue eitensinu in tlmte uasia iu *h 
inQainmsfciry nfl'ectiona of ibe joint iirc attended with alight eynot 
effusion. Reylier would not, however, enrirely reject the tTEHtmenl 
acuta Bynovitis with eftusion by Ibia motuud, but would adi 
OBpimtioii of the joint aa a lutiooat preliminaiy mesanre. Anotl 
meciuuiiciil effect of traction upon the limb, and one which the Ii 
ineulioaedobHrver Dioraesficciallydrawaatleutioa to in thi;ciii«af I 
hip-joiat, ia of importance in referonou to Ihia plnn of treatment— 1 
the alteration of the points of contact of the artiBulw gqrfaees, wUi 
in the cases of bolh the hip sod knee-joints, the different attitw 
suauLiicd by the limb under different degrees of force prove (o \» 
place. We luny then enumerute tbcao iis emongat the varioua i 
vaiitugeB claimed fur the nielhud of treatmeni of joint affection* 
extension: — the modiliinitiou of tlie intra-urticular pressure; t 
diminution of the contraction of the peri-articulur niuacles; t 
alteration of the points of contact of the arlicular turfacea; » 
flnnlly, the ttst and mobilization of the articulation."— [En.] 



VIIL' AND THE DIAGNOSTIC VAiM E oF TAIN, 



LECTUBE VIII. 

C0TASMOV9 BRANCH OF THE MUSCULO-SPIBAL NEBVE — PRECISION OF 
XIBVOCS fUPPLT TO MVSOLES — 8TMPTOHS OF INFLAMED JOINTd AND 
TmiATMXIlT BT BEST AND EXTERNAL AN.SSTHETIC8 — EXAMPLES OF 
PBmOLOOICAL BB0T — ^MUBCUIXMnJTANEOUS NERVE OF UPPER EX- 
TBKIfITT — ^BBRT ABM AFTEB YENESECTION — CASES OF INJURY TO 
mnCULO-CDTANBOUB NERYE — NERVES OF FINGERS, TOES, AND THUMB 
— BTFICr OF PBE88UBE UPON SPINAL NERVES — GANGRENE OF THIRD 
AMD lOUB T H FINGERS FROM PRESSURE ON ULNAR NERVE. 

T0WABD6 the oonclusion of my last lecture, I made the 
ftatement, — ^that the same trunks of nerves, the branches 
of whioh supply the groups of muscles moving any joint, 
famish also a distribution of nerves to the skin over the 
nme mnscleB and their insertions, and (what at that time 
more especially merited our attention) that the interior of 
the joint reoeives its nerves from the same source. Hence 
•rises an accurate, consentaneous, and physiological har- 
mony in these various co-operating structures. I availed 
myself of this statement for the purpose of explaining how 
it happens that an inflamed joint is necessarily rigid and 
is necessarily 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 for 
npwards of twenty-five years. I did not expect that I 
BQoald have occasion to refer to this fact at all, because I 
apprehended that after teaching at least three thousand 
itodents in Guy's Hospital it would be pretty well known, 
as the result of my public teaching. But I find amongst 
the excellent books published by the New Sydenham 
Society a work by Schroeder Van der Kolk, in which he 
states: "After I had, in the year 1847, detected a closb 



... iin; Huuic iirrvc trunk; 
muscle l)('iii;j; kiiDWii, \v<' can, i 
a priori, (U'liiit* tlii' distril»utiun 
tin.' skin." 

Here you will observe is the s 
gentleman in 1874. Now it so 
colleagues, Mr. Birkett, published 
book on Human Anatomy in t 
reference is made to this very a 
He added within brackets the fac 
of nerves to muscles and skin, but 
introducing it in the same way 
habitually treated by myself in \ 
Hospital during many previous yt 
it, no doubt, for the purpose of mar 
knowledge in that respect beyon< 
original. I have therefore no hed 
anticipation, or priority if we ma; 
servation and expression of the ft 
{Schroeder Van der Eolk as a disco 
not know that this is a matter of 
tance, but I suppose it right, in soi 
to maintain one*s own position, 
criticize the statements made by 
what I have done at Guy's H^^-—*" 
published ^"'- ' ' 



tnij AND THE DIAGNOSTIC VALUE OF PAIN. 179 

which I shall hereafter refer. For instance , I shall endea- 
vooT to show that this same principle of arrangement, 
matomically, physiologically, and pathologically considered , 
• to be observed, with an equal degree of accuracy, in 
lie serous and in the mucous membranes. Thus considered , 
t manifests a wide principle, which, if it has any applica- 
ion in practice, must be one certainly of large extent. I 
iiall endeavour to show that this is really its true posi- 
ion. 

I may now, for a moment, refer to another diagram 
Pig. 27), for the purpose of confirming the proposition that 
he same nerves that supply the muscles supply the joints, 
nd also the skin over the muscles. The musculo-tpiral nerve 
applies certain muscles very definitely, and none others — 
heee are the extensors of the ell)ow-joint, of the wrist, 
f the fingers and thumb, and the supinators of the radio- 
Jnar articulations. It also supplies the skin over all thesv 
iiiBcles, and the joints which they move ; and this is thf 
rhole of its distribution. Its cutaneous portion is accurately 
lawn in the diagram as far as it is exposed. This dia- 
;ram (Fig. 27) clearly gives expression to what 1 sliall 
lexeafter allude to more in detail with reupect to tliiH 
dnflculo-spiral nerve — the precision of nerv^ous supply to 
anBcJes. 

Precision of Nervous Supply to Muscles, 

The great precision with which muscles are supplied by 
heir nerves is worthy of remark ; and is such that if wo 
lave before us a contracted muscle, or a spasmodic condi- 
ion of a muscle, wo may be sure of the nerve which must 
le the medium, or the direct cause of it. Thus we see the 
eres minor lying in contact with the infraspinatus, yet 
lever, as far as I know, receiving a branch from the 
aprascapular nerve. We may notice the four muscles 
»laoed between the os hyoides and the lower jaw ; all four 
le usually considered as forming one group, but when 
'ou consider them with reference to their nervous supply 
hey are entirely separable. The mylo-hyoid and the 
nterior belly of the digastric receive their nerves from the 
aylo-hyoid branch of the third division of the fifth, thus 
Kxinting accurately to the strict association between theso 

jx 2 



^HQi^^^^H 


180 THE THEBArEUTIO IMFLDENOE 


OF BEST 


[LOT. 


iiiusclef atid the proceaa of maetioation. 


But lookini; to ' 


the gcoiu-hyoidens and the geuiohyoglosBUB, we e 


e^thil , 


they are supplied, by the hypogloasal 


heace w 


«,itiiat 


Flfi, 3>. 






r 


1 




M 



couclude that titey are functionally aaeociated with the 
movements of the tongue. And here let me observe to 
the rising generation of anatomiats (who will, I hope. 



BL] AKD THE DIAGNOSTIC VALUE OF PAIK. 181 

101186 my referring to such pointsY that I have always 
land anatomical lectures very mucn increased in interest 
ud utility by pointing out the functional association and the 
hyaiological relation of muscles by their nervous supply, 
mer than by their mechanical relation to the bones. 

There are some muscles that receive two nerves : thus, 
IT example, the adductor magnus of the thigh receives 
8 nervoius supply partly from the obturator and partly 
tnn the great sciatic ; clearly indicating that the adduc- 
n: magnus is associated in action partly with the adductor 
luscles and partly with the muscles at the back of the 
ligh, involving the idea of a double functional association. 

£i studying the supply of nerves to muscles, over every 
Birt of the body, we find a great degree of precision, 
'hich marks one difference between their distribution 
ad that of the arteries. Thus, if we look to the omo> 
yoideus muscle, we find that it receives its nerves from 
nee sources : it has a branch from the hypoglossal, and 
■ you trace that branch upwards, you find it receives a 
lament from the pneumogastric nerve, and there are other 
laments to the muscle from the cervical plexus. This 
learly points out that this muscle has three distinct func- 
onal associations — one in connection with the hypoglossal 
ad the movements of the tongue, which it aids by fixing 
xe hyoid bone; another connected with the pneumo- 
iistric nerve, so as to bring it into association with the 
rocess of respiration ; and a third to associate it with the 
Lovement of the muscles of the neck. 

I make these remarks for the purpose of pointing out 
lat there is a remarkable precision in the supply of nerves 
) the muscles. These examples are taken from small 
luscles, but they stand out distinctly, especially the omo- 
yoid, not so much from their size as from the precision of 
tie demonstration. This muscle arises from the superior 
Ige of the scapula, close to what we call the suprascapular 
otch, and in close proximity with the suprascapular nerve. 
f it had been a matter of no importance as to what nerve 
bould supply the omo-hyoid, there is a nerve close at 
And ready to do this ; but I believe it was never seen, 
hat the suprascapular nerve sent a filament to the omo- 
lyoid. The facts before you express clearly, that the 



182 THE THEBAPEtrnO IMPLOESCE OF REST [iJCr. 

muBclee receive their apprbpriBtB nerves in a very deddei 
aud detiiiite a 



The predfiion and accuracy of tlie oervotiB m^ly (a 
niiiBcloB are shown not only by each muscle Rweiving • 
definite nerve, but also by it« reoeiviug it in a definite way. 
Am a rule, nerreB enter the musclee where they would, ht 
nioflt secure from preoaure ; and it is curious to oboerv* 
how careful Nature has been in this respect to guard onn 
ef the most important ners-es of the body. The pfarenio 
nerves (our lives hang on tlieee threads), after paaing 
througli the chest, traverse the diaphragm, and distribute 
their branches TiyKm the under aurfuoe of the muscle, and 
are so situated that they cannot be oompreased duiiiig 
respiration. If they were diatribnted njKm the np{)er sur- 
face of the diaphragm, where there is a constant ^id forced 
contact between the base of the lung and the BUpenor 
aspect of the diaphragm, and especially so during a re- 
tiiiiit'd inspiration, if ia obvious that IIr'SC tibiiiivutd tif thi: 
phrenic nerve would under such circumstances be exposed 
or subjected to compression, and the action of the dia- 
phragm would be dangerously interfered with. The nerves, 
however, are distributod on the under or concave surface 
of the diaphragm ; the whole tendency of gravitation being 
to remove the liver, the stomach, and the spleen away from 
them, BO as to enable the nerves to carry their influence to 
the diaphragm unmolested.* 

Symplon 

I will remind yon, that when the shoulder-joint is in- 
flamed it is fixed. I apprehend that that condition occura 

■ Anotlicr ri«soii Ibi the pbrvnic nerves traverstng llie diBphia«n, 
sail breaking up into binnobes on its under aurlare muj be to enabla 
tliem to come into communicatiou with the sympathetic orvisoeral nervel 
uf the abdomen. From Ihis commuDication braachee are given to the 
lifpalic and solar plexnaes, aod lo the mferior vena cava, ETeryona 
knows the value of active eierciae when certain abdominal visL-en am 
torpid ia tlie performaDce of their functions, e.g. in constipation, 
biliiiUsneEB, eto. The perforation at' tbe diaphn^ l>; the phrenic sad 
its oommuiiicstioD with the sbdominal syuipathetio must bring the 
brain aud epinsl cord, tho diaphragm uuil abduminol mugclea, a) 
iiiipoilaDt in active respiration, into intimate ussociatiou with the 
«ubjacenl vieoera. — [Bd.J 



VIII.' AND THE DIAGNOSTIC VALIK (»F IAIN. 



1 . u 



from tliis fact : icheii tJie interior of the joint is in a state of 
tsiflammation or of irritation, the influence of this condition is 
carried to the spinal marrow^ and thence reflected to the various 
wudef of the joint, through the medium of the associated moU^r 
lenwt, ike mmides being supplied by the same nerves th<U supply 
(he iniericr of the joint, A fixed position is thus produced ; 
fer nndoabtedly, as I remarked the other day, if you givo 
mch a patient chloroform, you destroy the fixed condition, 
and the joint is perfectly moveable by the hand of the 
Borgeofn. Again, in the case of inflamed shoulder-joint, 
the skin over the shoulder is very sensitive. Perhai)8 not 
immediately, but in a short time — in a day or two — there 
is pain over the cutaneous distribution of the circumflex 
nerve, and not unfrequently considerable pain at the buck 
of the shoulder. You will recollect that the same tniiika 
of 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 suffering from disease in the 
shonlder-joint. 

Now, upon what principle should we treat the inflamma- 
tion of a joint ? In answer to this general inquiry, I would 
especially refer to the shoulder-joint, because it is so simple 
in its anatomical arrangement, that I can the more eanily 
apply these practical remarks. I should 6ay, 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, 
and its muscles, through the medium of the nerves u)K)n 
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 surface 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 
oar anaesthetics with accuracy and with sufficient intensity 
upon the exterior of the deltoid muscle, over the distribu- 
tion of these sensitive filaments. The thought will occur 
to you at once that there is nothing very remarkable in 



134 THE THEEAPEUTIC INFLrESCE OF BEST [LWKi 

tliia upinion, and that is quite tmo. The embrocatkni. 
however, which would ordiiiarily bo suggeetfld for tha 
purposti are not of a character sufficiently potent to alleriiU 
the ]>ain of the patient, and are, I believe, seldom emplo^ 
with a definite idea in the mind of the prescriber. I wonid 
flug^'st that we should employ our foineutationa utma^y 
uiodicated with belladonna, with opium, or with hemlock, 
instead of usiuK mero fomentations of hot water. Some 
will say, " Oh, hot water is quite as good ; " but I csn 
aasure you practically it is not so. The advantage to be 
derived arises in this way : the sensihUity of the fiJameutl 
supplying ttie skin being reduced, that influence i^ pro- 
pagated through the Bensitive nerves, to the interior of the 
joint, and to the muscles moving the joint. This dimisn- 
tion of sensibility tends to give quietude or perfect rert to 
the interior of the joint, which is one of the most importsitt 
elements towards the successful issue of the treatment ot 
cases of this kind. 

Examples of Pht/tiological Rett. 

Suppose you have a patient who is the subject of iritis- 
Yon drop sulphate of atropia upon the conjunctiva, and yoB 
act u]>ou the iris; you see its influence upon the coaditiui 
of the iris. How is this brought about ? It must bs 
through the medium of the impression made by atropioe 
upon the sensitive filaments of the ophthalmic branches of 
the fifth nerve, wliich are distributed upon the conjunctiva. 
I cannot believe it to be by its direct transmission through 
the various and dense tissues covering and surrounding 
the iris ; for we observe that exactly the same effect can M 
produced upon the iris by rubbing or smearing belladonna 
upon the eyebrows, forehead, and eyelids, which are sup- 
plied by the first division of the fifth nerve. If, then, 
admittwlly, you influence the condition of the iris by 
dropping atropine upon the conjunctiva, which is supplied 
by the fifth nerve (the iris receiving its motor supply &oin 
the third and synipathetie nerves), why should you not 
succeed in relieving muscular spasm in the interior of « 
joint by narcotics, applied to the ]ieripheral branches of 
the same nerve which supplies the muscles that move the 



VULi AND THE DIAOKOSTIC VALUE OF PAIN. 185 

t 

joint ? I feel confident that quacks oftentimes succeed in 

S'ving relief where legitimate surgery seems to fail ; and 
ey do it in this way : they employ the most potent means 
of ooonter-irritation in combination with anesthetics, where 
ve should use only an embrocation or infusion or a fomenta- 
tion of comparaavely little anaesthetic influence. These 
lioUowB employ potent remedies, and they succeed, without 
knowing how, where some of us, more legitimately circum- 
lianced, actually fail. 

Let us take another illustration. If we can, by intro- 
dacing opium into the auditory canal, relieve toothache 
md a stiff jaw, do we not come to the same principle as 
that which stands before us in respect to the circumflex 
nerve and its cutaneous filaments ? Last winter, during 
the very cold weather with sharp easterly winds, a gen- 
tleman called on me, and told me that whilst riding on 
horseback that morning down Highgate-hill, ho was sud- 
denly seized with stiff jaw and intense pain in his left ear, 
and he added, " I have been to my office, but in conse- 
qnenco of the pain in my ear I cannot do anything. I 
have endeavoured to overcome the pain by sitting cjuietly 
in my warm office ; but I cannot bear myself, and now I 
have the most exquisite sensitiveness and pain in the left 
ear, and I can hardly move my jaw." In order to relieve 
him, I employed the principle of physiological rest, which 
I have been advocating to-day. By my direction he in- 
troduced 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 ear, I thought it would be as well to give him a calomel 
pill at night, and a purge in the morning, and I requested 
nim to let me see him on the following day. When I saw 
him in the morning, he said, " I am much obliged to you 
for the medicine, but I have not taken it ; for I had not 

Ent the opium into the passage of the ear a quarter of an 
our before all my symptoms disappeared, and the jaw 
became free from pain and stiffness." 

Opium is injected into the rectum to relieve an irritable 
urinary bladder, or spasmodic stricture of the urethra. Is 
not the same principle involved here ? In like manner we 
apply anaesthetics to the skin of the perineum to relieve 



186 THE THERAPEDTIC INFLUENCE OF REST 

retention of iirin£<. Again, we find 8ome< patienta vi 
hip-joint disease Bufforing from pain in the knee. So 
although the dicease does not Ue tht-re. we know thut t 
paiu cftii be relieved by a belladonn* plMt«r, or Btr« 
hemlock poultices or fomentutiuna applied over the led 
joint ; thus ooting upon the nerves of the hip-joint thruuj 
the medium of those which are spread over the kn< 
joint. 

'I'here are some eircumBt*.nce8 in which the circiuufl 
nerve becomes injured and exceedingly painful, especial 
after diaiocation of the bumenie. In mich cades, t 
piitiente experience a wasting of the deltoid, and euffei 
great deal of pain in and about the ehoulder. This, 
part (Bometimes, at any rate), depends upon the tempon 
pressure of the head of the humorua upon the uerre, 
the stretohing cpt tearing of the nerve at the time of t 
accident. Although the patient is disabled for a tio 
ultimatfly tJie ]>aiii (liKiijiiiearM, the ili'ltiuii rL'fovers its si 
and the capability of the joint is restiired. The ea 
wasting of muscle and miu are manifested also, thou 
not so aatisfactorily explained, when the tendon of 1 
biceps is ruptured ; the deltoid becomes reduced in d 
and the ahoulder-joint suffers a great deal of pain, reliei 
by strong anresthetics applied to the skin of the should* 

I now ])roceed to the examination of the diatribnti 
of the 

External or Muecuh-Cntanenua Nerve of the Upper 
Ext remit y. 

The cutaneone portion of this nerve is verj' nicely aho" 
in the diagram (Fig. '^8). You aee the ner\-e spreadi 
its branches down the anterior and outer part of 1 
forearm, nearly as far as the base of the radius. Ni 
what is the object of this nerve? It is derived from 1 
fifth, sixth, and seventh cervical nerves, and it has a w< 
defined distribution to the muscles, fsiscia, and skin. 
goes to the coraco-brachialis, to the biceps, and then 
the brachialis anticus, and thence eends a branch to i 
anterior partof the elbow-joint, thua displaying the artioa 
association pointed out in the case of the circumflex ner 
The nerve now becomes subcutaneous, reflects a bran 



OTer the lower part of tliu ijiti'ps, ttiul then [iroli)nga 
nnmeronB branches (at first sight apparently) far away 




^plerdnff ... 
■uw-r, w WQ vu*ci BjidB oT tlw UndoD of tli« Uuiw. uul then dUdlbutlDg fu 
mDcba to lb* (kill of Uk Ion 
lb* Trin-Mnt. 
K kaadi of tbr nuciils-qilnl nem npplTing Ihc 
um, cm th* nplnatar limgct. 

&om the mosclea with which it is asiwciated. You may 
first observe the recurrent branch passing iipwards to tho 



I^"* nri': TiiEiiAPEiiTic isflue>xf: of rest [Ua, 

tkim.vvr iLu luwer jiart iif the Uceips. Fnnii tlic lendunuf 
this muscle proceeds -wliat is tormed its faadal insertion. 
Kcrtv the fascia of the forearm ia part of the iuaertioD cf 
the hicops— it is ao cBaential part of it. Instead, theiefon, 
of this miisculo-cutaneousnerre departing from the arrangfr 
meht to which I have referred, it substantiates it meet com- 
pletely, liecause it is distributed to the skin over the &Mii 
which that mnscle moves. And mark another aseociatifin ' 
hert' : a part of the muscalo-Bpiral nerve, as it ongfat to do, 
oomt's over the snpinator radii longue, because that mnaole 
is supplied by the nmsculo-spiral nerve. On the inner 
aide, a portion of the internal outaneoas branch " of the 
median nerve should be seen, because the fascia on the umer 
Bide gives attachment to the pronator radii teres, the fleior 
carpi rndialis, and the palmaris longus. These mosoUe 
are snpplied by the median nerve, and they arise from tl» 
fascia. When they contract, they cau exert some in- 
fluence Tipon the fa«cia : bo that this fascia is, as it were, 
the oommon property of three nerves. Hero, then, we have 
an nrrangement of nerves which shows very distiDCtljr 
the muscular, articular, and cutaneous branehes all ane- 
ciated in one trunk. The attachment of the musdee to 
' the fascia is no doubt the reason why we have sometimes 
each difficulty in treating injuries to the faacia. If we have 
totreat alarfresub-fascialaliscess, we .all know the difficulty 
of healing it, in consequence of the fascia of the forearm 
being freely moveable by muscles. Unless wo 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 bandages, so 
as to coapt the internal siirfaccs of the abscess. We quiet 
the biceps and the muscles of the upper part of the arm 
by making pressure upon them, and so secure mechanical 
rest to the walls of the abscess. 

• By " the internal cutftneona bmnch of the median " ia meant the 
intemftl cutuneone neire itself, vliich takes orieiu from the eiKlith 
cerviral hwI flret dorBal nerves, in common irith Uia ioner bead of tin 
median, o! which it may therefore be described as a outaneona bnndi, 
sDppljing the skin oror the fa-icial origin of nmolee rapplied bj the 
median nerve — [En.] 



tul] asd the duqnostio value of fain. mn 

I fee! bound to place before you one or two factH 
■MocUted with this nerve, bearing on the practice of our 
pniteadon, because, if I should take up your time without 




Anil ItB AccompoJirlDB Telnfl. d, Intcnul condyk' of 



thowinfc you that Bome practical advantage was to bo 
obteined, I should be askin); you to make a Haorifice which 
would not be juetifiahle. We have hero (Fig. 29) a draw- 
ingofadisaectionmadeby myself many years ago, showing 



\'M' TUy. TilEliArEITTH; lNFLLii:NCE OF REST fLl^^ 

tlie 6ui"_rlk'iiil iJorvfB uiid vfins 'if tli-.' aiitfriur [wirt ol'tiie 
elbow-joint and also the brachial artety and Its accov 
panying veing. Yon see a port only of the ertenall 
cutaneous nerve. The inner cutaneous filanientB are bmo, 
Bome travelling over and others under the different sapv* 
ficial veins. 

Cause of Bent Arm afUr Tenetecliim. 

Formerly, when bleeding was a common operation (itii 
now a very rare one). jwtientH used sometimes to sufler 
after, and as the result of, venesection, from what nv 
termed a " bent ana." It vrae explained by snppoenig 
the fascia had been wounded during venesection ; tliit 
supposition was adopted, because the fascia and tendon of 
theXiceps stood prominently out, and forced themwlvH 
upon the attention of the surgeon. It seems clear to n». 
that injury to the fascia is not the explanation. I wonU 
say, that in the venesection one of these little filamente cf 
nerve was wounded. As the lancet is passing into the i 
vein, the patient feels a veiy sharp, acate, electrif}ing 
pain runuin)^ from the seat of injury into the upper um. 
which then distrihutes itself upon the back of the oeok or 
shoulders, indicating that something nnnsual haa hap- 
pened. Now, under these circumstances, what occurs': 
Almost always the wound ia unhealthy: it suppurate. 
granulates, and becomes exceedingly painful, and thereis 
8ubse<[ni.'t)tly a very coarse cicatrization. How is it that 
the arm becomes bent ? The injured nerve is a branch of 
that trunk which supplies the biceps and bntchialis anticus. 
The effect of the injury is carried upwards to the spinal 
marrow, and reflected along the motor filaments supplying 
the biceps and brachialis atiticus, and thus produces a 
spasmodic contraction in them. This is really the cause of 
a " bent arm," which I accejit in preference to the other 
interpretation, of a wound in the fascia. 

But this point may be carried a little further. It is 
nearly twenty years ago since I saw a patient who for 
several years had had a bent arm after venesection. I cut 
away the old cicatrix, which was very tender ; Bmall 
filaments of nerve were delected in the cicatrix, and from 
the time of the excision of the cicatrix the patient was free 



TIILJ Aim THE DIAGNOSTIC VALUE OF PAIN. 101 

from ** bent arm." TMb demonBtrated to my mind, that 
the " bent arm" which followed venesection was not the 
Tesnlt of a wound of the fascia, but of a wound of one of 
tlie nerves supplying the muscles which are capable of 
lending the arm. Thus I have a right to say, that we can 
attach to these nerves points of practice which do not at 
first sight appear, when it is simply stated as a sort of 
axiom, that the same nerve that sup])lie8 the muscles suj)- 
plies the skin over the insertion of those muscles. 

Injury to the Mutculo-Cuiaiieoua Nerce hy a Bullet, 

I had once an excellent opportunity of seeing a well- 
tnarked case of injury to this musculo-cutaneous nerve. 
A lieutenant in the navy was at Lagcjs, fighting with the 
natives. He jumped ashore with his sword in his right 
hand, and ran with his men up to a stockade. Although 
■ he was struck once or twice, he went forward ; presently 
his sword-arm dropi>ed, he could grasp his sw(»rd in his 
hand with great vigour, but could not bend or raise liis 
forearm. This gentleman, before ho returned to liis boat, 
received seven balls, of which some went through the 
right side of his chest. When I saw him in Loudon, I 
removed a bullet from his leg, and he then explained to 
me the nature of the injury which he had received in his 
ann. This made one of the most precise experiments that 
you could possibly conceive upon the external cutaneous 
nerve. The bullet had bruised or severed the nerve, 
causing a paralysis of the biceps and brachialis anticus : 
both muscles were wasted, whilst the other muscles of 
the 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 over the ordinary distribution of the external cuta- 
neous nerve was destroyed. He had consulted the late 
Mr. Guthrie as to giving up his appointment in the 
Service, and he subsequently came to me with the same 
object. I said I did not think the nerve had been divided. 
It might have been ; there was no doubt it was seriously 
injured. I advised him, whether the nerve were divided 



J92 THE THEBAPEDTIC rSFttENCS OF BEST [Lkt, 

or not, to retain hia commiBaion, aa the probability wM 
greatly in favour of ite being ultimately n-pfiired. St 
tibtaineil leave of absence for two or tlirea years, wid woo 
hia ami in a short sling. I met him thit« years aftcrwud 
in Picea<lilly. when he flonrishiid his stick in the air vriti 
hia right arm, and said he was ready for anything. 
asked him how long he had been getting well, and he toL 
mo, " About two years and a half." His arm was quit 
Htrong, and the wasted muscles had nearly regained thd 
normal size. The power of graaping and movins tb 
fingers which this gentleman retained after his Injur] 
left no doubt that the metlian and ulnar nerves wei 
uninjured. This was a well-defined injuiy, that marke 
veiy completely the diBtribution of the muBculo-cutaDecu 
nerve. This gentleman, as a captain in Her Majtsty' 
Service, is now receiving his reward for his courage an 
his wounds. 

Exoelo»!s pregtinif upon the Nveeuto-Culaneoui Nerve. 

I may mention another fact with regard to the Mm 
nerve. Four or five years ago a boy came to me at Quy 
Hospital, with hie aim contracted, and suffering a goc 
deal of pain in the coureo of the external cutaneous neir 
On careful examination, I found a aimple exostosis preflsn 
upon this nerve as it passed through the coraco-brachlal 
muBcle. He hud several other similar exostoses at differei 
parte of his body, but they did not pain him. I cut dow 
upon the exostosis to which I have specially referred, as 
removed it. He had no longer any pain, and was soon ahi 
to move his arm freely. 

I am ajicakiDg in accordance with the experience < 
everybody when I say that an inflamed elbow-joint, pe 
mitted to take its own course, always becomes flexed andi 
the influence of the biceps and brachialis anticus muscle* 
and I think we can understand why it should be 00, froi 
the distribution of the same nerve to the joint and rauscdi 
moving it. I think we may find some advantage in it 
membering whiit 1 have now pointed out with reapect 1 
the cutaneous nerves of the arm, I believe, also, that : 
strong aufesthctics were applied over the course of thei 



cuuneuus iiervea, we should bo eaturiug iipuu ii lino of 
trefttment whicli would ultimately influence the some nerreti 
H they proceed to snpply the diSerent flexor muHcles. 

Dutr^mtioK of Nervea to the Fingeri. 

The other two large nerves of the upper extremity are 
tte median and ulnar. I luuet not trouble you with much 
of the details of their distributioii, except to point out ita 
gnat preciaioD. Theae nerves, together, supply all the 




ripM. •.Lnm „ 

■Bd thnm pnicccdlDC to tbc UM pbaLAqi of tbe UDger. 

MDd tepdon lumlcct Into IrndoD or Icmg etlennr. 
n^ 11. a, ud ft, Uh Hina u In Fig. 30. c, DIgtuI bnnch of niKllin aene puiIng 

to Ibe pAlmv curlvc of tb* Ongpr, And ■oidLng i luve uhI coDBUnt BUmepl lit 

Jc^ </] a portion of ttaa miuculo^BplTal nerve, 4Qd tben prw««dlog tlong Ibu 

doni nqnct to Uiv utmnitj of tbe flnErr. 

flexoiB of the wrist-joint, fingers, and thumb, all the 
pionatorB of the nMlio-ulnar joints, and all the joints that 
tbose muacles move. The separate distribution of the 
median and the ulnar nerve 1 need not refer to, beyond 
rsminding you of the fact. But when we come to look at 
this distribution closely, it is a little remarkable. We 
have here two middle fingers, drawn from nature : one 



j 



104 THE THERATEUTIC JSFLOENCE OP REST \\l 

with its muBclca fttid teiidous bIiowii, and the other inb 

tho diBtribution «f the nervee upon it. We Bee the leudwa 
of the extensor runiuDg along the back of the finger, bit 
scarcely further than tho base of the aecoad phalanx." 
Then by the side of tho fiugw, and joined f i the tendon d 
the esteuaorB, we may see two Bmall mueclea — the Iiimbri- 
calia and the int^rosBeoufl. Their t«nduns pass on to the 
end of tho finger, towards the dorsal aapect. Thns H 
might appear, at first sight, as if tho flexor (median) nem 
carae on to the ground of an extensor distribution ; bnti) 
is not really so, becaiise the interoBSei and the Itimbriealod 
which form a part of the flesor apparatus, are supplied 
by the median and nlnar nerves. We have here the 
tendons of these small musclea (supplied by flesor nervesj 
pasBing along the dorsum of the finger, in accordance viti 
the distribution of the flexor nervoB, We also iiheerve i 
distinct portion of tho ext(."[iBor nerve mnning along thi 
dorauni of tlio fiuHfr. iis fur an tliij tvi.di.itis of ihL- -.-xt^nsor 
proceed distinctly, and then uniting with the branch of tb 
median nerve. Bo accurately is this eystematic arrange 
ment carried out in the median nerve, that these littl 
niuacles — -the interosseous and the Inmbricalis— commanc 
as it were, an associated cutaneous nervous distrihntioi 
Hence this median norve, whilst passing along undemeat 
a portion of the finger, scuds a largo branch across thesid 
• Mr. Hutchirwin, ' On (he Besults wliich follow Injuries to Hen 
trniihB,' Ijitnl. Hnsii. Bjils. ynl. iii. 305— entirely cciifimiB the alw 
remarkB of Mt. HilluD. Id speaking uf division of the meilinn and nln 
nerves, be si>ys tbet eitrh roses afTonl good opportunity of dttenninil 
how much of (lie integument of the Kngers is supplied by the radii 
" Hy conclusions ou thia point ditFer I'u Uito from those of gui 
anatoniisLB as afBrm that the ntdinl nerte supplies the whole of i 
dorsal aspect of the thumb, fore and middle fingers, and tho tadial A 
of the riuR finder. It is quite certnin cimt those are right who, «i 
Swan, affirm that it docs not {rass nearly (o the ends of tbe fingers. ( 
tlie thumb it passes as higli as (he root nf the nail ; on the furefins 
aa high as the middle of tiie secoud phalanx : on Ihe middle and ril 
fingers not higher than the Urst phalangeal joint. The distal paiti 
these fliiRers are supplied behind as well as in front by twigs fma t 
median which curve backwards and encircle tho fingers. When t 
median is cut these parts lose all sensation, and the border tenilo 
between that supplitd by tho median, and that by the radial, ii ■] 
decidedly deflejent in ■cncatlon, altbougii not absolutely nutal 

-[ED.J 



THL] Aim THK DIA0H08TI0 VALUE OF rAIN. 



105 



rf the aecond ardcnUtion, between the first and aecond 
tmte of the finger, and diBtributes itself along tho dorsum 
of the finger. Here again we have an instance of tho same 
nerre supplying the muscles, and likewise thu skin uvc-r 
the iusertioD of the same muscles. 

Dittribntiem of Nervet lo the Toes. 

Now contrast that state with the middle tr>c. You will 
obKTve the extensor tendons and nervt-s running along thu 
donnm of the toe. But here is a markud diffcronco, iipjiii- 




msmtm. «. Pirtor ]ircili<UglUriiiD. / PUnUr DFiiie(ui>Uii;i>iu wdlgluJ N'rv<< 
sriiud),boInolinpplTlngaiUKllTiclbnDcti tn thFikinum uf Ihelw. «. Kil'-n- 

rently, in the distribiition of tho plantar ncr\-»;. Inttteail 
of there being a distinct dorsal branch from a plantar nerve, 
■i you observe from the median or ulnar nervts in th<' 
luuid, this plantar nerve (the analogue to the branch of 
the median nerve) does nut paw towards tho dorsum (if 
the toe, but confines itself to its under surface ; and it 
seems, upon careful examination, that the intorossei and 
lambricales do not extend themsolves so completely alonji. 




tlie dorBiiia of the toe an the correBpoiiding muscles do ] 
iipoa the dciraum of the fiiiger. Again we hare, un ■ i 
small Hcnle, the eame thing expressed with ^ual preoieioii 
—that the same nerve that BuppUes the muHcleB supplia 
iibo thu ekin over the insertion of those mnsclea, 

DUtriliiilion of Nerve» to the Thumb. ' 

In this drawing of the human thumb (Fig. 33) you sees 

rirt of the distribution of the mueculo-spiral nerve to whici 
have ttlreadj" alluded as Buppljiug all the extensora of 
the elbow, wnat, fingers, and tnumb without e: 
none others except the radio-ulnar supinators 



ceptioD, and 




Now the thumb stands in this peculiar position, that 
instead of having the tendons of its muscles blended 
together and merged into each other as in the fingers. 
making a sort of common ground for the distribution of 
two seta of nerves, you see the separate and distinct 
insertions of the tendons of the first, second, and third ex- 
tensors of the thumb and the musculo- spiral (extensor) nerve 
going exclusively to it on the dorsal aspect of the thumb. 
There is no branch of the median nerve proceeding t« the 
dorsum of the thumb, but there is a branch of it going to 
the dorsum of the finger. Why this difference? It is 
obvious that the whole of the muscular association on the 
dorsum of the thumb is confined to these three extensor 



VHIJ AND THE IMAfiNO-iTir vAr.ri: (ll- [■AIV, i:'7 

fcmiona, all of wliioh are supplieii exclusivelj- by tlio 
mnaculo-epintl or extensor nerve. In accordanoo with this 
urangement, the same trunk — the nmsculo-epiral nerve — 
ii the only one that sappliea the skin over the dorsum of 
the thnmb, thns making a marked differenoe in the outa- 




neona diatribntion of the thumb and the lingers. This 
■naof^ement is also subaervient to the rule or law which I 
fa»Te mentioned, that the same nerve which supplies the 
I flnppliea the skin over the insertion of those 



198 THE THERAPEUTIC ISFLCENOE OF BEST [Lb« |i 

nineclee ; it is an example on a small BCale of thfl dutn- 
bution, Lut it could scarcely be more oxaot. 

Even this little pioce of anatomy may be occasional!; of 
direct importance. I rememlier seeiug an error oomplrtdy 
checked by ite recognition. A patient waa Buffering from 
tetunua, having a wound upon the dorauni of the finger 
over the third phalanx. The surgeon proposed to divide 
the nerve which suppliea that part, and intended to dlvidt 
the iiiusciilo^piral nerve. That would have been an enw- 
The muficulo-Bpiral nerve does not eupply that part exdu- 
eively ; it is suppliod partly, if not chiefly, by the mediiii 

I now direct attention to this diagram (Fig. 34), takim 
from Mr. Swan's book on the Serves. It abows the fticia 
covering certain tendons just above the wrist-joint, and 
you observe upon the fascia three nerves arising from thiw 
different Bourees. In truth, the fascia in tliia portion of 
tlio forearm may be said to lie tlie ci^mmon property of the i 
lUiiBcles supplied with nerves derived from the median, the 
mnsculo-cutaneous, and the muBCulo-Bpiral nerves. The 
latter sends its brunches over the tendons of the supinatOT 
iiidii litngus, one of the niuacleB which this musculo-spiral 
nerve BUpiilies. This example is a good illustration of the 
law that the same nerve which supplies the muscle supplies 
the skin over the insertion of the muscle. Here (Fig. 34) 
are three different muscular aBsociatione — the median nerve, 
supplying the flexorB in front ; the musculo-cutaneout, 
supplying the fascia, which is part of the insertion of the 
biceps ; and the radial nerve, coming down to the outer 
side of the arm on its way to the dorsal aspect of the thumb, 
which it supplies exclusively. 

Ca»t» illustratins the Effect of Preamre upon Spinat Nervet. 

I will next for a moment refer to illustrations of the 
effect of mechanical pressure or irritation upon the median 
neivo. We know that a fracture near the base of the 
radiiiB, with displacement, ie 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 dne perhaps to the want of proper a 



11.3 J^^Sm THE DIAGNOSTIC YALUE OF PAIK. 199 

ent. The swelling and displacement together lead to 
:<e88iiTe upon the median nerve, and that pressure may 
noduce destruction of the tissues at the peripheral dis- 
ibation of the nerve. 

Some years ago a sailor came to Guy*s Hospital, under 
le care of the late Mr. Key, having had a bad fracture of 
tie lower part of the radius. There was no surgeon on 
card the ship ; the fracture was not proi)erly set, and in 
ODseqaence the callus pressed severely upon the median 
terre above the wrist. The man had ulceration of the 
kin upon the thumb, the forefinger, and the middle 
inger. The hand was puri)06ely flexed, and put in such 
k position that all the tension was taken oif the median 
lerve, and the ulceration got perfectly well ; but as soon 
m his hand was allowed to be freely used and extended 
Ijain, and the pressure of the uillus i)ermitted to exeil; 
fai influence upon the median nerve, the ulceration reap- 
leared on the thumb, forefinger, and middle finger. lie 
ould not pursue his occupation as a »iilor, but it was not 
bought right to submit him to any remedial ojK'ration, 
rbifSi might place his hand in danger, so he preferred 
smaining as ho was. He was allowed to depart from tht; 
ospital. subject, no doubt, to a recurrence of tlie ulcera- 
on to w^hich I have alluded. Tliis is a gocxl illustration 
f preBSuro ujwn a nerve prcxluciug deterioration of struc- 
ire.* 

* The followinf^ is a gtXKl iDstancc of the effects on the adjncent 
snret of abundant ciiUus following a fracture in a child. E. L. let. 8, 
■•brought to my out-pHticnts with the following history : — Viyh weeks 
{O he harl * fractured hid dhow 'by falling from some milings, the 
■cture was set almost imme<liately, and an anterior angular splint kept 
1 for five weeks. On his coming to mo there was very marked wrist- 
lOp, no power of extension of the wrist, some power of supination of 
le forearm, most of this, however, being clfarly done from the shoulder 
f the bioepe, the forearm was kept pronated, and the thumb and 
iigen flexed and drawn into the imm ; the interossei were wasted, the 
bSow between tlie thumb and index-finger l>eing esi)eciiilly distinct, 
Idoetion and abduction of the fingers were alinf ist completely lost ; on 
tiling the child to keep the fingers flexed and try and straighten the 
■t two joints— no action of the lumbricuies took place. Sensation was 
luoli impaired over the back and front of the wrist, palm, and fingers, 
urn} particularly over the distribution of the ulnar and radial nerves 
» the fingers and thumb. The movements of the elbow joint were 
Dooth, bat very limited. All this hud apparently originated m a 



200 THE THERAPEUTIC INFLUENCE OF BEST ( 

Oangrene of the Third and Fourth Fingers from Pretmn 

the Ulnar Nerve, 



I 



I have placed this sketch (Fig. 35) before yoa fi 
urpose of illustrating a fact somewhat like the proo 
t shows gangrene of the little, and of part of the 
finger of the left hand. I will give you in a few wor 

history connected with it. Elizabeth B , ^^S^ 

seven, came under my care at Guy's Hospital in Feb) 
1853. She was of healthy aspect and regular 1: 
About a year before, she felt numbness in the extrei 
of the third and fourth fingers of the left hand« wiil 
in the same parts, especially increased during the i 
The fingers gradually became enfeebled and lesaeE 
size. In a short time the ends of the above-named i 
bega]\ to appear discoloured, while the numbness anc 
increaised. She had no particular treatment for this, a 
mortification was impending, the surgeon advised 1 
come to the hospital. On admission, the third and i 
fingers were found to be gangrenous, the extent of ' 
is shown in the sketch. A healthy line of demap 



fracture, which, passiDg from without inwards, had detached th 
articular end of the humerus, traversing in part the line of 1 
physis. Considerable bony thickening existed in the neighbouz 
the external condyle, this tnickeninji; extended upwards along thi 
condyloid ridge joining the shaft with a sudden dip ; it quite •« 
for the pressure on the branches of the musculo-spiral and the 
motion with the altered seneibility in tlie parts supplied by its bi 
the radial and posterior interosseous. Similar callus-like thic 
about the internal condyle (which was itself displaced somewhat i 
but firmly united to the shaft) explained the pressure on and n 
of the ulnar. The PArtial interference with the median, as so 
the diminished sensioility over its cutaneous distribution and p 
of the outer twolumbricales, was due to thickening over the lori 
front part of the arm ; most of this latter thickening was owini 
pressure of the splint, as after some superficial suppuration at tl 
the thickening rapidly disappeared. The case is still under tn 
while this sheet is passing through the press, but great improvci 
the movements of the elbow, and comdderable gain in sapd 
almost complete restoration of seusation in the hand, with parmi 
over the interossei ai^d lumbricalee, have followed blistering, 
friction, and the internal administration of the perchlorides of o 
and steel.— [Ed.] 



Tm.] AKO THE DIAGyOSnO VALUE OF PAIH. 201 

tetween the living and dead stmctnrea was then forming. 
Ho puIbb was perceptible in the radial, and ouly a very 
dight one in the ulnar artery. On examining the cose 




with care to ascertain the cause of all this, I found upon 
the first rib an exostosis* pressing u]m>ii the sulK'luvian 

* Ht. Halke 'Clin. I«ct. Med. Tim. iind Unz, Fpb. 21, 1877) in 
ipeakiag of the stinlngj of these exosiosos. n-marka thiit «eK unil vnuth- 
AilneM (be rofen to five cases in girla) acem TiivoDrini; oonditiODs. 
" The exuct point from whioli these exostoacB usually spring cannnt be 
ht from Ibu tubercle at the insertion of t)io sntlenus anticus. anJ In 
tliit reapect the ouHtal exoritoalB reacniblos tlie cnmmon cxostoaiH at the 
lower end of the inner femoml condyle, wliicb is uaually rooted iti the 
nelghbonrhnod of tlie iimrlinn of the lonf; teiulon of the sd<luclor 
magniu. This nmilarity Diiggi'SlH tliat un'lcr immo c 



-"i: TH1-; ■riiE;[tAi'f-:r'r[c inflcesce of uest iLvn 

niUiTy m> ns to obliterate it, or prevent any blood from 
paauiig throusfa it. The erostoeis was prumiig npon * | 
iiervo also, whieli turned out to be tb« ulnar it«rve, I 
praised i»y finger upon tbe nert'e ovcrlyinc the exoeUisi, 
and imuieiliateiy tbe patient expt^rienced udaitionAl pain in 
the littlu and adjoining fingtre. The exoBtosis presnag 
upon the subclavian artery aflect«d every part of the upper 
extremity alike, as far ae the supply of blood was «m- 
cemed ; lint the additional oircumstance waa, that it preaaed 
upon the ulnar nerve, and ao produced a peculiar c&ct 
upon Ihi) two fiiigere aupplied exclusively by the ulnar 
nerve. The iiiterierence with the nervous power or 
nervous influenoe, or the irritation of tbe nerve, what- 
ever it may be, led t« etmotnral deterioration, and ftniJly 
to gangrene, of the ends of those fingers. Tbe case is quite 
analogoiiB to that of tbe sailor who receivad a &acture of 
the nidiuB, with a large amount of callus pressing npciu tbe 
median nerve, leading to ulceratiou of the fore&igur, middle 
finger, and thnmb ; for the line of demarcation between 
ulceration and gangrene is but small ; the one is mulecolai 
death — the other is local death, but on a larger soal«. 



uolmown to ni, exMnivo tensions of the bone and peTio*t«tiin bj 

inserted mudclGii may |irnvnke a hnnir (lUtRrowtli in these HitutttidTl^ 
The fonnution c( Ininy rn.vs in Hio fil.rons ullaplimiiils of tl]|. nddnclnr 
muscloH lo Ibo i-clviB, whil-h liaa ofl«n betn ubeerveil in mtn nbo pMl 
niucli nf their hvea lu the Kuldle, lonila support to this suppositioD." 
-[Ed.] 



U.] AND THE DIAGNOSTIC VALUE OF PAIN. 203 



LECTURE IX. 

ntEaSUBB ON ULNAR NEBVE PRODICINO GANGRENE Or THE THIRD AND 
FWhTH FINGKRH — rURRED TONGCK ON ONE SIDE DEPENDING ON A 
VECATED TOOTH, Dl{i£A8E WITHIN THE CUANIUM, AND FRACTURED 
BASE OF THE SKULL — DECAYED MOLAR TOOTH PIU^DUCING GREY HAIR 
OS THB TBMFLB-EZOURIATloli) OF AUDITORY CANaL AND ENLARGFJO 
IXanUTIC GLAND— NERVOUS SUPPLY OF THE WRIST AND LOWER 
XrrUEHITIES— CAUSE OF U1.CER8 ON THE LEGS UKING FREQUENTLY 
JUST ABOVE THE ANKLE — DISJTRIRUTION OP OHTURATf^R NERVE — 
CDTANEOU8 NERVES Of TmE KNEE— EXPLANATION OF HYSTERICAL 
PAUtS IK THE HIP- OR KNEE-JOINT. 

At the conclusion of my last lecture I was compelled 
abruptly to cut short the details of an interesting case of 
pieesure upon the ulnar nerve, leading to gangrene of the 
third and fourth fingers. That, at least, was my inter- 
[nietation 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 ui)on the ulnar 
nerve, subsided under the influence of the bichloride of 
mercury ? The exostosis did undoubtedly diminish in size 
during the time the patient was in Guy's Hospital ; but I 
have uot seen, her since that time. 

I might have said, with respect to the details and the 
treatment of this case, that there was a verj'' swollen con- 
dition of the left upper extremity, from pressure upon the 
artery and, probably, the veins also. The ami was mottled 
in appearance, and its temperature much diminished, fore- 
boding general gangrene of the limb. By the recumbent 
position of the body, with slight elevation of the ann, the 
return of the limb to a comparatively healthy state was 
very much facilitated and hastened, whilst the pain along 
the ulnar nerve became greatly reduced. A large and 
thick layer of cotton wool was placed around the whole 



204 THE THERAPEUTIC INFLUENCE OF HEST [Licr. 

limb, and ultimately portions of the two fingere. which ' 
were actually gangreDous entirely eeparated. The wonnda i 
healed np. ad d cicatrized healthily, and the patient went 
out of Guy'B Hospital free from pain, and, as far as I knonr, | 
perfectly well, except that the eubclavian artery did not 
cany blood, nor was any pulsation to be felt in the radial 
artery, and scarcely any, if any, in the nlDftr artery ; hot 
the mobility and temperature of the limb wens ni-arly re- 
establitihed. I might add, that there existed it anuU 
exoBtosis on the first rib of the right aide of the cheat, not 
80 large us that on the left. Certainly both exostoses 
appeared to move with the first rib. I say. appearad to 
move with the rib, because there may be some surgeonii 
who would question whether tho exoetoses were ootmectwl 
with the first rib, or with tho transverse proceao of the 
seventh cervical or first dorsal vertebm. As far a« I eonld 
tell, they appeared to be asBOciated with the first rib, Thif 
instance of looal gangrene is, I apprehend, an lllustratioii 
of destruction of tissue from physiological disturbajice utd 
interference ; that is, by pressure upon the tdnar nerve. 
If it could have been possible to remove that exostosis 
before tho ganfrrenous ulociiitiun t'Kik ]ilnco, 1 believe that 
those fingere wwilil not hiivo hi-ca ileKtri lyi'd. This, then, 
will complete all I have to say on this case, which is one 
of great interest ; not so much from its own individual 
value, as that, in point of severity, it stands at the head of 
a group of cases on which I shall endeavour to enlarge. 
They constitute a class not generally referred to in books, 
though not unfrequently met with in practice, which have 
a very close relation to the subject of these lectures ; I 
mean that of " physiological rest" 

Within the last three months I was requested to aee a 
young lady from the countrj' on account of some painfnl 
^mptoms she had in her right hand, especially in the 
httle finger and the ring finger. Associated with these 
symptoms there was tho suspicion of an aneurism of the 
right subclavian artery. I will not trouble yon with 
all the particulars of this case, but only those which bear 
upon the suggestions before us. The patient had a slight, 
hard swelling upon the first rih, which her mother thought 
had resulted from a fracture that occurred in her child- 



IX.} AKD THE DIAGNOSTIC YALUE OF PAIN. 205 

kood, she "being now abont nineteen years of age. The 
nrelling had lifted up the subclavian artery very much, 
ind gave it the appearence of unusual pulsation, and upon 
doae examination a sort of aneurismal bruit could be 
lieard, apparently the result of some enlargement encroach- 
ing upon the subclavian artery. There was really no 
aneurism. This was a case in point, where something had 
oocnrred to the first rib, possibly a fracture (of that I have 
my doubts, still it might have been so), which led to the 
IH:€nure upon this ulnar nerve, and had caused the loss of 
lensation in the little and the adjoining finger, the loss of 
temperature in those two fingers especially, and very 
constant pain in them. These are, as far as I can see, the 
preliminary conditions of the previous case, which ultimately 
teiminated in gangrene of the fingers. In the case of this 
voong lady, we have only the evidence of deterioration 
naving gone so far as to diminish both the size and the 
temperature of the fingers, and to produce considerable 
pain in them. What has been the issue of the case I do 
not know. It was, before I saw it, invested with a great 
degree of anxiety, on the part of both tlie patient and her 
friends, for they had received the impression that she had 
a subclavian aneurism, which would require a very serious, 
and, no doubt, to her mind a very dangerous, operation. 

Furred Tongue on one side caused hy a Decayed Tooth 

on the same side. 

As I purpose making the case of gangrene of the fingers 
from pressure uix)n the ulnar nerve the starting-point 
of a little group of cases bearing upon the subject of phy- 
siological rest, or rather the evil resulting from the want of 
physiological rest to the nerves, I must request your attention 
to this sketch (Fig. 36) of a, tongue furred on one side, and 
comparatively clean on the other. I dare say some of you 
at first sight wondered what this representation could be 
intended to elucidate, beyond the bare fact of one side being 
tolerably clean, and the other somewhat furred. Now, 
this furred condition of the tongue, let me say in anticipa- 
tion of what I have to speak of more in detail, is frequently 
associated with a diseased condition of the second and third 



206 THE TIIEnAPEimc INFI.l'E>fCE OF BEST 

divisiona of the fifth nerve. It is, iu fact, a fuiiotioai 
Btructnral dotorioration depending u|x>ii Morvuua iii&ar 
iu that respect yery much reaembling what we baveol 
Been in ftn extreme txindition iu tho case ' ' 

the fingoTB. 

• In othei wonli. this oonditinn of tho far n 
wliioh diaturbaiuy> if tlio iiurvt {nrae roaj prmliico 
a purL It U well knnwn that it ii nnt merely defcot, bnt dli 
cpf nerve force wl.ich inchtrea murbid imtritinn. For 
af^iyinnt of this nnd natnerniis inslaiiKi of the infli 
cyatem in mitritkm, the rmder ia refL-tred to Sir J. Paget' 
Fntliolni;y, lecL ii. He vill And tliere, aa itutADcea of nervi 
(ID otbei Kpithalial tiasiits, a esse nf the hair giowinj; qi_ 
tcmpriraiilf wliite alter nerviios heodoelie (cnata in which _ 
bt'fanie permnnently grey nfter mental anguiah are ««1I knotL 
ncsea quoted by the late Dr. ATistiefl^neet, Jun« 10th. I866),W 
not ouly unilHlcral furring of the tongue followml. but ulao led 
ULii<ntcral blanebiog of the ojehrov and seulp, and sleo uloeo 

In the inetanccs i]Unt«d above, the tongue was iinilaternllj 
over Hie diBtribution of the Uiiku d gustatory to the anterior pari 
tongvie. Rome yoan ago Mr. Hilttm pointed out to mu tliat in i 
oises of inflammntiiin of tho tiiDail(niiich receives its nerve snppi 
the KloKao-plinryQgeal) the posterior part only of Hie Inngoe (w 
supplied by tho Esme nerve) is furred. Since then outpatient p 
lias given ma abuudnrit opportunities, eapecially in cases ofay) 
ulcer of the tonsil, of proving the truth of the abovu obaorvation 

Quiti: n different explaiintion of tbia unilateruUy furred toug 
been put fornard — viz. that tliu aide of the jaw which correapo 
the furred half of tlie tuneue is but little used in ma^tioatio 
lience no removul of tlie epithi*lium of the tongue lakt-g place byl 
of the food on tliHt side. Tliua Mr. Hutcldnsoii, Lond. Hoap. 
vol iii. p. S92, writes as follows — "One-sided fui of ttie tongu 
b^eve, cfltianl aimply by thi> cireumstanee, that its aubjeot 
customed to tat on nuly one siile nf his nioutli, ... It is otlsQ t 
whfre tliere is mere Iobs of le.-th, no toothaclie or source of irA 
I tbcrcfnro cannot Hgree with the hypothesis, whii'h auppoM 
depend upon reSex ilisturtiani'e of nutrition through the lower 
of the Eflli. It is quite true that it occurs Ju ila most exaggerate 
when there is tuotliiu-hc, but this is precisely the condition in 
inastication on the affected side would be moat sedulously am 
Granting that there are cases, to which, owing to the absence of 
ache or any irrilatiou. Mr. Hilton's explanation will not apnl; 
quite clear that the ono which Mr. Hutchinson would aubstuii 
not account for those rases whiire, quite apart fnim toothaobe, thi 
distiuet source of irritation, deeply situated within the craninni 
two of the cnsi-a instanced aliove. nor will it meet the caoea 
limited to the posterior ttiird of the tougue. — [Ed.] 



: DIAQNOSTIC VALUE OF PAIN. 207 



The first time I had an opportunity of clcarin)^ up siicli 
I case as this occurred in 1843. On i)(.-c«ml)er ITth, lKi3, 
I examined, with Mr. Blenkarue. a Burp;uon in tho City, 
tb body of one of hia patients, w]io had diwl with diueaBu 
ai the DTun and spine. She had Bu9i.-ri.-d from intense 
niu on the left side of the head. She had also, durinj:; 
Wlife, a tou^e furred on the k'ft, and scarcely at all nn 
the right aide. It hecaiuc, therefore, an imjwrtant point 
to dear np what was the probahle cause of thiit coiiditiim 
ottho tongue. Wo made a i>oBt-mortoni examination, and 




found, as was anticipated, a diseased Bpiiic. Tlkon, u]iun 
very careful examination of the head, on turning up tht- 
dura mater from the anterior [lart of the petrous portion 
o( the left temporal bone, fur the eBpccial purpose, we 
exposed the Gasserian ganglion, or the ganglion of the 
fifth nerve. We there found what might bo called a 



:1 



208 THE THEHAPEUTIC INFLUENCE OF BEST lU«i jS 

ucrofnloHs depoeit upon tho convex edge of this ganglion.' 
involving tho second division of the fifth nerve more thui 
the thinl, >mt atill involving all more or leas. Here, thiai, 
appeared to us to be tho probable esplanation of lie 
tongue furred on iU left side. If I should not mentioo 
the fact again, it will be clearly undoretood that th» 
ilisoased wiudition of the tooth, or of the fifth nerve, wm 
alwa}-6 found on the same side ob tho furred tongue, and 
that the fur was confined to the anterior two-thirds of the 
upper surface of tho tongue, over the dietribution of the 
liuguftl gustatory nerve — a portion of the third djvinoitof 
the fifth. 

In 1844, when delivering some lectures upon the nerva 
at Guy's HoBpitat, I mentioned this oaee, and one otlMl 
tJiat I had seen before, the cause of which I had BOt 
liUtinctly proved. After the lecture one of the BtndenU ^ 
said, " Look at my tongue ; it is furred on one side, and I 
-■jmnot get rid of it." Tliia sketch (Fig. 36) was taken 
from his tongue in 1844. He had a decayed and painful 
tiioth^the second molar in tht,- up}>er jaw. Thst tooth 
was, by my advice, removed, and after a short time the 
fur on the tongue entirely ceased. 

Case of Fractured Base of the Skull, tcilk Furred Tongtu 

only on one tide. 

Some time afterwards a case of fracture of the skull was 
brought into Guy's Hospital, where the fracture ran acnas 
tlie foramen rotundum containing the second division of 
the fifth nerve. In that case the man had a furred tongue 
on the same side, indicating a probable relation of cause 
and e£fect. 

When Mr, Bransby Cooper was alive, a gentleman was 
admitted into Guy's Hospital, who was believed to have 
lectured the base of his skull, and being anxious about 
the case, he requested Sir Benjatuin Brodie to see him. 

• For a ciiBc where ft growth (apparently Barcomatons), developing in 
the firth nerve and tbeGaSBeriiiQ gunglion, caused loss of sight, bearing 
und smetl on the left side, togetlier with violent pain Id the part* 
supplied by thie nerve, and waiting of the lell temporal mDMsle, we ■ 
paper by Mr. Dixon, Med. Chr. Tra., ixii. ISl.— [Ed.] 



AHD THE DIAGNOSnO VALUE OF PAIN. 209 

patient had a faired tongae on one side, and lie had 
idicationB, from the loss of sensation abont the face, 
16 line of firacture interfered with the seoond division 
fifth nerve. He had a furred tongae on the same 
I that which we supposed to be the seat of injury 
I the whole time he was in the hospital. 

ed Tangite on one $ide; Second Molar Tooth of Upper 

Jaw disecued, 

ently, a lady, whom I have known for some years, 
.ted me regarding some matters not of importance, 
, perhaps not for any very precise purpose, said, 
me look at your tongue.*' She put out her tongue, 
. was furred on one side. I said, ^' You have a bad 
" «nd she thought it was exceedingly clever on my 
" Yes," she replied, ** and I am going to Mr. Bell 
re it taken out. She went and had it extracted ; I 
ler a fortnight afterwards, and all the fur had sub- 
This was a second molar tooth in the upper jaw of 
me side of the furred tongue. 

y recently my bootmaker had some little accident, 
le came to my house to consult me. I found he 
» fdrred tongue on the right side, and I remarked 
t, " You have a decayed tooth in your upper jaw." 
' he said. ** I have not ; but I have had a bad tooth 
id, and it is very painful when I touch it in this way " 
ing his finger upon his cheek over the tooth) ; 
iBt ever since I had my tooth stopped my tongue has 
ike this." 

w these cases, taken together, and considered as a 
or small group, seem strongly to suggest the influence 
tation or of pressure upon what we may call common 
. nerves, regarding the fifth nerve as a common spinal 
» although it has its relation only with the face and 
«d.* 



interesting list of cases in which some portiDiis of the 
I wjtbesm have been affected by dental irritation, either reflexly 
motely, or directly and by contiguity, including instances of 
^ of the face, neck, and arm, paralysis of the arm, wry-neck, 
if tetanus, epilepsy, ulceration of the cheek, ulceration of the 
naorosis. deafiiess, is given by Mr. Salter in a paper on Nervous 

P 



liair nil my left tciiipk' has all tii 
to lla^'<' lilack liair on one side ii 
liad inv liuad shaved and wear a 
liib mouth, 1 fuund he had a decay 
on the left side of the lower ja'' 
division of the fifth nerve. Th 
peared to me to be the e£feot of t 
the auriculo-temporal branch of 
fifth nerve with tne decayed tooth 
this second molar tooth in the 1 
the neuralgic pain very nearly oe 



Affections from Diseases of the PermaiM 
1867).— [Ed.] 

♦ Dr. Hart (Practitioner xxi. p. 342) 
Pain, dealing especially with sapra-orbitt 
carious teet^ and infra-mammary pain in 
following explanation of '* sympathetic " p 
in connection not only with the above Ctt 
on these pains in Lect. iv. '* From the m 
of the fifth in the special carious tooth an 
centre of the fifth, causing hypersBmia in th 
out for the special fibrils. Fain is felt thei 
part of the brain. The irritation of the 
hypersemia relieves itself into the adjac< 
this way we get pain in tlie adjacent tee 
pain in the original tooth, because its t 
normal blood supply recoverod. The arc 
aunculo-teraporal nerves become next cor 
exposed to pressure nnd dmiin'>^*" -^ ' 
C-Clitrf> f"- *' 



IX] AND THE DIAGNOSTIC VALUE OP PAIN. 211 

the patient smoe, and cannot say whether the hair haH 
Teoovered its colour. 

jDi$ea9ed Molar Tooth of the Lower Jaw producing Excoriation 
of ike Auditory Caned on the same nde, and nn Enlarged 
Lymphatie Gland : cured hy removal ofthi Tooth, 

In a previons lecture I mentioned that a professional 

fiiend of mine had suffered from a condition which bears on 

the sabject of the influence of nerves upon the structiires 

■applied by them. That friend, unfortunately, 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 wurds. Some 

years ago Dr. Addison had a very offensive discharge from 

one external auditory meatus, wliich annoyed him verj- 

much ; and below the ear was a small gland enlarged 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 specially 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 

aaditory canal. On disciissing the question between us, we 



into that for the infra-manimary region, and tliiis tlie pnin 

The question now ariBes as to the cut bono of this sympiithetic pain. 
Why should a woman with pelvic di^trebs be misled by uu ini'ru- 

maiomary pain ? Prolonged congestion in any organ It adB to 

nriona results. This is well seen in cyanotic atrophy of the liver due 
to congestion from right-sided cardiac regurgitation, l^rolonged 
eongestion of a nerve-centre will have similar serious results. Thin 
dsnger seems to be avoided by a neiglibouring uervc-ccntru becoming 
co ng ested, and in the case of the infra-mammary pain the nervc-contro 
IS one fnnctiouHlly less valuable than the ovarian. But furtlu^r, the 
sensory activity of the skin-centre is, through constant external 
edocation, much higher than that of any other part. A woman (loe8 
not know, under ordinary stimuli, where her ovary and uterus arc, 
wldle she is thoroughly cognisant of the locality boneuth her UHt 
wMwima^ The same holds good for the knee-pnin in hip-disease. The 
hip-joint gets a branch from the obturator, which also aids in the 
entsneons supply of the skin over the knee-joint. A patient knows 
where the skin of the knee is, but not where his hip-joint is. Tiie 
irritation congests the area in tlie obturator-centre for tlie hip-joint. 
l%e congestion extends into that for the knee-skin, and, accordingly, 
pain is felt there, as already expUiined."— [Ed.] 

P 2 



^laiKl 111 the ii|>|H'i" ]tait of tlie irm 
(•a^^• is <»t' j-'l'^'at ilitiicst. Tliis ('a 
^iniip (»f ivsiilts of mivoiis (listurba 
iiave seen, that irritation induced i 
upon a nerve, is sufficient to lead t 
in function and structure, and that 
may after a time induce a deterioi 
sufficient to produce, a furred tongue, 
or gangrene of the fingers. In Dr. 
was an ulceration in tine auditory 
enlarged as the consequence of thi 
absorbing and carrying the morbid fl 
to the lymphatic glands. Fortunatel 
are highly conservative in their ten 
the progress of the morbid fluid ii 
towards the circulation of the blood, 
influence might be more diflused, and 
to the occurrence of the more seriouf 
are in the habit of calling by the gen< 
I thought I might be excused this 
hardly think it requires an excuse, sii 
to bnng before you this very illusti 
which, as far as 1 know, have neithe 
tion nor a right interpretation. 



tlic rc-otii8, iiinl sartorius iimsolfs — iire iiun[>lii;il liv tlic 
Ulterior cniml nerve. Not only are nearly all these muBcles 
aapplied by the anterior crural nervo, butaoalao is the akin 
orer their uieertion, aa well as the joints which they move. 
We are all acquainted with the nunieroufl cutaneous iien-efi 
(branches of tlie anterior crural) which supply the akin aB 
&r as the knee-joint, distributed over the thigh, inclnd- 
ing the external cntaneons nervo, and corresponding with 
the subjacent distributiun of the anterior crural nerve to 




rmn ■ dliKctlon Dltbe Iniur fUe a 
Ondlli. IrarrlHl |»rtly Into Ihc hum U 



fiut. Into tbc loam uf Ote [«. <-. 

.*. e. T.ndDn of 8™it-I'iillno«ii 
Jilp fvifk if left in »if H, n-olvlnic pa 



the varioos muscles. But from these various cutaneous 
nerves I must select the long saphenous, which pursues a 
peculiar course, and runs ahead (seemingly, at first sight, 
without purpose) of all the other nerves downwards as far 
as the ankle-joint and the side of the foot. I Bay, at first it 
appears extraordinary that this long saphenous nerve 
should run away from its comrades, and apparently from 



2H THE THERAPEUTIO IHrPLrKNCE OF BEST [\xer. 

its proper inmicnlar aiid cufanpoua association, and procwd 
as far as tho inner aide of the font : but. when -we ome to 
examine this drawing, the thing ie explained. Here it ■ 
Hket«h ( Fig, 37), taken from a dissection, of the inner vSt 
of the knee. The Bartoriu8(b)iB seen to be most intimfttdj 
and largely attached to the fascia of the leg (A) ; in trntli, 
tho fascia of this portion of the limb must be oonsideredai 
part of the insertion of the sartorius. just ao the iaadi 
of the forearm is tt) be considered as part of the inscrtioi 
of tlm biceps muscle. Not only is the surtorius supplied 
by the anterior crural nerre. but as you will obatiTTB, 
the fascial insertion, extending down the lee somu OOD- 
eidorable diatanoe, even as far as the ankle-joint, when it 
is blended with the fascia over the foot on the inner side o: 
the inner malloolns, receives its nervous siipply from tbi 
same source. This explains why the long saphenoni 
ncr\'e. which is derived from the anterior cntral, shoiilc 
tlirust itself through tho fascia of the thigh, l^ecomc sob 
cutaneous, and then follow the course of the skin as far ■< 
tlie inner side of tho ankle-joint, and sometimes as far a 
the inner side of the dorsal aspect of the foot, thus follow 
ing the fascia. It appears a deviation from tho natuis 
order to find this anterior crural sending down branches t 
tho leg as far as the foot ; yet, when you come to eiamin 
this fascial association, you see that it is only carrying oa 
the princi])lc that the same nerve which supplies th 
muscle supplies the skin over tho insertion of the muscle- 
tbe sartorius having a long fascial insertion as far as th 
point I have already indicated, and requiring an eqnall 
long ner\-ou8 supply. 

Tho anterior crural nerve sends branches also to th 
hip-joint. I have here a little sketch (Fig. 38) by 11 
Durham, of the nerves of the hip-joint, which has bee 
taken from his notes of the various cases he met with i 
dissecting tho nerves going to the ca|>aular ligament of tb 
hip-joint. I wish you to understand that these articnli 
nerves are not copied directly from dissections, but &1 
sketches made from different nerves, and grouped togethi 
to convey to yon the idea of the supply of nerves to the Mi 
joint, although not with that precision of anatomy whij 
no doubt, is always desirable, and especially so wittii 



IX.] 



ARD THE DIAONOSTIO VALUE OF PAIN. 



215 



this eollege. We Bee filaments of the anterior crural 
Berre tnoed to the anterior part of the capsular ligament 
of the hip-joint ; this nerve also sending branches to the 
muBclea of the thigh, and to the capsular ligament of the 
knee-joint. 

Thus we see that the anterior orural nerve enpplies the 
junta which its muscles move, the anterior part of the hip- 
jcnnt, and a portion of the knee-joint ; and it supplies the 
•kin over the whole of the muscles of the thigh, as well as 




I the inner side of the leg, as low down as the 
limits of the fascia to which is attached the sartorius 
mnsole. 

It is important, in tracing the nerves in this way, to fix 
Upon them, as far aa we can, soma useful reference, bo that 
wo may not only bear them in mind, but see the practical 
application of the subject. Now, we know that the long 
aaphenons nerve follows the course of the saphena major 
vein ; and this is, no doubt, the explanation of patients 



,.,^,v iUKircssed you t^ 
Tilt' pain in tlic Irjj: tliiiK expo 
wlit'U the ]Kiti('iit is standiii<2;, wl 
n[' l)lo()(l, and thereby encroacliin 
the leg bo lifted up, and the bio 
pain is quickly relieved. It is 
that causes the pain under thorn 
very often reoommended (with 
patients) elderly persons su£ferin( 
or without sore legs, to raise the 
which they sleep in such a mann 
little higher than the pelvis; th 
nearly aU the night, and the reenl 
sure ; and if the patients are in be 
their lives, Nature has an opport 
injuries that have been inflicted. I 
sons by this simple contrivance 11^ 
freedom from the repetition of th 
lower half of the bed being slightl; 
patient was asleep or awake, the lej 
a slightly inclined plane ; the venoi 
easily to the neigh oourhood of the 
freely into the general circulation. 

CauBS of Ulcers an (Hp. T^^' ^'' 



AND THE DIA0NO6TIO VALUE OF PAIN. 217 

f we may bo term it, is retrograde. If that were the 
MMon, moers should occur by preference on the feet 
the toes, because these are more remote from the 
1 circulation than the ordinary site of ulcers from 
Be veins. Hence I suspect this cannot be the cause. 
Kplanation has always — at least for some time past — 
red to me to be this : — The superficial and deep veins 
) leg freelv communicate with each other in the 
xmrnood of the ankle-joint. The first two inches 
that point is the spot where the greatest stress is 
pon these superficiaL veins; below tliat point they 
communicate, and if the blood cannot return by the 
icial veins, it can do so by the deep veins, or vice 

But when you reach the point where that 
L patch of skin so often occurs in old persons, 

tne inner malleolus, the anastomoses are less 
tnd this appears to me to be the reason why ulcers 
rariooBe veins occur so frequently about that neigh- 
3od. 

return, however, to the subject of nerve distribution. 
irly the muscles of the knee-joint were grouped in 
ray : ten muscles to the knee-joint — four extensors 
z flexors — and they may be so now. Amongst the 
I were placed the sartorius, the gracilis, and the 
endinosus. Now I shall have occasion to show you 
itly that a better grouping of these muscles might be 
led ; for we shall find, upon examination, that they 
t receive their nerves from the same source, but each 
i different one. Thus, the sartorius receives its nerve 
the anterior crural nerve, the gracilis from the obtu- 
or adductor nerve, and the semi-tendinosus from the 
Bciatic ; thus clearly indicating the three different 
itions of those muscles. It is hardly fair, then, to 

them as three of the flexors of the knee-joint. It 
mv opinion, better to look at them in their functional 
itum, and then I think you will perceive a distinct 
tkm that the sartorius, receiving its nerve exclusively 
the anterior crdral, is, in ordinary circumstances, 
ited with the other muscles supplied by the anterior 
• So with regard to the gracilis, it is supplied by 
me nerve as that which supj^es the adductor muaoles ; 



218 THE THERAPEUTIC INFLUENCE OF BEST [Lb^' 

henoe tiie ^p-aciUs should be called an adductor rather tliu 
ft flexor muaclo. Again, the aemi-tendinoBMs roceirea iu 




This driwlng irpraienui neuljr tho wl 
popllMil upvx lo tbo InUrtor ot 



•upplyfng the . . 
tlguntnlfltlie btp'^oinL 



IX" AM) THE DIAdXoSriC VAIJK ('F IVMN. L'l'.' 

nerve exclu8ively from the great sciatic, whicli controls 
the flexors of the knee-joint. I shall have occasion almost 
immediately to allude to this more in detail. 

Here is a beantifal diagram, or rather drawing (Fig. 30), 
of a recent dissection made for the purpose of displaying 
the oourse and distribution of the obturator nerve. The 
trunk of this nerve is seen coming out as usual of the ver- 
tebral canal, between the third and fourth lumbar vertebree. 
I do not attach much importance to the point of exit, 
because you will remember that the spinal marrow ceases 
opposite the second lumbar vertebra ; there is no marrow 
below that point in 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 vertebrae, then passes down through the 
pelvis, and you will observe it in the drawing passing over 
the sacro-iliac articulation. I am disposed to think it sends 
some filaments to that articulation ; at any rate, it lies close 
to it, and would be likely to suffer from its proximity to it 
when diseased. The nerve then passes down across the 
brim of the pelvis and along its inner aspect, then over 
the obturator intemus muscle and through the obturator 
foramen (which in this drawing is exposed by cutting away 
part of the horizontal ramus of the pubic bone), where it 
throws a branch into the obturator oxtemus muscle. The 
obturator nerve then gives a filament to the capsular 
ligament, branches downwards to the notch of the aceta- 
bulum, and one filament to the hip-joint to be inserted 
into the base of the ligamentum teres. This explains those 
** sympathetic " pcdns 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 distribution 
of this nerve ; you see it supplying the obturator extemus, 
and here the adductor brovis — 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 accessory obturator 
when present. Here are filaments passing to the adductor 
longus and to the adductor magnus, and also to the gracilis. 
The muscidar supply of this nerve is very precise to the 



220 THE THERAPEDTIC IKPLt'ENCE OF BEST [LbcI 

obturator extemus, the three adductors, aud the giai 
Then trace these two ttensitivo filamontA i ooe pamea den I 
to tho inner side of the knee-joint, and iha other (a Mitsf 
the jioBterioT divisiou) proceeds throngh the aaaiujtcil 
magnus into the popliteal region, and there enters the 
knee-joint at its poattrior part. The distribution of thi» 
nervo is another illuBtratioD uf the eame nerve supplying 
moBcIeB and also the Jointe moved by them. 

XiOi:)king at the long course and ndde distribution of tJiil 
obturator uerve alone, it is obvious that there are many 
diRereut causes for pain felt along its branches to the inner 
side and interior of the knoo-joint; and here I would 
remind you of the importance and value of precise obaei^ 
vation with regard to the locality of pain on the surface of 
the ekin. Tracing the trunk of the obturator nerve, WB 
find it afiBOciated with many internal and external parts. 
Assuming the obturator aoTve to be the seat of pain on the 
inner side of the knee and within the knee-joint, it ia 

itlain that this utay depend upon disease within the vart»- 
iral canal, or it may depend upon some diseased oonditioib 
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, i>atient« com- 

Elain of paiti within the knee and on the inner side. I 
ave known patients complain of pain on the inner side of 
the knee when the disease was not in the hip-joint. I 
recollect a patient — a lady who Mr. Solly knows very well 
— who had a diseased condition of the articulation between 
the sacrum and the ilium, and suffered pain in the knee 
and other indications of hip-juint disease. As the obtura- 
tor nerve proceeds downwards, it is obvious that a psoas 
abscess might produce the pain in the knee. It also runs 
on the left side under the sigmoid flexure of the colon, and 
the colon, when distended by feeccs or diseased by cancer 
or Bcirrhns, is quite capable of producing pain on the inner 
side of the knee. Only recently I saw a gentleman from 
South Wales, who was the subject of stricture of the 
rectum from malignant disease. He suffered pain in the 
knee-joint and in tlie 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 



IX.] AND THE DIAGNOSTIO VALUE OF PAIN. 221 

tbe nervee on the anterior part of the sacrum, and also, no 
doabt, the obturator nerve. This was the explanation of 
the pain which he had experienced on the inner side of the 
biee-JQint, partly depending upon the obturator, and 
purtly also upon the distribution of the great sciatic nerve. 

About two years since a surgeon brought a gentleman 
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 ojit the cause." I 
examined the leg carefully, and it seemed to me that the 
miBcbief, whatever it was, had been impressed upon the 
obturator and sciatic nerves. I made some suggestions as 
to the cause of the symptoms, and ho said, " Well now, 
let us go into the other room, and I will tell you what 
happened." I then learned that this gentleman some tinu^ 
ago was going officially down to Southampton by the 
express. Before he started 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 South- 
ampton. I suppose he did not know the strength of liiH 
little sphincter ani, but he had to rely upon it in liiH 
emergency. As I have said, he sat quietly, but in great 
distress, imtil he got to Southampton, suifcring great pain 
in his leg. That was the history and essence of his case. 
It was pressure upon the sciatic and obturator nerves, 
which seemed to have been extreme in this nervous man, 
and led, I believe, to the painful symptoms res jx3C ting 
which I was consulted. 

We know that hip-joint disease is capable of produciiig 
pain on the inner side of the knee. This disease, on 
the whole, I suppose, commences more frequently in tlie 
ligamentum teres than in any other portion perhaps of 
the articulation.* Seeing that one branch of the obturator 

• Mr. Key, who originally (Med. Chir. Tre., vol. xviii. p. 230) 
faioogfat forward tliis view of the usual origin of hip-joint dispense, did 
m on the following grounds : ** The beginning of the affection is often 
to be traced to a fal^ by which tlie legs have been forcibly separated, 
■Dd tbe ligRinentum teres (stretched. . . . The motions of tlie 
joint that give the patient most pain are strongly indicative of ttui 
<eat of the affection. In the earliest stage, before the soft parts could 
well be affected, if the disease ooinznenccSd in the cartilage, cvcrsion cf 



.>..-'xMi ahmit this JiLTiinif 
tn l>c atta-littl to two />tlu r ur^^Minu-i 
inu.-t hr uiliiiittc*! tt> .^tioii;:;ly snj)i)<)rt 
di.-sra.S'. wIhmi \vc nijiciiihrr tluit, ill t' 

nroidtd of early hip-disease, inHanii 
wad always present as the chief, if n 
** A similar indication of the ligament 
pain sometimes expressed on pressiDg 
the acetahulum. In its healthy state, 
the hollo ^v of the aoetaholum, receives 1 
is swelled by inflammation the cavity < 
tection, and when pressure is made by 1 
upwards the ligament is compressed, anc 
01 pain. The circumstance, too, of 
des^yed by ulceration, when the head 
are only partially ulcerated, maj be con 
of its being very early engai^ed m the difi 
It is well-nig) 1 impossible to decide w 
is correct or not. If, in examining a < 
surgeon endeavours to make out the cond 
(rendering it tense by flexing and addw 
it outwards), he flnds it impossible — his ] 
ftom five to twelve— to satisfy himself 
either produce pain or increase it A 
possible for patients to die from the effee 
early stage, and when death has taken ] 
either no examination is made, or the ac 
for, and the hip-joint left unnoticed. T 
great interest, that where opportunities hf 
ing hip-disease in its early stage, the li( 
case b&Bn found chiefly or solelv im.^i-*--' 
(in whi^h ♦»'- ^* 



.] AND THE DIAONOSTIO VALUE OF PAIN. 223 

\ see how it ooours that disease in the interior of the 
Moint can produce, ' sympathetic ' pain on the inner side 
toe knee, and in the interior of the knee-joint. I do 
t know that it is important to insist upon this piece of 
fttomy, because there are other explanations of the point. 
we find that an inflamed tooth in the second division of 
i fifth nerve can produce irritation of the tongue, and 
ue it to be furred, surely it is not forcing the principles 
anatomy and physiology to say that the obturator nerve, 
ii^ involved in mischief in the hip-joint, may, by con- 
luty, convey irritation to the surface of the skin on the 
aer aide of the knee, and also to the interior of the knce- 
nt. But whether that bo physiologically the true ex- 
mation or not, we know it frequently happens that 
tients have pain on the inner side of the knoe, and 
en within the knee, when suifering from liip-juiiit 
lease. I think that if the distribution of the nerves 
are studied in this way, trying to fix u}>on them some 
actical reference in relatiun to symptoms which are 
bentimes very remotely situated from the real cause oi 
e mischief, it might tend to make the study of tliis part 
human anatomy more intensely interesting, and certainly 
an useful, than it at present api)ears to be in the con- 
leration of many surgeons. 

Beverting, for a moment, to the distribution of nerves 
I a means towards diagnosis, let mo remind you of the 
aertion of these three muscles — the sartorius, the gracilis, 
id the semi-tendinosus. The sartorius receives its ner\''es 

DDth after the first symptoms were noticed, almost the solo morbid 
ipearance was ulcerntioo of the ligamentum teres. 80, too. in a 
w recorded by MM. Martin and Collineau, and mentioned {loc. 
pr. Hi.) by Mr. Holmes, whore death took place a few days after the 
«t onset of the symptoms, the condition seems tf) have been identictd. 
tfaer conditions of the head of the femur, which mav be noticed uftcr 
cdson, point to the same ori^n of the disease, in tliat tlicv appear to 
Kiw that the first stress of the inflammation fell upon tlie hgnmentum 
m; thus ulcemtion of the cartilage is often most marked just at 
le ptiiiition of the lin;amentam ten.'S, and in a cose in which I recently 
Ecued the head of the fumnr (and I have seen a second very similar 
■e), a dibtiiict sequestrum lay not quite detachoil just below the 
m^ of the head of the femur, immeiliately beneath the thickened 
tmains of the ligamentum teres. 
See also note, p. 338.— [Ed.] 



■ niral ihtvl- (.■umiiig to the it 
branches of the obturator and 
ing to the 8am« point. And he 
natnre (Fig. 40). Hera(b) is th 




part of the anterior crural ; here i 
the obturator— that nerve which so 

* From tnch exfvrieDce as I have had d 
1 have been n DemoiiBtrator of Anatom; 

tliink tUfil thin hrancli is conalantly preaei 
he on Mr. Hilloi/s .».-'---■ 



AND THE DIAGNOSTIC VALUE OF PAIN. 225 

ftgain (e) is a branch of the small sciatic nerve, the 
ifions nerve associated with the great sciatic which 
ies the semi-tendinosus muscle itself. These three 
«, then, supply the fascia and the skin on the inner 
»f the lower }Mkrt, and just below the knee-joint, and 
irectly associated with tiie three muscles, the sartorius, 
racilis, and the semi-tendinosus, which receive their 
toB supply from, them. 

is not unworthy of admiration to see the precise 
on of these musdes. If you measure with accuracy 
jBtance of the points of insertion of these muscles 
yeaa. the fulcrum (or the hip-joint) and resistance (or 
xyt), you will find that these muscles are inserted just 
id the mid-distance between the fulcrum and resist- 
Hence the gracilis is a great help to the adductors 
) thigh ; it helps to adduct the leg ; it goes far enough 
IBS Sie limb just beyond the midway between the 
im and the resistance. Again, the semi-tendinosus, 
ireifiil flexor, and the sartorius in like manner, are 
bed just in the same way. The sartorius, then, is a 
powerful assistant to the muscles employed in the 
^Ebrt of progression, slightly everting the leg, spread- 
nt the foot, and widening the base of the column, so 
make it more ecusy for man to maintain the upright 



a former lecture I made use of two or three diagrams 
1 11 and 12), to point out the importance and value of 
ing precisely the distribution of the nerves to the skin 
e head and face. If a patient complain of pain at a 
in part, supplied only by one sensitive nerve, it is 
in uiat nerve must be the seat of the pain, 
w let us apply the same method in examining the 

of pain on the inner side of the knee. Here are 
m from three different sources — the obturator, the 
ior crural, and the great sciatic. It is quite clear, 
that if the patient complain of pain on the inner side 
e knee-joint, we ought not to be satisfied without 
baining which of the nerves produces that pain. We 

that there are three possible lines of direction for 
pain, and we are bound to examine those three lines 
section for the purpose of ascertaining in the coiu'se of 

Q 



•■• « ». V^ O*- 



iiii<:;nt ])ro(nice 
Let us fix {mother ])ractical . 
«listril)nti()n of nerves. From i 
tivc explanation of what is torn 
joint disease : — 



Explanation of Hyderieal 

The saoral ganglia and the lo 
sympathetio nerve are oonneoti 
nerve, and partly alBO with the ob 
ganglia are oonneoted Ukewiae ^ 
throuffh the broad ligament to the 
I think we have here, then, an ei 
oceurrenoe of what we call hysteri 
knee-joint. If the nerves in the 
in a state of irritation, that irrita 
these sacral nerves or to the < 
aocordanoe with the generally reo 
of nervous influence, irritation or 
at the other peripheral or articula 
Hence it may be expressed withi 
inner side of the knee-joint, or ii 
joint, because the hip-joint as w 
receives its nerves from these va 
terior part of the hip-joint, you "w 
coming: to i* ^'^•^ ^^ 



1 ASD THE DIAGNOSTIC TALVE OF FAI!t. 227 

teUe expUnatioii of the fact, that of all tho joints in 
t kniun body affected hysterically as we torm it. noiif 




I, ftWIOB of totoitliK (nlcnu « onir) no^Tliic mlnnM 

(tail Bsmi iDd (rmpMbcUc ntm. /(laiigUiot*TioF*tlH>lciHrvF, umini i<< 
■ifc «th» br lonaKniHiul SUmniM. uhI mvlvlnf; bniKha trviB. u i»11 i> 

■ !»■ « Ipjlciw UwdlncUmB wUch lor iDintlul. utprln*. or ovuliui Irrluitim 
tfiM psnaa ccntrUnnllr, clUwr dtRctlj tockwinb to th« aUn In thit n^ti, 
w Blp* fjtmti wlui > q>lni] ntrra to IK Dxuenliir, tnimliir, •» cnUwou> 

■o frequently involved aa those of tho hip and the 
e.* By tracing these two nerves, I thittk we may fiud 

Bir J. Puet, to whoae lot it has Mien to see more of the«e mn^t 
I to any □thM' Burgenn, mve, perhapt, the late Sic B. Broilie, Bptnks 
4low* in bit Clin. Lect aiid Eesfija, eilited hj Howard Mnnli. 

fl : " Among all the joints, the bip and tlie kot-e, which are tlii' 

I fteqiwnt Beats of rea! diseaio, are eqaallj so of the mimifry— 
it not ewy to aceoant for. It may be due to mental luianciatinii, 

SI nncoDBciotitly. or to a mingled inhtritoDce — for instani^', (» 
Biitaoce of nervoiu (^oDBtitiition and of relative wuikucBB in tlu' 
i «r jcdnti moat weak in prajteniton." — [Ed.] 



228 THE THERAPEUTIC IIJFLCEKCE OF BE6T 

a probable interpretation of that frequency. I have kr 
conatruuttd a diftgram intended to reprewint what 1 lu^ 
been ulluding to. Suppose thiB (/) tu represent tbe lire 
giingliit of the aympatlietii: ; we have then a apioal Jivt^ 
(d) attached to the epiual marrow, and taking its onwu 
course to the muscles and the Bkin. We know that thn 
spinal neryee communicate with the ganglia, and ao. by \i 
sympathetic branches travelling along the arteries (f 
reach the inteetino (e), ntoruB, and ovaries. Let us aasiui! 
then, that a patient may have irritation ft'om any cause 
the intestine, in the uterua or ovaries, or iu the bro 
ligamentfi. On this map wo may trace the course of tli 
intestinal, uterine, or ovarian irritation through the gangl 
through the spinal nerve and spinal marrow, thence to 
reflected to any part of the peripheral or articnlar dist 
button of that same spinal nerve. This condition, 1 app 
hend, is eometimee verj' clearly recognised in the case 
the intefrtiint'S, Wbo in there that has not ft-lt grip: 
pains in the interior of the intestines from some mor 
agent lying there, or from drastic purgatives tiaveTsi 
the gut, accompanied by pains or cramps in the leg, i 
pains in the loins? — conveyed in the latter instance hy 
filaments of spinal nerves, which pass to the posterior p 
of the body or the lumbar region. And is it not a oomn 
occurrence in cases of uterine and ovarian irritation 
the patients to complain of pain in the loins, but parti 
larly over the posterior part of the sacrum ? The ovai 
and uterine nerves traverse the ganglia of the sympathy 
and so reach the spinal nerves. Hence the morbid 
fluence conveyed by the posterior branches of the epi 
nerves to the skin over the lumbar and sacral regi 
explains the lunibar and sacral pains experienced by b 
patients. 



ANB THE DIAGN06TI0 VALUE OF PAIN. 229 



LECTURE X. 

UAB AMD omrAiriouB miTBiBunoir of the nebtes of the 

■— DBLOOATIOir AXD OQXmiUOTIOll IS DIIBA0B8 OF KNEE-JOIKT — 
kraOMT — ^mnOULAB AVD ODTAVBOUS DISTBIBUnOK OF THE OLU- 
's VBBVM— OBDIB OF BUPFLT IS THH DI8TBIBUTI0N OF NBBYES 
■FfflBEVT MfJ8CLI8-— PADT OV OVB 8IDI OF PENIS DEPENDING ON 
AOE or THE FEBIVBAL BBAVOH OF THE INFEBIOB GLUTEAL NEBVE 
ILAIOKD BDB8A OV T0BBB08ITT OF ISOHIUIC — CHELATION OF THE 

vcnrauM TO ocTAnons avd mosoulab dietbibution of nebves 

PHJOATKnr TO PEAOnOE— BELATiOV, BT HBBYOUB DI8TBIBUTI0N, 
m* PBUOASmOC to THB XHAPHlUaM. 

e latter part of the last lecture I directed your atten- 
x> the numerous nerves which are placed around and 
ii the interior of the knee-joint. I observed that 
nerves are derived from many sources, and I may 
idd that the great sciatic not only sends branches 

tthe popliteal region to the posterior part of this 
t its external popliteal branch supplies numerous 
filaments to the outer side of the knee-joint, both 
) and below the inter-articular speuco. The distribu- 
)f these latter nerves is well shown in this sketch 
42^ taken from Mr. Swan's book. 
lirelt especially on the distribution of the great sciatic, 
nterior crural, and the obturator nerves to the three 
lied flexor muscles inserted on the inner side of the 
, and to their fascial insertion, and to the overlying 
I took occasion to remark that these nerves ought 
I made the medium of an attempt to elucidate any 
.tions of pain which might be experienced on the 
• tide of, or within, the knee-joint. These observa- 
are, of course, directed to those cases where the pain 
treme or severe within the knee-joint or on its inner 
when there is not the slightest evidence given by heat 
mJ inflammation, the absence of which clearly indicates 
•aeh pain depends upon a cause situated remotely 



TIlECArElTK.- INFLTENCE < 



liniiL IliL- i"iiiit (if miinifestatioii. 1 t-u(kav(>nred U- bL"« 
tlmt by tracing these nervee upwards or oentrally. * 
havo an opportnnitj- of detecting the real cause of the pi 




1 think wo should make uao of these nerves for another 
j)ur])OBo. It is (^uite certain that local antesthetics, applied 
to the cutaneouB branches of ner^'es which supply the 
muBclcB, have a ]iowcr of action upon those muscles whic^ 
reduces thoir 8]iasm, lessens their contractions, and thus 
remove one source of irritation from an inflamed joint. I 
shall not have occasion in this lecture to speak on this aub- 
ject again ; but. as aome think that in the use of fomenta- 
tions it is a matt«r of little imjwrtance whether they be 
medicated or not, 1 beseech those who do so to carefully 
reconsider the opinions which they may have formed on 



X.] 



AND THE DIAONOSTIO VALUE OF PAIN. 



tlin mbject, beoaTue I am quite certain (and I speak from 
a fur amount of experience, and close observation, too, on 
the matter) that local anssthetics applied to the skin over 
the knee-joint have a power of dimiuiBhing pain — in the 
Mp-joint, for example. They oertainly have a capability 




of diminiflhing exoeedve sensitiveness, even in the interior 
of the knee-joint. I verily believe (though this is referring 
apparently to a small matter^ that the reason why these 
applications are so often inefioctive, and why they are not 
more frequently employed, is, that the solutions are not 
■btmg enough, and that the proportion of the anfesthetic 
materials is not sufficient. 

Another disturbing cause in an inflamed joint, as I have 
already intimated, is muscular force, the muscles nnooas' 



■^■i2 T[[i: TIIEHAFEUTIC INFLUENCE OF BEST ^LcT 

iiiglycoiitractiiiKiluyainliuglit. In L-vcrj- oasc of ilis«a»il 
joint, if you will oompote with tiiis muecular contnctiati 
by the means of some meohanical rosist&noe, mch as a 
firm, resisting eplint, you will counteract its effect. 

I will confine my obeervations in this lecture to the 
knoe-joint, and I only enter upon the subject for the eake 
of giving a little practical interest to what might otherwiw 
appear to be a matter of dry anatomical detail. Havijig 
dwelt upon the anatomy, which is in itself very importanl, 
I fcel that one ought not to lose sight of its practiial 
applioation ; for if we cannot make anatomy and phv- 
sioio^y useful in practice, the information is 8c«n^ 
worth its acquisitiun. 

Fig, 43 represents a diseased kneo-joint, whore the 
muscles have had their fullest opportunity of doing, »tt 
speak, exactly what they like with the joint. It follow 
the common rule of dislocation of the tibia and fibula oat- 
wards and backwards, and points at once to the cause of 
the disli>cation taking that direction. I think it will be 
in accordance with experience that in almost every caw 
(I do not like to say every case, because some exceptionil • 
instance may have presented itself to those present) tbt 
tibia and Jwala are dislocated backwards and outwardi 
under the influence of the faieeps. and rotated inwards by 
the pojilitouB.* N'>w, the biceps was shown in my lust 
locturo to be supplied from nerves which supply also the 
interior of the joint. For the purpose of sliowing the 
application of this point, I say wo ought to resist muscular 
force through the means of splints or other mechanical 
resistance, or wc may divide tne tendons of the muscles 
which produce this displacement, 1 have a case which 
will serve to illustrate this point. It is only one of many 
that I might adduce, and hereafter I may be able to develop 
this subject more completely. 

lliis sketch (Fig. 44) was taken from nature on the 3nl 
ofJune, 1861. Thehistory of the case is very short. The 

■ Tkij displacement b«iiig pennitted to tnko place by the aonening 
and uloerstion of ttie lii^ineiitB, more psrtlcnlitrl; the omoiiU, tlM 
aDterior of whiclt obecka rotation inwards, Bad fta wuntsncta tb« 
pDpliteus, while the poaterior pieTeots rotation outwards, the aolioB of 
U» bicepfl.— [Ed.] 



I] AHD THE DIAONOSnO VALDE OF PAIN. 233 

jxtieDt is aaw sixteen. He wu admitted under my care 
U Gvfa Honiital in October, 1856. He had already been 
in a London hospital between three and four months, and 
liad left it six months before I saw him. The sut^eon 
Cnder vrhooe oare he was, judgiug from the boy's appear- 
knoa, from the snpparation taking place in the joint, 
the general tendency to displacement, and the constitu- 




tional distorbanoe from which he was suffering, the indica- 
tiona of perhaps a rapid death, proposed to the patient that 
the 1^ ahoold be removed or the joint excised. The boy 
waa 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 &om the hospital. In October, 1B66, 
he oame under my care. At that time the joint waa in a 



i'.\ 'iiii: THt:i;Art:rTir infi.i'esce of kest [hv^ 

l.id C'iiiL(liti>.ii. tiK.R' was a <i(-^\ .k-al of ewelling, Mipp""- 
tiou had octurred. and abeCGiaes were discharging pu 
freely. The leg was raiher moro tlian eemiflesed; the 
jiain in the jdiot was not very severe, exoept when it vaa 
muved or handled ; uid the amount of dtBolutrge ww aatt- 
what diiuiuished. The whole of the joint and ennouiuliiig 
struoturos were much awoUen from infiltratioD with aerna 
and lymph. Seeing the boy in this condition, and havii^ 
iibservod several other like cases (one as early as ISM. 
"■hero active disease was going on. and where, after I W 
divided the t«ndonH of the flexors, the patient did very 
well), I felt that I might trust to previous expcrionoe. In- 
stead, therefore, of proposing amputation or excision. 1 
resolved to divide the tendons of the flexors, which wei» 
dUiturhing the joint. 

Three weeks after admission, and after giving the patieut 
chloroform, an attempt was made to put the leg straight, 
hut without success, the miisclue being too contracted ; » 
that it became necessary to divide the tendons of Uu 
flexors. I divided the tendons of the biceps mnscle, th* 
gracilis, semi-teudinosus, and the somi'mombranoBus. TfaB 
latter were all divided in the popliteal region, doM t» 
the inner side of the head of the tibia, and the biocpl 
tendon was severed about one inch above its insertion. 
taking fare, of courw, to avoid the piTotieal nerve. 
The limb was then put upon a straight wooden splint, 
and remained bo during eight months. By the aid of 
simple strapping and pressure, the joint soon became 
free from pain. At this time the leg was nearly straight 
and the jwticut was almost free from any constitutional 
disturbance, the discharge being exceedingly small. It 
was then thought right that he should go to the Margate 
Infinnary, whither he was sent by the lienovolence of the 
late Ht. Couchman in the summer of 1858. He remained 
at Margate one year and ten months, supporting himself 
on crutches, and afterwards using a stick for sevoral 
months. Whilst at Marcato the wooden splint was re- 
moved, and a gutta-percha one ])ut on the limb, with a 
bandage. Soon after that the knee began to be a little 
flexed, and the tibia to be displaced slightiy backwards and 
a little outwards, so as to deform the joint in rather a worse 



•V" AND THE DIAriNOsriC VATJK Of I"AI\ L^ 



— ' ' ' 



banner than the sketch indiciites. 1 thiiik it was an error 
to take off a resisting splint like wood or thick leather, and 
to put on gutta-percha. I am certain that when the 
boy went out of Guy's Hospital the knee-joint was straighter 
than is shown in the figure now before 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 three or 
four miles without difficulty, and was occupied the whole 
of the day in business. On examining him, I found the 
patella fixed to the femur, but there was a slight degree 
of motion between the tibia and femur. It seems to me 
that this is a very good illustration of the value of rest 
considered with reference to the disturbing causes — those 
disturbing causes being the muscles, which disturbed the 
joint in oonsequonoe of the irritation in the interior of the 
joint being conveyed to the muscles, through the same 
nerve that supplies both the joint and the muscles. I did 
nothing more than any other surgeon 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 time 
Nature consolidated the parts, leaving the boy with liis 
leg in the state represented, which is not exaggerated in 
the slightest respect, but is an exact representation, as far 
as the artist could accomplish it, of the leg as it was on 
June 3rd, 1861. 

Having to trace a few more nerves in their muscular 
and cutaneous distribution, I will take the su^xiiior 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-sciatic foramen, it is 
distributed to the gluteus medius, the gluteus minimus, 
and the tensor vaginae femoris. In this drawing (Fig. 45) 
we see the associated cutaneous lumbar nerves coursing 
along the lower part of the abdomen, then over the crest 
of the ilium, and distributing themselves to the skin over 
the gluteus medius and the gluteus minimus. You may 
observe how they seem to avoid the skin over the gluteus 
maximus, which, together with that muscle, is supplied by 
the small sciatiG. Thus we have another example of tho 



236 THE THERAPEUTIC INFLUENCE OF BEST [Lwr, 

same nerves BUpplylng mU8clo« and the skin over Uion 
mueclos, ulthough the cutaneous and muscular pOTtkme^ 
not, as is uHuttl, travel together. 
^ Speaking of nervous supply. I might direct your atten- 
tion to two nerves which take a very peculiar course, ud 
may, to some minds, denote the special interest vhich 




belongs to this inquiry. I refer to the course of the spinal 
acoeesory and recurrent laryngeal nerves. We see the 
spinal accessory arising from the cervical portion of the 
cord, passing upwards, and blending with the sub- 



X.] AND THE DIAGNOSTIC VALUE OP PAIN. 237 

nerve. The snb-occipital is almoet exclusively a motor 
nerve ; it is usually devoid of any sensitive filaments, and 
is distributed to the 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-occipital nerve, before it sends filaments to supply this 
group of muscles, receives a branch from the spinal acces- 
sory. When these muscles are in a state of contraction, 
they carry the head backwards, and fix it for a purpose 
which we shall see presently. The spinal accessory nerve 
passes to the interior of the skull through the foramen 
magnum, and out of it through the jugular foramen, where 
it has intimate structural association with the pneumogas- 
tric nerve especially (I do not detain you with the minutiae 
of this, but simply state the broad fact) ; and having esta- 
blished 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 
sub-oocipital, those which have the power to fix the pos- 
terior part of the skull : the message is then sent on 
to the stemo-mastoid and the trapezius. The posterior 
part of the head being already fixed, these two large 
and powerful muscles act more effectually in concert with 
the ^enmogastrio nerve in the proce^ of respiration. 
From this explanation I think we 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 point out what I shall not now, unfortunately, 
have the opportunity of laying before you in its extended 
form — ^that the same nerves which supply the mucous 
membrane supply also the muscular apparatus acting upon 
that membrane. This is a uniform law with respect to all 
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 pneumogastric distributes itself 



238 THE THERAPEUTIC INFLDENCE OF EEST [iBT. 

upon the mucous membrani^ of the interior of the laryni, 
inoludiug tho laryugeal surface of the epiglottis. Tbii 
same pneumogastric nerve ^euds off a rBcurrent brand], 
distributing itself to all the intriuHic inuacle* of the larynx, 
except the crioo-thyroideus. Thus the pueumogaatric nova 
Hupplies the musoleA which move tho vocal cords, and the 
meiubrauo lining tho interior of the larynx. Here, then, 
wu have an illustration of the same nerve supplying tin 
muscular apparatus which ttcts upon the vocal coidl 
with their investinff mucous membrane, as well as tto 
rest of tilt) laryngeal muoous membrane and tho joints of 
the larynx, just as we have seen the same nerve Bupplying 
the niuflclcs moving the joint, the interior of the joint 
and the skin over the ineertton of the muscles. IIh 
superior laryngeal (or sensitive nerve) is accom]>anied by 
a motor branch, which proceeds directly to the cricn- 
thyroideus muscle ; and while considering this criou-thyroiil 
brant'h, I must remind you of what I just now stjttt'd— thai 
no matter how rapidly thu ntrvouH tiiHueiifo passL's, it niusl 
reach the nearest point first, and that is apparently the 
reason why this little nerve takes so short a course to the 
orico-thyroidouH. It has long been my habit to regard the 
crico-thyroidei as the muscles which are intended to tune 
the vocal instrument ; and, as the instrument must be tuned 
Ijefore it can be played upon, so this nervous influence first 
reaching the crico-thyroidei, the vocal cords are put intu 
a due state of tension, preparatory to the more precise and 
accurate influence of the other muscles acting Erectly and 
indirectly upon the vocal cords. But let us try to explain 
why the recurrent laryngeal takes so peculiar a course. 
Some say it must be because it has to wind over the sub- 
clavian arteiy on tho right side, and around the arch of the 
aorta on the left side. Now, it has fallen to my lot to see 
examples in tho dissecting-room in which the nerve did not 
wind round the arch of tho aorta or the subclavian art«ry, 
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 recurrent nerves, goes from below upwards. And I 
think it will be apparent why this nerve takes its coume 



XJ AND THE DIAGJIIOSTIC VALUE OF PAIN. 2.'{9 

from below upwards. It is an essential thing, to my mind, 
that the muscles which are acting npon the air as it escapes 
aatwards from the lungs so as to make the voice, should 
be acting from within outwards— that is, from the lower 
part of 'i^e lairnx to the upper. It is quite obvious that if 
they acted in tne 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 singularly recurrent course, ulti- 
mately distributing itself to these different muscles. The 
spinal accessory and the laryngeal nerves are, I think, two 
good examples of the rule — that there are strong reasoiiH 
for the remarkable order observed in the supply of nerveH 
to miiacles (see pages 179 — 182). 

I will now adduce another illustration of the same iiei-ve 
sapplying muscles and the skin associated 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 frequently presents 
itself to the dissector as a single trunk. Hero, however, 
you will observe that the muscular branches seem to 
oome off from the great sciatic. Now, although this is 
not quite in accordance with what I might have wished, 1 
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 from the great 
sciatic. I have very little doubt, however, that if these 
motor filaments had been traced upwards towards the 
spine, we should have there found intimate associations 
between the cutaneous filaments and the motor portion 
of the same inferior gluteal nerve. I do not speak lightly 
of this explanation, because I have several times — not with 
this nerve, but with other nerves — found that to be the 
case. Where the motor nerve comes off unusually, if you 
trace it upwards some distance towards the spinal marrow, 
you will find that it is in communication with its ])roper 
cutaneous nerve. Let us suppose that these muscular and 
cutaneous branches of the inferior gluteal nerve are in their 




>f J Is >■ 

111 lb ' 
■ ik -«* I 

III nl I 

J IjiSf si-' i 



AND THE DIAGNOBTIC VALUE OF PAIN. 241 

1 aBBOciation, and we shall Bee that this inferior 
1 nerve supplies the glutens tnaximus muscle, and 
ofat cutaneous branches, which distribute themselves 
be lower edge of that muscle. It then sends a branch 
the ischium, towards the perinseum, and here it is 
[Fig. 47) coming close to the tuberosity of the 
m, near to the seat of a bursa placed there ; after- 
it joins a branch of the pudic nerve, and they 
d together to the genitals. You will observe that 
Inteus maximus is firmly inserted into the fascia 
3 thigh ; it is one of the most important muscles 
isrenoe to this fascia, which may, indeed, be con- 
1 as part of the ins^iion of the gluteus maximus. 
mght, therefore, to find nerves proceeding froni 
%me trunk which supplies the gluteus maximus 
i akin over this great length of fascia: and so we 
rhe fascia is there cut through, and the cutaneous 
I are left distributing themselves with beautiful prc- 
to the skin over the posterior part of the thigh, and 
down below the popliteal region. Thus the distri- 
i of this nerve, wiiich at first appeared to stand 
position to the principle of distribution which I 
mentioned — viz. of the same nerve supplying the 
8 and also the skin over the muscle — is in reality a 
; exponent of that view, when we admit that this 
is filrmly connected with the gluteus maximus, and 
to be considered as part of the insertion of that 
e. 

;h regard to the branch of the small sciatic which 
inwards to the perinaBum and genitals, I think we 
ee reasons, associated with coitus and the action of 
inteus maximus muscle, why a cutaneous branch 
I go to this region. This is a subject, however, 
I do not wish to dwell upon, but merely direct your 
ion to the fact. 

I recognition of the distribution of the pudic or 
sal branch of the inferior gluteal nerve is sometimes 
^nt in practice. 



R 



THE THEBAFEUTIC INFLDEKCE OF BEST [Uct. 



Case of I'aiii on one eideof the PeaU depending on D'wiolivj 
the Pmnieai Branch of the Inferior GltUeal t/r Small StMe 

Soon after the denth of the ]&t& Mr. Key, a gcntlemu 
came to mt) saying, " I have eoiuethiug the matter with a^ 
uixtthra null bl&ilder, &ud I suffer paiii in the peuis." He 




care of Mr. Key and another sargecoi, 
1 for diseased bladder and various other 



s situated. He traced the pain, crossing the a 



A.l AND THE DIAGNOSTIC VALli: OF TAIN'. L' 4 . 

ramus of tho ischium, to one side of the penis. This looked 
more like a one-sided than a central cause. Upon careful 
examination of the neighbourhood of the tuberosity and 
the ascending ramus of the ischium, I found a considerable 
thickening of the soft parts, and, after some manipulation, 
I felt a cord-like mass rather bigger than whip-cord. On 
making pressure upon it, he said, ** That is what gives me 
pain." It was quite apparent that the cause must be asso- 
ciated with the perinseal branch of the inferior gluteal or the 
pudic nerve, for no other nerves go to the side of the ])enis. 
I think Mr. Key and others had well sought for the cause 
in the pudic nerve, but had not detected it. It was obvious 
that pressure upon the perinaeal branch of the inferior glu- 
teal nerve gave the pain along the side of the penis. Upon 
inquiry it turned out that this gentleman was accustomed to 
sit upon a hard and somewhat uneven seat ; this led to the 
thickening of the soft parts, and to the pressure on the 
nerve which produced the painful sensations he had ex- 
perienced. I explained what I thought was the cause of 
the pain, and he said he was willing to do everything I 
thought necessary. I then applied some strong nitric acid 
over a circle about an inch and a half in diameter, cover- 
ing the thickened structures, which included the nerve, so 
that he could not sit ujjon the ])art ; 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 thing was done but this. We see, 
then, that an acquaintance with the distribution of even this 
branch of nerve may be of the greatest importance in 
practice. This patient was cured by removing pressure 
nrom the nerve, and so giving it rest. 

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

*^ .Enlarged Bursa upon the Tuberosity of Ischium. — On 
August 10th, 1860, my attention was directed by a lady, 
aged sixty, to an enlargement near, and rather on tho an- 
terior 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 numb- 

R 2 



244 THE THEHAPEtTIC INFLUENCE OP BEST [l.tn. 

ncBd an<l painful BcnBation iu the part itself, and Dfnfk 
liourhood of the labium on the eam^ §i(lc. more esjieciRlly 
when ridinp; in her carriage and sitting in her study, bw 
had only discovored a marked enlargemetit a few ixji 
before. 

" On examination, a deeji-seal*<l moveable or pliut 
swelling could be detected, which, on being compremd 
by the fingers, conveyed a somewhat Temicular eeosalidii 
with a sense of fluctuation in it, though c^st-like, lla 
examination was painless. Iodine was applied daily. tJi 
the use of a hollow eeat recommended. The swelling in- 
creased in size, andbecame more painful. Mr. Hilton wi» 
considted on Aug. 25th. The swelling had become Jsum 
tense and globular, with indistinct fiuotuation, surrounded 
by some undefined consolidation and enUrgement. Hi. 
Hilton pronounced it to be an enlarged bursa, and thicken- 
ing of the Btructttres surrounding it : no heat or rednev: 
noliifai uv idciifLM if sujijui ration. The patient was directiii 
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 effectually remove all pressure from the part. He 
directed an eschar to be made with nitric acid over the 
enlarged bursa, so as to prevent the patient sitting upon 
the part, Ac. The eschar separated on the sixth day, and 
the swelling gradually diminished. 

" At the end of September — that is, in one month — 1 
could only detect an ill-defined, deep-seated vermicular 
thickening, which has since still further diminished. 

"May, 1H61. — The patient continues to protect the part 
irom pressure by the pad, and has not been reminded of 
her affection since October, nor does she now suffer any 
in <»n venience ." 

I bad known this lady for some time, and was aware 
that she sat daily during many hours, occupied in literary 
pursuits. She c\])lained to me 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." 1 have no doubt 
it was that distorted position which led to pressure upon 
the bursa, and thence to thickening of the surrounding 
structures, which, involving the perineal filaments of the 



X] AND THE DIAQKOSTIO VALUE OP PAIN. 245 

inferior gluteal nerve, caused these unusual sensations in 
the neighhourhood of the vagina. Here is another case 
illostrating the value of recognising the distribution of 
even so small a branch as the perinaBal, derived from the 
inferior glutectl nerve. The bursa was cured by ** rest *' and 
the v€tginal symptoms subsided. 

Ab a last observation with respect to the distribution of 
oatanedus nerves, and their influence upon the muscular 
apparatus — in the hope of laying the matter before you 
more explicitly another time — I would remark that part 
of the contraction resulting from the cicatrices of bums 
may depend upon the circumstance that when the bum 
takes place the nerves of the skin are exposed. The irri- 
tating 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. T his may remind us of the importance of using 
mechanical extension during the cicatrization of bums. 

It seems to me that if the anatomy which I have ad- 
vanced for your consideration be correct, and the law of 
nervous distribution which I have affixed to it in reference 
to the joints be true as a broad principle, we ought to find 
a corresponding arrangement in the serous and mucous 
membranes of the body. The same trunks of nerves that 
supply the muscular apparatus should supply also the 
serous membranes which those muscles move. With regard 
to the mucous membranes, also, the same nerves that supply 
the muscles which move the walls should supply the mucous 
membrane which lines those muscular walls. Ilere, per- 
haps, it might be thought that in dealing with the peri- 
tonenm, the pleura, and the pericardium, 1 am treading on 
the domain of the physician. But surely these parts 
belong as much to medicine as to surgery, and to surgery 
as to medicine. It appears to me to be a fictitious line 
which divides the principles of medicine from the prin- 
ciples of surgery. Both must be essentially based upon 
precisely the same physiological and pathological laws, 
and therefore if I, as a surgeon, show you that there is a 
certain systematic distribution of the nerves to the muscles, 
to the skin, and to the joints which those muscles move, 
surely I may be at liberty to extend ray illustrations to 



246 



THE TBERAI'EVTIC IKFI.lfEKCE OF REST [LkT. 



other imrts of tho Wly — via. to the iterous u well m the 
niuooiis nienibrAui>B. Ou this part of my Bubjcct I jirapuW 
tu dwell only for & short time. 

L«t lis take, for example, the peritoneum ; and I wiJl 
■livide the abdomiua! parietee into two parbt — an nppw 
.'knd a lower, the line uf demarcaticin being the lunhilicu; 
the upi>er part of the abdomen being the re«piratory por- 
tion, wnilut the lower half of the walla may be considendii 
strictly a bdinuinal. Yon may see in Fig. 49, d. theiagnt 




i:on)tng do f th ) t tl abdo nal m ticles, and 
biippl^'iug ale tl pc t eti u ut the al dom nal parietee. 
Ill this dra fe 'I g -i taken f ma ec nt d Bgectiun, 
we see so ot 1 e en u n s d pluj d i>on the akin 
Lit' the extei'iitr of tlie abdoiuen. Here, then, we have the 
Miiue uervcH wliioli mipplj' the lower half of the abdominal 
miiHclct) GxtL-nding themsc'lv«« to the cutaneous aspect 
bi'Kiw the uiiibilicus, and diiittibuting blanitntH t^j the skiu 



X.j AND THE DIAGNOSTIC VALUE OF PAIN. 247 

over the muscles which are supplied by the same nerves. I 
might also say that I believe that the same spinal nerves 
send filaments to the visceral peritoneum covering the in- 
testines. I may direct your attention again to the diagram- 
matic map (Fig. 41) which I used in my last lecture to 
point out the relation of the spinal and sympathetic nerves 
to each other, and to indicate the nerves of communication 
between the spinal marrow and the sympathetic ganglia. 
I venture to express my belief that some of these filaments 
of spinal nerves go through the sympathetic ganglia, and 
thence, associated with the sympathetic, travel upon the 
artery, and become ultimately distributed, I believe, 
to the walls of the small and large intestine. I 
remarked in that lecture that there could be but few 
persons who had not experienced '' painful sensations " 
in their intestines, and that such sensations could only 
be derived from, or transmitted through, the spinal 
nerves. The colon is the intestine which ought to be phy- 
siologicaUy associated with the lower half of the abdominal 
walls, because they aid the peristaltic action of the colon to 
empty the large intestines of their faBcal contents. Here 
we see, then, that the same nerves supplying the abdo- 
minal muscles supply the parietal peritoneum, and the skin 
over those muscles ; and further, through the mediun of 
such a map as Fig. 41, we may have the indication of 
some of the spinal nerves proceeding to the serous mem- 
brane of the intestines, or to the other structures forming 
the walls of the intestines. The muscular apparatus of 
the abdomen, its serous membrane, the skin over the 
muscles, and the intestines themselves, are thus brought 
into harmonious associations. 

I think I am not putting this proposition too strongly 
when I say that we never see a case of acute peritonitis 
where the abdominal parietes are not drawn backwards 
upon the contents of the abdomen. Perhaps the only 
exceptions * are cases of the asthenic forms of peritonitis 

* It la not only in cases of pysemia that the presence of peritonitis 
may be ill-marked. This condition, though described as possedsina; 
signs 80 unmistakable, is frequently latent 1 allude more particularly 
to cases of paracentesis in chronic visceral disease, whether of the kidney 
or liver. The traumatic form which comes under the notice of the 



248 THE THERAPEUTIC INFLUENCE OP REST [Ua. 

which depend iipon the blood being poisoned ; then ^ 
influence of the nervous syistem ia as nothing, and w 
should not expect to And this teneo and tight conditiim rf 
the abdominal parietea. But excluding this kind of can. 
if the patient haa acute peritonitis, the abdomen is. I 
believe, always drawn backwards, but with oocaaoiul 
spasmodic contractions. This, I apprehend, is an illustrstioii I 
of the effect of the same nerves supplying the j>eritoDeniii 
supplying also the abdominal musdes. The irritation of 
the peritonitis causes the oontraotiou of the abdominil 
muscles, and the sense of constriction or carrying hack- 
wards of the abdominal parietes towards the peritoneum. 
A patient suffering from acute peritonitis always lies 
with the thigh bent upon the abdomen. There mnstlK 
Home reason for this, and I suppose it ia'for the pniposeof 
removing tension, or rather, l should say, of removing 
opposition to the contraction of the abdominal muscles. 1 
think the latter must be the true explanation of this posi- 
tion of the patient. This contraction may, in one sense, 
bo regarded as a spontaneous effort on Nature's part to 
secure quiet and rest to the subjacent inflamed structures, 
suggestive, I think, of the value of fomentations strongly 
medicated with poppies and other aneesthetic^, such at 
belladonmi, opium, or hemlodc. I hod an opportunity of see- 
ing 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 gentieman 

BnrRooii ia UBOaUy more clearly niBrkcd, but liere too the preseni* o( 

r^ritonitis may be masked as in tlie Bubjecta of constitutionni syphillt. 
remember the case of a wilor ndmitte)! with an obscure BWttlltngintbe 
right side ; opinions were divided as to vhether this was ialra-sbdomiiial, 
or deeply seated in tlio abdominnl wait. On the latter snppositioQ 
the natiito of the swelling was ciplnreit, and wad than tbuod to be a 
gummatoua tumour in the liver. After tbree dnys the pntient MUlk 
with tciircely any evidence of peritonitis, though alter death this was 
found Ui be clearly pronoQDcel and abundant. In diagnoaing the 
elistenra of this ponditton, a sudden rise of temperature, abdotniDal 
distension, especially a tympanitis, which stealthily but steadily inereaaei^ 
end a gnulual pincliing of tlie features would appear to bo far more 
trustworthy than pain, a symptom which, on account of its not infrequent 
abacnce, aocma to mo to be not reliable. — [Ed."] 



:.] AND THE DIAGKOSTIG VALUE OF PAIN. 249 

md oonsiderable pain in the colon, and spasmodic contrac- 
ion of the abdominal walls associated with his rectal 
liaease, and he suffered a great deal of pain at night, so 
M to deprive him of his sleep. For the purpose of pro- 
nuing sleep, it was essential that he should take opium ; 
t was administered by the mouth, but the opium thus 
aken destroyed his appetite. Here was a patient suffer- 
ng from cancer, tight abdomen, and pain, and we were 
pving him opium, and destroying his appetite. Well, it 
iras suggested that, instead of giving him opium by the 
noath, we might possibly relieve him by rubbing the opium 
into the skin of the abdominal parietes. We accordingly 
lad a strong solution of opium made, and rubbed it upon 
the abdominal parietes every night and morning. From 
Qiat time the patient had scarcely any pain or 8|)asmodic 
ikbdominal contraction ; he required no more opium by the 
tnoath to make him sleep, and he regained his appetite. 
This affords a clear exempliftcation of cause and effect in 
the local application of ansesthetics upon the exterior, 
leading to general repose or sleep, and actually nullifying, 
or reducing the abdominal contraction and the pain. 1 
believe this plan of treatment — I mean the application of 
uuesthetics to the cutaneous nerves — is, as a rule, most 
imperfectly carried out in practice. 

We notice that, just in proportion as peritonitis subsides, 
80 does the abdomen become softer, more moveable by the 
hand* and less tight to the patient. If I have stated the 
beta and symptoms truthfully, we have here evidence of 
the same muscular and cutaneous and serous association of 
nerves as is observed in regard to the nervous distribution 
to the joints, &c. 

Let us now see how far we can apply this law to practice. 
Every surgeon knows that, after an operation for strangu- 
lated hernia, he need not make much difficulty about the 
Bpeneral symptoms of peritonitis. He has merely to put 
his hand upon the abdomen : if he finds the abdomen soft 
and pliant, however much the patient may complain of 
pain, there is no peritonitis, unless it be one of very low 
team indeed, associated with pyaemia, or depressed condi- 
tion of the system through the medium of poisoned blood, 
which would manifest itself by other symptoms. 



250 THE THERAPEUTIC ISFLUENCE OF EEST [Lwt. 1 

I do not mean tn assert that a ti^lit abdoman jMr H il i 
indioativt of perittinitis, because thnt may be the retnltfj I 
flatulfncu Bnd a diatonded condition of the inteetinck. M ' 
hysteria. But in bysteria, although we may see (frwt 
eontractiou of the abdominal musclee, that contmction it 
verj'' irregular or unsteady. Sometimes it is in om Y»ii 
and sometimes in another, and upon ^ntle |»iMBDro it 
subsidee. Teuaicm which ia associated with tme peritonilii. 
m far as I know, never subsides under the infloence of 
f-entle or even of more severe pressure. Taking tlip 
analogy of a joint, we may say that the pcritonBaiD nyt^ 
Hents the sjnoTial membmue, and the abdoniiual m<mM 
the musck-B moving the joint ; so that if yre meet with an i 
nMomen the muscular walls of which yon can finnty muve 
over it« contents, we may conclude that the peritonmn it 
not inflamed, just as, when we see that a joint ia perftctiy 
moveable and without pain, we may he euro that the joint 
is not really inflamed. 

Now. li>t' me plaw l*ior" you niiotluT ilhistmtion fnnii 
tlie upper part of the alxlomen, above the omtnlicm. 
Here we see the lower intercostal nerves, thc^e whic^ an 
associated with the false ribs after supplying the inter- 
costals, passing through the edge of the diaphn^^, or 
close to it, and then distributed to the abdominal mnscles 
upon the upper part of the abdomen, and some going to the 
skin over the upper half of the abdomen.* Here observe 
another relation l>etween the cause and effect of a local 
inflammatory condition, which, if overlooked, leads to error 

* TJ]>nn this cnnimuiiicafinii lietwocn the nerves of the abdominil 
snd thoracic Wiilla.nmHeqiient u|iont1ippiit<Ea(;G of the lower intercutal 
nerves tbrmigli tlie cliBphrapm itntl Iheir liistribulion to the upper put 
of tlie sbd'iniiTiiil niunelps, iIc|«ii(1b in ereat roeHsure the character rf 
the luovcnicntsuf reapiratioii in perilonitJB. The breftlhinKia eminentlj 
lliorecic, tite ahilominnl musclcB are I'sid not only lo kits reel to the 
parts bent-nth, but also lo mitn^-oniee tlie <1e8ornt of the diapluagin : 
the movements aC this and tlio ribs lo wl,ieli it is attached are sccotd- 
fnjtlj reduced ti n niiniinuin, while the work of the upptr part of tbe 
elieit ia corrcrpondinKlj inTtaiied. 

The fnct thnt Ilie abdotniiitil miisries, the peritoneum lining than, 
and tlie conti'niB of the petilonral Ciivily are all supplied by asHiciitted 
nerves will also nrcount for thevomiline whirh ropicUy follows the 
stmninilationorn hernia wlitch, on clnloratiuD, is found to conust solel; 



X.] AHD THE DIAQM08TIC VALUE OF PAIS. 251 

in diagnoeis, and the application of local remedies to the 
Abdomen instead of ihe chest. In cniies of costal pleurisy 
of the lower half of the chest, it b a common occurrence 




lurk on Ihc > 

narti ttKir dlHiribinloii In tbo miucliii of the upper hull oT Uw ■Mumlnil villi 
mnd the DVrrlTlnfr fiklii. d, Loiubftr nvrvH pTVCFrdlna to tlw lown iwrtlon nf 
Uw abdHDlul nil u<d llie >liln. (. (. AnUiior ilxluiulDil vill. I. KrIIU 
mbdomloii muKlt. p. OMurdlurnFrrc. «. IMiphugm. 

that the upper half of tlio abdominal parietos is tightly 
drawn backwards, and the skin over thut purt very tender 



■^."ij ■i'i]f: Ti!Ei!ArFrTir ixfliirntk of rest [I.&t, 

to the tiiuoh. yet (lepcndiug iijum [ik-uriKj- of tho hv;i! 
half of the chest. Hero also vfo have aa exemplificatioo 
of the same nerre supplying the muacles, the skin ovw 
the musclea, and the peritoneum associated with tliesi; 
muscles. The patholof^ical cause, in pleuritic inflamnik 
tion, is within the ohest, yet the aMominal muscler •-- 



& fact of this luQ'l 
in normal anatomy without fixing upon it some point in 
practice. It has been ujy habit Uirough profeseioiu] lifs 
to make this practical couibinatiou. 

In -Inly, 1860, a gentleman, aged twenty-two, whoml 
had previously known, came to mo, looking very ill. After 
a little detail, he said, "I have been very ill for some time. 
I hiivo hiid such pain and spasm in my belly, I believe 
there is something wrong about my liver. And then my 
stomach has been getting bad. I have been treated tut 
disease of the colon, I think you call it, and various other 
things, l)ut I am not a hit better." I inqnirod of liim, 
" Are the pains on both sides?" " Yes," lie said, "the 
pains are here," placiag his two hands over the pit of his 
stomach ; " both sides alike." Having just before that 
time been lecturing ujmn the symptoms of diseased spine, 
it struck me, at first, it was a case of that diwt'ase. I 
accordingly examined his spine, but I could find no cause 
there. I stated in a previous lecture that whenever we 
meet with an instance of symmetrical painn, the cause 
is either central or bilateral. Well, not finding a diseased 
spine, I questioned luni further, and he said, " I cannot 
lie down in bed on either side, and in going up-sturs 
I can hardly get my breath." I then thought I was 
upon the confines of a medical case, and ventured to jwr- 
cusa the chost. and recognised marked dulness on percus- 
sion. On applying my ear, I could recognise altered respi- 
ratory sounds. He had a collection of fluid in each pleura. 
The whole thing was now explained. He had had these 
pains and cramps in the upper half of his abdomen, which 
misled his previous attendant, and induced him toooncea- 
trate his attention— which he did, I must say, with great 
energy — upon the viscera lying immediately under the 



X.] AND THE DIAGNOSTIC VALUE OF TAIN. 253 

• 

"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 we 
got rid of the fluid. Here, then, is an instance where the 
same nerves which supply the mubcles supply the skin 
orer the muscles, and where the local manifestation 
of the painful symptoms was remote from the real cause 
of the symptoms. Through the medium of this ner- 
vons association and supply, and the symmetrical de- 
velopment of the pains, I came ]:)retty accurately and 
qiu(udy to the real cause ; and we know perfectly well that, 
whether in medicine or surgery, nine-tenths, of successful 
practioe 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 — the liver, and perhaps the 
fltomach, 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 circula- 
tion, especially when 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 sufler from congestion 
when plethoric persons are suddenly confined to bed by 
accident, thus losing the opportunity of free respiration. 
Under such circumstances the liver is especially liable to 
congestion, sometimes leading to jaundice. 

If we look to the relation of the pericardium and 
diaphragm, we discover a correspondence in the distribu- 
tion of the nerves which appears quite analogous to that 
which we find in the inusctdar apparatus moving a joint. 
May we not consider the fibrous pericardium as part of the 
fascial insertion of the muscular diaphragm ? The pericar- 
dium is most intimately blended with the diaphragm, dis- 
tinctly identified with it, and capable of being acted upon 
by it at all times. It is also attached above to the deep 
cervical fascia. It is thus kept tense by the action of the 
respiratory muscles in the neck attached to the cervical 
&8cia above, and the diaphragm attached to it below ; or, 
in other words, these two muscular forces are acting on the 



2.'.4 THE THEBAPEDTIC INFLUENCE OF REST [Lkt. ^ 

interposed pericardium in opposite directions, and so reodtt 
it tense and resisting. And the special object, uo donbtof 
this piece of anatomy is thut during a full inspinit:uiL,*'lm 
the Innga are distended with air and the right Hide uf th» 
heart gorged with blood from a, Bnapensian of r<w]jiMti<«i 
theheart should not he encroached npun by the HurTOQDiiinf 
lungH. Here one observes a peculiar circumstance. Q«ir 
ostroordinar^' it is that the phrenic ncrvo (a nerve so ii»- 
portant to life) can pass through the chest Iietwecn the 
dilated heart and the disteudol and espandud lunes. nfid 
yet, an far as we know, never receive any untoward infla- 
v.nixi from pressure ? It is true the normal hiwltliy lnu|^ 
have, as 1 demonstrated long since, a reraarkubly de&nilt 
t'oncavo form towards the heart, arching over the ooune of 
the phrenic nerve ; but when the lungs are emphysematoufe, 
it seems to me qnit« probable that these nervee might enBei 
from pressure, and cause some difficulty in breatbiu);. 1 
pointed out some years ago how it was, when extravsMi- 
tion of air occurs from rupture of the trachea or a large 
bronchial tnto, that the patient died rapidly, and witfi 
extreme shortness of breath. The extravsaated ur entetf 
the track of the phrenic nerve, thus oauung estreme 
preNsureon tlie inirve. uiid, liv dostnn'in!^ tlii> [Hnveriif ihe 
diaphragm, leads to the rapid death of the patient, l-et 
us trace these nerves below the diaphragm. The phrenic 
nerve, in its Course from the neck, passes thi-ough the 
chest, ultimiitely reaches the diaphragm, and is then dis- 
tributed upon the inferior asjwct of that muscle. Now 
physicians tell us that if a patient baa pericarditis, there 
IS always a sense of oppression at the epigastrium. Some 
say there is a catch in the breath ap])arontly associated with 
the diaphragm." 

* In the Hed, Timi^e nnd Gaz„ Sept. 5. iS!fi, nill ba Tound some re- 
murks b^ the late Ur, Buluwou the restraiued action of thediiuihiagin in 
pericarditis, as a useful ei^ in the dinguoBis of this aOection. The 
subject of pOTicttprlitifl, aniioua to ovoid the pain cansed by any moTO- 
ment, holds his whole chest bs immoveable as possible, but eapeetally 
rastraina the aotion of tlic diapbru^m. In tlie case of a bo; wk) 
vaa admitted with this affection, it wa^ found tiiat he hod tied a broad 
belt tightly round bis body, doubtless for tbia purpose, by limiUiig 
tba movements n( the diaphragm and the lower rilu to which it ij 
attached.— [Ed.] 



I wi*J 
entetfv 
[treme ^ 



.] AND THE DIAQNOSTIO VALUE OF PAIN. 255 

I most not dwell upon this subject, but I ought to have 
id that this phrenic nerve gives off a small branch, as it 
IMOB along the middle mediastinum, to the pericardium. 
am not prepared to say, but I think it is probable, that 
OB may be a sensitive filament of the phrenic nerve ; and 
•o, we have the analogy to a joint pretty well completed. 
Te have the diaphragm, representing tlie muscular appara- 
m; we have the serous pericardium, representing the 
nu>Tial membrane ; we have the fibrous pericardium, 
ipresenting the capsular ligament, and all capsular liga- 
kents have muscles attached to them. We have then, 
udc^oally, the representatives of a joint. Although time 
in not allow me to extend this subject, I may remind you 
lAt we thus have an explanation of the sense of constrio- 
on and tightness and shortness of breath of which patients 
iflering from pericarditis usually complain, if through the 
ifrili^ii^ of a cutaneous or sensitive filament going to the 
Blicardium, jpericarditis can produce muscular spasm, or 
mtraction of the diaphragm, precisely as the nerves in the 
iterior of an inflamed joint can lead to the muscular spasm 
r that joint. 



^E^^B^^IB 


256 THE 


THEEAPEUnC I»FLUZSCE 


OF REST 


Om- f 






LECTURE XI. 




1 


oirrANEOCB Atn 


jmrecT-'i 


^B HBBVI DlSTBIBCnON 1 


V BCLATimt 


nnt 1 






i TO THE TBEATUWIT Ot 






UECHAMICAL 


AMD FU' 








KENT OF FEBICABDmB— IMALOOT BETDTBEIJ THK 




>r Lnn 


BT A BEBOm 




MjB AMD TUk paoorcnoH or call 


Di n A 


FRACTCRE-^SWOLLKK 


JOINT A IIEA1I8 TAKKlt 




TO fie^ 








m TWE TUAnDBT. 








YE— ySBTB 












-CHRp^lC 



FHTMOUIOICAL 

I WILL now proceed to consider briefly the aDatomy of tha 
upper intercostal nerves, for the purpose of explaining 
the same anatomical low of distriljution with regard to the 
pleura which we have considered in reference to the peri- 
toneum and the pericardium. We observe that the same 
intercostal nerves, which supply the Intercostal musclee 
moving the ribs, supply also the serous membrane lining 
the thoracic parietos and the skin over those different but 
physiologically associated structures, in order to produce 
narmonions and concerted action during the varied states 
of respiration. Here, then, wo have the pleura represent- 



e synovial membrane ; the intercostal muscles repre- 
g the muscular apparatus connected with and moving 
a joint ; and the cutaneous branches of the nerves spread 



r the intercostal muscles, assimilated in their arrange- 
ment to the cutaneous bi'anches which supply the skin 
over the insertions of the muscles moving the joint. 

But this physiological anatomy, without some applica- 
tion to practice, would, perhaps, bo scarcely worth dwelling 
upon. 

Pleurisy of the pleura costalis, at the upper part of the 



U.] AND THE DIAGNOSTIC VALUE OF PAIN. 257 

heat, is often accompanied by pain and tenderness of the 
kin not only over the seat of the pleurisy, but also in 
he axilla, and inner side of the upper arm, resulting from 
he course and peripheral distribution of the intercostal 
iBTves. 

It will be recollected that some filaments of the inter- 
ostal nerves pass through the walls of the chest to the 
kin covering it, and that some cross the axilla, and are 
hen distributed to the skin of the inner side of the upper 
rm ; hence the pain and tenderness in these parts result- 
1^ from pleurisy. 

It may be noticed that persistent pain on the surface of 
be upper and posterior part of the chest, and upon the 
atenor part of the sternum, is not unfrequently associated 
dth disease of the heart or large blood-vessels. Indeed, 
think I might generalise on this part of my subject, and 
lake an artificial division of the back into three compart- 
teats. First, high up between the shoulders, where persistent 
iins — pains of nervous continuity — as a rule, coexist with 
iaease of the heart, aneurism of the aorta, disease at the 
ifbication of the trachea and bronchi, diseased glands, or 
ziotore of the oesophagus within the posterior mediasti- 
mn ; second, between the middle and lower part of tlie scapulce 
wd a litUe lower down, where the existence of like pains are 
lost frequently associated with disease in the abdominal 
igestive viscera, through the medium of the great 
Manchnic and the intercostal nerves — (I believe I have 
len some cases of disease of the transverse colon where 
le patients have had these lower interscapular pains) ; 
liza, the surface in the lumbar region, where the pains 
Ee more distinctly associated with local disease in the 
ana, such as disease of the ascending or descending 
don, the kidneys, ureters, lumbar lymphatic glands, and 
■ticles. 

Patients suffering from cancer of the breasts often com- 
iain of pain in the back, between the shoulders, or on tlie 
de of the chest, sometimes down the inner side of the 
rm and across the axilla. In such cases we not unfrc- 
Bently find cancer tubercles under the pleura costalis, or 
mcerouB glands in the axilla, or in the posterior media- 
inum. Such remote '* sympathetic *' pains, occurring u 

s 



-■'>^ Tin: TKRItArEUTIC ISFU'ENCE OF REST [Lli-T, 

long wiiy from the real disturbing cauae, are eiplaintJ 
by the course of the interooetal nervea. 

Theee eupeificiRl pains, although depending npon ft n- 
mote cauec, may Bometimes be relieved by local aneethetics. 
as proBsic acid, hemlock, belladonna, and opinm. Some 
yean ago I saw tbie point well exemplified in practice. 
Dr. Mnnk asked mo to see a young lady with himwhowii 
Bnfferinrr, and likely todie, from pulmonary tubercrdu cm- 
sumption. I saw the lady at the Bank of England, ud 
found tliut the complaint (for which I was consulted) wu 
pain and tenderness of the akin in the armpit, the ahoold^r 
and down the ami on the right aide ; these pains were ex- 
cessively distressing to her. Ujk>d examination, I foimd 
she had had a large abscess in the right armpit, and uptm 
lifting the arm from her side, and looking through an 
ulcerat43d opening in the skin, I saw the Uttle ccdta ot 
interoostal nerves denuded of areolar tissue, and proceeding 
across the axilla towards the superficial parts 'where her 
pains ^'cre expressed ; and when 1 touched the exposed 
nerves with a probe I induced a great increase in the 
severity of these pains. I recommended that all the Bkin 
whereon the pain was expressed should be thickly coveied 
with the extract of belladonna sprewl upon soft leather, 
and that the arm should be kept quiet by being bandaged 
to her Mde. By those means the ymliont waw wrj- nni./h 
relieved from the pain and tcndemesB during the remain- 
ing short period of her life. 

I would venture to suggest the following explanation of 
the painful cfieuts resulting from the local application of 
cold air to the peripheral branches of the intercostal 
nerves. I believe that the local influence of cold air may be 
suiBcient to explain the occurrence of " gtilch," or that cramp 
in the mugcleg of the chest which prevents a full inspiration, 
by inducing tonic or spasmodic contraction of the inter- 
costal muscles which are supplied by the same nerves (the 
intercostals) which supply the skin upon which the cold is 
applied. This explanation will hardly be deemed untena- 
ble, when I remind you that if a patient faints, wc, anxions 
to excite respiration as quickly as possible, throw cold 
water over the face, or denude the chest and flip itssttrface 
with a wet towel, and throw cold water abruptly upon the 



XI.] AND TUr-: DIAGNOSTIC VALUE UF TAIN. -")!• 

walls of the chest. And we do it fur what purpose? It 
cannot be for the direct application of cold to the muscles 
themselYes. It must be for the purpose of exciting the 
miuoular apparatus which moves the walls of the chest, 
through the medium of the local application of cold to the 
CQtaneofUB nerves. 

Hitherto I have been looking at this associated anatomy 
chiefly in relation to symptoms leading from without to 
within. Now let us regard it from within to without, and 
nee 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 
tabject 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 
(intercoetals), and thus engender the limited breathing 
and the painful cramps and '* stitches " from which such 
patients suffer, in addition to that which results directly 
from any local inflammation of the pleura, and whicn 
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 inflammatory 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 rig^id, and difficult to move. If the pleura be 
inflamed, we ought not to be surprised if we find its 
muscular apparatus in a like condition, excited to power- 
ful contraction and a spasmodic condition from the assi)- 
ciation 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 breath ; do not permit him to carry on any 
long-continued conversation, 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 
ansestheiic fomentations to its exterior. We know by 
experience that if wo apply strong poppy or opium fomen- 
tations, hemlock or belladonna poultices, or anaesthetic 

s 2 



jii't ini: TiiERArEUTic inflvenxe of rest [Lia. 

LUil.ivpoiitii.tis, upon thu fxtvi-iiir ui tlio ciifst. in l\v-^ 
mflttniinatory conditions of the interior, th«y give a gn«l i 
amonnt of relief through the medium of the interc«t>l 1 
nerves which come to the surface. If a joint be inflamei, I 
we put a splint upon it to keep it at rest. Why notetrsp I 
or bandage the chest in cases of pleurisy, when the aeiiM I 
niisehief has passed off? Surely it would have ih» J 
tendency to siibdue the inflammatory condition, bypre-1 
veniing any friction betw^een the two opposite pleutil 1 
surfaces, " 

All surgeons must have ohm>rved, in cases of pleurisy, 
that if the patients be asked to take a full hnutli. to 
raise the ribs and expand the longa. they cannot ilo » 
without suffering pain. This is Burely very eiingealive of 
the importance of reet, and points to the value of atrapTibg 
the chest in caaett of acute or chronic pleurisy, witli nr 
without fraetui-ea of ribs (1 have no doubt about its grnl 
utility in the latter complication); for it not only keeps . 
the ribs quiut, but prevents any friction of the pulmonai; J 
pleura upon the inflamed pleura coetalia. I 

These obBervations of course suggest another pracUolJ 
lesson — never to allow a patient suifering from pleuriqfl 
or pneumonia to talk or to answer questions except vM 
uionotiyl tables, so as to avoid a full inspiration. Let tM ^ 
patient write nil his or h(-r wishes upon a elate. This may 
appear a small item in practice ; but 1 could mention 
several instances where this little element has been the 
turning-point in thecase. Aphysician.residingnot veryfar 
from me, had under his care a patient who had received a 
blow upon his chest by a fall ujKin the part : and as he 
was, after several days, still suflfering a good deal of pain 
in breathing, the physician asked nie to see him in refer- 
ence to the possibility of fractured ribs. I could find no 
fi-acture ; but I observed that the patient had a most 
worrying wife. She was incessantly talking to him day 
and night, and there were continual contentions between 
them upon domestic afiiiirs, I suggested to the physician 
that the sole cause tif the pain was, in all probability, 
produced by the patient constantly moving the injured 
or bruised soft parts, by using his chest and lungs in 
speaking. All I recommended was, that he should hold 



AND THE DIAGNOSTIC VALUE OP PAIN. 261 

tongue, and have his chest bandaged. I requested 
his wife would not say a word to hitn, but would 
ide him with a slate and pencil so that he might 
» down all his desires. From that time he got quickly 
fry local rest 

ftonk it is a fair common-sense deduction, that if we 
ceep the inflamed pleura perfectly quiet, and prevent 
flEering the ill effects of undue friction, we certainly 
', contribute something towards arresting the con- 
inoe of the inflammatory condition. I do not think 
important subject is usually considered in this light ; 
I am convinced that it ought to receive a larger 
int of attention than it has done. 
j^ain, with respect to the application of local ansBsthetics 
le outside of the chest. I think I have shown that we 
I a power of acting upon the walls of the chest and the 
dd8 of respiration, through the medium of ausesthetics 
led to the cutaneous nerves associated with the nerves 
16 pleura costalis ; but I admit we have very little 
rtnnity of acting directly upon the heart or peri- 
Lum through the external or cutaneous nerves asso- 
d with the cardiac nerves, so as to induce physiological 
in that organ by the external application of ansssthetics. 
will be impressed with this conclusion when I remind 
that there are but a few filaments of the upper inter- 
d spinal nerves which join the cardiac plexus of the 
pathetic nerve within the chest ; and that these same 
tXMtal nerves distribute only a small number of cuta* 
B filaments to the skin of the chest and back. It 
; not, however, be overlooked, that the cervical spinal 
es communicate with the cardiac nerves derived from 
ympathetic ganglia in the neck. These are apparently 
only nerve-trjwks extending from the surface of the 
' to the heart, which would permit of direct anaesthetic 
once being propagated from the skin to the heart. 
it us now see whether the subject of ** mechanical and 
■ological rest " can be made therapeutically available, 
rferenoe to the treatment of acute pericarditis. The 
icSmn cannot fail to admit that, whilst treating pericar- 
, he has to deal with a membrane investing and sur- 
ding an organ with whose functions complete rest is 



:it)2 THE THERAPEnTIC INFLUENCE OF BEST [Lin, 

iucompatiblo, since the rhj-thmioal movpiueut of the hwrt 
LH iieceBsary to the pemBtonci? of life- Yet he mUNt allov 
that it is only through the medium of lenn-aed action Mid 
diminished dietonBion of thiH organ, with a concurrent lai 
condition of the diaphragm and peiicardium, that he c«t 
exj>ect to obtain any relief from friction to the navm 
membrane itself. Allow me, then, to put before you lliil. 
suggestive question : whether, in a case of acute pciicarr 
ditis, it woiild be jMssible to over-estimate the value 0^ 
local rest as a therapeutic agent ? We, Be mirgeouB, Ki 
the ill effects of friction npon infliinied parte — aa in tMct 
of inflamed jointa, of inflamed ulcere, inflamed conjunctiv*. 
inflamed skin, &c. Hence we may fairly assumo llirt 
friction upon tlie two free and inflamed surfaces, u !& 
the early stage of pericarditis, must add ttmterially to ths- 
local mischief, and tend to keep up the inflammiituty 
condition. * 

I assume — tor 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 diniiniHh its muscular excitability, and thu* 
to moderate the friction and its ill effect. I may venture, 
in addition, hypothetical ly to imagine that he would desin 
even to stop the movements of the heart for a time, for the 
purpose of jireventiug friction, provided that it« arrest was 
compatible with life, or that he had the power to insure 
the resumption of its activity. But although this direct 
influence is bevond the limits of human power, yet I think 
we discover tliat the treatment adopted in euch cases it 
founded upon the principle of giving all possible rest to the 
heart. Vontesection, antimony, opium, digitalis," are, or 



pOWE. .. _„.. __ . „ . ^- _ 

more perfect, nnd llirbtatBof the lieart, Hre reilucpd ii> fnquency. 'The 
diminution of ILe frcqaciic; of the benrt's beat under digitalis klaaji 
meana sn incrcnse in the period of the ditalation of tlie ventiidei' 
(Balthazar Foetcr). The coneequence is that tlie heart'a brief alwp it 
lengthened, anil tlie nddition thuB given to ite aggregate real in twenty- 
four bourn is conaiderahle, Tljis ib one pninl of much importance. 
Another ia. that by its effects upon the peripheral arleriolca the outflow 
of blood from the arterial svalem ia eheeked, end the arteiies ue better 
filled vith blood. Tbie arteiial fulncae ptoducea a general effecton 



^CL] AND THE DIAGNOSTIC VALUE OF PAIN. 263 

have been, I apprehend, resorted to for this purpose, or, if 
not employed with this precise view, I conceive that their 
beneficial influence is to be traced in part to their insuring 
Ififls frequent and less rough friction between the two 
■urfaces of the pericardium, by diminishing both the dis- 
tension 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 6idmit, for the sake of 
illuBtration, what I believe to be the right interpretation, 
that the efiWon of lymph in this pericarditis results from 
lome 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 kidney 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 surfaces, which are not only 
■ecreting, 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 mem- 
branes are very rapidly absorbing organs indeed. 
Observe this illustrative 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 And in 
the abdomen after death ? No serum ; every drop of it is 



efery pari ; it fills the brain with blood, while it increases the blood- 
preMore upon the glomeruli of the kidneys, of which the increased 
flow of urine is tho outward visible sign. The heart itself partakes of 
the advantages derived from the arterial fulness, especially as the 
aortic recoil is the propelling power into the coronary arteries. The 
increaaed arterial tension produces a better flow of arterial blood to the 
heart itself: and betwixt a longer sleep and a better nutrition the heart 
often recovers its lost power." — [£i>0 



2>'A llli: TTTERArErTlC ISFHiESCF. OF ItF.ST [Ltci. 

ii<-ne. iU'u-^ ^vllt■^l■? All of it is al.twrlx-d. The d.-l -A 
blood remaiuB, but the fluid part of it hft« been taken up>* 
There is no doubt that solid effusion has been known io 
exiet diiring life between the pericardial sorfecea, recog- 
nised by certain diagnostic aoiuids which havB sakifr 
quently ceased ; and the patient dying some time tit/ft- 
wards, the poet-morteni hae proved that the whoI« (if ^ 
lymph had di§appeared, no doubt by absorption. 

Tne result of the effusion of the infiammatory fluid it, 
that the bptous Burfaoes become defended immediately freo 
direct and intimate surfaoe-friction ; thus that jKwaWe 
source of irritation is removed. Thenceforward tH« 
acquired rest, or freedom iroui direct friction, onalilcs the 
serons membrane to recover itself, and then to resume its 
important function of absorption. So. too, in other parts 
of the IxKly. For example, in the caae of oronjt, when 
effuaion of lymph takes place, the false membrane adhen* 
for a time to the mucous membrane ; the niucouB mem- 
brane thus obtains a physiological rest, and the littki 
glandular structures, imbedded in the submucous tissue, 
recover their strength through their physiological repoM. 
They then renew their function of secretion, and thus 
detach the false membrane. I think I might with rcMoa 
compare (in relation to the subject of rest) the effutdon 
of lyniph in pfricarditis with the " provisioniil " calhiB 
formed hy Naturo in casfCH nf bud I'ractiircn. ■J'licri' is no 
doubt that the longer the inflammation of the pericardium 
continues the more unhealthy the membrane becomes, so 
that, if inflammation of the pericardium becomes chronic, 

* Aa benriDg on tliis point the inveatigalious of Recklingbansen uid 
more rci^eatl; of Klein, which have proved the peritoDeum to be in 
intiiUBle rchition with the lymphatics, should be bom in mind. The 
power of abeorpiioii by the poribmeiuD, and some of the further rMulti 
of this, were well shown by experimentB of Dr. SichardBnn. Thoa ho 
injected into the perilonea] cevity of a dog, weighing twentj-threa 
pounds, foot pounds of water. The animal groduallj tank in abont 
twelve hnura. An hour after death no trace of fluid could be found in 
th(i peritonenm : but Ihe venous ayetem was gorged with blood, u 
fluid ns wal«T itarlf, and showing no tendency to coagnlate (Coun. of 
the Blood, p. 128). It is possible that deteriorations of the blood 
dependant on the absorptive power of the peritoneum are, in someoMes, 
cauces of those denthe, which in acute and aepticsemic peritooitia haiw 
hitherto been attributed to shock or blood-poisoning.— [Ed.] 



XL] AND THE DIAONOSriO VALl'i: oF VMS. '2h:> 

the pericardium acquires such an unhealthy condition 
that it will not perform its second function of absorption. 
Patients so affected are those who die with a large 
quantity of fluid in the interior of the pericardium, 
constituting dropsy of the pericardium. 

We observe the curative principle of acquired rest dis- 
played in other parts of the body when suffering from 
mnammation, such as the occurrence of solid effusion 
(callus) associated with the repair of some fractures of 
bones, and the massive swellings which we see encumber- 
ing the exterior of inflamed joints, whether in ccises of 
acute or of chronic destructive inflammation 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 
exterior of the fracture, when the fractured pieces are 
sabjected 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 
fractnred ends of the bone in actual rest, and that, in 
truth, this external splint is developed in proportion to the 
amount of movement to which the fragments have been 
sabjected.* 

I saw a most instructive case of this kind some years 
ago, which made a great impression upon my mind. On 
Sfispt. 3rd, 1845, Mary Ann L , aged thirty, washer- 
woman 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. She 
told me that she thought she hurt it six weeks before, as 
she felt a sudden pain in the swollen part whilst trying 
to stop the fall of a chest of drawers. In a few days the 
part began to swell, and continued to do so up to the time 

* Compare an interesting case in Guy's Hospital under the care of 
Mr. Howae, in which an incomplete fracture of Uie tibia was surrounded 
wiUi abundant provisional callus, owing to prolouj^ed irritation of the 
frvctored parts from the patient's eflforts to walk about From the 
iUioQets of the history given, the case was remarkably difficult of 
diagmwia, simulatlDg tumour of bone, or rapidly forming periosteal 
twdling, possibly syphilitic. It was cured by antiseptic exploration and 
trephhmig. The case will be found in Mr. Davy's * Prize Commentary,' 
wita remarki by Mr. Howso, in the Gay's Hosp. Rep. 1878.H[Ed.] 



-fiti IflE TRKRAPEUTTC IN'FLVE>-CE OF REST [Ldtt, 

I Baw hiT. A bliMtcr liatl l-ceii applied by a sur^uuii t*n 
days before, without any apparent adTantage. T )i i nking 
it a case of dieeaae or new growth in the bone, I ordens 
her to rub the compound iodine ointment freely into ^ ' 
tumour, and to take some amniouia and hark ; and, hknog 
fixed her arm in a sling, I enjoined her not to use it, n 
make exertion of any kind, for she always bad paiu in tbc 
BwoUen i>a.rt of the collar-bone when Bhe did bo. I b»w 
this woiuan again in thre« weeks, and the tiunonr wac t 
little reduced ; and I was congratulating myself with tho 
idea that here was a case of malignant disease being cnW 
by iodide of potassium. From that time I lost sight of 
her. Being anxious and determined to know tho result, 
on tho 24th of May, 1847. 1 went with Mr. Chabot to th« 
houBee of nearly aU the washerwomen in CamberwoU. and 
we at length discovered her. I examined the claviole. 
There waa a slight overlapping of the fractured end>i,hnt 
the bone was consolidated. It was thus clear that she 
had hod a. broken clavicle, and what I had treated was the 
callus of a fracture. She told me that the swelling went 
away gradually after a few weeks, and she found she 
could resume her duties at the wash-tub and ironing-boaid 
without pain. It thus appeared that by fixing the arm 
I bad secured rest to tho fractured bone, the necessity for 
that amount of chIIiih whirb N.ituru' had 8iipplit-.l for the 
purpose of securing rest to the fracture was dispensed 
with, and then the callus disappeared without any fiirther 
treatment. 

In a caee of doubtful fracture of a bone I have seen this 
subject tliua brought forward in a court of justice. A 
counsel has asked a surgeon this question, " Would you 
Bay the plaintiff has had a fracture, seeing that you find 
no callus ? " And the answer has been, " Ko, I should aay 
there was no fracture, because there 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 being no callus is, to my mind, the beet 
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 
be won in the treatment of a fracture by the surgeon, who 



AND THE DIAGKOSnO VALUE OF PAIN. 267 

i adjuBted the fractured ends bo completely, that there 
I no necessity for Nature's splint or callus to secure 
chanical rest to the ends of the bone. 
This same physiological point is also well displayed, in 
■otice, in the occurrence of the thickening of soft struc- 
ires external to inflamed or diseased joints. This thick- 
iixLg has the decided efiect of giving mechanical rest to 
lie interior of the joint, tending to steady it, to support it, 
Tender it comparatively immoveable, and to oppose dis- 
nrbanoe by muscular contraction, showing the value which 
Nature attaches to rest as a curative agent. How con- 
nicuonsly striking is the changed configuration of the in- 
flamed joint when the inflammatory condition has subsided, 
when IJie joint has recovered itself, or when the disease 
ham resulted in membranous or bony union of the articular 
tnrfaoefl? 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 no longer 
required by the joint for its rest. So it is witli the solid 
effnaionB which are intended to circumscribe the inflam- 
matory abscess ; it is noticeable that as soon as such an 
abeoees is opened, the necessity for the dej)osit around it 
no longer exists, and it is absorbed. Thus, I think, we 
may by analogy see the evidence of the beneficial in- 
fluence of rest in the treatment of pericarditis; and we 
may discover some good to be derived from the inflam- 
matory effusion by its giving rest to the pericardium 
for a time, and enabling it to resume its other function of 
abeorption. By considering the subject of solid effusions 
associated with local inflammation in this light, we recog- 
nise the folly of the surgeon who attempts to get 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 surrounding swelling associated with chronic joint 
diseases before the joints themselves are repaired ; in fact, 
it cannot be done. 

Having examined the distribution of associated nerves 
in the joints and serous membranes, and pointed out 
some of its results, as evidenced in the symptoms in- 
duced bv it in the diseases of those parts, I now propose 
to consider briefly the same anatomical and functional 



2<''i TUE rilERArEUTIC IXFLUEKCE OF HEST [Lect. 

l>rauea and their directly aeaooiated muscles. Let us look, 
for inetanco, at the oonjnnotiva, the orbicnloria P«lp^ 
Jjranini, and the skin covering the eyelid, in their due 
Buatomical and physiological relatioDB. Them parVi itiad 
very much in the same relation to each other as the ayno- 
vial membrane of a joint, the muscular appamtuB monng 
that joint, and the ekin over the iiiaertione of the mtuclei. 
We find that the facial nerve is one of the motor Bubdivinoni 
of the great oraniat compound nerve constituted by the 
large orif^in of the fifth nervo, as the Bensitive nxit, andttie 
third, fourth, fifth (motor portion), sixth, and seventh 
cranial iiervea, which toother fonn the motor routs of this 
■cranial nerve ; the whole of this nerve association stme- 
turally resembling a common two-rooted spinal nerve. The 
sensitive root of the fifth nerve supplies the conjunctiva and 
skin with sensation, and the facial nen'e supplies the orbi- 
cularis palpebrarum, the muscular apparatus, with motor 
power: these two nerves are most intimately associated both 
anatomically and physiologically ; heuee the constant and 
Active sympathy between these itarfs. Now notice wbat 
happens when the eye is inflamed, or the light is too strong 
for the eye. The eyelids are immediately closed — the eye 
is placed in darkness, which is the eye's ■' rest." Here is 
an indication on the part of Nature which han been visible 
to mankind from one generation to another, and soliciting, 
as it were, attention ; yet how little is it appreciated, 
how rarely made the guide of jiractice ! Surely the neglect 
of such an indication is a great error, and requires correc- 
tion. If the eye be inllamed fpainful, irritable, red, con- 
gested, very sensitivoj by exposure to a strong glaring 
light, or to intense heat, immediately the eyelida are in- 
stinctively closed, thus adopting the principle of rest as a 
means of rest<iration. Tears are secreted, analogous to 
synovial secretions in joint inflammations, to lubricate tba 
conjunctival membrane, to interpose a layer of fluid between 
the globe and eyelids, to prevent direct friction of the 
two mucous surfaces, and possibly to foment the eye. If 
the eye be thus kept in temporary darkness, free from 
friction, and thus rested, it will return in a few houn to 
its normal state without any other aid. 



Xr] AND THE DIAOXOSTIC VALrK OF TAIN. 200 

Jt is certainly an interesting and most instructive fact, 
and well worthy of dlBtinct notice here, that the portion of 
the body, in which Nature displayB most conspicuously her 
immediate appreciation of the value of rest m relation to 
its Teetorative power, is the organ of vision — the part of the 
human body, be it remarked, the most completely under 
the fallest observation of the surgeon, with the least 
■mount of trouble, and where ho may see the evidence 
of the good to be derived from rest to the diseased or 
injured organ most graphically expressed. I suppose every 
living 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 that natural stimulus, which in excess becomes 
a great source of excitement. But I must add, as a stigma 
and opprobrium upon the mental percej)tion of some of us, 
that although we recognise the law and the principle as 
applicable to the eye, we do not appear to see it so clearly, 
and certainly do not act upon it with the same fixed notions 
and the same precision, in its application to the other parts 
of the body when suffering from accident or disease. 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 
1867 little J. G burning his face and eye with gun- 
powder ? 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 

aqnib ; the powder did not ignite well, and he lowered liis 
face close to it, and blew to kindle the flame, which he 
sneceeded in doing, and in an instant the squib explode<l, 
burning his face and eye. I saw him almost immediately, 
and found him in excruciating agony ; the face darkened, 
skin ingrained with gunpowder, the conjunctiva of one eye 
black, and looking puffy and half roasted. The cornea had 
a peculiar appearance ; the outer lamina and conjunctiva 
over it had shrivelled, presenting an uneven, opaque sur- 
face (pretty much resembling the appearance of a cornea 
that has been so compressed after death as to have had its 



27ii lilE THF;i!ArEL'TIC INFLUENCE OF" REST [LWT. 

luiiiiiiur stiiioturo irregularly dispiiiceil, and so bewmu 
opaque), with a sooty dust ingramod and deeply pitwd on 
it8 surface. ITie eye waa wtiished with wanu water. Ha 
lid thou closed down, a drop of sweet oil having been fint 
inserte<l under the lid. and a piece of plaster applied ta 
keep the lid closed, but not to press upon the eye. The 
other eye was then also closed. Two days aftcrwarda the 
intier cauthus was wuhed with warm water, biit the eye 
not opened. On the fifth day I opened the lid, and found 
tho cornea bright and clear, mid a new and healthy Uyer 
of epithelium covering the entire globe. Under the bfln- 
enct; of rest, healthy nutrition had cSecled oompletu repair." 
This iiatient got quickly well. 

Observe the effect of morbid action in another purtiun of 
the mucous membrane, in order to mark this same nerve 
distribution. If you have an inflamed throat with inflamed 
tonsila. are you not constantly, in spite of yourseU, swal- 
lowing and producing pain in the throat which yon wonld 
be glad to avoid ? What is it that excites this involnntary 
act of duglutition ? It is an irritated or inflamed conditioQ 
of Ihe mucous membrane of the pharynx and pali«t« which 
excites the associated muscular apparatus, thruogh the 
mediuDk of the glosso-pharyngeal and the pneumugiuttric 
nerves. You are constantly forcing and rubbing the in- 
flanml tonsils. pliar>-iix, and |.alnti> upon uiioh ..th^: an.! 
thus " swallowing " ia excited frequently, painfully, and 
against your will. I'his is exactly the samo thing as irrita- 
tion or inflammation of tho 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 {minting the throat with a solution of optum. 

Some time ago I saw, with Dr. Herbert Davies, of Fina- 
bury Square, a gentleman who could scarcely swallow at 
all, for, directly he put fluid into his throat, it produced a 
violent and chokiug spasm. He was then nonriahed by 
nutritive enemata. I saw him endeavour 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 larjns. Numerousand difl'erent gargleo. 
weak and strong solutions of nitrate of silver, had been 
well employed, but without any advantage, and the patient 



XL] AND THE DIAGNOSTIO VALUE OF PAIN. 271 



rapidly emaciating. I advised the use of a powerful 
ftiuesthetic to the irritable mucous membrane. I requested 
him to use a gargle containing prussic acid. From the 
first time he adopted this plan of treatment he began to 
improye, and ultimately recovered. This application of 

rBsic acid was adopted on physiological principles, merely 
the purpose of reducing the sensibility and irritability 
of the mucous membrane, and of putting an arrest to the 
«8B0ciatcd spasmodic contraction of the muscles. Subse- 
quently this patient went to Hastings, and there the 
pharynx was painted with a solution of chloroform, upon 
the same principle of inducing 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 
pneumogastric 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 
asaoeiated laryngeal muscles. This irritable state of the 
larynx is usually treated by the local application of nitrate 
of silver in solution, or in the fonu of a very fine powder, 
which is blown into the larynx ; and the relief is sometimes 
very complete and speedy, by the physiological rest wliich 
it gives to the mucous membrane. I apprehend that rest 
is afforded by the nitrate of silver acting upon the mucus 
and albumen, forming a solid albuminate of silver, con- 
stituting an adherent temporary covering to the mucous 
membrane ; thus giving it rest by defending it from the 
atmospheric air, and so destroying for a time that nervous 
irritability and muscular contraction which produce a sense 
of suffocation. After all, the production of physiological 
rest is the curative principle, based upon the fact that the 
same nerve-trunk supplies both the mucous membrane and 
the muscular apparatus of the larynx. 

This principle of nerve distribution obtains throughout 
the whole distribution of the pneumogastric nerve, viz. 
the same trunk of nerve supplies the mucous membrane 
and the associated muscular apj>aratus. It is the same 
with respect to the intestinal canal : the mucous membrane 
and muscular walls are supplied by the same nerves. 



■112 TllF THERArEUnr INFl.nPNTE OF REST [l.f 

ciuisiug direct eympathy lK'twe*n tlieiu. I have no douW 
in the wwld thftt the effect of most put^tiTe mediciit 
to induce irritstion and increased secretion from tlie moooni J 
mumbrene, nnd increased inUBcular contractioii inthewuli I 
of the intcatiues. I must therefore expre*» my conrictkB I 
that the frequently repeated introdaction uf initjttiD| I 
medicinea into the bowels is very likely to do a great dw I 
(if injury by exciting mOBCular contrairtion, and theutt i 
diminishing the calibre of the gut ; and that aufaeequesll]' | 
a Rreat length nf time, with carefully managed diet, ii 
required to replace the inU-atines jii a perfectly healtb; 
condition. 

The muecnlar urinary bladder, with its mucous B 
brane and nervous supply, offers another example of thi" 
iier\-oti8 distribution. We see this exemplified in a paticnl 
who has in his urinary bladder a stone, causing a prrat 
deal of increased irritation, with frequent desire to pu> 
his water. How is this condition to be explained ? Il _ 
oliviously depends upon the fact, that the same nerve thiial 
supplies the mucous membrane supplies also the muscnla^fl 
apparatus of the bladder. Hence the atone, by umOTin^l 
the mucous membrane, becomes & oonatant source of unfl 
citation, which causes contraction of the muscular walls wl 
the bladder. Thus it happens that the bladder becomM'l 
in some inRtances so c-xcfedingly diniiiiiKhcil in its r?apncity, 
and BO contracted u|Min the Htone, as to leave scarce any 
room for urine, and hence the frequent micturition. If 
the stone lie removed, the local irritation subsides; and 
then the capacity of the bladder is restored. In cases of 
irritable and painful bladder, my colleagne, Mr, Cock, has 
long been in the habit of injecting sedative solulion of 
opium into tlie interior of the bladder, with great advan- 
tage to the jiatient's condition ; and I havo repeatedly 
obaerved the good effect arising from such a proceeding 
mysulf. Hero is a case in point. 

Chronic Ci/elitis rcllirtd by Opium Injecliom, inducing 

" phi/siologival regt.'' 

A woman, aged sevunty-four, came under my care June 



AND THE DIAQKOSTIG VALUE OF PAIN. 273 

1860. Twelve montliB previotiBly she noticed that 

ixine contained blood, which was sometimes bright, 

times dark and coffee-coloured ; there was also g^reat 

, extending up to the nmbilicus, of a ** cutting" or 

isting " character. The urine seenieil to scald tlie 

mal parts, and she had great irritability of the bladder, 

dug urine everv five or ten minutes. These 8ymi)toMiH 

. continued with increasing severity up to the time of 

oission. She had become very thin, and liud lost lier 

petite; she slept very badly, and her bowels wen- 

aally coiifined. lliere was a sliglit teudernoss u little ti» 

e left of the umbilicus, and on deej) pressure towards 

le left loin, but no pain in the loins or evidence of disease 

f the kidneys. The vagina and vulva were healthy, 

except that there was a small, but not ])ainful, growth at 

die meatus urinarius. There was no tendemcHH over tlic 

Madder or in the vagina. No calculus existed in the 

Uadder ; the urine was ammoniacal, and contained jilum- 

phatic deposits, with blood and muco-pus ; no cancer cells 

oonld be detected in it. Kectum healtiiv. There were out* 

or two enlarged and rather hard inguinal glands on the 

right side. On June 28th she was ordered an injection of 

fifteen drops of the sedative solution of opium in half an 

ounce of mucilage. The bladder wa« emi>tied 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 she Ixjgan to be relieved. 

and this is the rejHirt of her condition after four days of 

this treatment : — ** The urine has now beetmie clear and 

free from blood and pus, and on one occasion was neutral. 

She still has some pain during and after micturition, but 



dilating the neck of tho bladder, and so inducing temporary panily»<i^ 
of the Bphiocter. Quite apart from those cases where the lienefit of 
this diliitatioD is intelligible, e.g. for the remoyul r>f calculus or gniwth. 
the application of such Kolutioits as that of the silver nitrate, th(^ cure 
of some fissure or ulcerated crack in the mucous membrane of the 
neck of the bladder, or the providing of a free exit for pus or blood coming 
down into tlie bladder from the kidney, there would ap])eur to be caser: 
of painful and frequent micturition with normal urine where this oiK>m* 
iitm may be expected to give relief, though the exact modut ageitdi in 
here not ao eauily explained. — [Kd.] 

T 



i;74 -niE THEIiAI'EUTlL' IKFI.L'ENCE OF BEST [Lot 

tho bladder is much leas irritable; she can now retuuW 
urine sometimes for an hour." This patient was imlif 
much relieved by the opinm injeotions. 

This, then, is a case indicating the valne of r«ccqpuB>g 
the anatomical distribution of motor and BeneitiTe uervet, 
and of employing local aniesthetica. There la nuUiiiiE 
more remarkable in introdnoiug opium into an infiillM 1 
and irritable urinary bladder, to relieve ita initaUli^. 
than there Je in applying a hemlock poultice to an inAauMil 
joint to reduce ita eenaibility. or a telladonua plaster tmff 
a pEiinfiil Bhoutder, or dropping a solution of xnlphateof 
atropiii upon the conjunctiva to relieve the pun and 
muacular contraction of the iris in iritis. All this ii doDu 
upon the aume priooijile, and la Itesed upon the recogii 
of the same anatomical and physiological facts. , 

Attain, if a man is suffering from acute gonorriiaa, h« 
is likely to have retention of urine from contraction of the 
muscles or muscular fibre of tho urethra, or he ni&y expe- 
rience a very violent erection. What doe-s all tliia nKOUi? 
Merely that the same nerves which supply the lining 
membrane of the urethra supply the muscular walls of ths 
urethra, aa well as that niuscnlar apparatus ivhich, bjr 
acting on the venous circulation of the penis at its root, 
tends to produce a conjjeBted condition, or a fiilnem of the 
penis. Thi> irritiiliim iu thi> miicoiaa iin'iiiliriiiu- uiunift'Sts 
itself by contraction of the muBcles of the urethra, so as to 
induce spasm and retention of uriuo, and interferes with 
the return of blood trom tho itenis, so as to cause distension 
of the organ or a state of semi-erection. How frequently 
wo see a spasmodic condition of the urethra supervening 
upon old organic stiicture, and causing retention ot 
urine ! 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 muscles of the urethra, through the excito-motor 
function of the spinal marrow. Laige 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 in the case of fracture of the spine in the dorsal 
region, when a portion of the marrow is left uninjured 



XL] AND THE DIAGNOSTIC VALUE OF TAIN. 275 

below the fracture. In such cases, by repeatedly pinching 
the akin of the penis or scrotum, you may produce a spas- 
modic contraction of the muscles of the urethra and penis, 
and a fulness of blood in the penis, so as to make it re- 
semble an imperfect erection or priapism. The pudic nerve, 
which is distributed to the mucous membrane of the 
urethra, supplies the muscles of the penis, the skin cover- 
ing them, and the penis itself. It is the friction upon the 
nerves of the surface of the penis whicli induces the erection 
and emissions associated with sexual intercourse, or with 
masturbation, by exciting associated muscular contraction 
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 difficult to contend with in practice. I know of no 
way to prevent onanism except by freely blistering the 
penis, in order to make it raw, and so sore that it cannot 
be touched without pain. This plan of treatment is sure 
to cure onanism. I have adopted it during more than 
twenty years. Gentlemen have come to me and said, '* I 
have for many years suffered from this abominable, dis- 
gusting habit, and I have tried to cure myself of it, but I 
cannot ; for my morbid inclination overcomes my disgust 
when awake, and when asleep I think I am sometimes 
pursuing it. Can you offer any suggestions ? " I have 
said, •• Paint this strong solution of iodine over the whole 
of the skin of the penis every night ; and if that does not 
make the organ too sore for you to touch it, then apply in 
the same way a strong blistering fluid to the penis.'* Tlie 
result in practice of my experience has been that in almost 
every instance the continuance of the habit has thus been 
entirely prevented. 

Here is a case which bears on this subject. The notes 
are from the patient's surgeon. 

*• W. B , aged fifteen, is one of eight children, all of 

delicate constitution. After repeated exposure to cold and 
wet, he Cfidled upon his surgeon Sept. 4th, 1860, complain- 
ing of pain in the sacrum and left hip and thigh. He was 
relieved by purgatives and salines. I saw him on Sept. 
11th, with both knees flexed, and complaining of great 
pain in the lower part of the sacrum, with so much tcnder- 

T 2 



■^7i; Till-: TITKHArKT-Tiri INFI.I:EX(;E of rest [Lu-i ' 

iiLvss as i.i Ik: unublf to sit dowii. TIili kft tliigh and lej 
wore very tender, and them wbb exoeasiTe tendemew of th* 
Hurface all down tfae spine. No local iudicationa of iM 
in any of tJieae parta ; bowels coDstipated ; tongue ooalol. 
Ho was ordered cAthnrtic pilla, colohiciim. and an apericfkl 
mixture, in stronR doses ; croton oil tind tartar emetic lini- 
ment to be rubbed along the dorsal and lumbar portioD of 
the spine. Within a week there was great pain along the 
cervical portion of the spine, extending to the left Mm. 
Says the motion of the shoulder is very painful; elbcnv 
free; left band closed tightly, and any touch either of tliit 
fingers of wriet caused him great pain. 

"Sept. mth.— Left hand firmly dosed; both tWglii 
drawn up ; knees bent, and eanuot be extended ; " toee of 
left foot inverted, and whole limb very senBitive. Tlii" 
mouth ia closed for a few minutoB two or tlireo tinidK a 
day. 

" This went on till Oct, 3rd, when a physician from Lon- 
don saw him. This gentleman, in ooiisultation, thought 
that he recognised an important pathological state of the 
brain or spinal marrow, and pointed out with great 
precision the pathological anatomy which waa sure to be 
i'ound at the expected post-mortem esamination. Thw 
prospect made the friends of the patient very anxions 
indeed. 

" On October 7th he was no better ; head symptoms 
were now added, and for a minute or two he l)ecame un- 
conscious. 

" 1 1th. — No better ; vulcrianate of zinc, with compoimd 
rhubarb pills, quinine. &r., were continued. 

"lltth.— Oi.nsultod with the jihysician again ; fits and 
trismus worse. lie was ordered lo have Liehloride of 
UiCi-cury, icKlidc of potaRsiuni, and bark." 

" Dr. Lewis A. RajTC fOrfhnpipdir Svirtrwy.' p. IB) giies « caw 
of contraclion nf the knee joinla ftrin piirnljaia nf the quadriceps 
extcni!Oni, and one nf dnublc panilytic Tullpes Equinu-vanu, bolli 
rcaulling from the motbitl nervous irrilntioii from ^oDital elcitemenL 
<iiLO t(> cul>genilul phytiituia nud Hdherent prepuce, and iMired by rir- 
cumcieion. For a fuller aoemmt or the inJuricB nrcnrritig to the 
iicTTdiia HyHtem from irritntiim of tho senilnl 'iriiniiii nf both sexfs. av« a 
])«pi.r by the aiiaic author in the Trans. Aiiier. Med. Aseoc. IST.-i.— [Ed. 



^"1] AND TIIK DT.VriNo^Tlc VATJ K <>F IAIN. -77 

.*30th. — As the patient was getting woibe I was requested 
to see him. I found him sitting in his chair, the left fore- 
arm flexed, with the left thumb turned inwards towards 
the palm of the hand, and the fingers flexed over it ; his 
&oe flnshiiig 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, but not when the mind was diverted 
from it. The contraction of the limb and hand was con- 
stant, but could be overcome by persevering efforts on my 
part, giving way very suddenly. The spine was tender the 
whole of the way down. I requesteil that he might be 
denuded. The penis was very sensitive, and the prepuce 
prolonged ; the genital organs were cold, but highly sensi^ 
tive ; the hands were cold and damp. He had insisted on 
sleeping by himself, and in having a room to himself. The 
patient watched especially my examination of the genitals, 
and when I at that moment looked at him seriously, averted 
his face as if ashamed. I felt convinced 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 unol)- 
served. I ordered five grains of mercurial ointment to be 
rubbed once a day into the axilla, so as to divert his mind 
from the thing I had in view, and I 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, the 
legs remaining contracted; this contraction continued 
during sleep. The trismus persisted, • but with longer 
periods of muscular relaxation. The blistering was con- 
tinued, small doses of morphia were given at night, and 
the ointment used till the 20th of November. The mouth 
was a little sore, having been made so by the mercury. 
The ointment was then omitted, but the application to tlie 
penis was maintained. 

Nov. 23rd. — This is the surgeon's report : The " fits," &c., 
continued till to-day, and to-day the trismus lasted longer 
than at any former time. He suddenly opened his mouth, 
regained the use of his legs, and no relapse occurred. Sub- 
sequently a mixture of strychnia was given twice a day. 



■J.'i TliK TUEUAPEL'TIC INKLVEKCE OF REST [Ltrt 

I iiftunviii-da received this letter respecting the cane hm 
his surgoou : — 

" My dear Sir, — Yimng B is, and has l)een, quite I 

well ; he ia now in London. He was carod by the end of ^ 
last November " (one month from my visit). " A §light glMl | 
remained fur months after ; I did nothing for it but coW I 
batli§, Ac, The application 1 painted the whole penis ndl I 
with was the componnd tincture of iodine, made strougn I 
by ten or twelve gi^ins of iodine to each ounce. It I 
' touched him up well,' I can tell you ; but I don't think 
the friends ever had any idea what we considered the cans 
of his itlnesH." 

Here ia a caiie, then, which bears upon vrhat I h^vt: 
said— viK. that the same nerves which supply the skin sup- 
ply the mucous membrane, and the muscular apparatus of 
the penis — and which shows how a knowledge of anatoui; 
bears upon practice. Not long after I had vieited thu 
young patient, a gentleman called upon me. When he 
came into my room he said, " You have performed s 
miracle, sir." " A miracle ! " I said ; " you really take 
me by surprise. What do you mean ? " " Why. you 

cured young S ; he ia quite well, and at school. 

Dr. said he would surely die from fits resulting from 

some constitutional iufiuences inherited from his father 
and iiiotlnT." I nsHured him that, what I had done was 
no marvel ; that I simplv acted upon common sense, expe- 
rience, and physiological deduction. With that assurance 
and explanation lie seemed to be satisfied, and so was 1. 



Xll] AND THE DIAGNOSTIC VALUE OF PAIN. 27ii 



LECTUEE XII. 

XBBITATION OF ITDOOVB MEMBBAMB OF URETHRA AND VAGINA— OOlfPABA- 
TITK IHBBNSIBIIJTT OF UPPBB PORTION OF THB MUOOUS MBMBBANB OF 
THB BBCTDM, IL1X8TBATBD BY CASES OF CANCER, TA80ULAR GROWTH, 
AND OTEBLOADED OOLON— <}REAT SENSIBILITY, DIFFICULT DILATATION, 
▲KD BMDUBINO POWER OF CONTRACTION, THB CHARACTERISTICS OF 
LOWKB POBTION OF BBOTUM — ULCERS OF THE RECTUM CURED BY 
mOHAXICAL AND PHYSIOLOGICAL REST— ANATOMICAL RELATIONS OF 
THE NBBVE^, MrSOLES, AND MUCOUS MEMBRANE OF ANUS— ARTERIAL 
SUFPLT OF THE RECTUM — ARTERIAL ASSOCIATION OF TARIOUS PARTS 
OF THE BODY — ENLARGED LYMPHATIC GLANDS NEAR THB RECTUM — 
BTMPATBBTIO PAINS PRODUCED BY ANAL ULCERATION — ^DIVISION OF 
XXBYEB AND MUSCULAR FIBRE IN THESE CASKS — ANAL ULCER, PRO- 
DUCINO RKTENTION OF URINE AND SYMPTOMS OF PREGNANCY, CUBED 
BY DIYIDINO THB SPHINCTER — ANAL ULCERATION TREATED BY DIVI- 
nOK OF SPHINCTER — INTESTINAL OBSTRUCTION TREATED BY MECHA- 
HIOAL AND PHYSIOLOGICAL REST. 

Towards the 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 recognise that normal ass^iation causing, through 
the medium of the nervous system, cei-tain symptoms, such 
as spasmodic stricture of the urethra, and of erection 
during gonorrhoea. In allusion to the same subject, I 
may now add, that cases of chordee, accompanied by 
a twisting or bending 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 gonorrhoea, 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 the penis. In one set of cases this 
occurs very suddenly, and is due to spasm of the muscles 



2B0 THE THERAPEUTIC ISFLlfENCE OF REST [U* 

wliicli control the blood suppljr of the orjiai), this «{>um 
lioing in its turn caused by irritation of tlie pudic nenv, 
which supplies alike the elector penis and thcimtateiland 
tntianied mucous membrane. Another such coniUcion. like 
the first sudden in its onset and t«mporarj' in ita duntiuD. 
i"3cur9 especially at night, and is due to Home thin g vm 
like exrtt<i-motor action residing, and at thi8 timoaroiiMd. 
ill the cord, now that it is deprived of the control of t^ 
hrain, the patient having usually just fallen aaleep. Tin 
above cases are those which are relieved, as previcraalj 
stated, by opium. 

Another condition, though described by the esme nuno, 
is quite diatinot in its origin from the above. It ia that 
twisting or bending of tlie penis which ie brought about 
by effusion of inflammatory products into the corpufl i^OSr 
giosum : this condition often lasts some time, and may fat 
very obstinate. 

We all admit em]iirically the physiological rel.-ition of the 
mucous and muscular stnicturcs when we treat such case« 
by the sedative influence of opium. I will relate an inter- 
esting case as illustrating the contraction of the muaculat 
walls of the vagina caused by exiKjsed nerves upon it« 
surface. In November, 1860, I had occasion to see a lady 
who had been, and was then, suffering exquisite pain and 
sensibility of the vaginal surface, and distressing contrac- 
tion of the surrounding muscular walls. She had been 
married during twelve years, but bad never had complete 
coitus, and coitus only very rarely, and with extreme suf- 
fering. She had been uilBer the professional care of many 
physicians and surgeons for the relief of her distressing 
state. A fortnight before my visit to her, a surgeon had 
given her chloroform to insensibility, and used great me- 
chanical force in order to dilate the vagina. I examined 
the vagina with care, and fuund several raised papillie, or 
tubercles, exquisitely tender, so tender that she could not 
liear their being touched. Dr. B. Hicks subsequently ex- 
amined her, together with myself, and we noticed that 
merely blowing air upon the parts gave her exquisite pain. 
Chloroform was administered, and we removed the sensitive 
tubercles, and brought them to Mr. Quekett for his micro- 
scopic examination. Mr. Quekett explained to me that he 



Xrr] AND THE DrACJXO^TIC vvLn: OI- r.\IN. li^l 

iiad foiiiid that tlie papilla) were denuded i)f the natural 
amount of epithelium, and that exposure of the nerves 
ronning into them was the explanation of the highly sen- 
sitive cJiaracter of the surface of the vaginal mucous mem- 
brane. The mucous membrane and the muscles being 
supplied by the same nerves will explain the extremely 
contracted condition of the vagina. For some time after 
this operation the patient was considerably relieved. For 
the purpose of ascertaining whether she was much relieved 
permanently, I saw her a short time since, and she admitted 
that she was somewhat better, but not decidedly cured. This 
conditicm of the vagina has been do8cril)ed by the general 
term of vaginismus, or some such name. The explanation 
which I have now offered is the only one that I can arrive 
at based on morbid anatomy. Ovarian irritation and 
nervous association should not be overlooked while tracing 
cause and effect in such a case.* 

I now proceed to the consideration of the mucous mem- 
brane of the rectum. First, I would allude to its want of 
sensibility in a healthy state, except at its lowest part near 
the anal aperture — a very wise provision, accounting for 
the absence of pain and irritation from the almost dry 
hardened faeces frequently lying there for a considerable 
time, and distending the gut. The combination of little 
sensibility and great distensibility causes no direct warning 
or prompting by pain to patients except when the dis- 
tension is extreme, or the mucous membrane inflamed. 
The anatomist and the surgeon may, I think, make a 
very decided and practically useful distinction between tho 
upper two thirds or more, and the lower part of the rectum. 

• Dr. M. Duncan (Clin. Lect. on Vaginismus, * Mod. Times and 
Gaaette,* Oct 19, 1878) defines this c^mdition to be a spasm of the 
Tmgina, from spasmodic contraction of tho constrictor vagina) and the 
Anterior fibres, if not the whole, of the levator ani, with probably 
pftinfdl contraction of the involuntary muscular fibres of tho uterus, 
two varieties are described: — 1. Primary, simple, uncomplicated 
▼aginiBmus, a pure neurosis. 2. Secondary vaginismus, much more 
commoD, and depending usually on one of the following complications 
—(a), a painful red spot about' the fourchette, together witli a fissure 
there or close by ; (3), vaginitis, acute or chronic ; (7), one or moro little 
nloeratioDB about the orifice of the vagina, intensely sensitive, prone, 
mider treatment or without treatment, to heal and break out in other 
parts, and possibly allied to lupus. — [Ed.] 



2ii2 TUB TIIEBAFEUTIC INFLUENCE OF REST [Ltct. 

TKe upper part manifeets great distcneibilify abd scKTcdy 
any senBibility, while tlie lower portion poesenee ei- 
<{i]iBitG Bcnsibility, aaeociatod with great muBcnlar fam> 
which rceists distension. Diseased canditionsof theupper, 
middle, or lower part of the rectum, except the last utd 
tiT two, indnoe but little pain. Hence canoor, otdinMj 
ulceration, polypna, extraneous bodies, vascular tufla, or 
other disturbing cauaeB, may exist above the lower tvo 
inches without caiiBing pain. I have often seen theK 
observations confirmed by patients, who could scaroeljr 
believe it poseible that they could have bo serious a diseaw 
as cancer of the rectum without feeling pain. Some tinw 
since a gentleman came to me in great mental diBtren 
Ho said, " I have been told that I have cancer of the rectnm, 
and am Bure to die soon. 1 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 clearly enough, 
three or four inches above the anal aperture, and told him 
so. He was rather angry with me for confirming the 
opinion of his surgeon. Experience, however, cximpelled 
me to force roy conclusion upon him, notwithstanding his 
freedom from pain. I know a gentleman who hoe had 
cancer of tlie rc'ctum five years without jtniii, anil lie bHII 
pursues his daily occupation. If remote pain or cramp in 
the lower extremities bo associated with cancer in the 
rectum, it is a bad indication, because it is suggestive of a 
direct encroachment upon some of the adjoining nerves, 
either by enlarp:emcnt of the glands, or by simple extension 
of the original disease. 

I may mention another case illustrative of the slight 
sensibility of the upjK'r part of the rectum. About fifteen 
years ago I saw a lady, with Mr. Prance, a surgeon at 
Hampstead, who 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 longi- 
tudinal depression upon her faiccs. Wo examined the 
rectum by the aid of a long, narrow, glass, reflecting 
speculum, and we found, about four inches from the anus, 
a vascular growth, projecting into the gut from its pos- 
terior aspect, which explained both the impression made 



XII", AND THE I>IAON(>STI(* VALI i: (»F PAIN 



— • • 



ujK>n the faeces and the cause of the haimorrhage. 1 applied 
strong nitric acid to this growth in the rectum through the 
glaas Bpecolmn. After several applications, we ultimately 
cured it by sloughing. It was noted at the time that the 
nitric add 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 nand, if the 
acid be carelessly applied, and runs over the edge of the 
sphincter, then the patient suffers extremely. Distension 
of the rectum by faeces 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 faeces, and at length succeeded in empty- 
ing the rectum. She could not believe 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 alluded. Little 
sensitiveness and easy dilatability are the physiological cha- 
racteristics of the rectum, except at the lowest part, where 
great sensitiveness, little dilatability, and enduring power 
of contraction are the normal physiological features. These 
natural loccd peculiarities should be borne in mind both in 
forming a diagnosis, and in considering the principle of 
treatment to be adopted in any case. The strength and 
endurance of the anal sphincters are well exemplified by 
their successful antagonism to the peristaltic action of the 
colon and rectum upon large quantities of fluid or solid 
feculent matter, constantly gravitating towards the anal 
aperture, guarded by the watchful sphincters. Who is 
thef^ 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 



284 THE THERAPEUTIC INFLUENCE OF HEST [Itri. 

indomitable sphincter, vliich has averted the potnlilc 
cataBtrtipht ? 

Simple nicer in the rectum, extending upv&rda fim 
one inch above the lower margin of the internal Bphinctai. 
iDay Iw spoken of as capable of being cured by plijiao- 
loRical rest alone. Here ie a case in [wint, A mai™d 
lady, strong and healthy, about thirty-six yeora of wgs. 
had enjuycd remarkably good health up to the summer of 

1859, when her bowels be^n to bo constipated, aod dis 
had eome pain in passing her motions, followed by a tinutQ 
quantity of blood. In Augost, 1859, the pain was « 
severe and oonstant that ehe could not sit on a uhair 
without great Buffering, the pain being much incronMd 
after dofecatiou, and continuing duriug many hodlB, 
although ehe placed herself in a recumbent position, tiuri 
being the one which seemed to suit her b««t. She haA 
decided difficulty in micturition, and pain over the posterior 
part of thf Bucnitii : hor Jiienstnmti<in wiiti lioalthy. yb' 
was advised to take " warm " purgative medicines daily 
(I suppose the term warm was employed that they might 
be considered the more inviting), to use fomentations 
to the anus, and to be careftil in her diet. She strictly 
a<lhcrcd to this advice until the spring of 1860, suffering 
more or less the whole time. She had no distinct purulent 
dischat^e from the amiH, but thought she saw some matter 
occasionally with the motions ; very small quantities of 
blood were commonly mixed with the fmees. In Apijl, 

1860, being then a great sufferer, she applied to a physi- 
cian in ray neigh binirhood, who examined her rectum, 
and treated her for piles, without any improvement in her 
symptoms, until the middle of June, 1860, when, by the 
physician's advice she consulted me. I passed my fore- 
finger through the s]>asiuodicttl!y constricted or tightened 
sphincter without giving her much pain, nor did I induce 
any jmin by pressing my finger carefully over the whole 
of the inner circle of the sphincter, the ordinary seat of 
painful ulcer. This freedom from pain induced me to 
believe that there was no ulcer directly within the pressure 
of the sphincter. Extending the finger inte the rectum. I 
found I gave the patient some pain by pressing ujwn the 
gut towards the Siicnim, and on withdrawing my finger 



XII. ^ AND THE DIAGNOSTIC VAI.l K OF TAIN". 'JS 



_ ■ ' 



there was some blcxxl upon it. 1 then introduced the small 
reflecting speculum, cut obliquely at the end, and, on direct- 
ing it towards the sacral aspect of the rectum, an ulcer 
^was vifidble, ovoid, but irregular in form, its margin a little 
thickened, with its long axis placed vertically. It was 
abont an inch and a quarter in length, and three-quarters 
of an inch in width at its widest part. The lowest part of 
this ulcer was placed a full inch above the sphincter of the 
anus. All the painful symptoms before alluded to were 
still in existence. 

I would most urgently press upon your attention that 
these cases are 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 nourish- 
ment made from meat, plenty of milk, with some lime 
water; to take, if necessary, the confection of senna, with 
bicarbonate of potash, in the middle of the day, in order to 
soften the motion, and to secure relief from the bowels 
just before going to bed ; she was also directed to use a 
warm-water enema every night. After the bowels had been 
fireely relieved by these means, one large tablespoonful of 
decoction of starch, with twenty drops of the sedative 
solution of opium mixed with it, was to be thrown into 
the rectum, to remain there. From the first time this 
injection was used she began to be relieved from her 
symptoms. All nay recommendations were very carefully 
earned out. At the expiration of a fortnight she came to 
town again, cheerful and free from anxiety. She was fi*ee 
from pain excepting occasionally, and she told me she 
thought she was well. I examined the rectum again with 
the speculum, and saw the ulcer reduced to short and 
narrow dimensions, and cicatrizing healthily. I i>ersuaded 
her to continue the same plan of treatment for another 
fortnight ; at the expiration of that time she came to me 
quite well in every respect. The introduction of the 
finger gave no pain, nor was it followed by any blood. 
This lady contmued during several months perfectly 
well, since which time I have not seen her. This is 
a case, I think, cured simply by mechanical and phy- 
siological rest. It is not too much to say that she was 




■"to". nKdtei^ ?7™^'><«»r«»>. 



XII.] AND THE DIACiNUSTiC VAJJ'i: OF I'AIV. 2bl 

not auy cancer, but they could feci aud bcc an ulcer in his 
gut, to which they had applied, in the form of injections, 
solutions of nitrate of silver, sulphate of zinc, sulphate of 
copper, and some preparation of lead. Ue added, "I 
nrajBt honestly tell you that although I have taken an 
ixnmenBe quantity of medicine, 1 am a great deal worse 
than when 1 went to them." I proposed to examine his 
rectum. " No," he said, ** you must not examine me ; I 
won't be examined any more. 1 have suffered so much 
already from that speculum." I said, " You are very 
foolish ; I cannot tell with certainty what is the matter 
till I have examined you." But he would not permit any 
examination, and I was very angry with him. 1 advised 
him to get his bowels well emptied every night, just before 
going to bed, by large common gruel or warm-water injec- 
tions ; after that to inject twenty drops of sedative solution 
of opium mixed with a solution of starch. 1 finished by 
■aying, "Let me see you two or three weeks hence." 
"What." said he, "no pills?" "No," "No medicine?" 
" No." " What, nothing at all ? " " Yes," 1 said ; " do not 
neglect your diet, take care that the fseces 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 me that he had felt quite domfortable 
ever since his former visit, by only doing what I had told 
him. Now, here was a case in point. This man's rectum 
had been painful for nearly throe months ; besides the 
almost constant use of purgative medicines, two or three 
times a week he was examined by a speculum, and had 
injections of nitrate of silver, or sulphate of zinc or copper, 
and all that sort of thing, adding, as 1 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 1 know, he was cured by 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 treatment by 
rest and quiet in preference to one of irritation. 1 am 



ajH'rnirc, witli its associiitcd iiiu 
saci'al and ]m<li(' l)i"aiK-li«'S ; son 
as jK'itoiatin^- tlie muscular lil)i 
luucous membrane. 

Here is another drawing (Fig. 
of great interest, because it exhi 
landmarks capable of guidine the 
If you ask a surgeon, '* Wnere 
divide the sphincter of the rectn: 
to direct you?" " No, none at 
will answer the purpose. Fig. 
part of the rectum laid open, and 
by dissection (c) ; a white line (/),ip 
any surgeon can recognise, shows i 
and the mucous membrane (h), Tl 
exactly with the linear interval 1 
and internal sphincter muscle (e), 
mark, exact and truthful, so tha 
The circular fibres displayed abov- 
portions of the internal sphincter 
become more attenuated as you tra 
the walls of the gut. The levato: 
tion on each side, in a position e 
muscle. 

The special object of this di*awii 
line of junction or demarcation of 1 
sphincter of the anus, and that lin 



that anatomical arraugemeut, but 1 wum nut iLci|uaiiite<l 
'vrith what Fig. 52 bo clearly displays, viz. that filaments 
of nerves (and they are very numeroue), derived from the 
pndio, and poedbly from other nerveB. pass thron^h the 
sat exactly between the internal and external ephmcter. 
toerefore exactly underneath that white line of nnion of 
mnoooa membrane and skin, and thence Bome proceeil 
upwards towards the lower part of the mucous membrane 




«f the rectum covering the internal sphincter, and othem 
proceed to the skin near the anus. 

In order to complete the nerve anatomy of this i)art. 
which requires to bo well considered for the purpose of 
explaining the varied nervous symptoms which may be 
induced by an nicer within the rectum and near the anus, 
I have made (Fig. 53) a rough map of these parts, with 
an nicer depicted upon the surface of the sphincter. Two 
linee indicating two oorves are seen directly communicating 



■ii)0 THE THEBAPKUTIO INFLUENCE OF BEST [Un. 

with tho ulcer, and the arrows point to the fact th»t ik 
Heiifiitive nerve oonveyB its influeiico from the Burfara uf 
the ulcer to the eiiiual murow. aud that the ijthcr, or 
motor bniiioh flf tliu same nerve, couveys motor imwat 
trum the . eninal marrow to the sphincter muscle : thn* 
explaining how the excitation or irritation engoudered *t 
the nicer may be wnveyed to the spinal riiarrow. and pn- 
iliice rellected effects upon the aphincter musale. leMJcg 




icioH mpmbriiiip, y. N«rv« AupplyLni; the ^t\n and mocou^ id 
' anal ■ppnurp. ithicb It reaiati* by pdMlng fint txitmtUy i 
iHi4 tbpn gw-t through tbc Inl^rvAl botv«m tbe two spJiinctfin, vnj uiti>\t- 
iv ilvlribntH Dpun llie nmcoiui monibrw and the »kln. A« Jk, Uhcodb mnn- 

iietvp fllameiitM iupplyinK tbc^^ lurU- 

to painful contraction. I would further notice that this 
" sign-pwt " map tells ub that the jmdie nerve, which sup- 
plies the portion of the amis upon whi(,-h the ulcer is placed, 
in intimately ussiiciuted with other nerves arising from tbe 
li>wcr part of the Hpinal marrow. It also shows that some 
lit' those associated nerves go to the lumbar region, some 



over the hiiis. BOiue iluwii the leg, inid ulhers tu the iiriuarv 
bladder aod urethra. It is an indiaputable fact that tltUHC 
anal ulcers cause lumbar pains, iliac painn, pains and loss 
of senaation, or cramps, in the leg, and irritation about thu 
bladder and urethm. These symptoms cannot be explaiueil, 
except under the title of " anomalies," unless you choose 
to refer to the nerve anatomy of the part, when the explana- 
tion ie made easy and sufficient. 

Mr. Quain has shown that tbe upper jart of the rectum 
receives a comparatively small quantity of arterial bhxid, 
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 digression, with the view of 
alluding to the great precision which marks the 8Up]ily 
of arterial blood to some parts of the body. I might put 
the subject belore you in this manner, and ask, Why 
should uot the whole of the rectum be sup|>lied with bh>od 
from the inferior mesenteric artery? At first thought, 
there appears to be no reason why that artery should 
not carry the blood downwards to all the lower part of 
the rectum, as well as to the upper. Yet it is not so; 
the lowest part receives its arterial supply almost exclu- 
sively from the pudic artery. A few branches may 



. , , .» jiicii IS (lis 

• 

(liL;osti<>ii, find iiotliiiijj; else : it s 
pancreas. spU'eii, and part of th 
that it docs. A« these are all u 
proceKS of digeBtiou, the coeliac a: 
the " digestive artery.*' Take ai 
hyoides, placed between the lar 
functionally and structurally a88« 
not anatomy tell us that the ob li 
from the superior laryngeal art 
the lingual artery on each side^ 
connected with the functional an 
both the larynx and the tongue, 
the double source of arterial bl 
nutrition ? There is a disposition 
to think and to teach that nerv 
designed accuracy, but that there 
the distribution of the arteries. 1 
many years ago, when endeavor 
students of Guy's Hospital the pu 
the subclavian artery into its ] 
pointed out that the branches dii 
clavian trunk, apart from its ooi 
extremity, are distributed with on 
supply all the parts concerned du 
the process of respiration — that is 
distribution of the subclavian arte: 
The vertebral, besides simnli'i 



XII. j AND THE DIAONOSTIC VAIJE OF VMS. L" ) 

diaphragm, and the upper half, or the respiratory portion, 
of the abdominal muscles. 

The superior intercostal artery goes to the first and 
second ribe. Now, the first is the most important of all 
the ribe in the respiratory function, as it forms the fixed 
point for the action of the intercostal 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 upwards (ascending cer- 
vi<»J) which accompanies and nourishes the phrenic nerve, 
and constitutes, in fact, an ascending comes nervi phrenici. 
The transverse cervical supplies the trapezius and tlie 
posterior border of the scapula, with the muscles attached 
to it, all of which may be considered accessory to respira- 
tion. The supra-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, deghi- 
tition, and mastication, so we ought to discover that its 
arteries are derived from the trunks of those arteries which 
supply the face and lips, those which supply the mastica- 
tory japparatus, 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 
seems to take a wandering, devious course up to the soft 
palate ; one from the ascending pharyngeal arteiy ; and 
one from the internal maxillary, the true " masticatory 
artery :" * Here, then, is a simple piece of anatomy, which 

^ Mr. Hilton, in his Lectures on the Cranium, speaks thus of the 
ooune of one or two branches of the internal maxillary artery which, 
at first sight, seem to have nothing to do with mastication ; anrl first of 
the course of the middle meningeal to the interior of the skull : *" If it 
were only for the sake of a supply of a certain quantity of blood to the 
dura mater, the special intra-cranial arteries, viz. the two internal 
carotids and the two vertebrals, would be amply sufficient for this pur- 
pose, and there would be no necessity for the entrance of those streams 
that are derived from vessels supplying ^rts on the exterior of the 
skull. There must, therefore, be some design in such an arrangement. 
The essential purpose of the internal maxillary artery is to build 



1 lir lyuipliatics of the rectini 
within thr ]>t'lvis, and stniu'tiiiii 
(•iilarmniciit of those irLuids. TI 
the reetuiii within the pelvis, 
BuggeBtive of malignant disease 
of great anxiety. I remembe 
Mr. Aston Key, a private patiei 
ulceration within the rectum) tb 
expressed by another surgeon, b 
lar masses could be detected witl 

up or nourish those parts directly neo 
cess of Rihstication, so that it may be 
artery. From this trunk is derived 
which, whilst ramifying in the dura m 
that supply the squamous portion of 11 
of the sphenoid, the frontal, and the pi 
fact, which oontrihute to form the tem| 
the temporal muscle, one of the most im 
It also g^ves a branch inwards to dey< 
portion of the great wing of the sphen 
external pterygoid — another important 
middle meningeal artery, therefore, may 
nal maxillary into the interior of the en 
wards to nourish, thut portion of its ex 
ment to masticatory muscles, is rendered 
function. 80 fully, indeed, is this intei 
artery given off from the middle meningi 
maxillary itself, enters the cranium by 1 
for the express purpose of furnishing m 
division of tl)e fifth — tlie norvn <i-"«^ - 



A' 



IL] AND THE DIAGNOSTIC VALUE OF PAIN. 295 

pon the rectum, and leading him to think that the patient 
mm suffering from cancer. It turned out to be nothing 
ore than swollen lymphatic glands in a state of enlarge* 
lent or irritation, in consequence of their having received 
kOrbid fluid from the ulcer ; and, as soon as the ulcer was 
ared, the glands subsided, and there was an end to the 
ifflculty. In that patient I repeatedly felt the enlarged 
luidB, about three inches within the rectum. This asso- 
ifttion of enlarged glands with ulcer within the rectum 
i a point that should be borne in mind, but is generally 
rerlooked. 

The pathological relation of the ulcer to the various 
emree already referred to is very clearly evidenced by 
otioing that the pains associated with those nerves, are re- 
eved as soon as the ulcer is divided. From that time all 
lose pains cease. It amounts pretty nearly to a dcmoii- 
kration that the ulcer was the cause of all the remote 
uns propagated by nervous continuity from the site of 
le ulceration. Physiology, anatomy, experience, and 
nctice indicate that a patient may have pains over the 
nnB and hips, pains down the legs with loss of sensation, 
un and contraction of muscular fibre connected with the 
Tinary and generative organs, all produced by an ulcer 
pern tne internal part of the sphincter, so largely is this 
applied with nerves which endow it with exquisite 
mnbility. 

Let us now apply this local anatomy to explain the 
^ptoms manifested at the seat of the disease, as well 
I inoee remote (or so-termed anomalous) symptoms of 
ain, cramps, slight numbness, and slight loss of muscular 
ower in the lower extremity, generally on the left side, 
r diflficulty in making water, with fretjuont desire, 
)tention of urine, dilatation of the bladder, with pressure 
pen the rectum, &c. &c. All these sym])toms can be 
roduoed by an ulcer within the rectum. The character- 
(tioB of the ulcer within the circle of the external sphincter 
re, more or less pain when passing a motion, and severe 
od enduring pain for some considerable time afterwards. 
lie severity of the pain is explained by the exposure of 
msitive nerves in the ulcer, and the persistence is ex- 
Imined by the abundant supply of motor filaments which 



L'96 THE THEBAPEUTIO INFLUENCE OF REST [LiK. 

endow the Rphiacter muBcle with the power to preiK, rub, 
and persoreringiy equeoze the opposite parU of the uImi- 
ated and eonaitive BurfaoeB upon each other. EefleotUigeo 
the large amount of nervea which proceed to the Bjihuie- 
tor mu§cle. one undcrBtande how it happens that it ii «> 
enduring in its power. No doubt the strength of a mnsclc 
will in a great measure depend upon it« extent or sin', 
iiut the endurance of active power depends upon tliu 
iiuinher of nerves supplying the muscle ; hence the gntt 
ciiduranoe of this sphincter muscle, and I know of noue 
that can compare with it in that respect. The principltci! ' 
treatment of all the varions forms of fissure or ulcer nor 
the sphincter is very siraplo, and usually effective. It ii 
based, or ought to be, on giving the part phyaiok^icsl 
and mechanioal rest. To apply this to practice, the wo- 
tions should be kept soft and pulpy, so that the aphincUi 
may not be too widely opened during defecation, nor the 
uIcL-r exposed to thi: fiietion of ii large or iinrd nivlinn. 
This is obvious comuion sense ; the recumbent position 
should lie observed, which is rest to the capillaries and 
veins — also coniinou sense. If the case be a simple crack 
or fissure in the akin or mucous membrane, and we apply 
nitrate of silver or a solution of bichloride 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 of substance. The explanation 
ordinarily given of the beneficial influence of these albu- 
men-coagulating agents is, that they '* set up a new action," 
as if the agents took an active part in the reparative or 
reproducing process. On the other hand, I believe their 
usefulness depends chiefly on their giving " rest" to the 
parts, and 80 enabling Nature to fill up the gap. And if 
this be true, one can see how it is that the rude application 
of nitrate of silver may do harm, whilst the well-considered 
and gentle use of it may do a large amount of good in 
many cases If a patient has a crack or fissure in the 
margin of the anus nithin the area of these numerous 
nerves, it is exipitsitelv stusitivc. so that if the end of a 
jirobo is pri.sBed upon it the patient sometimes calls out 
with [lain but diiectlj you cover that surface with the 



XIL] AND THE DIAGNOSTIC VALUE OF PAIN. 297 

nitrate of silver, the patient is free from pain. Now, what 
has led to the difference ? Simply that these filaments of 
nerves are not then exposed, but are covered by coagulated 
slbmnen. Thus the parts are defended from the external 
sir and all morbid secretions ; and in twenty-four hours, 
perhaps, that crack or fissure is healed, not by the nitrate 
of silver, not by the surgeon, but by Nature herself. I 
often employ, as a local application in such cases, a lotion 
ocnnposed of two grains of bichloride of mercury, ten drops 
of nitric acid, and one ounce of water; this fulfills the 
object just as well as nitrate of silver, since it is applied 
simply for the purpose of coagulating the albumen upon 
the ulceration, which acts as a mechanical defence to the 
Boriace of the ulcer. 

If the ulceration, whether oval or circular, he limited to 
the mucous membrane, and very sensitive from exposure 
of nerves upon its surface, it may sometimes bo treated 
imccessfully by the application of opium ointment, or by 
■tarch and opium injections at night, or night and morn- 
ing, the bowels being previously opened by a warm- 
water or a thin gruel enema. For the purpose of ascer- 
taining the sensitive point of the ulcer ( for every part is 
not so), it should be exposed to view by the aid of the 
anal speculum. The blunt end of a probe should then be 
applied to the surface of the ulceration, so as to enable the 
lurgeon to detect the precise point of exi^sed nerve, by 
inducing sharp pain. Keep your eye ui>on that spot, and 
there apply a very small drop of strong nitric acid ; the 
patient will be almost immediately free from pain. In 
that way you may successfully treat a sensitive ulcer at 
the verge of the anus, as you may best treat an irritable 
and painful one upon the leg ; that is, by destroying the 
exposed nerve in the ulcer. Dividing the mucous mem- 
brane by a bistoury is recommended by some surgeons to 
cure these anal ulcers. How drawing your knife across 
the mucous membrane of an ulcer is to cure it is unintelli- 
gible to myself, except I add that by so doing you divide 
the nerves, and destroy the exquisite sensitiveness of the 
ulcer ; but the rationale of cure by a simple division of the 
mucous membrane, without reference to the nerve, is to 
me utterly unintelligible. I do not desire to speak pre- 



8 THE THEBAPErTIO INFLUENCE OF BEST [Un. 

mptuonsly in the presence of go much profeBsianal eipe- 
inoe. but I feel confident that the dniple division uf liit 
membrane, witlioiit the nerve an well, can do 
nothing curative for an nicer of that kind. On the other 
hand, when yon micceed in dividing the exposed nerroiK 
filamenU, by drawing a bistoury an'osB the ulcer, yon in 
that way separate the ulcer from the trunk of the nerve, 
and BO give it " physiological rest" by relieving the pun. 
I most state, however, that in the majority of the bmI 



Ib^cUI Spcculi 




, ijuj-9 iio-pim, 



ulcere which I have examined by the aid of the speculum, 
the circular fibres of the sphincter muscle may be seen to 
form the base of the ulcer, and in snch instances its 
edges are especially sensitive. I would have it under- 
stood that 1 do not speak with any degree of hesitation 
in this matter, because I have over and over again, by 
means of the speculum, seen tbo circular muscular fibres 
forming the base of the ulcer, I have observed them 
with as much precision as 1 see them in the diagram 
before you (Fig, 55), so that I have not the slightest 
doubt upon the point, I may add, that if you touch 
the muscular part itself with a prulie. it is not sensitive ; 
but touch the margin of the ulcer in the same way, and 



tht; [latieiit wiuiilaius bitterly. It is that kiiiii uf ulcer 
in which the circolar mascular fibres are actually seen, 
which ifl BO Buccessfully treated by dividing the sphincter 
miuNite. 




The reason for this anal ulcer being so very painful is 
the number of nerves associated with it ; and the cause of 
the continued painful contraction which accompaniea it lies 
in the enduring strength of the sphincter muscle. Thus 



300 THE THERAPEUTIC INFLUENCE OF REST [!jcf. 

it happens that exposure of those norvoUB sensory iiU- 
liients upon the ulcer causes excito-motory or involuut«rj 
(ind spHsmndio contraction of the sphincter, throne}) iht 
uiudium of the spinal marrow. The sphincter muacle cue- 
tracts towards its own centre, and, as long as the uitui^ 
JR iu a state of contraction, it hringa the suimtire edgMof 
the »ic«r into forced contact ; this oxdtes more muaunlu 
contraction, and thus, by time and exercise, the niluclt 
becomes hypertrophied, massive, and increased in diaeQ- 
eiona. It is worthy of notice that when the innede hw 
been divided in such cases, it soon returns to its mun 
natural condition, by the muscular fibres resuming tieir 
uattiral dimensions. When we divide the sphincter muscle 
forming the base of the ulcer, what do we acoomplMi by 
this ? We cause the two portions of the muscle to contiaet 
to their then more fixed points ; that is, away from the 
ulcer. Therein lies the rationale of the operation so fre- 
(|iu;ntly performod — it prevents the iiiuwi-lc^ irrit.ititij; "r 
niiimying the surface or cdgce of the uIcit liy pn-spiii^ 
them ii]wii eiich other during its cinitriieti!)iis. Hi-n(v 1 
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 casesis 
really absolutely based upon bringing about local phj-sio- 
logical rest, for by dividing the muscular fibre you merely 
jirevent further friction by the contraction of the muscle, 
and, after a time. Nature repairs the ulceration, by filling 
Tip the gap which the surgeon has made. 

I will now direct your attention to two or three coses 
illustrative of the anatomical and physiological facts to 
which I have alluded. 

CcufofAnal Ulcer. pToditeing Retention of Urine andSymplom* 
of Pregnanci/. cared by (iirid!n-j the Sphincter Muscle. 

The first is the case of a young lady, aged about twenty- 
two, whom I saw some years ago with the late Dr. Golding 
Jlird, She was an excellent dancer, good company in a 
drawing-room, and thought to be a very agreeable and 
attractive iHjrson. (gradually she receded from that position 
in society, lying down a good deal on the sofa, suffering 



XII. _ AN1> TIIK hlACNOS'I'IC VALIK (►!' TAIN. :;"i 

much pain, always uncomfortable, occahioiially quittiuj^ 
the room, whether in society or at home amongst her own 
relations. It was noticed that she had occasional sickness, 
menstmation was not regular, the ahdomen was decidedly 
incieasing in size. She hecame very fond of lying in l)ed 
instead of going to balls and dances — in fact, she said she 
ooald not dance or enjoy society at all — and was very 
uncomfortable. A surgeon was considted, who, perceiving 
the patient's changed character, and finding the lower part 
of the abdomen decidedly large and prominent, mentioned 
a suspicion of pregnancy to her mother. Her mother, who 
was personally acquainted with the late Dr. Golding Bird, 
took her to him. He examined her carefully, and said, " She 
is not in the family way, depend upon it ; I think the symp- 
toms arise from piles, or something wTong in the rectum.'* 
It was under these circumstances that I was requested to 
examine her. I found her sufiering from piles and pro- 
lapsed rectum, retention of urine nearly complete, enlarged 
abdomen, sickness, loss of a])petite, always in ])ain at the 
" lower part of the stomach,'* l)owels constipated, freijuent 
loss of blood from the rectum, and extreme pain during 
and after defecation. Her illness commenced, many weeks 
liefore I saw her, with great pain in passing a motion, and 
all her urgent symptoms resulted from the original anal 
idcer. This was the order of events : — The nerves of the 
anus and neck of bladder being derived from the same 
trunk-nerve — the pudic — the nerve irritation extended 
from the anal ulcer to the muscles of the neck of the 
bladder and urethra. This caused them to contract, and 
produced difficulty in making water, and subsequently'^ 
the retention of urine. The j>rotracted distension of the 
bladder caused pressure upon the rectum, interfering with 
the return of blood from near the anus, and this, added 
to the straining of the patient to relieve herself, caused 
distension of the rectal veins and j)artial prolaj)8e of the 
rectum. Hence arose all the other symptoms to which I 
have adverted.* 

• •• Fissure of the rectum often causes most distrcf^ing symptoms of 
TaginUmus .... Ulcerationof the rectum, producing burning pahi in 
the left iliac region, dyuparennia, dysnienorrhoeu, and frequently 
menorrhagia as well, has often been overlooked, imtil a careful examina* 



M2 THE THERAPEUTIC INFLUENCE OF BEST [Lm 

I posBed a probe between the projecting folds i<f (bie 
ivctuni, and soon made out whore the ulceration eiiib^l. 
I removed a portion of kh ext«mal pile, and then obUined 
a clear view of it, situated just witjiin the kuub, full balT 
an incli wide, and more than three-qnarter« of an iiich in 
length ; muscular fibre formed its base. I divided iJm 
sphincter muscle through the centre of the ulcerations, ai 
nearly the whole of the painful symptoms quickly sul«iriK!, 
and the patient was soon well, and as happy and ^y »» 
ever. I have Been the lady several times tiinoe, and «!"■ 
has remained perfectly well. 



Case* of Anal Ulcer aeootnpanied bi/ Pain along the Soabi 
Nerve, Pain over Li'fi Hip and Loin, Pain in l)it Bi^ m 
Leg. Case of Arterial Hamorrhage from an Anal rb* J 
aired by DipUion of the Ulcer. I 

A surgeon wiio had pain down the left leg on uue 
side was not relieved until the operation of dividing the 
sphincter waa iwrfwnned. Time will not allow mc to dwell 
uiion this ease. I saw a wise some time since with Mr. 
Aiken, of Clifton Place, Sussex Square. The patient had 
jmins over the left hip and loins : he had no treatment 
except opium with diacetate of lead locally, and this with- 
out any Iwiietit. Tlie speculum exposed an ulcer about 
three-quartei-B of an inch long and a quarter of an inch 
wide, ctimiuenciiig just within the internal sphincter, and 
running diri'ctly downwards ; transverse muscular fibres 
formed a part of its floor, the other part was covered with 
granulations. The pointed bistoury [>assed through the 
internal and external sphincter, and, dividing the ulcer into 
two portions, gave him iumiodiate and permanent relief: 
he liHd nn ]>iiin, even the first time his towels were open. 



(Lim JH-T rcolmii liiu pn>ve<) tlint the syaiplomscomnlaiDed of neredueto 
this »[i<l nut U) niiy uterine iJiMiidcr, and a slight incision through the 
Bptiinctcr, with pruper utteiilion to the ri^giilalion of the bowels, b>e 
f fleeted in a fuw itays what months of treiitment directod to the uteimi 
iiloncluul failiid to iiooomplish." (Dr. Edia'The Becium.in its a-klion 
to Ulerine Diseaae.' Brit Mi-d, Juum. vol. ii. 187*.)— [Ki>.] 



SJL] ANB THE DIAGNOSTIC TALUE OF PAIN. 303 

•Iter the operation. He was kept recumbent during five 
or six days, and then began to move about without any 
inoonvenience. Mr. Aiken saw this gentleman the day he 
Muled for New Zealand, a month after the operation ; he 
was then perfectly free from pain. 

The next case is that of a young woman wlio had an 
uloer at the anterior part of the rectum ; Hhe 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 
neceesary to be very cautious in dividing the muscular 
fibres. A very small knife was passed through the circular 
sphincter fibres of the anus, and the patient got quickly 
well. 

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 suffered severe pain during 
and after defecation, accompanied by considerable arterial 
hsemorrhage from the rectum, which had of late largely 
increased. She was thought to be the subject of malig- 
nant disease in the intestines, stomach, or liver. A large 
quantity of blood was passed with the faicos. The motions 
were white; she was in a state of advanced ansemia. 
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 ])ill 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 intro- 
duced the speculum into the rectum, and saw an ulcer 
towards the back part of the anus, on the j)atient'8 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 tlie 
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 



3fl4 THE THERAPEUTIC INFLUENCE or BEST [Lkt. 

a great deal of good. The pfttient was a surgeon of gnat 
intellect. When I eaw him. with Dr. .leuffreson and Mr. 
Hancock, hi* had had insuperable conBtipation for thittj- 
one days. There was great Tomiting, We agreed ilut 
thi; (ibstnii'tiou must be aomewhere in the neighbonrhood 
of the lower part of the colon, or the nppor part of the 
rectum. We could not detect it with the fioeer. We 
thought that without relief he would die before the more- 
iiig. audi operated on the same evening. Aft«rapeningtiif 
bowel ill the loin an euormoua quantity of feculent satter 
at once eaeaped, and continued to do bo for a cooaidetable 
period, to the great relief of the patient. I had requested ] 
that he would not allow it to cIobc up ; howeTer, ho I 
improved bo much that he thought he might do so. The 
peculiarity of the ca«e was this : that on the fourth d«y 
after the operation, from the relief of the distended con- 
dition of the colon, he passed motions by the natural anua. 
and eontinupil to do so fi.>r eome wpckn. until a gra[liml 
accumulation took ])Iaee, and then a recurrence of the 
ityiuptoiua. I tli^n operated upon him again ; the same 
kind of relief was afforded ; and, as the l)owel8 continued to 
l)e opened through the anni aperture, bo went back to his 
work, and saw thirty or forty patienta a day. Later on he 
had HyniptooLK of paiu in the hip-joint, and ultimately 
uisenBe of it, from which be died more than twelve months 
after the first making of au artificial anus. After tbefirat 
operation he used to coni})lain of great itain in the lower 
angle of the Wound ; when I operated the second time. I 
put the bietcmry lower down, to divide the nerve which 
had given hini ao much ]>ain, and from that time he was 
comimratively comfortable. 

UlKin making a post-murtera examination, it was found 
that tliero was no cancer. 'J'hero Iiad been a contraction of 
the intestine where the sigmoid flexure of the colon joins 
tlie rectum. This had produced an obstruction, and, coii- 
senuently. a disfenuion and overloading of the colon. The 
weight of the fieces had caused the colon to descend con- 
siderably below its normal jtoBition, likean inverted syphon ; 
the ffeecB, therefore, had to ascend, and then could not pass 
over the fixnl point where the constriction had taken place, 
the weiglit of the colon making this part an acute angle. 



I AHD THE DIAQHOBTIC TALUE OF PAIN. 



305 



•o producing inanperable constipation. When the 
ling was made into the ^PP^i' portion of the colon, the 
j^t of fiBdcee was taken off ; tne accumnlation in the 
v part was then forced upwards, and made to pass 
iig^ the rectum. 



KI^^^^^^^^I 


306 


THE THBHAPECnO INFLfKSCK OF 


BEST [Lnr. 






LECTITRE 


xiir. 




MANI 


PIBEABES or J 


nmt Attribctkd 


TO IICnOFDI.A 


THE EWCLT or 




3KNT— CiHB OF 


DISEASE OF THI 


KNEE- AND Bl 


P^WKTB <«WI 1 


B\aE 








KHATion inn 




B8— HIP-JOIMT 


CUBED BT BEiT 
BE— JOISTS IKOT 


^l!!?*r™!i''u 


MTi BWDIM • 

HCBT o« om- 




nos aE<<ESAi.i.v thkb fbob 


itEUS—THK oono-rBnwiL 




EX*KF» OF 


•Bl»— FELTIO 








OHK rWjCRNT IN 


TBI wwsa T 


HAN TDC urm 


EITBEHITIU—UtBEAU Or OirrElt N 




KUUB rsBunsT 




INNKB— HKAli 


THT JCHNl* NOT 


LIKELV TO DITEBInRATE WOM 



In my seventh lecture, after referring to the fact that the 
Bame trunks of nerves supply the joints and the mnBcles 
and skin over thorn, I 8tat«d that one of the normal results 
to be obtained by this distribution of nerves was to insure 
mcchauical and physiological consent between the external 
musuular, or moving forces, and the vital endurance of the 
parts moved, chjoHy in the interior of the joint, during 
friction or pressure ; thus securing in health a tni« balance 
of force and friction. If this point of balance or adjust- 
ment be overreached by accidental violence, or undue exer- 
tion, then pain. Nature's warning prompter, is produced 
within the joint, and suggests the necessity of diminishing 
or arresting exertion. Without this muscular and articular 
nervous association in joints, there could be no intimation 
of the exhausted function of the internal jmrts. When 
this functional exhaustion of the internal parts has been 
reached, and articular pressure with friction is nevertheless 
continued, thenmischief to the 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 



IL] AND THE DIAGNOSnO TALUE OF PAIN. 307 

ktement are the elements of my opinion and belief, that 
leaaes of the joints in children are the results of accident 
over-work, and that they are not simply selected by 
ktore for the development of the constitutional or scrofu- 
la diathesis. Yet I do not think I wrongly express the 
3vailing opinion of the profession, or, at any rate, of 
my surgeons, when I say that there exists in their 
nos an inclination to believe that diseases of the joints 
young persons- are most frequently to be regarded as 
I manifestation of a constitutional tendency, spon- 
leoosly expressing itself as scrofulous, and starting 
khoat local injury. Indeed, by some surgeons, it is 
mght that such diseases of the joints may be deemed, 
it were, the local emunctory of a scrofulous or cachec- 

oonstitution, and that such cases, therefore, are not 
tmUe except through the constitution or general health. 
xther, that if the local disease of the joints be cured, the 
ne kind of disease will show itself elsewhere, perhaps in 
De part of the body more important to life. Now, this 
mid be almost to argue the impropriety of curing the 
ease of the joint at all. I must state my own conviction, 
kt in comparatively few cases is the interpretation sound 
1 good. I base this opinion on the aggregate cases of 
ot diseases which are brought before the notice of the 
rgeoQ, both in private and hospital practice ; indeed, I 
iffve that the diseases of joints are almost invariably the 
nlti of local injury, and that if they were recognised 
iy, and treated by appropriate rest, nearly all of them 
lud get well. This, then, is to contravene the generally 
eived notion that so many cases of joint disease are the 
nit of scrofula. I will admit that the untoward con- 
[uenoes or results of such cases, originating, as they 

in slight local injury or over-exertion, are in some 
■sore owing to the unhealthy constitution of the patient, 
1 that the same amount of injury in persons perfectly 
dthy would, in all probability, have caused no such 
donsed condition of disease. But then it should be 
oembered that if the general health be bad, it is equi- 
ent to the confession thnt the powers of reparation are 
ble, and that, therefore, rest, or freedom from local dis- 
'banoe, becomes in such cases the more necessary. Unlobs 

X 2 



■:><|-* Tin. THEliAPEUTlC INFLUENCE OF REST [Lett. 

ii tluuuLiil imiiwrtiuiiatc amount of rest hiis i-pen mainlJiiued 
from the lieginniag. they do not offer a fair compuivD 
with oasee in which the oonstitntion is absolutely health;- 

Cage of DiecoMe of (ke Kmec- and Bip-Jointa on t\e mimt ait. 

To give this subject a practical bearing, I may joit 
iutrodiiL-e a few short notes of a case wMi^ cftme under 
my uotiue some years ago. It sbowH the adrautage of 
removing, in certain mre caneB, a. " scrofulous " joint si it 
is termed, and also demonstrates the value of rest in Uia 
treatment of disease of the hip-joint in a " scnifnlou'' 
patient. 

On the last dayof Docemiier, 1849, I saw near Ipswudi, ^ 
with Mr, Bartlett and Mr. Bullou, surgeons of that town. 
a young gentleman of unmistakably strumous diatbens. 
suffering from severe disease of the left knee-joint, origin- 
ally the result of an injury. This diseas^ knee was 
destroying his general health by pain, sleepless nighte. 
loss of appetite, and other depressing symptoniB, in addi- 
tion to a. very profuse discharge from sinuses couununi- 
cating with tlie interior of the joint. His constitutional 
condition waa very bad ; he had at the same time — and 
this is the remarkable point in the case — serioae diaeaseof 
the hip-jpii)t on the wime side, with some local indications 
of iiliac^nM iin8oci.itf.-(l with it in tlie miper i>iirt nf the lefi 
thigh. The question for our consultation waa, whether 
the removal of the knee-joint was justifiable and to be 
recommended, bearing in mind his scrofulous constitution, 
and the existence of hip disease. We argued in this man- 
ner, 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 freciuent venesections, we might expect, 
if we could free his system from these sources of vital 
exhaustion by the amputation of the limb above the knee- 
joint, that there would, in all probability, be a great im- 
provement in his general health. The knee-joint was ver)' 
much flexed, and it would have been neeleee at that period 
to put it straight. We also argued that the freedom from 



Xra.] AHD THE DIAGNOSTIO VALUE OP PAIN. 309 

dtftnrbanoe, which the removal of the knee would secure 
for the diseased hip-joint, might be a great advantage in 
reference to the repair of that joint. For by gi^'ing him 
a shorter lower extremity, and by making his limb less 
weighty for his enfeebled muscles to support, we might 
■nooeed in our expectation of insuring rest to the hip-joint. 
On these grounds especially, there being no distinct 
phthisis, we decided that amputation of the leg should take 
place, and it was well done by Mr. Bartlett, with the loss 
of but very little blood. The removal of the knee-joint 
allowed the appetite and general health to be (luickly 
leatored, and the patient was in a very short time off his 
bed, and out of doors ; still suffering from the disease in 
hia hip, but yet going about on crutches, with a very short 
femiir, and therefore very little weight of limb. His 
miucles, although feeble, were yet sufficiently strong to 
sapport, without any difficulty, the shortened femur, and 
to sustain its head in easy contact with the acetabulum. 

Here I may remind you that it is impossible to obtain 
anohylosis between 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 experience so 
mnch advantage and comfort in being absolutely in the 
recumbent position. For if they be allowed to \ye up and 
about, it is impossible, even with great efforts on the i>art 
of muscles already enfeebled by disease, that the easy 
contact of the two bones, so essential to the accomplish- 
ment of anchylosis, can occur. By shortening this young 
gentleman's leg we enabled the feeble muscles to draw the 
femur upwards towards the acetabulum, and ultimately 
the patient did very well. The abscess in the neighbour- 
hood of the hip-joint soon discharged its contents, the 
sinuses closed, the hip-joint became anchylosed, and after 
a time he went daily into the town, where he was occupied 
many hours in business. This patient has, since the am- 
putation, had a serious disease and distortion 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 his limb, which 
was ten years ago. In the summer of 1860 I saw him, and 
then he was in perfectly good health. Here was a case of 



;nO THE THEBAPBUTIC ISFLCKSCE OF REST [Lret. 

" etrumoug" hip-joint dieeaAe cured by reet, A« regildl 
the koee-joint, tlut was dispoeed of in anotliet wa^,lnl 
certainly I think 1 may Icfj^timatelj lYincluile tiwt At 
liip-jaint disease was cured by rest, and that reat conn 
not have been obtained except by placing the patient b > 
nxiiuubeDt poeitioQ for a great Icugth of time, or, m m 
di>ne. by ahorteuing the liinb and diminiiihiDg the wei^t 
The auohyloBta, or perfect local repair in this iaae,ra 
aocomplisiied in spite of tl»e scrofulous oonstitutitm. la 
fact, I may Bay the hip-joint was cured by cutting off tfcft 

I would now aek. What is there in r joint, with lb 
epiphysoB, which should, independently of local injury, 
lead to the development of tubercle or scrofula ? Jmnti 
hhow no special or peculiar inclination to manifi-^t ooostitii- 
tioual tendencies ; rather the contrary. We never see cancer 
beginning in Ihs joint. I belieyc sypbiUe in a joint is very 
rare ; this may, however, be, in the opinion of some peraona. 
doubtful ; but true malignant disease oomniencing in the 
interior of a joint is, as far as my experience goes, unhcftid 
of. So with regard to the vicarious influence of gonorrhteal 
■disoharge, which is frequently unid to Ihj the cause of joint 
disoase. I dimbt vitj- iqucIi itH imji](;ij<;". It in tnic we 
meet with gouty deposits in joints, but these occur chiefly 
in joints ali'cady deteriorated, and under the influence of 
disturbed health, and get well with its improvement. In 
canes 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 ajiprehend, 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 constitutional depressing influence 
of the disease then led to the inflammation of the bone or 
joint, which especially manifested itself when the sc&r- 
latiua or measles was subsiding, or had Bubeided. If you 
go into the history of thc^e cases, it will almost always 
turn out, upon close inquiry, that the patient with diseased 
bones or diseased joints, as a sequel of scarlatina or 
measles, had, before the onset of the fever, a blow upon 



3 AHD THE DIAGNOSTIC VALUE OF PAIN. 311 

mrt, or had nsed excesdye exercise so as to tire him- 
and to lower the vital endowments of the bone or the 
dilation by over-fatigue.* (See Lect. XVI.) I have 
loyed these points for the purpose of indicating my 
t that diseases of the joints are not so generally soro- 
18 as they are reported to be ; that is the object of my 
irkB. 

fvould ask again, Is a London Hospital, or Southwark 
Wfedlenee, if you like, a good locality in which to com- 
with scrofula? Tet diseases of joints in children 
Boeedingly well in these places, by allowing them rest 
plenty of time. But I hold it to be impossible that 
to importantly diseased can be cured with rapidity. 
m I hear it stated, therefore, hv surgeons of hospitals, 
ihiey have had cases of diseased hip-joint or knee-joint, 
)h were doing uncommonly well up to three months, the 
erne duration of possible residence in the hospital, that 
I they were obliged to send them away, in accordance 
L the r^ulations, I cannot but think that the governors 

ndt explanation of Mr. Hilton's would seem to me to aooount for 
t eases in which ioint-inflammation appears very early in a fever 
t than those where it occurs later on, and may be accounted 
If some ulceration and suppuration which have appeared in the 

of the fever. The subject of pyiemia and indammation of 

1 sllflr fevers is one of the most obscure, and withal one of the 
intcnesting, in medicine. It occurs most commonly in the course 
srlatina or measles, sometimes in severer cases where there has 

mnoh ulceration of the throat and neck, but aUo in much 
ur eases, where it is spoken of as ^ rheumatism.*' It also follows 
sMO^MBxal state, and, as Mr. J. Hutchinson has shown fhnn post- 
am eiaminations which he made on the parturient ewes which 
OQ his brm, its presence may be explained by a retained and 
npofiing placenta. 

oecim after variola, and also after typhoid fever, where there is a 
net uksentive lesion. 
'• A. P. Stewart has shown how common pysBmia may be in 

a when the cases are crowded together. FiniBdly, joint troubles, 
7 of a pyemic nature, and, more rarely, graver and even fatal 
(Corns of pyemia, are well known to occur in gonorrhoea, 
le iSftct that pyemia appears in some of the fevers which have 
mentioDed above, where no lesion can be detected, must make 
oeAil, I think, not to insist too much on the presence of a suppu- 
g rarfigice as necessary to pyemia; while such cases as Dr. 
artfs go, I think, further than this, and point to the miasmatic 
a of pyemia as being a vera caiisa.— -[En.] 



312 THE THERAPEUTIC INJLUENCE OP BEST [Ua. 

of hospital§ who made such kws or re^l&tiona pieitail 
joint dieeoBcw beiog cured at these institntions. The pt'iiud 
of rcsidenue in the h<«nttal being tixed at three luontiu, it 
is a iKatt^r of impoaaibility that jointe importantlv diaetwd 
i:an ho ciirod in that time. I am quite sure if the khuot 
daughters of these governors could be cured of a aerioniljr 
diseasetl knee- or hip-joint in one or tn-o, or, perhau,is 
some oases, in three years, they would be grat«Ailly in- 
lighted. How unfair, then, is the expectation that the 
same severity of disease can be cured in three m<mthi 
within an hoepital ! It must require lit least many nieiiths 
to cure cliaeaaed hip-joint. I seldom eew a really diwaied 
hip-joint go through all its stages, and becompletelycural, 
in less than six months : and that 1 looked upon as an 
extremely rapid oure. I saw it onoe, and I was completely 
aetonisbed. So with respect to the knee-joint : I am qohe 
convinced that limbs are amputated, or, perhaps, some othcT 
operation ^lerftirmcd, Ixiforo tho pn.ipcr prii>iatioiii»rv]n:Tii"l 
lor a cure without 0|>0TOtioii Ii.ih li<>en alluiv.-d t J ..kpst. 
I hold it to bo impossible that knee-joint disease can be 
cured by anchylosis (and that is the kind of cui^ to which 
I now refer), save very rarely, in less than a year. That 
this opinion is proximately correct will be allowed, when we 
remember the number and variety of soft structures which 
occupy the interior of this joint. All of these must first 
become sintclurally deteriorated, and then absorbed. Much 
the same must hapjjcn to the dense laminee of bone which 
intervene between the articular cartilage and the cancel- 
lous tissue ; and, when all this has been effected, the granu- 
lating bones must bo brought into apposition before the 
period of direct repair can be said to commence in earnest. 
All these processes must necessarily require some consi- 
derable time for their accomplishment. Again, with respect 
to the tarsus : it is not to be expected that a disease of one 
of the tarsal bones or joints can be sufficiently cured so as 
to render it competent to sustain the weight of the body, 
except after g.reat length of time. 

I will now advert to two or three general considerations, 
which appear to myself to load towards the conclusion that 
local injury is the most frequeut starting-point of diseased 
joints. 



Xmj AND THE DIAGNOSTIO VALUE OF PAIK. 313 

The joints of the human body which are the least likely 
to suffer from internal injury, or from over-exercise or 
fiitigue, are also the most free from disease. This indicates 
a probable relation between their freedom from externa] 
injury or from over- work, and their immunity from disease. 

The costo-vertebral articulations afford a conspicuous 
example. These joints are scarcely ever the seat of disease, 
•0 far as we can judge, during Ufe ; 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 vertebrae. 
It is true of course, that in cases of diseased vertebrie, we 
not nnfrequently find anchylosis of the heads of the ribs 
and the sides of the vertebrsB ; that is palpable enough ; 
bat isolated disease of one of these costo-vertebral joints is 
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 ap- 

Sointed rest ; and a fourth might be mentioned, that they 
o not readily become anchylosed because a band of fibrous 
tissue is interposed between the bead of the rib and the 
intervertebral substance. This latter fact, however, forms 
no part of my important argument, because we find anchy- 
losis in the knee-joint, notwithstanding the interposition 
of large masses of interarticular structures ; but this piece 
of anatomy does not apply to the first, eleventh, and 
twelfth ribs ; yet I have never found any disease between 
the heads of those ribs and their associated vertebrsa. 

I had a patient — he is still alive, and therefore I have 
not an opportunity of presenting to you a pathological 
specimen — who had a disefised spine which was caused by 
a blow on the lower part of the cervical region. He is 
now actively employed in business, and is thirty-two or 
thirty-three years of age. After being about four years 
in a recumbent position, he is now again able to occupy 
himself fully in business, and yet not one of his nbs 
moves during respiration. If you were to look at his 
naked, bro€ui, well-formed chest, and put your hands 
upon his libs, you would find that not a single one of 
them moves during respiration; all the breatlung takes 



314 THE THERAPEUTIC IXFUiESCE OF BEST [LnS. 

plnce by the aid of the iliaplini^n and the aMomisil 
niUBcluB. The actual condition of this g«ntleuiau'B uxto- 
vertebral joints is very doubtful." 

This freedom from disease is a remarkable thini; in jmirti i 
so actively employed as are the costo- vertebral jidnta, dtj I 
and night, and it requires a few words of esplanalion 
or reference. Aa I have already eaid, there are two rireniB- 
stancws that may contribute to the freedom Iroin disoueof 
these joints. It must be admitted, I think, that scrofukiiM 
tendoncioB or diseasea manifest themselves moatly in mtIt 
life ; and the earlier in life, in proportion to the intenm^ 
of the eonstitutional taint. It is at this same early pericn 
of life that the oosto-vertebral joints are the moet actively 
employed in relation to rapid breathing, and the boow. u 
well as the soft parte of those jointa, must be under the 
full influence of tiiction, pressnre, and tension — conditions 
likely, in the minds of some, to induce the local devel<^ 
ment of tliL-cnnslitutiimal Uih.t, hs in thi- lune:^. Nntn-itli- 
standing those sources of structural deterioration. th««e 
jointB esciipo 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 roach them. Broken ribs, as we 
all know, are frequent enough ; and no doubt, if the heads 
of these ribs were not maintained strongly in their position, 
they might lie frequently displaced. Ueflecting again 
physiologically on the costo- vertebral articulations, we must 
remember that, although on occasion of any exertion their 
nioveinente may be excited temjiorarily by volition, yet the 

* This grtilltMiiBD is now dead. Ht: lived for twelve ye»n niter 
hie ritis l>«cHi»t: tixed. and woa able to returc to bnsitiesa, rennuDinf 
for si^veral fears engat;o<l od Uir btuck Exchange. DoriOK thia 
period he bad lisemoptyisia seTeral times, but, aa do atmctiira) cban^ 
cuulil bo delected in tbe lungs, Mr. Uillou advised him to look upon 
the htemorrhage aa a nieand adopted by Nature fur ^ving relief to the 
lungs, in tlieir fixed condition. Later on tbe ^nlleman removed to 
Devonshire, and here, after exposure to cold, he died rapidly after a 
sudden attack of pneumonia. Thin wsa marked by its grtat severity, 
the distress in breathing being much sgeravated by the fixed state of 
his ribs, a condition which contributed a great deal to his speedy 
death. There wns no pont-mnrtem cxnminntiou to ascertain the 
nature of the old injury, and the coudttiou of tbe coslo-Terlebrat 
joints. — [Kd.] 



Xm.] AND THE DIAGKOSnC VALUE OF PAIN. 315 

respiratory movements mnst soon subside to their normal 
state of comparative quietude, and during sleep these articu- 
lations must have a certain amount of repose in accordance 
with the diminished frequency of respiration. Under all 
crircnmstances, they may be said to have the advantage of 
what may be called their appointed rest — and this rest 
might oertainly be termed Nature's strong conservative 
principle, strongly marked in parts the freedom of which 
from difiease is most necessary for active life. 

It has occurred but to few persons, perhaps, to note the 
number of times that these articular surfaces are rubbed 
upon each other during respiration ; but here are the figures 
representing the facts. I have taken the case of a child 
five 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 
must be double. Consequently, at five years of age, the 
number of movements is about 31,536,000, in a 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 in the articulations of the pelvis depends upon their 
immunity from local injury by accident or by over-exertion. 
One of these joints is here shown (Fig. 56) between the 
sacrum and the os innominatum, ana you see a large mass 
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 observing and 
reflecting surgeon ? The facts speak for themselves : they 
all tell him in the strongest language which crippled Nature 



■in; Tin: TUERArEUTic influex^f. of best [l.B-r. 

iniil ilL'1'iniii.'il hiiiuiiiiity tan ust-. tliiit the ilit'^ise of lli'; 
Juint was nut Borofulous ; or that at titaat, if acrofulons. in 
a[dta of the adverse ctrcumetanocs of constitntion&l taint, 
poverty, lioine discomforts, foul air, improper and defec- 
tive food, and unconstrained muscular diBturbanoe, or 
forced esertion for the sake of livelihood — that, notwith- 
standing all these drawbacks, and probably aim lbs 
abeenco of good ^irofessional care. Nature has suooeeded 
in relieving the patient, either by forming a new but im- 
pei-fect articulation for the dislocated bono, or, finally, by 




consolidating the two or more bones which lie in contact in 
their displaced positions. Again I say, let the surgeon 
ask himself what might have prevented the disease pro- 
gressing to snch an extent of severity? — what would have 
shortened or prevent«d the extreme suffering which the 
patient must have experienced ?— what would have averted 
the deformity, and what would liave secured for the 
patient, if not a comjiletc cure, certainly a sti-ong and 



XHL] AND TIIK DIAGNOSTIC VAIJ i: or TAIN. -U 7 

iieeful limb, without displacement and with little lameness ? 
On reflection, 1 believe ne will reply, Rest, local rest, by 
fixing the limb in a proper splint, aided by time, Nature s 
powerfdl ooeAjntor, 

An argument, supported by &ct8, against diseases of 
joints bemg considerod simply the expression of consti- 
tutional taint, and in favour of local injury being the 
earliest and true cause of articular disease, may be found 
in the relative frequency of diseased joints in the lower as 
oompared with the upper extremities. There will be no 
hesitation in admitting that diseases of the hip-joint are 
&r more numerous than diseases of the shoulder-joint ; 
and that the only additional local disturbance to which the 
hip would be liable would be that resulting from frequent 
fiitigue, over-exertion, or direct injury. The same with 
respect to the knee and the elbow: no one can doubt 
the greater frequency of disease in the knee-joint as 
oompared with that of the elbow. Here, again, the 
same explanation would apply — viz. the greater proba- 
bility of accident or of over-exertion (which is structural 
and physiological exhaustion), and of continuation of 
fiitiguing exercise. 

It has fallen to the lot of few surgeons to see many 
cases of isolated disease of the superior articulation of the 
tibia and fibula ; yet that joint lies very close to that of the 
knee, which suffers such frequent disorganization. Tliis 
superior tibio-fibular joint is, however, seldom the seat of 
direct injury ; hence its freedom from disease, except it be 
as an extension from the knee-joint. 

With regard to diseases of the ankle and wrist, I do not 
know how they may stand with respect to each other 
numerically, but certainly we often see disease or enlarge- 
ment of the base of the radius in children. Now, I thmk 
it must have been observed, that whenever a child falls, 
the hand is put out to prevent its being hurt, and the 
whole impulse must concentrate 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 radius is broken by the impulse con- 
veyed from the convexity of the upper row of carpal bones 



318 THE THERAPEUTIC tNPLUESCE OF BEST [Lwr. 

of the htuid, and the radios is thus split or iracturad. We 
mom frequently meet with disease in the phalanges of tlie 
tiiigeri* than in the phalanges of the toee ; this &ot. I 
Hppreheiid is to bo referred to the circumstance that in 
falling or in other fortuitouB aocidentB, injnries to tlip 
phalaugea of the h&uda ore much more likely to occur thtm 
to the oorreBponding hoiice of the feet. 

In smull accidents to the jointg, a great deal of iDJnrr 
to the intonwl part« sometuaes takes place without it« 
Ijt'ing seen. Some years ago I had an op)iorttuutj of 
obtterviag this occurrence. A man going across Bla^- 
heath, rather the worso for liquor, fell down or jumped 
six or eight feet into a gravel-pit. and alighting apon hit 
feet, his leg was veiy severely broken. I ampatated the 
limb below the knee. On examining the anklti-joint, which 
apparently had not been injnred, I found the artiealai 
cartilage upon the astragalus actually depreeaed at ond 
jiart, and at another purt I buw within it a large black, 
deep patch, and upon carefully cutting off that portion of 
articular cartilage, and bringing it up to Mr. Quekett, it 
turned out to ijc extravasation of blood, or ecchymoaiB; 
this local injurj' or bruiBe had no doubt occurred firom 
the impulse of the tibia falling upon and bruising the 
astragalus on its upper surface. This mtschiof to the 
articular cartilage would probably have led to disease 
in the ankle-joiut, as the secondary consequence of the 
accident.* 

These points are adduced for the purpose of combating 
the belief which sooins to prevail with respect to the gene- 
rally scrofulous character of diseased joints. That tiis b 
an error is shown when we note the greater frequency of 
(liiteased bones and joints in the outer side, compared with 
the inner side of the foot in children. Now, there must be 
some reason for this difference. I believe there are two or 



tion of diseaae of tlie aokle-joiDt, he speaks nf Ihia exUavaiatioii ot- 
' blood-blialcr.' " If the iajury is the result of a blow or coociMDim, 
witb, or without muoli twisting, but nm-ived in suvh a manner M lo 
produee rupture of the blood-iessels underDcuth the articular carttUge^ 
m the tuti<.-ular liimt-lla. either at the top of Ibe astragalus, base of the 
tibia, or inner Burl'aces of the inalliM>li, then there will be but alight pain 



XIIT.] AND THP: diagnostic VALli: OF TAIN. :\i\* 

three causes which determine and explain this relative 
frequency— namely, that the outer side of the foot is more 
exposed to the reeolt of direct accident, and that it has to 
■uatain the weight of the body in an erect posture ; it is, 
moieoTer, that portion of the foot which, during progression 
or walking, leoeivee the chief concussion between the weight 
of the body above and the resistance of the ground below. 
Thus the outer side of the foot becomes more likely to 
Buffer local injury from fatigue and continued exertion. 
Mr. Ward, who published one of the best and most philo> 
aophical works ever written upon the human skeleton, 
divided the foot longitudinally into two portions — the inner 
■ide, or the elastic portion, which includes the astragalus, 
the scaphoid, and 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 
my custom 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 depicted in Quain's Ana- 
tomy, ed. 8th, vol. i. pp. 121, 122. We there see the early 
ossincation of the os ^cis and the cuboid, and the late 
ossification of the other or elastic group of bones ; and it is 
especially worthy of notice that the scaphoid is the last to 
oomplete its growth as well as its ossification. In fact, it 
is this bone which completes and determines the elastic 
configuration of the foot. The os calcis and the cuboid 



at fifst ; bat, afterwards the suffering will be altogether out of proporti<m 
to the appearanoes presented. At tirbt the eztravasatiou into the bone 
is very slight, and, oeing in a tintsue which cannot swell, no apparent 
enlaigemeut takes place, nor is disooloration observed, because the 
«iti»TB«itioii is so deep-seated. The ligaments not being specially 
inToWetl, making them tense does not produce pain. All these facts 
add to the deception, and make us very liable to pass over the case as 
one of trifling importance. When this accident has occurred, the only 
manner in which it can bo recognised is by means of direct pressure 
upon the part affected by the extravasation .... If the blood-blister 
is ooDBtautly irritated by friction, an ulcer is formed which rapidly 
increases in size, and involves the deeper tiiisues." 



:iJO TlIK THERAPEUTIC ISFLUEKCE OF BEST [Leci I 

liuiio ari) the tirat uf tlie tursitl ijouea to l>e oeBitied, pn;- 
paratoty to their having tu sustain the n-eight of the body 
m progression or ordinary exerdae. We know, as a nutttl 
of fact, thttt children arc oft«n (compelled to contimb 
their walking exerciae notwithBtanding fatigue — whioha 
nuiBcular exhaustion — and thus uot only the fVeqneneyot 
diseased tarena at that age is explained, but also tlw 
l)eeuliftrity of the position of it — that is, on the outer mk 
of the foot in the os calcis or the cuboid. 

We very rarely see disease in the stcmo-claviciiU)' 
articulatinn in children or in adults. It is also rarely the 
scat of local injury. 

I might also remark, that the success attending the opera- 
tion for excision of joints tends very much to the suae 
conclusion ; for if all the diseased joints in children, or the 
majority of them, are the results of a scroftilous stale hegiu- 
ning in the hones, how does it happen that these oaees do 
so remarkably well when the joints are simply excised, 
Avhen the bones ought to be unhealthy ? The bones, which 
ought to lie unhealthy and scrofulous, do unite and become 
consolidated in auch a way as to render 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 beoomes important that I 
should nnswer one or two objections. Two argumcnte ate 
advanced Hgiiiiist the empiovmtjut of l«ij;-oiiTif inueii rett 
in the treatment of diseased joints — viz. deterioration of the 
general health, and anchylosis of the articular ends of the 
bones jireviouidy healthy. Now, as regards the deteriora- 
tion of health, all I can say iKisitively ia this : that, taking 
fur illustration extrenic cases of diseased hip-joint, I have 
never yet seen a case of severe hip-joint disease in which 
the general health has not been benefited by quiet and rest, 
even in a public hospital, more or less vitiated as the air 
of such a i>lace must necessarily bo, and I shall by-and-by 
mention casfs confimiatorj- of this atatement. 

Many persons, however, believe that the joints, theii 
soft jMirts especially, being unused and kept in restndnt, 
although not at the time actually diseased, may suffer 
irrejiarable stnictural change or deterioration bylong-oon- 
tiuued rest, and that healthy joints may become anchyloeed 



xiir] ANT) THI-: i)rA(;N()sTr(' valti: of i'ain. ;.'1 

as the cousoquence solely of that rest.* This opiiiiun is 
advanced as an argument against the employment of long- 
continued rest to diseased joints. Now, I doubt the sound- 
ness of this conclusion ; nay, indeed, I believe that it is 
essentially untrue. It is possible, and may be probable, 
that a temporary alteration and a diminished elasticity 
of articular cartilage may occur ; that the ligaments may 
become feeble, and the synovial membrane unmindful of 
its duties, without the stimulus of friction ; that the bones 
may lose their firmness, and the muscles their strength, 
from disuse ; but such deteriorations are only temporar}\ 
for reparation is perfected in all these structures by careful 
and steadily increasing use or employment, and after 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-continued period of rest to the whole limb, as 
well as to the diseased joint itself, is required to brinj^ 
about anchylosis, or bony union ; yet the unused foot, 

* Thia subject seems to haTC attracted little attention amongst 
Engliflh writers on Surgery. 'Vhe three following |:)aper8, on the eflects 
of abflolute immobility or long-continued rest on joints previously 
healthy, contain much imfiortant information. M. Teissier (Gaz. 
M^cal e , Sept. 25-Oct. 2, 1841), relying only upon actual dissection 
of jointa, shows that long continued immobility may produce 1 — Escape 
of Uood or serum into the cavity, into the sub-synovial cellular tissue, or 
into the soft parts outside the joint. 2 — Vascular injections of tlie 

rovial fringes, with formation of false membranes. 3 — Alterations of 
cartilage, e.g. swelling, softening, and erosion. 4 — Anchylosis ; this 
IB shown to be not otaly frequently fibro-ccllular, but, in one case at 
least, where the thigh was amputated for non-union of a fractured 
femur after twenty-two montlis of extension and immobility, it i.s 
proyed that actual fusion of contiguous articular surfaces may take 
place. M. Teissier believes that the above follow upon an engorgement 
of the joint structures due to the suppression of synovial fluid, which 
in its torn is caused by the inmiobility of the joint. Dr. Menzel (Arch. 
f&r Klin. Chir. Bd. xii.) confirms these observations of M. Teissier 
by experiments on animals, whose limbs he confined in plaster of Paris : 
his theory as to the ulceration of curtilage is that it is brought 
about by much the same process as a bedsore, from the sustained pressure 
of contiguous joint surfaces upon each other. A third paper, very long 
and elaborate, upon this subject will bo found by Dr. Beyher, Deut. 
Zeit fiir Chir. Bd. iii Experiments on dogs are given in great detail, 
proving that in certain cuses, especially where the immobility has been 
from time to time interrupted, ulceration of the joint-cartilage takes 
pkoei Sir J. Paget (Clin. Lect. p. 97) speaks of '* adhesions in the 

Y 



322 THE THERAPEUTIC INFLUEKCE OF BEST \Xxt. 

&nkle, and hip-joint are not damaged ; they KFe ready l<tr 
careful cmploymont when their activity &iid stmctml 
energj' are required. 

In chronic diaeaseB of the knee-joint after long-contiuud 
rest, requiring amv"**'^**^' "ii examining the interior uf 
the joint after removal, we aoniGtimcH see that wheu the 
'Whole of the joint may bo eaid to have been more or lev 
diseasetl, and the whole of it has been kept certainly in • 
fitjite of quietude or rest for a oonsidemble period antmor 
to amputation, the patella is fised by bone upon the ood- 
dylee of the femur. But, on the other band, we gee caka 
(jf extenBiTe disease of the knee-joint requiring amputA' 
tion, where, after amputiitioa, we raise the moveable 
jtatella, and find tliat a separate diatiuct joint exists 
lietween it and the condyles of the femur, each part pre- 
iserviug ita proper quantity of articular oartilage. 

On looking at the late Mr. Bransby Cooper's descriptiun 
of a Chineae lady's feet, I find no mention made of any 
disease of the structures forming the articulations. The 
jointa are distorted, and the whole foot dwarfed by rest 

anklc-jointB of lege empulttted after being long at reat, though the 
joints liwl not been evidi-ntly inflameiJ ; " anii Mr. Butlin liwi rt-Ialcd 
(Truna. I'ftth. Soc. vol. xxv. [j. 212) n ease of anchylosis of a kuee joint, in 
n liuih wliic'h liad been kept straight for ten months for an ununited 
fraduro of llif ftmlir. In riglitly estimating the effects of rpat itfplf 
in auoh cases due weight should be given to the fallowing points, i. — that 
in a certain propottion, e.g. wht-re the joint changed have followed 
I>rolongnd trcatmoat for friu'lurc, the iiriniory iiijurj may have set up 
mischief in tlie joint, uiianticed at tlie time, ii, — the poasibitit; of tlii- 
pre-exiatence of a coiittilulioiml condition pre-<lisposing to degenerative 
arthritic rliuTip:es. iil. — the proncneaa of certain joint-cartilages atler 
young adult I ifo to show signs of commencing degeneration. Dr. Moxoii 
'^Wilks' Hiid Moiun's Path. p. 83} apcaksof this as" degenerative erostou" 
of curtilage. " Cnrlilage, which reaembleii the elasiic nelsofarteric* 
in being vvascuUir, also agrees with them in early stioiring a deficient 
power of endumncc. A man baa grueraily imt resched hts thirty-Gith 
year b-fore his rartilnges, like his uurta, ^haw signs of being the wurN' 
for tveur. The paits wliicli reveid the ehauges are those most pressed 
ii{)on in use, such as tlie prominences of the condyles of tlie femur and 
the curri-Bpuiidiiig parts of the tibia ; the patella hua ahio a very special 
Ii»bili1v." A euicfid account of these c ban gis and their frequency will 
lie fmiiiJ in vol. xx. of the Puth. Tra. by the lat» Hr. Bruce: tlie 
mi('roM»piml chnngee tlierc described should bo conlntsted with thocc 
isivou by the above mentioned German writers. — [Kn.] 



\[II] AXi> the: Di.M^NiisTir VAi.uc OK iv\iN, :;l':; 

and preasure ; yet, aa far aa 1 can eco on uxaminiiig tlie 
dried preparation, no bony anohyloeis has occurred in any 
of the aitioiilations. 

It ao happena that this College is rich at this time in 
Chineae ladies' feet, and I place before you a very good 
•pecdmen, which I shall employ for the purpose of sus- 
taining the view that I entertain regarding the non-dete- 





T«r7 uDonuJ bj ml . 



riorating influence of rest in healthy joints. Fig. 57 is 
a drawing of a preparation preserved in spirit. I do not 
know how old the lady was, but, looking to the appear- 
ance of the bones, we may fairly presume that she had 
arrived at, or beyond, the age of puberty, Kow, these 
joints have been compreBsed upon each other during perhaps 



:124 THE THERAPEUTIC INFLUENCE OF BE8T [Lwr. 

twenty or thirty years, and yet their surfaces are in a pM- 
f'fcct condition ; and the articular etructures are not in the 
Mlighteet degree detorioratud by it. If one wist* aaW to 
produce a notable inetanoe whero pressure and constrained 
position are everted upon joints, by the strong competitioQ 
carric-d on for many years between the eSbrts of Sataie 
from within and the application of brute (though hutnaot 
force from outside, without producing injury to them, this 
is sorely the one. Yet there never was a case in which the 
conciufiion could be more manifest than in this, for the 
articular surfaces are perfectly entiro aud healthy, l a t 




Httltukuioua, wiUi Ilic scspbgld buns. 

note that I had from Mr. Bader, one of the curators of the 
College Museum, on the 23rd of Januarj-, 18*jl, ho says, 
■' The articular cartilages from the articulation of the 
Chinese foot arc microscopically [lerfcctly healthy." This 
illustration ought, I think, to displace the needless fear 
and apprehension, that the continueil mechanical rest of 
joints may lead to their irrepiirable deterioration. 

To take another instance. 1 f you strap up a foot firmly 
ill oriler to cure disi.'ase of one of tlie t'irsal joints, do ttie 



Xmj AND THE DIAGNOSTIC VALUE OF PAIN. o25 

other tarsal jointB become anchylosed? Certainly not 
neooflflarily. Here (Fig. 58) is an illustration of this fact. 
It is the foot of a young man whose limb I removed for 
disease 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 are not in any way involved iu that 
mischief ; there is no anchylosis ; they are perfectly 
healthy. The anchylosis 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 
purpose to which I am now referring, namely, to show 
that, although pressure by strapping the foot, (juiet, and 
rest were resorted to during a long period, in order to cure 
the disease between the astragalus and scaphoid, yet the 
only two bones which became anchylosed were those 
between which the joint was in an unhealthy condition. 

Again, in a case of severe cut throat, is the larjnix 
voiceless after a rest of six, seven, eight, or ten weeks ? or 
is a stomach, after a patient has been fed by cnemata for 
three weeks, incompetent to resume its duties of digestion, 
if provided carefully with food and a small amount of 
necessary exercise ? Certainly not. In cases of cataract, 
either congenital or of recent date, is the retina after an 
operation incapacitated to receive the rays of liglit care- 
fully introduced into the organ ? Certainly not. Then, 
I 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 induce those 
gentlemen who entertain the opinion that scrofula is so 
very constantly the cause of mischief in diseased joints. 
to admit that other causes, such as a chronic inflammatory^ 
condition and slight local injury, are by far the most 
frequent ; and, further, the rest to healthy joints does 
not induce disease leading to anchylosis. I might here 
say, that, in teaching on this subject at Guy*s Hospital, 
now many years ago, I used to take occasion to point out, 
to those whom I had the honour of instructing, that the 
generally received impression that scrofula is, as a rule, the 
foundation of joint diseases, is really not true. 

It is not stating too much to say that the diseases of 



326 THE THEBiLPKDTIO INFLUENCE OP BEST (ltd 

jointH are modified by age, eepecially in one or two 
reapocta. In the adult period of life wo see disease of 
the individual articular atructureB, whether of synovul 
membrane or bone, and we observe that not only is thr 
progress of the disease usnally slow, bnt tlie progreaa of 
repair at tiiat period is also slow. In children. howev«, 
we note a very quick implication, if we may so tenn it, 
of all the articular structures in disease, and quick deetmc- 
tion of the parts, and subsequently very speedy lepaii- 
In young children this progresa is very rapid in acuU- 
{Usease. I have here the outline of a cast of on ancby- 
losed knee-joint. It does not, perhaps, represent a siieoi- 
men of perfect surgery, but it indiuatea the rapidity of 
■oung person. The boy was three and a naif 
'■ " " ' ' id damaged bin 




knee. The injury led to suppuration within the joint, 
and enormoTia swelling around it ; absorption of all the 
true articular structures, and ultimately to complete bony 
anchylosis. The whole of this was accomplished in a few 
months. 

Biit I advance this case in reference to another and verj- 
important point. It ia a common thing for surgeons U\ 
conclude that a joint is irreparably damaged, when they 
hear or feel the articular ends of the bones grating upon 
each other. Now, I had a good opportunity of testing the 
value of that point in this child when he was very ill, and 
the joint waa very much awollen, and auppuration going on 
in it. My dreaser 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 



XIU.] AND THE DIAGNOSTIC VALUE OP PAIN. 327 

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 laminas 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 laminas 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 a position as I could. I wished to divide the 
tendons of the flexors; but it was determined by the 
father that as the child was so ill he would not permit him 
to be touched any more in the way of operation ; therefore we 
did the best we could with mechanical 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 cause of the 
grating sensation when the surfaces were moved upon each 
other. It arose clearly from the persistence, for a time, of 
the articular laminsa which exist between the cancellated 
structure of the bones and the articular cartilage. 

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 overlooked 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 this 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 conclusion, 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 



H28 THE THERAPEITIC INFLUENCE OF REST [Uct 

tliig grating ntaae in the (ingere. ankle, hip, and ntiuB 
jirticuJatitms, and yet the patient's jointB have done well 1^ 
aucbyloBifl. 

I purpose placing before you the fact, that diBesflCB of 
tho joints in childrea follow a peculiar conrac, and one not 
j>ert'ectly in correspondence with that which obtains wiUi 
rcspert to adults. In adults the individual stnictnreBof ■ 
joint may be diseased, and each may present ife own lowl 
indications, or special local symptoms. Thus, we may 
meet with isolated inflautniation of the Bynovial aiem- 
lirauoB and ligaments, or a disease of the articular ends of 
tho bones in the adult. Now. although these structoree 
arc at all ]>eriods of life netteBsarily continuous with each 
other, and closely allied in function, yet it is at the adult 
)>criod— after the completion of Uieir developnaent — that 
i-aoh separate structure smms to have aocjuiitd, and thenw- 
furn-ard to manifest both in health and disease, a structonl 
iniifppndcucL', wliith |iivc*s a chiinw^ter of individijiilitvand 
iNiilatiiin to the dieeasfs of tho diffcrcut etmcturee of the 

in cliildrcn all the structures of the joint must be formed, 
built u|), and nourished in concert and in due relation to 
eaCli otlicr. On this intimate sympathy existing between 
tho different parts of a joint during childhood, or during 
tho jwriod of growth, depends the tendency to diffuse 
disease contemporaneously in all tho articular stmctures. 
Hence wo seu in our practice tho quick propagation of 
inflammation from one articular stnicturo to another, and 
H rapidity of implication of tho various structures of the 
Joint in childho'id and youth, which we do not observe at 
a Liter i>urioil of life. 

It is, therefore, to mymind^and this is no new idea, for 
I have taught it publicly fur many years— an unsubstan- 
tiated roHnoment in most oases of joint disease in child- 
hood, to uttemjit to depict the symptoms indicating distinct 
or separate patholc^cal states of the individual structures 
comjiDsing a joint. It is certainly not in accordance with 
clinical exjicrienco, and surely it is not a sound basis upon 
which to tJK and dotenniiie the plan of treatment. 

TJiis close sympathy between different structures both in 
gr'>wtli and in disease, met with in children, is not peculiar 



XUL] AlfD THE DIAGNOSTIC VALUE OF PAIN. 329 

to the joints alone ; it is the great feature, it is the patho- 
logical type, which this young period of life constantly 
displays in other parts of the body. Some of those gentle- 
men whom I now address know better than myself, and I 
take it upon the statement of those in whom I have con- 
fidence, that in adults you meet with pneumonia as a 
separate disease ; you may see pleurisy as a separate 
disease, or bronchitis as a separate disease, each recognised 
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 these structures nearly at the same 
time. 

It is the same in diseases of the brain. It is a common 
thing to see diseases of the membranes, or disease of indi- 
vidual parts of the brain in the adult ; yet it is rare to see 
theae in the same distinct and isolated manner during child- 
hood. In disease of the larynx in children all the soft 
parts become equally involved ; whilst in adult life, when 
the laryngeal structures seem to have acquired a normal 
independence, which they had not in earlier life, they 
appear to possess the same kind and degree of indepen- 
dence in disease. 

Kow, I think we have here a feature of high physio- 
logical and pathological importance, and very suggestive 
as a guide to treatment in practice— viz. the difference 
between the relative progress and implication of the 
various structures of diseased joints in childhood and in 
manhood. In children vigour and rapidity as to the dif- 
fusion and progress of inflammatory conditions, as well as 
rapidity of repair, stand in very strong and distinct an- 
tagonism to the like conditions (in all other respects 
similar) which mav attack the same structures, but at a 
more advanced period of life. 



330 THE THESAPBUTIC INFLUEKCE OP KEaT [L«- 



LECTUHE XIV. 



-IMPQWtK*Ca w 



LOJIS fRIM.^EUIHO BIMILAK CASE, DL9L0CATE0ti TWICE RKDllXO. 

It will bo the object of tliis lucturo to direct your attentiou 
to diMGa.>L'B of tbe hip-joiut, itiiil to demonstrate the value 
of iiJBt as a thurapeutio agent in sucli caBcs. 

I may commcni^ this mibject by observing, tbat in luoet 
systematic works on tjurgery, whilst diseasoB of the joints 
are arranged undur onu head, there is generally a SL'i>anite 
chapter duvotcd to morbus coxne, or uiorbns cosarius as it 
is tei-med. Wo arc thus led to entertain the idea that 
there is some sijccial jicculiarity witli reB})ect to the diseases 
and symptoins, or the pathological anatomy of the hi])- joint. 
1 believe this to be a mistaken idea. So far as 1 know 
there is nothing in any way sjiecial or peculiar aa regards 
the structures or the diseases of the hip-joint, when com- 
pared with those of other joints. Their ph^'siological and 
pathological 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 is auj-thing 
distinct in the constitutional tendency of hi]>-joint disease, 
though it seems to me that professional opinion jKiints to 
the hiiv-joint as emphatically the chosen scat, or special 



XIV.] AKD THE DIAGKOSTIO VALUE OP PAIN. 331 

locality, for the manifestation of scrofulous disease of 
joints. This, to my mind, is a great error — an error, also, 
which has a very bad influence. If we understand by the 
term scrofula a constitution highly cachetic, 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 scrofulous 
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 suflfering 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 
majority 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 
ne will surely fail in the proper treatment of the disease. 

Another error often committed is one which we have 
inherited from a previous generation of surgeons, the 
entail of which I should like to see cut off. It was, and is 
now in some places, the disposition of surgeons to require 
that the patient suffering from hip-joint disease should 
manifest those marked symptoms which are deemed to be 
characteristic of hip disease, such as the shortening or the 
lengthening of the limb, a fulness or flatness over the 
gluteal region, want of symmetry in the sub-gluteal folds, 
pain at the inner side of the knee, greatly disturbed health, 
and considerable lameness. Now, the very fact of its being 
the opinion of some surgeons that shortening of the limb 
is characteristic of the disease, and of others, that length- 
ening of the limb is characteristic of it ; of some, that there 
ahould be a want of symmetry in the gluteal region, and 
of others, that the symmetry is not necessarily altered — all 
this, I think, is a satisfactory proof that these symptoms 
may fail as direct and positive indications. As far, how- 
ever, as I have been able to judge, lengthening or short- 
ening of the limb in the early stage of the disease is almost 
always the result of inclination of the pelvis. I have 
taken great care and trouble to determine this point, by 
carefufiy measuring and comparing the two limbs, and I 



■ .■■•2 Tlir, THEItArEUTIC ISFLUESCE OP BEST [Lict. 

ilo not know that I have ever aecn a ease of well-nmlffid 
iincompUciit«d hip-joint disease wheiv there was a differ- 
ence in the loeaBiirenieiit in which the Itriigthening ot 
■ihiirteniug did not depend upon the inclination of the 
]ieU-is. I am not speaking of cases of admnced dianaau 
ftbout the joint, nor of oasoB of dialocation from dteesae. 
These highly ohoraeteristiii BymptomB, which arc pnt pio- 
iiiinently forward as indicating disease of the hip-joint, are 
not the early Bjmptoms of hjp-joint disease. WTien we 
see BTich syniptoinB, we may be sure that the disease in the 
joint has made oonsiderahle progress. It is highly important 
that the surgeon shonld recognise the diseasea condition 
cif the joint previous to that period, for that is the time 
when the most bonefiuia] effects will follow a steady anil 
loiig-pursiied plan of tj-eatmont by rest. 

If we sacc«ed in an early diagnosis of diseaBC of the hip- 
joint. I am quite confident that it will not fall to the lot of 
surgeons to see those sad and sotnetimee hideous cases 
which wo so frequently observe, more particulariy in hos- 
pital practice. It is, I think, a most serioua fault for 
tiurgeons to assume that there is nothing wrong in the 
hip-joint, unless some of those very conspicuous symptoms 
l>e present. Tlie all-iniportHnt point is the earlT reoigni- 
tinn of till' liist d--vi!,tioii fnmi a li.;.iltliy bI.iiV ; ^.Ti.l I 
would anxiously urgeu]>on you, that even a suspected state 
of disease jitstificK a plan of treatment by rest, which, in 
my I)elief, would, in the majority of such doubtful cases, 
be the means of preventing the occurrence of the more 
formidable aynipfoins. I would venture to affirm, that if 
even the more advanced and more formidable symptoms be 
displayed, still the case may be amenable to the influence 
of I'CBt, and this I hope to jirovc by illustrative cases. 

Keferring to hip-jiiiut disease in children, let me say, it 
will Iw eapecially imiwrtant for the sui^oon to bear in 
mind that the acctaliuluni in a child is very shallow com- 
imred with that of an adult. It thus offers great facility 
for dis|>laceiiient. Tbis, I ap|)rehend. may be the reason 
why there is so often a tendency to dislocation of the thigh- 
bone in hip-joint diuease at an early period of life. I do 
not know that this is the only clement which determinee 
this tendency, but I think it may be considered an influ- 



ID THE DIAONOBTIO VALUE 07 PATS. 333 

I shall not dwell upon the anatomy of the hip- 
pt to remind you that its muBcles perform their 
n groups, that each group hae a trunk nervo of 
td that each nerve contributes a branch to the 
Mlf. In FigB. 60 and 61 you see a branch of 
■rcruralnerre passingtotho hip-joint 1 a branch 
at&tor going to the capsular ligament and to 
mtnm teres; and a branch proceeding to the 




th« captaUr ILEomfnl 



wpect of the hip-joint from the sacral plexus 
ipUes the gemelli, the quadratus femoris. and 
ttor intcrnuB. This anatomy should bo borne 
because it explains liow it happens that the 
L"B^pathetic pains," associated with an inflank- 
idition or chronic disease of the hip-joint, are 
B found at the same part of the Umo. We all 
' well that, in some cases of hip-joint disease, one 
iiest symptoms is remote from tho actual seat of 



334 



THE THEBAPEITIC INFU^ENCE OF BEST \Un 



luiBchief — nftinely. paiiiwitliin theknee, oron the inner sidi:' 
uf the l;ne«-jumt ; and we are familiar with the es]>l>iia' 
tion of it — namely, that the obturator nerre, which con- 
fributcB a branch to the liganjentum teres, sends a hiaaclt J 
to the interior of the knee-joint, to the iBDereide of it,aad.| 
soiuetimee even lower down. The inflammation or a di^l 
eaeed condition of this ligament neccBsarily involr^ ^a 





plena. 



little branch of the obturator nerve, and a " B>-mpathctic " 
l>ain is produced at the other end of the same nerve, on 
the inner aide of the knee or within the knee-joint. Ab it 
is frequently with tJie obturator, bo it ought to be some- 
tiincB with respect to the other nervcB of the hip-joint ; 
but the frenjucncy of this knee-pain, whether within the 
knee-joint or on its inner aide, indicatcB that the liga- 
mentum terett in the most common seat of early disease. 



XIY.] AND THE DIAGNOSTIC VALUE OF PAIN. 335 

We observe this same ^' sympathetic '* pain in old persons, 
who may or may not have had a slight injury to the hip, 
but in whom the ligamentnm teres softens down and dis- 
appears. Such persons oft^n complain of severe pain 
within or on the inner side of the knee-joint. Some years 
ago I saw a case in which, after injury to the hip, this 
symptom of pain in the knee-joint was well and early 
marked. Afterwards the limb was slightly shortened, and 
the foot everted, imitating the reputed symptoms of frac- 
tured neck of the thigh-bone. 1 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 receives a branch from the anterior crural) is in- 
Iflamed, applying the same law, you will see how it may 
happen that a patient with a diseased hipjoint may have 
pain on the front of the knee, or on the inner side of the 
ankle, because the anterior crural nerve sends branches to 
these particular spots. Or if the inflammation or injurj' 
begins at the posterior part of the capsular ligament, which 
receives a branch or branches from the sacral plexus, then 
the patient may have a "sympathetic" pain actually at 
the heel, or in the foot. I repeat these remarks in reference 
to the nervous supply, because an impression, I think, is 
abroad that the " sympathetic " 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. 221), the liga- 
mentum teres is, perhaps, the part where liip-joint diseawe 
in reality most commonly begins, and this corresponds with 
the frequent observation of the "sympathetic" pain on 
the inner side of, or within the knee. To put this point 
more strongly : it sometimes happens in hip-joint disease 
that there is no pain in the knee-joint at all (I have seen 
several such cases); this local pain, therefore, must be 
considered as a fortuitous, not a constant, symptom, and 
not 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 



- ix'ii vM 11, 111 relert 

iinii-rxistciKv (»!" an iiillammatory 

ft 

local syiii]>t<tiii (»t' increased boat 
satisfactory.* But you will ob8er\ 
tonis wliicli you may not be able tt 
stage of hip-joint disease, because 
seat of the inflammatory heat lies b( 
at some parts by such a large mass 
it is difficult for the hand to appreci 
perature on the surface. When, ho 
symptoms of lameness and tender 
presently allude, you find an inc] 
neighbourhood of the hip-joint, yoi 
existence of a subjacent infiammator 

Here, then, we see two sources o 
existed in the diagnosis of hip diseas 
tion of the " sympathetic '* pains, and i 
existence of heat. 

There is another source of diffioa 
to which I shall refer again (Lect. XA 
or spinal-marrow disease, which may 
of the physical signs of hip-joint diaei 

Now let us consider what may be t 
of hip-joint disease in children. Her 
I cannot conceive why it is that surgi 
the hip-joint itself in the same exact, 

• Of the imnnrtoT^n'^ r^F — -• 



XIV.] AND THE DIAGNOSTIC VALUE OP PAIN. 337 

Cftl manner that they employ in the examination of other 
joints : why, in examining a suspected or obscure case of 
disease in the neighbourhood of the hip-joint, they should 
depend upon, or place so much reliance on, what might be 
called the outlying symptoms. If we are desirous of ascer- 
taining the nature of an abnormal condition of the ankle, 
knee, elbow, or shoulder joints, we try to make out the 
actual condition by close and precise manual examination of 
the joint in reference to the exact site of the pain, the sense 
of heat at the joint, and the influence of direct friction 
or pressure upon the articubir surfaces. But, with regard 
to the hip-joi#t, many surgeons seem to be satisfied with 
merely examining the general features of the case in order 
to recognise those outlying symptoms which are described 
in books as characteristic and indicative of hip-joint 
disease. 

If we see a child with a slight degree of limping or lame- 
ness in walking, that must depend uj)on something. If 
we recognise 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 be certain that the 
mischief is not there, and we may bo pretty confident that 
it will be most i)robably found at one of the pelvic joints, 
or in the immediate neighbourhood of the hip-joint, either 
within the articulation itself or the epiphyses of the Iwnes. 
Possibly, on placing the hand attentively upon these latter 
parts, the precise 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 inflam- 
matory 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 flexors and 
adductors, which compels the thigh-bone to follow the 

z 



33S TUE THERAPEUTIC ISFLUEKCE OF BEST [Lbtt ' 

mean direction of the two mnscnlar foitios." There w » 
C(Hi§tant law to which I have already alluded — that vhen 
a joint is inflamed, the movoablc part of it is obedient ta 
tlio more powerfiil muacnlax action. If, then, yrm we * 
child that limps a little in waiting, the femnr eoinewhat 
bout upon the abdomen, and the toe a little pointed, witii 
iniibiUty to bear the whole weight of the body nprm &e 
limb, and when you make a litfle pressure over or upon 
the trocliaiitcr major, excoBBive or moderato pain is fi-It. as 
compared with the result of a like pressTiro upon the 
corresponding imrte of the opposite side ; if in aseociatioD 
-with uieee eigiiB there he pain on pressure Tipon the fTont 
of the hip-joint, and pain in or near the hip-joint whon the 
foot is struck upon its sole ; and if. in addition to then 
local symptoms, there be a slight decree of febrile oxdt&J 
ment towards night, a little restlessness during the nigl^l 
with oceasional startini;; of the limb, the Buspectcd limb 
being more flexed and mure adducted during sleep (an 
almost constant occurrence), then, I say, you may be sure 
that these 8yiui)tonis are indicative of something wrong in 

* Mr. Oneu (A DenionatratioD on tbe Anatomy of Hip-joiiit DiwaEn 
in Childlioud, Brit. Mt-d. Joum. Dec 14, 1S78) gives tbc following 



L'Xpluiiation of tlie posilioiis amnmed by tbe tower limb in 
p-joinE iiiscoau. b&md upon tfic eipcrimont of injurlin^; ||ie op ' 
» ircphine-ipenin),- Ihmujrh thepeivicaspectortheacetiilmlom. ■ 



i ibe synovial mt'inbrsne becoi»ee affui-tml. Iliin syiii 
Bvcrctcd in abmnlaticc, tlie joint fills aod batgcs inln the groin. anJ the 
limb seiiiiiiiej a fuulty poi-ilion, which I will immtrdintely deriionstrate. 
... I will injictn little water i[ilo the joint to imibi'tclbe Bynovial 
f-lTiiBioii, and sec how tbu femnr nbilucta itself. This mecbanickl 
abdnclion ia tliuB elplninpd. Tbe joint is filliug, and ia flllnl, and is 
to disttnded tbnt more room is requin^. The upper and nnterioT port 
of lliR ciipsiiic cannot yic-ld, but the lower part can gim room by 
ahdiiclion rif t^ie femur; and Hbduotion is tlio rosnlt. But tbe inflam- 
mati.in isHdvnneingnndmore synovia in pounH) out. How can inciT«Kd 
room bo obtained? Letmv inject more water and eee. Incioaaed nwm 
ia obtainod by Bexioii. Kkxion wo know is tbe position iuTariakly 
Bssnuu^l in ndmnurd liip-ji>int diwuso. (Injection rigiilly Beies tbe 
fomur). But, later on, llio limb beanies inverted. Further injection 
into the joint will not force tbr fiexed fomur into un inverted poeitiou. 
But the inn>t«inn may, I tiiink, be tlius a<<couuttd for. The psoas, 
iliwus, rcrtiiB fvmoris. tensor va!;ime fimoris, and tie addaotorlitngus, 
become tireil with holding tlie fi'mnr so that Ihc joint may be as tuouiy 
as possible: so tiny compel the limb to accept tlie attiHctive euppuTt 
oQeicd by the front of the oppoeite tbigb."— [EJ.] 



XIVJ AND THE DIAGNOSTIC VALUE OF PAIN. 



339 



or near the hip-joint itself. It will be remembered that, 
at the early period of life to which I am now alluding, the 
bones forming the joint are composed of several parts 
(Fig. 62). The trochanter major is an epiphysis ; so is the 
trochanter minor ; so likewise the head of the femur is an 
emphysiB, having a separate circulation, and joined to 
the neck of the femur by temporary cartilage. This is 
no mere anatomical refinement, for I place before you a 




Sketches of young thigh-bones (copied fh>m Qoain's Anatomy), showing the 
epiphyses, or separiu>le pieces of the bones, i, Head of thigh-bone. 2, Tro- 
Goanter m»Jor. 3, Trochanter minor. 4, Condyles. Hie head and the two 
trochanters nnite with the shaft about the f^ightecnth year ; the lower epiphysis 
leinains distinct from the shaft till after the twentieth year. 

pathological specimen which will testify to the fact that 
the results of disease may be modified by the normal ana- 
tomy of that early period of life. We have here (Fig. 63) 
a drawing of a preparation from Guy*s Museum, sent there 
by Dr. Holman, of Beigate. It is the epiphysis of the head 
of the thigh-bone separated from the neck of the femur, in 
a girl fourteen years old. He discovered it lying in the 
upper part of the thigh, within the abscess associated with 

z 2 



340 



THE TOEBArEUTIC INFLITENCE OF BEST [UkT. 



the Lip-joint (Usease, and, by making' a «ntnll iuofiot) 
through the soft {mrtit, hp was euahlwl to take itr>iit iJr. 
HolmtLU iiifunnfj me that this putieut ie dead, and th«t Im 
had not the oppurtnuity of exttminine tlie body. 

Now, to revert to the fiyniptoinH of hip-joiut diseam. If 
n patient proeeutA Huch local and general symptoms as Uioae 
tu which I have nlludctl, it is hurdly worth while going into 
the question aa to whut tiwue is involved in the misoJiief. 
That, to my mind, i» a pathological refinement whiuh b uf 
no advantage whatc'wr in the treatment of tht; caau. 1 
think it is buyoiid tJio prufeesioual acumen of any man to 






.Ij drUdiM. It pnwnu two 




convrx •rlkular lur^ice <• 


deprived of 11k wliul.' of lu snlcul^.r uRlliRi'. 


(.■It tlie iniculir luulni sf 


Iwiw rmuinlng (!tvM It > Mniortli appemmnct. T 


hrroiicarc "urfim Li ««bn™ 




Th»r* Is nu slnidnr^ tndk 


cvloD of «i«tul> 111 il>li phcE of bonr. a. C.<,n 


ve> .nlculir surfue. k. Cm- 


™vc.urlia^l,y.bkb ttK« unllod lo .he n«lt 


nf .h-thigh-l>onf(hm.rt.tt« 
In plate of bone, a muU nan 


mcJiam of wmpur.ry culil.Kr. «upp..rt»l l.j- >• th 


of wlikli roinaliu, and to tbst on Khicb tbe Inur b 


ispluod. 



lie al.le to tell deoideilly. at that period of chilJhootl, 
whether the diwiise lie Iwtween the neck of the bone and 
its cpiphyBiN, the head, or whether it Ix) in the lisamentum 
tores, ov upon the Burfnce of the head of the bone, or upon 
the floor of the acetahuluni, which at that period is divided 
into three eegniente, indicating the separate contributions 
of these three individual [wirta— the pubea, ischium, and 



ilit 



A little child, however, suffering from such so-called 



XrV.] AND THE DIAGNOSTIC VALUE OF PAIN. 341 

obflotire or tincertain symptoms of hip disease, is likely to 
suffer from a misinterpretation of the symptoms, on the 
supposition that they may be caused by teething, or 
perhaps rheumatism. These, I may say, are very common 
professional phantoms with the surgeon when considering 
Bueh a case, so that all the attention is given to the inno- 
cent teeth and gums, which are scarified and punished 
unfeirly for sins which do not belong to them, whilst the 
hip-joint symptoms are allowed to continue, or are left to 
themselves, 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 my own views as to this mis- 
placed 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 scarify- 
ing the gums too deeply." It is obvious that it must be 
so. If the gums are scarified deeply, the rudimentary- 
apparatus, which determines the development of the teeth, 
must be very much interfered with, either in their direc- 
tion or integrity, by a reckless or badly directed incision 
into the gums. 

I should have no hesitation, in a case presenting 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 required remedy would be sufficient 
mechanical rest, secured to the patient by the recumbent 
position during several weeks. In cases presenting these 
milder or less striking symptoms of hip-joint disease, I admit 
that it requires a strong determination on the part of the 
surgeon to say to the parents, " This child has disease about 
the hip-joint, or symptoms which lead to the suspicion that 
the hip-joint is diseased, and 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 con- 
fidence. I feel strongly on this matter, because I am con- 
fident that if these early symptoms are properly made use 
of, and the surgeon does not wait for the next series (said 



iiio lail iirest'iiti'd tliewG car 

so on. His inotlior had been i 
t-jT life, aud therefore not eligi 
Baid, " I Bfaall never be able to g 
has hip-joint disease ; and I ha^ 
as to what I had better do wit 
too old." I recominended that t 
intermptedly for as long a perio 
The mother assured me that he b 
conch for four months : at the e 
oame to me perfectly well, cured 
admitted into Christ's Hospital 8 
Some years ago the proprietoi 
blishment came to me with a pa 
brought you this young gentlen 
Boventeen years of age, ana has 01 
establishment. He oonsnltod i 
eminenoe in London, who assnied 
important the matter with the 
ennering from rheumatism or som 
advised turn to take abundance of < 
advice, he is now suffering great 
very lame. His parents sent him 
be cured of his rheumatic hip-jo: 
am not doing the patient any mat 
ment, I have thoiiRht it ""*''■- " 



XIV.] AND THE DIAGNOSTIO VALUE OP PAIN. 343 

snrgical advice and Buperintendence ; it was, however, too 
late, and he soon afterwards died. 

But suppose that time should show that you are wrong 
in your opinion regarding the disease in an obscure case, 
rest during one, two, or even three months is not a very 
serions matter to the child. Assuredly, if you have given 
the proper advice, after the child has been lying down 
about a fortnight, many of those constitutional, and nearly 
all the local, disturbances which formed the early symp- 
tomB will have become much mitigated, and it will then be 
apparent that if you have not hit u^wn the precise patho- 
I^ical anatomy or the exact locality of the disease, you 
have discovered the right treatment of the case. 

I am anxious to inculcate the importance of recognising, 
or of diagnosing a case of disease of the hip-joint or its 
neighbourhood, at a period before the full manifestation of 
{hose symptoms which are spoken of, and traced in books 
as the characteristic symptoms of morbus coxarius. I must 
admit that it is still the opinion of some surgeons that 
inflammation or irritative disease of the hip-joint is some- 
times associated with, or induced by, unhealthy teething. 
I cannot say that it is not so, but I think it must be a com- 
paratively rare occurrence, for it certainly has not fallen to 
my lot to see more than one or two cases which could give 
any legitimate support to such an interpretation. On the 
other hand, I certainly have seen a great number of cases 
in which teething has been said to be the cause of hip-joint 
fiymptoms, where it has turned out to have had nothing to 
do with them, and a great deal of time has been lost, and 
the patient has been placed in danger by the delay. 

Disease between the sacrum and the ilium may some- 
times be mistaken for hip-joint disease. I have seen 
several cases of this kind, but another occasion will 
be afiforded me for bringing 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 rignt 
side. I examined the hip-joint, and there was certainly 
nothing wrong ; it might be rolled about in every direction 
without pain ; but on turning her over, and putting my 
finger on the space between the sacrum and the ilium on 
the same side, she exclaimed, " Now you give me a great 



joint disease, I find inyeelf i 
private practice, beoauee we 
in the hospitals. In truth, a 
seen in public iuatitutions'unti 
dieease have become esceedii 
advancing towards suppuratloD 
attention upon the state of the 
severe conditions, for no doubt ( 
earlier the cases are rightly int 
chance of recovery for the patiei 

Cate of Diieate in the ShDuMer-Joit 
and the Joint detlroyed; Hip- 
Patient cured 6y "Beat." 
This young gentleman was b 
mother was phthisical ; she hat 
lunga when the child was bom. 
Inflammation or a diseased condil 
joint. The father took him to hi 
now passed away, and who did n< 
an inflammatory condition, the 
injury, nor as a case to bo cunk 
a scrofulous joint, ari'' *'■■ 



XIV.] AND THE DIAGNOSTIC VALUE OP PAIN. 345 

became very bad, and there was a fair prospect of his 
dying from suppuration. I saw him professionally in 
1848, and he had then all the symptoms of incipient hip 
disease to which I have alluded, and Mr, Key, in consulta- 
tion, confirmed this opinion as to the distinct existence of 
iiip-joint dise€tse. The prospect for the patient was not 
good. The mother was dying, and did die, of consump- 
tion ; she had also hip-joint disease, with dislocation of the 
head of the femur, as the result of a very slight accident 
whilst travelling with her husband in North Wales. The 
ohild was very delicate and unhealthy-looking, with a 
thin, fine, silky skin. Suppuration was then proceeding 
abundantly from the shoulder-joint. In fact, his health 
was going 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 been given to her to repair the injury ; no use- 
ful kind of mechanical rest had been prescribed; and the 
disease had been allowed to take its own course. 

When 1 saw the patient in 1848, he had disease of the 
left hip-joint. I had him placed up(m a well-stuffed hair 
mattress, with a leathern splint upon his leg, thigh, and 
pelvis, like that depicted here (Fig. 64). I kept him lying 
there uninterruptedly for the space of six months, — from 
September, 1848, to March 29th, 1849,— with the left arm 
(the side diseased) fixed in a sling, but giving him per- 
mission to use the right as freely as he might wish, in 
order to amuse himself with his various playthings. The 
parents were constantly saying to me, " Let him get up ; 
lying in bed will make him so weak, and his general 
health will suffer," and I as ccmstantly replying, " No, no, 
his health is imj^roving," and insisting upon the child 
remaining absolutely quiet for at least six months. The 
child was then allowed to get up, and to be carried about out 
of doors, but the splint was not taken oif until the end of 
August, eleven months 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, and the 
shoulder was also greatly improved and approaching cure 
by anchylosis, yet discharging now and then little frag- 



348 



THE TUERAPEUTIC INFU'ENCE OF BEST [Leci. 



inentB of cancellated bono. The liip-joint w 
]iaiul(!8s, and would hear the weight of the Ixwly ii 



eehle, 
_ ft stand- 
without inconvenience ; so tfi^at, in truth, i 
person, with the same oonntitution, the okoulder-juint had 
been deatroyeii and the hip-joint saved. 

What was the cauae of the ditTi-reuco in the a«tual ootK 
dition of t!ie two joints in this case ? Just this, I ajipitihettiL 
With the shoulder. Nittiire never had a chanco of carioKit 
liy rest ; and with the hiii disease she had every opportanitf 




offered to her, and she did not fail to make good nse of it. 
The treatment adopted for one joint was ineffective, and 
that for the other quite Biicccseful. In 1850 the shoulder 
was still suppurating, still disoharginga little thin pus and 
very minute portions of bone, and there was a larpe open 
ulcer at the jiosterior part of the joint. In 1854 I had a 
leathern splint placed upon his shoulder and np[>er arm, 
which he wore for two years, and at the expiration of that 



XIVJ AND THE DIAGNOSTIC VALUE OF PAIN. 347 

time 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 efifects manifested them- 
selves 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 
fiide was not so much developed as on the other ; hence the 
left lung and chest-wall wore 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 the result of long- 
continued hip-joint disease in the female. Thus I have 
ascertained by examination that the os innominatum on 
the side of the disease does not grow 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 parturi- 
tion at the full period of gestation.* I may add that this 
pelvic deformity is most conspicuous, when the hip disease 
occurs in, or continues into the period of early menstrua- 
tion. 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 consequence 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 

* For defonnities of the pi,'l?i8 caused by congenital diBlocaiion of the 
hip see note to p. 417. 

At the recent Congress at Montpellier (Brit Med. Joum. Oct. 4, 1879) 
fhe pelyis of a woman was shown, whose thigh had been amputated 
fai early childhood. The deformity consisted in the atrophy of that 
poriion of the pelvis which corresponded to the amputated thigh. In 
ahape, it resemhled much the obliquely distorted pelvis produced by 
congenital luxation of one femur, except that in this case the distortion 
corresponded to the side of the lieafthy articulation. See also note, 
p. 417.— [Ed.] 




Left. 

On oompAring these two figureA, it is obvious that 
the right sMe, and the same undeveloped ooo 
this patient's protipects In alter life might, ft 
been much impaired. 

not a believer in Bcrofula to the € 
are), whose mother died Bcrofiiloi 
tubercular phthiKia «»- 1 ^ * 



XIVJ AND THE DIAGNOSTIC VALUE OP PAIN. 349 

Ktient; he was then fifteen years of age. His general 
alth was excellent ; the formerly diseased shoulder-joint 
was fixed and healed np, and painless ; the hip-joint was 
normal in every respect ; and the boy Jbad great mental 
abilities, combined with considerable energy. The loft hume- 
rus 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 scapula 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 ground-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 of a well- 
trained, and most powerful prize-fighter. I could not have 
conceived it possible that the muscles of a boy of fifteen 
oould have acquired such large dimensions and such beau- 
tiful development. 

Case of Diseased Hip- Joint cured by Five Months Best. 

In 1847 I attended a young gentleman in London, aged 
seventeen, with severe disease of the hip-joint. He was 
pale, unhealthy-looking, and flabby; he had enlarged 
tonsils, and a thick husky voice. The hii>-joint disease 
was the consequence of fatigue from a long walk. His 
mother, four sisters, and two brothers had died of pul- 
monary consumption ; so that his prospects, constitution- 
ally speaking, did not appear to be very favourable to a 
cure. Sir Benjamin Brodie saw him in consultation with 
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. 64) ; and he was com- 
pelled to maintain the recumbent position, with the splint 
on, and his hip-joint in a state of entire rest, during five 
months. After that time he gradually resumed his 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 health, and looking at what had occurred to 
his mother, brothers, and sisters, seemed to present an 



3S0 THE THERAPEUTIC INFLUENCE OP REST [ISS-I 

uikfaToni-able prospect; but this young gentlemui wmIkI 
Iiiiiia fyr tlire* and « half or funr yeara, in very octifflul 
occupation, during the late rebcllioa, and is now perfec^^ 
wull. Uo can uu)ve his joint freely, and can walk sevon 
or eight niiles withont any difGoulty. He is rather thinner 
thaji formerly, bat is apparently quite well. 

I shall endeavour to show you, that uotMHthstAnding 
that disease of the hip-joint may have advanced to a 
period when the symptoms of hip diaease are oonspiouously 
distinct, thongh the constitution may be very bad, and 
the soft parts of the joint destroyed, patients may sliU 
get perfectly well by rest, with an anchylosed hip-joint. 
This would at oace appear to negative the idea of a 
scrofulous oondition of tae bones necesBarily exietiag; in 

The notes of the next oaae to which I shall allude on 4 
taken from my private practice. ' 

Case of Hip- Joint Disease of One Year's Duration cured i* 
Seven ISonths by Sett. 

In January, 1855, the patient (a little girl between four 
and five years old), lame, and in great pain, was taken to 
a aurgoou, who pronounced that she had hip-Joint dieeaae, 
and that he regarded it as scrofulous. She was under Lis 
profoBsional care about eight months, lie directed her to 
be taken to the sea-side, to have medicine, and to move 
about or to take oxerctuc, that her general health might be 
improved, thus hoping to cure the case by invigorating 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, 1865, 
eleven or twelve months after the appearance of the first 
symptoLos, she was brought to my house. She could not 
bear the pain of being very gently and carefully carried in 
tlie arms of her mother. The child was much wasted, and 
a 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 had scarcely any sleep during 
many weeks from the pain in the hip and the outer side of 
the knee, these pains being especially severe at uight. 



XIV.] AND THE DIAGNOSTIC VALUE OP PAIN. 361 

The thigli was flexed upon the abdomen, adducted, and the 
knee tnmed inwards, evincing a disposition of the head 
of the femur to be dislocated backwards ; there were also 
falnesB and rotundity at the back of the joint. The slightest 

?>Te68ure upon the trochanter major or upon the sole of the 
bet, for the purpose of forcing the head of the femur into 
-Hie acetabulum, caused great agony. There was a marked 
disposition of the head of the bone to be displaced back- 
wards (always a serious complication), and the distinct 
fluctnauon of an abscess below Foupart's ligament to the 
outer side 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 
•plint (see Fig. 64), or case upon the pelvis and upon the 
hip, with an extension to the foot, for the purpose of keep- 
ing 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 move- 
ment of the joint, but also to insure easy, persistent con- 
tact between the articular surfaces without pressure, so as 
to facilitate bony union, supposing the soft parts to be 
destroyed ; or if the soft parts be simply inflamed and 
swollen, then to prevent undue pressure (the result of 
unconstrained muscular force) of the soft parts, mutually 
inflamed upon each other. Another object in this case 
was to prevent rotation of the limb either inwards or out- 
wards, because it is obvious that if no «*cA rotation he per- 
mitted^ no disloccUion can occur. All the requirements were 
carried out in this patient by the splint. It was accurately 
adapted and answered remarkably well. You will observe 
that a sliding footpiece is attached, so as not to interfere 
with the growth or elongation of the limb. Children grow 
Tery rapidly, especially so if well fed, when in the recum- 
bent 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 there- 
fore be allowed to elongate itself as the child grows. The 
splint is also provided with a transverse portion under the 



352 THE THERAl-EUTIC INFLUENCE OF REST [LiCT. 

footpieco. which prevents the posaibility of any rotation 
either inwards or uutwanls. The patii.'ut was placed od 
her back upon a wijll-stuffed hair-iuattresH bed, and thiB 
splint vfOB kept on tminterruptedlj, or nearly so, dnriiig 
Bcven months. It was taken off three or four times \ij 
myself with cnre, merely for tlie purpose of examining the 
progress of the cure, and of facUitatiiig [lersonal cleunU- 
UC88. Ihiring the latter portion of the time she was token 
out of dc^rs, with the leathern case or eplint on, and l>Tn(; 
horixoutullyuiKtna little wheeled carriage with easy Hpriii)^ 
The medical treatment consisted simply of opium, iu laijff! 
doses at first, to secure sleep, and one-mxtoonth of a grain 
of bichloride of mercury twice a day. with san>aparilla. 
during about a couple of months. No eeton, no iRsue, no 
tartar-cmetio ointment, uo oruton-oil liniments, iioUiing of 
the kind was used. The general health and appetite im- 
proved rapidly after the first month of conJinetneut t« bed. 
At the i-xpiiuti..!! uF tl,.. s.^viii luoiitl.H, all pain, tenderness 
jindc'ui--i ii !!■ I .' ' ■■ .:'.,■.■ ■ 1 1 iiigdiniippeared, she was 
allow'il ■ ■'■.iit;h6d walking exercise, 

without. 1i;li::i. Ilif ;LiiM(--> in tlie thigh gradually sub- 
sided, and wiis iiii;illy alwiji-Led, 1 saw the patient again 
about sixtt'cu or ciglitouu numtha from the time she began 
to take indejiendent exercise. She walked into my room 
quito comfortably, well in health, but rather flat-footed. 
She could then walk two miles without any difhculty or 
jMiiu. The mitsvtcs of the thigh and leg wei'c increasing in 
size almost weekly- Tliero was a slight limp in the walk, 
the foot very little everted, and there waa. [wrhaps, from 
about a ijuarter to half an inch shortening of that limb, aa 
coniiuireil with the other; there was no abscess to be felt, 
no fluctuation to Ije detected anywhere, and the bony 
auchyh'siK was perfect. For tlio punioHe of testing this 
latter point of bony uniini, I jilaccd the child recumbent 
upon a couch, and )nx"Bsiug downwards upon the j^lvis, 
endeavoured to flux the thigh-bone upon the pelvis, but I 
could not carry the tliigh bone towards the aMomeu with- 
out lifting the ]ielvis at the same time; the other lower 
liiub was perfectly natural in alt its movements. I might 
suggest that the slight shortness of the diseased Umb wub 
due to the arrest of growth ou that side, wliile the other 



XIV J AND THE DIAGNOSTIC VALUE OP PAIN. 353 

dde was growing, this defect in development as to the 
length of the limb bein^ a constant result of hip disease. 
This case proves, then, that although hip-joint disease may 
have existed uncontrolled during nearly a twelvemonth, yet 
it is perfectly curable, with a stifif joint, by rest alone, 
which may be styled the best possible result m such a con- 
dition of joint. The case, I think, shows also that there 
was no scrofulous condition, no tuberculous state of bones, 
for I cannot believe that if those bones had been scrofulous, 
we should have obtained such a rapid and perfect anchy- 
losis, or bony union. 

I now come to another case of hip-joint disease, of which 
I have the post-mortem results. The patient had been 
jMirtly in the hospital, and partly a private patient ; and the 
oase shows that, notwithstanding a tubercular constitution, 
yet, by rest and proper treatment, persons with severe hip- 
joint disease may do well. 

Ckue of Hip Disease occurring in a Scrofulous Patient ; the 

Hip Disease cured by Best. 

A. R was thirteen years and a half old when he died, 

in Oct. 1867. 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 to an hospital surgeon, who 
believed the pain to be rheumatic. The patient was 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 was nut at all diminished, and 
he was, by particular request, admitted into Guy's Hospital, 
under a physician, in July 1856. He was then thought to 
be rheumatic, and was treated for rheumatism. He remained 
for six weeks without the slightest benefit. He was brought 
to my house in October 1856, fifteen months after the joint 
disease had commenced, clearly sufieiing from hip-joint 
disease, and presenting a very tubercular and scrofulous 
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 

2 A 



\iv." ,\N]i Tun niAi^NosTrr VAT.T K OK lAis" . ; ■ '■ 

no appetite, and waa exceedingly feverish. Tliu Icdtlifni 
Bpliut (Fig. 66} was plaoed apou the patient, and, as there 
was an abmees of considenible size then forming, it was 
neoeoeary to make an apertnre in the splint to allow of 
•ome local application, and to enable me aubaequently, 
if DOOOOPBTy or advisable, to open the abeceas without 
distnrbiDg the hip-joint. The patient died abont a year • 
afterward of ohronio tabercular peritonitis ; he had also 
some tubercles and cavities at the apioes of both lungx. In 



Flg-M 




opperputofUM aceUibiilQii) 



_„._ IMrtMD UHt ■ Imlf, 1., ,.. 

e, GplphTflli or taud ot bone uniud w thr 

ijnka of trocbuur majut. 



this case we find both in the peritoneum and in tho lungH 
the pathological evidences of the tubercular diathesis, or 
(if taberote is to be the histological basis of Bcrofnla) of 
the true scrofnloas constitution. Notwithstanding all this, 
hy keeping the patient's hip-joint perfectly qniet, we not 
only prevented dislocation, bnt allowed Nature to produce 
bony anchylosis of the hip-joint. If ever there was a local 



su. I liav,. ],li.ir.l l,,.f„re v( 
ol,M.iv,. tli,.t tiio hui-il ..f th 
til.- ti<")ruttlR' a;;utalj«Imn. 
ati'oiig wiui the medium of tin 
that he had walked out of doo 
itplint, and could bear his wei| 

Here, then, was a soiofiiloa 
no evidence of tubercular dep 
repair ia good. This case ia all 
pursuanoe of a peraevoiing plai 
The medical treatment of ibi 
Whilst the boy was suffering fn 
took the ordinary fever medicii 
gave him for a short times smal 
mercurr with earsaparilla, and a 
steel wine, securins; at the same 
Absorption of the absceat too* pm 
remains of the abscess were foni 
quantity of sero-purulent fluid i 
deposit upon the floor of the oontn 
cavity communicated, by a ven 
scarcely larger than a probe, wi 
the joint, but we could not det«c 

Severnl of the cases of hip disc 
occurred some time ago, and I s< 
poso of showinc *^"'' '' 



XIVJ AND THE DIAGNOSTIC VALUE OF PAIN. 



357 



Diseased Hip-Joint ; lAmb much hent ; straightened under the 
influence of Chloroform ; Splint applied ; cured hy Best. 

The first case is that of a little girl aged seven. She 
was admitted into the hospital under my care in June 
1860, with rather acute disease of the left hip-joint, and in 
very bad health. Three years ago she fell downstairs, and 
was supposed to have hurt her hip ; she had been more or 
less lame and in pain ever since. By irregular rest and 
quiet, and getting about on crutches, she was, after some 
time, ifecovering, when she was knocked 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 1800, she 
had all the indications, local and general, of severe hip- 
joint disease, with deep suppuration in the anterior, upi)er. 

Fig. 68. 




and outer part of the thigh. The limb was flexed and 
adducted ; the patient was suffering great pain in the hip, 
had little sleep at night, and little or no appetite. Chloro- 
form was administered, and the contracted muscles of the 
joint yielded steadily and nicely to carefully applied exten- 
sion. The flexed limb was made straight, and a long common 
iron splint (Fig. 68) applied along its outer side, extending 
from near the axilla to the foot, with a transverse bar to 
prevent rotation ; the recumbent and supine positions to be 
strictly maintained. Immediately after the application of 
the splint, all the disturbing symptoms began to disappear, 
and her apx)etite returned. So free from suffering did the 
patient continue, and so efficacious was the splint, that I 
did not disturb it for five months, that is, till November 
1860, and then the joint was found to be fixed or anchylosed 



:ij8 



TQE THEHAPEUTIO INFLUKNCE OF BEST [tn-r 



U) ihe acetabnlDm, nnd tbe experiment&l movements HA 
uot produce much pain. Tlie patient was ordered to oon- 
tinuo tho splint. In Feb. 1861 there was not a eingle 
untoward aymptom ; the heAlth was guod. 'I'he splint hiv- 
ing been removed, the bony anchylosiB was firm, and the 
lower extreniitieB were of nearly tho same length. She 
bull no pain when direct pressure was made on the hip-joisi 




below Poupart'a ligament, nor when the sole of the foot 
was struck. This eketch (Fig. 69) was made on June 0th, 
1H61. I'he child was quite well except that an abscess was 
still there, which was not to bo opened under any cirenm- 
stancee for a considerable length of time, in the hope that 
it woTihl be absorbed. The child went out on tho I6th of 
June, 1861, since which time I have not seen her. 



XIV.] AND THE DIAGNOSTIC VALUE OF PAIN. 359 

The other two cases are more remarkable. They are 
specimenB of hip-joint disease, cured, as far as possible, 
l^ rest. In both cases dislocation outwards and back- 
wards on to the dorsum of the ilium occurred from disease, 
and in both the dislocations were reduced, and the bones 
have since remained in their proper positions. 

jyiahcation an Dorsum Ilii of Left Femur from Disease ; Dislo- 
cation reduced ; Anchylosis proceeding, 

C. B , aged five. No accident or local injury was 

known to have happened to the child, who was previously 
in good health. He complained of pain in the knee six 
months before he began to be lame. He was under the 
care of Mr. Stormont, of Cheshunt, eighteen months ago. 
He used to lie in bed for a week or ten days ; then get up 
and soon became lame again, taking alternate rest and 
exercise, but on the whole steadily getting worse until 
December 1860, when he could not get up, since which 
he has been constantly in bed, lying on his right side. 
Dislocation of the thigh-bone must have occurred when in 
bed. The left leg was drawn up. Ho suffered great pain 
in the knee and hip. The general health was very bad, 
and he could scarcely bear being moved by the nurse. This 
patient was in an hospital in London during the months of 
April and May 186(). He had an issue made over the hip- 
joint when in that institution without any benefit; no 
splints were applied ; he was more lame when he came 
out than when he went in ; and he was represented as in- 
curable. He came under my care on the 23rd of January, 
1861. 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 chloro- 
form. 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 
footpiece 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. His health appeared perfectly 
good, and the limb was in an excellent position. I'here 
was no pain, but simply an abscess upon the anterior and 



■0 THE THEEAPEUTIC INTLUENCE OP HE8T [Uci. 

Der part of the thigh, which was left alone. Bony 
lion had taken place between the head of the feniur ud 

e acetabulum. 





This appears to bo a good case ju reference to the influ- 
ence of rest in the treatment of diseased hip-joiuf . 

Di»loeation of Tkigk-htme upon the Dorsum Ilii from Disease ; 
Dislocation twice reduced ; Anchylogis in good potition. 

The third caee is a much moi-e cnrious one. Mr. Stanley, 
who happened to be at Guy's Hospital in the summer of 

1859, saw this little patient. M. P , aged seven, was 

admitted into Charity wnnl on March 2nd, 1869, under my 
care. Her mother stated that ehe had always been a very 
delicate child. In November ItJdB she first complained of 



XrV.] AND THE DIAGNOSTIC VALUE OF PAIN. 3(51 

Ci in the left knee, and was noticed to walk lamely ; her 
th also began to be seriously damaged. The mother 
took her as an ont-patient 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 pre- 
scribed. This plan was persevered in, but so severe was 
the pain experienced in moving, that 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 great aggravation 
of the patient's symptoms. This led her friends to seek 
admission for her into Guy's. The report on admission 
states that she was a feeble, strumous-looking child, with 
delicate skin, long eyelashes, 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 ilii ; in fact, the head of the 
bone could be felt lying upon the ilium behind the aceta- 
bulum when the leg waa rotated inwards. A fortnight 
after admission she was placed under the influence of 
chloroform, and the limb forcibly extended or drawn do^vn- 
wards 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 
a^in dislocated backwards, with its head upon the dorsum 
iliL On April 30th, 1860, ten weeks after the first occur- 
rence of dislocation, she was again placed under the influ- 
ence of chloroform, and the dislocation once more reduced. 
A long straight splint was again applied to the limb and 
pelvis, and short splints put upon her hands, to prevent her 



iiiiuli; nil i:iuu}i]aii]t uf jiuiu- '. 
reailjusted at intervals, care be 
joiilt. October 1859 ; The p« 
diaeaaed limb seemed rather li 
the symmetry of the two hip-joi 
femur oould only be slightly flex 
was still slight tenderness (m ] 
major and the head of the femm 
yet oompletod. Oti March 26tl 
Anchyloeis is perfect ; at least til 
I^B femur without pain : the pati 
upon the left limb, and can waU 
support. There is no tendema 
head of the femur or the troohi 
inches below Ponpart's ligament a 
The splint to be re-applied. Th 
kind of case. I have a photogn 
dition of the patient as she stoo 
Fomer, one of the surgeons of 
obliged me by taking her under 
three months at the seaside, v 
health, free from pain, and could 
hospital ward. At the expirati 
parents brought her to town by 
splint had been +"'■— "■ 



XIT.] AKD TBE DUGNOSTIO VALUE OF FAIN. 



363 



greatly emaciated, badly t&A, and badly nuiaed ; no splint 
upon tlie limb, and a profuac diecharge from the abaceSB. 
8be was admitted into Guy's Hospital under my care, 
with the second injury to the hip-joint. Her health 
gradually improved; the discliarge diminished, and ossifio 
cimsoUdation again took place in the hip-joint. Tbiscaso 




S™C' 



'pre'nmutlon or thfir o 
tbe Ihlgh, iDiUcuMi tli> nptvlnR 
dlacbargn a bduI] qiuDiity of 



bslDgmno'.. . 
The lUrk >poi, iHn npmi Uii 
coniinuDtciiUng viUi uic aba 
punliDt BniiL 

was finally cured, and remained so up to the last o 

on which I saw her, some years after the date of her 

leavine the hospital. 

In discussing the question of the influence of Kcst in 
the treatment of disease generally, I thought I might. 



3l!4 THE THEBArEIlTIC INPLrENCE OP BEST [Ltci 

more especially by pointing out its application to the 
diseitHeH of the joints, induce in the minds of some of imr 
prufesBioual brethren n mom philoeophic con si deration of 
the pathology and trefttmcnt of a class of oases which are, 
not Hnfreqnently, abandoned to the care of the empiric and 
the mindlesa. 

By regarding thia subject of physiological and mechanical 
licBt in what I oonoeive to he its proper professional light, 
the surgeon will be compelled to admit that he has nopoieer 
to repair direcllg AT\v in jury . It will induce him lo acknow- 
ledge, in ail humility, that it is the prerogative of Nature 
alone to repair the waste of atiy structure. Ho will thus 
i-ealizc that his chief duty consists in ascertaining and 
removing those impedimenta which obstruct the reparatiTe 

Erocese, or thwart the efibrte of Nature, and thus enable 
er to restore the parts to their normal condition. 



XV.] AND THE DIAGNOSTIC VALUE OF PAIN. 365 



LECTURE XV. 

DISLOCATION OF RIGHT FEMUR ; REDUCED TWO MONTHS AFTERWARDS ,* 
DEATH FROM PTJEMIA — HIP DISEASE SUPPOSED TO BE SCROFULOUS 
CURED BT ANCHYLOSIS AFTER REST,* NO DISTINCT ABSCESS — HIP 
DISEASE IN A PHTHISICAL PATIENT CURED BY ANCHYLOSIS ,' ABSCESS 
ABSORBED — ^DISCUSSION ON THE PROPRIETY OF OPENING ABSCESSES 
CONNECTED WITH DISEASED JOINTS — HIP DISEASE ; BONY ANCHYLOSIS ; 
OPENING OF ABSCESS DEFERRED; RECOVERY — CHRONIC ABSCESS 
ABSORBED — ABSCESS IN DORSAL REGION ABSORBED — DISEASE OF HIP- 
JOINT ; ANCHYLOSIS AND LARGE ABSCESS ABSORBED — DISEASED HIP- 
JOINT, WITH SUPPURATION OF THE LEFT SIDE, CURED BY FOl'B 
months' rest; abscess absorbed — diseased HIP-JOINT, SUPPOSED 
TO BE OONORRHOBAL; ABSCESS OPENED BY NATURE; PORTIONS OF 
BONE EXTRUDED BY GRANULATIONS ; CUBKD BY REST, WITH PERMA- 
NENT ANCHYLOSIS. 

From the unfinished state in which I left the subject of 
"hip-joint disease" in my last lecture, I feel bound to 
give 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 
** rest." 

I am well aware that 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 by 
mechanical rest, before I can induce my brethren to follow 
my plans in their daily practice. I now proceed to lay 
before you some additional facts and cases in support and 
corroboration of the views I have long entertained on this 
subject. 

At the conclusion of my last lecture I mentioned two 
cases of hip-joint disease, in each of which dislocation of 



366 TUE THERAPEUTIC ISFLIJENCE OF KE8T [LelT 

the thigh-1x>iiQ had oocarred from diseaae. aud in each wu 
BubBOquently redutred. At that time one of the casea hml 
been doing remarkably well up to the period of an aocideol 
which led to a severe injTiry of the new medium of bouy 
union (ancbyluBia) between the femur and acetabulum. 
That child remained aomo months after her readmiAsioD 
into the hoBpital, and was finally cured. I hare lost 
night of her for some years. The other patient alao left 
the boepitiil, going on must satiafactorily, and wearing 
a leathern apluit. Here ia a short report (March tltb, 
1862) of the actual condition of the Utter patient from 
Mr. Storiiiont, of Chesbunt ; "I saw the hip-joint cbsb 
yesterday. His genurai health is very good ; the limb 
preserves its position and its leairth, and tbero is no pain 
at the hip-joint on pressure. The splint has not been 
taken o£f since his return home." 

I now bring forward two other cases bearing on this 
subject. 

Case of Dwlorntion of hi.lh Tluijh-bonei from Diietue of the 
Hi'ji-joiiit« ; one Fniiur hrimj ilix/daced on tt> the Dorsum 
Ilu. near to the hehiaHe Noleh ; the olhiT dUlocated 
doienicardi', hehw the lecfi of the Acetabaliim, and cloae to 
Ike Foramen Onile. 

K. S- , ft girl aged fourteen, was admitted into Charity 

ward, under my aire, in July 1864. The child wm 
greatly emaciutt'd, and daily growing weaker from » 
large amount of thin purulent discharge, which came 
from numerous sinuses communicating with the hip- joints. 
The head of the left femur was distinctly felt and seen 
Hiwn the dorsum ilii, the Icit leg lying across the right 
tliigh just lielow the level of the puljes, and pressing the 
right tliigh down into the bed, so that it liecarae difficult to 
ascertuiu wliat had hapi>cned to the head of the right 
femur. This, after chloroform had been given, was found 
Iviug deep l>olow the right acetabulum, iu the neighboar- 
ho(Hl of the foramen ovale, in the hope of improving the 
general health, iiny attempt at ri.'duction was deferred for 
about a fortnight, wlien. uiidtT the iufluence of chloroform, 
the reduction of the k-ft femur was accompliahod without 



XV.] AND THE DIAGNOSTIC VALDE OF PAIN. 367 

mnch 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, 
steps for restoring the position of the right thigh were 
deferred for nearly a month more, when chloroform 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 ])laced between the 
legs. The health of the patient was restored rapidly, the 
discharge from the sinuses becoming less and less until it 
almost ceased. The splints were removed occasionally 
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 
shuffle about the ward swinging her trunk upon the 
pelvis, anchylosed to the femurs. 

She left Guy's Hospital in April 1865, to go to the 
Cripples' Home, getting about on crutches. She remained 
here two years, and left to go to a dressmaking establish- 
ment in Kilbum. At this time she walked very well, and 
without crutches. All inquiries to ascertain her where- 
abouts have ended in failure. 

Dislocation of Bight Femur from Disease of the Hip-joint ; 
Beduction of the Dislocation Taso Months afterwards ; 
Death from Pyoemia, 

The patient, S. R , aged twenty-two, was admitted 

into Guy's Hospital, under my care, on the 31st of October, 
1861. Her history was this : — 

Four months ago she was taken ill, without any known 
cause, with pains down the right leg and thigh, which con- 
fined her to bed. She remained in bed some time, her leg 
being then nearly straight. She was suffering great pain 
in the hip, with inability to move the limb. She had been 
treated for various local diseases by different medical men, 
and latterly, up to the time of her coming to Guy's, most 



368 THE THERAPEUTIC INFLUENCE OF BEST [Lmrf 

uBttiduouuly, by a homoeopathic physicdaQ, for " rheumatic 
Buiatica." Two months before mliaission, one evening 
Huou after falliug atikep. the thigh became soutewfati 
suddenly bent, and the foot inverted. From that time shi 
was unable Ut straighten the limb. She then had in- 
rrtased pain in the right groin and right knee. 

Here I think it worthy of a paasing oonsideratiou to 
iriqiiirL' why it is that these dislocatiooB from disease almwl 




InnuaiinHtum. b. Kiiiphjsls •■{ hrxl al fnniir, panLalLy 



■s |>rurml[nB 



I eplpbjtd^i 



ilwavH occur just hh the jiaticnt is falling off to sleep. It 
s lliin that volition Ims witbdmwn its influence from the 
ii-rviiHs system genci'ally. and the cscito-iuotor function of 
In; Biiiual cord sceiuB to obtain an exclusive authority ovi-v 



XV.] AND THE DIAGN08TIO VALUE OP PAIN. 369 

the limbs, and produces the inyoluntary 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 ahnost always occur just as the patients are going 
ofif to sleep. 

This patient came under my care on the 3l8t of October. 
On the following day I found her lying in bed, on her left 
side, sufifering much pain in the right hip, thigh, and leg, 
which was increased on attempting to move the limb. Th« 
position of the limb corresponded exactly in direction with 
that usually occupied by the head of the thigh-bone when 
dislocated on to the dorsum of the ilium ; and this, she 
assured me, had been her condition for two months previous 
to her admission. I state this with confidence, for she 
asserted most positively that the bone had been in that 
position certainly for two months. The thigh was flexed 
and turned inwards, knee and foot inverted, and the limb 
shorter than that on the other side. Pressure upon the 
trochanter major caused great pain. She had a large, 
unhealthy bed-sore over the sacrum. As no careful exami- 
nation of the limb could be made without inducing extreme 
pain and distress to the patient, chloroform 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 present. A powerful 
and steadily continued effort to reduce the dislocation by 
simple extension and counter-extension was ineffectually 
made. I then grasped the thigh, and flexed it several 
times towards the abdomen, so as to give more freedom to 
the mobility of the displaced head and neck of the bone ; 
the thigh was next forcibly abducted, and then rotated 
outwards, in order to lift it from its abnormal position, and 
to tilt the head 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 Foupart'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 

2 B 






370 THE THEBAPEUTIC IKFLUENCE OF BEAT 

afford direct evidence tbat the dielocatioii was actuall; 
reduced, and reduced two months after the occurreDoe (tf 
the dielocatioB. She waa placed upon ber hack, a long 
etraight Bplint, with a footpicce and transverao luppott, 
was applied along the outer side of the lower limb and 
pelvie, uud simpiy haudaged to them, bo as to prevent 
njtatiou of the limb, and any recurrence of the dislocation. 
In three or four days, although she bad been Buffering for 
as many months, a!l the untoward Byniptoms of ibis caee 
had Bubsided. This improvement was simply and entirely 
the result of the rest which had been givau to the Jiip- 
,)oint by readjusting the two bones forming it in their 
projter relation to eaoh other. She slept well, waa free 
from pain and fobrllo condition, tbe swelling of the thifdi 
had nearly disappeared, and her appetite wa« got^; 
indeed, she felt better than for the four previous months, 
..onipkining only of the bod-sore. She was absolutely 
ijuite comfortablti, exeeptiug the annoyance of the bed- 
sore, and improving daily in appearance and Btreng;th up 
to the I'ith of December, when she had an intense sbiver- 
ing, followed by fever, headache, and sicknosB ; no pain 
in tbe limb or hip-joint, tbe pulso very rapid, and her 
appetite gone. She was. in fact, the eubject of pyaemia. 
These symptoms continued, and developed into pneumonia, 
which proved fatal in nine days. She died on the 2l8t of 
December, forty-four days after the reduction of the dis 
location. The right limb, by accurate measurement, was 
found to be rather more than half an inch shorter than 
the left. Thebody was examined on the following day, and 
the whole of the right lung wae found pneumonic, witli 
numeroiiB, well-defined, small collections of pus in different 
parts of it. There was no disease iu any other viscus ; but 
1 may add that the bed-sore had reached the interior of 
the vertebral canal, and involved tbe membranes of the 
spinal marrow, which extend downwards as far aa the 
second portion of tbe sacrum, although the marrow itself 
ceases opposite the second Itimliar vertebra. I have 
several times Been fatal miscbiof result from a bed-sore 
extending to the interiorof the vertebral canal, and eaiisinf; 
inflammation of the spinal cord and its membranes. 

Fig. 73 is an accurate drawing made by Mr. Tuppcr 



XV.J AND THE DIAQNOBTIC VAtCB OF PAIN. 



RecnmDEto the case we have been considering, you will 
otjserve evidence (and it is well worthy of note) that at the 




br mjsrlT) U°lDLroducnl to RiQlnd tbe aucgRin ot'lbe cluM iiruxlmli} uF tbn 
tbtttb ill ibt spiniJ buttow w the pMterior w»ll of Iht mrriJ portion of tlic 



Tuo. d. IMrtlon of 111 



Thin Dudcr^ coDtklDlng c»udft wjuLiu, mnchoold mnA cenbro-Bplntl Hijld reachll](C 
a point oppotiu thfl Hcoodbono uf the ucnim. NBDiflTDiu Buong ll^taeQtiuv 
HCD ftdLtlng the don mutt to the pootcrlor ll^uneqt of the spine And Mcrum 
oppMlt* the HOLiiid portion of Ok ucrnm. Tbne dlMtncI ilenil.r ligunrnu 
procgedtd thelUrd, fourtd. ■»! flhhpertlomof tlieitcruin. 

age of twenty-two the head of the femur may be atill in 
part an epiphyBUi. Looking at tho whole preparation 
(Fig. 72)pathologically, it will be Been tliat reparation had 
been proceeding in the joint very satisfactorily indeed; 
2 B 2 



'ATI THE THERAPEUTIO INFLrENCE OP REST [Let. 

and I think we may fairly conclude that, if the patient htd 
not he«n thu suliject of fatal pyKiuia, tliis woiild have been 
a good example of the great advantage likely to accrne 
from the reduction of a femur diBlocat«d by diseaae. 

The qTiestion occurred to my mind, on seeing the bony 
iiniou of the edge of the acetabulum to a portion of the 
head of the femur, whether the tnie epiphysis had been 
diaplaced from the acetabulum at the time of the disloca- 
tion ; whether it waa not the projecting portion formed by 
the neck of the bone which I folt upon the dorBum of the 
ilium proviouB to the reduction of the dislocation. If k, 
it would render the case still more interesting, because it 
would show that, notwithstanding that both the upper and 
under surfaces of the epiphysis of the bone were diseased, 
rejiaration was in progress, and that, as far as the Up wmJ 
concerned, it may be deemed a successful cose. fl 

Encouraged by these caseB, I hope surgeons may be 
induced to iry lo dimiiiinh to auiue i^xttut, if nut to com- 
pletely remove, that extreme deformity which they so often 
meet with in cases of hip-joint disease with dislocation of 
the thigh-bone, provided they see them before Nature has 
formed a substituted joint or a consolidated ossific union 
between the ilium and the thigh-bone in an abnormal 
jiositioD. I knew it has fallen to the lot of my colleague. 
Ml'. Cock, as well aa to myself, to treat such cases with 
great advantage to the patients. I'hus, when the head of 
the thigh-bone has been displaced high up on the dorsum 
of the ilium, producing great deformity, pain, and consti- 
tutional distress, although it may not have been in hb 
]X)wer or mine to replace the head of the bone actually 
within the acetabulum, yet we have succeeded, in some 
instances, in mitigating the deformity, in relieving much of 
the pain and constitutional distress, and in restoring the 
limb to nearly its proper length. 

Bip Disease, Scrofulous (?), treated by "Sett;" cured bij 
Anchylosis ; no distinct Abscens. 

The next case to which I must allude is that of a girl 
who waa Raid to have scrofulous disease of the hi[>-joint. 

Elizabeth L , spied nine years, came under my care 

at Guy's on February i3th, 1861. The mother stated that 



XV.] AND THE DIAGKOSTIG VALUE OF PAIN. 373 

fifteen months before that time the child fell on the pave- 
ment, and struck her right hip, but after a day or two did 
not complain of any inconvenience. (It is worthy of notice 
that if we inquire of the parents or other intelligent person 
old enough and willing to tell the whole truth, it will 
nearly always turn out that patients suffering from hip 
disease have met with accidents. Without exaggera- 
tion, I believe we may almost always associate acci- 
dent with the origin of hip-joint disease. I am quite 
aware that it is sometimes very difficult to ascertain the 
exact account from a child, especially when it has been 
under the care of a servant ; but I feel confident that most 
of the hip-joint diseases in children depend on small acci- 
dents.) About a month after this occurrence she spoke 
of having pain in her right knee, and was lame. These 
symptoms continued to increase, until she was compelled 
to use crutches. She attended at an infirmary for two 
months as an out-patient, and liniments were applied 
without any relief. She then became an out-patient at 
University College Hospital during four months ; had 
blisters applied over the hip, and took cod-liver oil ; but 
she got giudually worse. 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-bone on to 
the dorsum of the ilium. By accurate measurement, the 
limb on the diseased side was three-quarters of an inch 
shorter than the opposite one. Much pain was experienced 
on moving the right hip-joint ; some fulness (but no dis- 
tinct fluctuation) existi^d over the front and back 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 was ordered, 
but good food freely supplied. 

Now here was a young girl who for eleven months pre- 
viously to her admission into Guy's Hospital had had 



:!74 TUE THKRAPErTIC ISFI.UENCE OF IlEST [Ii/t. 

■liBeape in the right hiji-joint. Those who had «*u lier 
ilurinj; that time had no Amxbt about it. Al tho linie of 
iifimiBsion hip-joint diseoBe wh§ imoqaivocally tu&iiifceled, 
and her general health was declining. The wooden sjiltnt 
was put on simply for the purpose of insuiitig rest to tiwi 
tliHeased joint, and it remained on for five months. At tfat' 
end of that time, on July 6th, 1861, the clinical reptOfe 
states : " Up to this time the eplint has been removed only' 
onoe, as she has been in every respect comfortable ; »carce^' 
any tenderness on pressure over tho front of the hip-joint^ 




11(11' is any induced by presbing upon the trochanter major 
or l)y striking the heel ; both legs afc ap[>ftrently the same 
in length; tho fulness has disapjieared ; no evidence of 
suppuration; the joint is becoming firm. Splint to be re- 
applied, and rest cuntinued." Then she is not examined 
again for three months more ; nothing is done but f o feed 
her well and to keep her lying in l.icii. On October 15th. 
lK61,aft«reightmonthsof rest, we tinil that the tenderness 
over the head of tho thigh-bone is entirely gone ; the femur 
is united to the acetabulum i the thigh and pelvis may be 



XV.] AJTD THE DIAGNOSTIC VALUE OP PAIN. 375 

moved together freely without pain; the right limb is 
about half an inch shorter than the left ; she can bear her 
whole weight upon the right leg — that is, the diseased 
one — ^without pain ; her general health is first-rate. A 
leathern splint was made for her by Milikin, and she was 
permitted to get up. She left the hospital in a fortnight, 
with injunctions not to attempt to do too much in walking, 
and to wear the leathern splint night and day. I saw her 
again on January 21st, 1862. 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 limb 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 was desirable that she should 
take a proper amount of walking exercise. Vertical 
pressure upon the thigh-bone was permitted, but the splint 
was applied for the purpose of preventing any accidental 
twisting or transverse stress upon the new medium of union 
between the head of the thigh-bone and the acetabulum. 
This patient I think you will admit was fairly cured by 
** mechanical rest." 

Hip-joint Disease ; Phthisical Patient ; Abscess absorbed ; Hip 

DisecLse cured by Anchylosis, 

The next case represents more distinctly the scrofulous 

aspect. The patient, Mary Ann O'C , aged seventeen, 

a dressmaker residing at 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 remembered that two years previously she 
fell, and hurt her left side or hip. In the course of two or 
three days all apparent effect of this accident had passed 
away, and she believed herself to be then in unimpaired 
health of limb. Four months afterwards she began to be 
lame ; some days she could walk somewhat better, other 
days not so well. Beariog any weight upon her foot, or 
stamping, gave rise to pains in her left hip-joint. She 
paid little attention to these pains, for some of her friends 



;i7e THE THKEAPEBTIC INFLCESCE OF REST [Lkt. 

said they were " growing pains ; " other persoQB attributed 
tliem to " the rheumatica," which she inhorited from her 
mother. She soon suffered from coiitinuoiis and severo 
pain in the great trochnDter and in the gluteal re^on ; and 
i'rom that time she l>egan slowly to lose flesh. Id the 
ooiiTBo of another month or so she could only just managv 
to limp about. On admission to the hospital she was in a 
very weak oonditiou, suffering from great pain in the hip, 
(vith cough and expectoration, and suspected disenseat the 
apices of the litngB, there being alight pulmonic cansolidit- 
tion. She could manage with assistance to stand upright 
on her right leg, and then the toos of hor left foot (or 
iliseased side) just touched the ground. In the recmubtut 
[xwition the left thigh waa finuly flexed and slighdy 
iidducted . Great pain was felt in the hip-joint on preying 
the knee or heel upwards towards the hip. A day or two 
after admiasion chloroform was administered, and the limb 
was forcibly straightened ; and then a straight wooden 
splint was ajiplied along the outer side of the limb. To- 
wards the litttur end of July the fluctuation of a deep 
abscess could bf felt in the groin, below I'oupart's ligament. 
The splint was kept on till the middle of December (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 with the 
femur. Yielding to the importiinities of the patient, whose 
condition had so greatly improved, I allowed her to walk 
about the ward ; but she soon afterwards had considerable 
pain in the hip, and the swelling of an abscess appeared 
on the outer side of the thigh. I admit that this permis- 
sion to walk waa a great indiscretion on my part ; for I had 
no right to expect that, in so unhealthy a patient, the new 
structures which formed the medium of union between the 
two articular siirfaccs 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 qiiickly improved again by rest- 
ing ufjon her bed. On February r)th, 1858, after eight 
months of rest, the femur and acetabulum were firmly 



XV.] AND THE DIAGNOSTIC VALUE OP PAIN. 377 

united, and the flnctnation of the abscess had disappeared. 
Here, then, is a phthisical patient, having unhealthy 
phthisical parents and severe disease of the hip-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 you must not keep 
a patient in bed, because the health is damaged by it\ 
and the hip disease is nearly cured — that is, anchylosis 
is effected, llie patient was able to get about, under 
my observation, for some considerable time, and then I lost 
sight of her. 

I may say that I have never seen a severe case of hip- 
joint disease under treatment by rest, where the patient has 
not been improved in general health by rest in bed. As a 
role, nearly all the constitutional disturbance has usually 
disappeared after a short time — two, three, or four weeks. 
In mv opinion, then, it is neither sound in argument nor 
true in fact to state that the general health of a patient, 
who has hip-joint disease, suffers uncompensated injury 
by lying in bed and keeping the diseased 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 find an 
abscess near a diseased joint, that it should be in direct 
oommunication with the interior of the joint. I have 
several times seen 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 com- 
munication through the medium of the lymphatics, and 
not the result of a direct extension of suppuration from 
within the knee- or the hip-joint. I have also seen the 
following erroneous interpretation committed in consulta- 
tion. The existence of enlarged glands in the groin, 
associated with hip- or knee-joint disease, or the like 
glandular condition 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 scrofula. Such glands 



!i7S THE THEEAPEL'TIC INFLUENCE OF BHST [Lkt. 

have entirely subeidod as soon as the diseased joints have 
got well, thus shon-iDg their aflsooiation to be simpljwith 
hmphatic abeoq>tion. and the arrest of morbid fluid within 
the gliinds. No doubt, however, the rule is, that when 
deep suppuration occurs in close proKimity to a diaeseed 
joint, it communicates direttly with the int«rior of th«t 
joint, and then the question wtiat ie to be done with thu 
abscess is brought before the surgeon for his decinon. 

DiiausioH of the propriety of opening Abtceuea eamKfUd m(k 
Digefucd Jmnts.* 

This is a, very imirortant subject, and the proper answer 
to the question should be deliberately considered and de- 
cided, on physiological principles and those of expeiienw. 
Some surgeooa woul<l say, " I see no harm at all in opeiung 
the abscess aa soon as it shows itself;" and they accord- 
ingly advise tlint treatnient. For luv part, I btdievc sntli 
a recommend ittiun to Ije fraught with extreme diingcr to tLe 
patient, and that it marks the indiscretion of the surgeon, 
in opposition to such a plan, I would solicit your attention 
to one or two consiJeratioufl, for the purjiose of showing 
that the attainment of physiological rest ought to be the 
guiding principle to direct us in the right course. 

* In rlei'iilJQi; this qiic-tiati wo nm nasialid \^y paying attention to 
Hie clianioler of llie abscoss. I'wu kinds of Bl«ce&3cs nre mtt witli in 
or ncnr Joints, viz. tlie cllronic, ot " cold," and the acute, or inSani- 
iiuitory. The fir^t viiriety U rtmracterizeJ not only by the attributes 
denoted hy the almve iiiiiues, by llie abieni'e of hrnt, rednt-sp, wtd pain, 
hilt aJwj hy (he qunliticn of the pus, which is l.fli'n thin, preeinting 
cMCouB masufs 1« llie naked eye, ami. mirrcBcopii'slly, but few well- 
lonned pua oells, mucli inolecnlur disinti'grBtion. and abundant clioles- 
terine crystals. These are the iibseeBses wbicb may bv left untoitcbed. 
in the hiii)e of tlieir eontcnta being absorbed. Very difiVreot are \\u*6 
Bbwesteq which, to di«tin;{iiisb tlicm from the sbnve, may be calleil 
acute or iiiflanimatury. coming on with coiiatitutiunnl diBtiirbanee. 
rigors (often abauiit or ovirlooked in children). &c. These should be 
opuneil at an eiirly dute : if in the joint, tbey only prepare tlie way for 
further cliaiigte ; aail, if peri-nKiouliir, they entend rapidly, separating 
the luuselca, and miiking Ihcir way amoniist Ihem in diffprciit directions, 
no that tlie taic. originally single, comes to have nuoifrouB pruceasca; 
lastly, there a always to be borne in mind the liability of their burst- 
ing into the ji'tnt, eHpeeiHlly in the case of the bip and knee, i^ee aim 
uuCi; to page 3S5. — [£d.J 



XV.] AND THE DIAOKOSTIC VALUE OP PAIN. 379 

In the first place, we know that the healing process of 
the deeper-seated parts of the hody always goes on better 
when the injured or diseased structures are not exposed to 
the external air. It must be admitted that if we open an 
abscess, communicating with the hip-joint, for example, or 
any other joint, and keep it open, we permit the contact of 
the external air with its interior. It is well known that 
this is the chief agent — or starting-point, if I may so term 
it — in the putrefactive process ; and it seems to be pretty 
well ascertained that if you exclude air from dead animal 
tissues they will not become decomposed. Again, if we 
have a cut, or raw surface, upon the finger or hand, and 
the denuded structures be exposed to the atmospheric air, 
we suffer pain, irritation, and local inflammation ; cover 
the raw surface with some harmless material, exclude from 
it the irritating influence of the air, and immediately 
all pain subsides. Thus, we have analogically presented to 
us, by examples, the evidence of the deteriorating influence 
resulting from the admission of air into the interior of an 
abscess. 

Experience teaches us that so long as an abscess remains 
unopened, and its walls are kept free from local disturb- 
ance by the muscles or other causes, no inflammatory con- 
dition is usually manifested upon the walls of the abscess. 
Then one might fairly say, " Why open it ? — why not leave 
it alone? It is not doing harm in any way, either as 
regards the original local disease or the general health ; 
why meddle with it?" On the other hand, all surgeons 
know that when such an abscess is opened, it becomes, or 
it may become inflamed, and great local and constitutional 
disturbance may supervene. The effects of that inflamma- 
tion will be that the originally diseased parts, as well as 
the new repairing structures within and outside the joint, 
will participate in both the local and constitutional dis- 
turbance, which lowers their vitality. They then soften 
down or ulcerate, and become subservient to the law, that 
inflamed, or newly-formed, or renewed structures suffer rapid 
deterioration from constitutional or local disturbance. This 
is no exaggerated statement ; I have seen many illustra- 
tions of it. Thus, we know that if a person has had an 
ulcer recently healed up healthily, or a sore which has 



3fi0 THE THERAPEUTIC INFLUENCE OF BEST iLarv- 

(^losed welt aftor a bum or scald, and ho ooiitracta erygipeUs 
(a blood jioisou), not at the Hcat of the injury, tmt else where. 
or is attacked by small-pox. scarlet fever, or moaolcs (blood 
poisona), the cicatrix, which was perfectly healed, will 
■piiclcly ulcerate, break down, disintegrate, or entirely melt 
away. If this be true with regard to external parts, may 
wo not argue that it ia equally tnie with regard to iittrma] 
structurefi ? If we can see the fact manifeeteti on the sur- 
face of the body, that scarlet fever, erysipelas, Ac, or local 
inflammation, can so damage new tissues as to lead to their 
deatruotioii, whilst those which have not been previously 
disoased or structurally deteriorated will pass unscathed 
through that ordeul, surely that is a potent argument 
against the propriety of opening thcee absceesee euly. 
These facte form the basis of one of our arguments against 
the propriety of opening an absceea connected with a dia- 
eased joint, before it is absolutely nocesKary, or before the 
iiiediuiu of reparation ilcji'isitud within ur iilx;iut the j'lint, 
Of interposed between the bones, is so completely consoli- 
dated, and so efficiently organized, that it is structurally 
compctetit to resist the twofold deteriorating influences of 
local and constitutional disturbance, or of either of them. 
Jjet ns look at this subject from another point of view. 
If a person sullers from the escajw of a large quantity of 
pus daily, may we not deem it tantamount to his being 
bled to Kome extent every day ? I think we may. As- 
suredly, if wo were desirous of inducing a healthy local 
process, or of aiding the general jiower of repair in a 
jjatient. we should not daily draw even a few drops of blood 
from him, with the hope or intention of improving either 
his general health or tlie looul disease. That would be 
adverse to sound physiological princi])leN, against common 
sense, and ojiposed to the experience of every one. If a 
largo chronic abscess be opened, it very often, nay, gene- 
rally, happens that its interior surface freely iiour^ out an 
abundance of serum, lymph, and pus. It must lie admitted 
that the more it discharges, the more it drains the patient 
indirectly of his blood, so that I apprehend, under such 
circumstances, he is being bled every day, and it is pain- 
fully apparent that hia liealth becomes greatly and some- 
times fatally damaged by it. Nothing can exemplify this 



XV.] AND THE DIAGNOSTIC VALUE OP PAIN. 381 

pofidtion more emphatically 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 Essex brought me his only son (nearly 
twenty-one years old\ one of a numerous family, having a 
large abscess, extending under and below Poupart's liga- 
ment, associated with diseased spine. The young man 
had not suffered any pain, nor was his general health 
declining, and he was out of doors taking exercise every 
day. His surgeon suggested that I should see him, as he 
did not wish to open the abscess. I acquiesced in that 
advice, and explained to the distressed father the probable 
contingencies of his son's condition. He went home, and 
was kept lying down. ' Soon the abscess began to discharge. 
From that day he had an exhausting illness, which gradu- 
ally wore him out, and in a few months, in spite of all that 
could be done for him, he died. He was bled to death by 
the profuse discharge. 

Instead of hesitating as to what we should do in the case 
of an abscess communicating with a diseased hip-joint, I 
would advise that the opening be deferred as long as 
possible, until we can be pretty well satisfied that anchy- 
losis or bony consolidation has actually taken place in the 
joint. If the bony union be perfect, then we may open 
the abscess without involving the patient in undue risk 
as regards the repair of the joint, or as regards the general 
health. 

Hip Disease ; Bony Anchylosis; opening of Abscess deferred ; 

excellent Recovery, 

Here I may just refer to a case in point, which I saw 
some years ago with my friend Mr. Ray, of Dulwich. It is 
a case which shows well the influence of rest in the treat- 
ment of hip-joint disease, as well as the advantages of 
deferring the opening of the abscess until consolidation has 
taken place between the femur and acetabulum. You will 
observe that the hip-joint cases with which I am now 



THE THERAPEUTIC FNTLUENCE OP BEST 






dealing are not trifling, but serious cases of disBase: but 
they may UBually be said to terminate well, provided 
ancnyioeis can be accoropUehed, This patient, a young 
lady, came under tlie care of Mr. Ray in 1846, sufiering 
from disease of the right hip-joint, and continued nndcr 
liis treatment during. 1847, '48, 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 left her much 
enfeebled. In. June the hip-joint syraptooifl on the right 
aide recurred, but yielded to rest, counter- irritation, ood- 
liver oil, &c. She did not, however, regain her former 
health, and in the early part of December 1849, between 
three and four years &om the first indication of hip diseaao 
on the same side, much more marked symptoms oocurred. 
with great constitiitional disturbance. TIiu pulse bcc^ame 
very rapid ; the pain was of an intense character, sugges- 
tive of iufiammation of bony structures, and was referred 
to both the hip and the knee ; the upper part of the thigh 
i»ecame swollen ; and cousiderable enlargement could be 
readily felt at the posterior part of the trochanter major. 
Leeches and linseed poultices were applied to the groin, 
opiates and bichloride of mercury administered, and 
she was directed to wear a leathern splint. In Januaij- 
1850 I was consulted. The constitutional and local 
symptoms were increasing in severity, the pain in the right 
hip-joint, except when influenced by opium, being uu- 
eudurable; 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 severity at night. Up to this time the joint 
had not been sufficiently fiscd, nor the local rest sufficienth- 
complete or prolonged, to enable Kature to repair the rais- 
cliiof. A luug straight wooden splint, with a footpiece, 
was now applied to the limb, sedatives freely given towards 
night, and good fluid nutriment administered. The paiu 
and constitutional disturbance steadily subsided. A large 
abscess presented itself at the anterior part of the hip- 
joint, and slowly descended the thigh. Cod-liver oil, steel 
wine, and quinine were administered as medicines; the 



XV.] AND THE DIAGNOSTIC VALUE OP PAIN. 383 

Tecombent and a fixed position of the diseased joint were 
strictly and uninterraptedly maintained. These were all 
the means employed. No counter-irritation, none of the 
old horse-doctoring style of treatment — no setons, issues, 
or painful applications of any kind. In March, ten weeks 
from my previous visit, I saw the patient again, and found 
that her health had steadily improved. The abscess siib- 
seqnently 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 con- 
stitutional disturbance, the abscess was opened at its most 
depending part ; it discharged a strumous, purulent scrum, 
containing cheesy flakes and masses. The thigh was after- 
wards 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 the patient 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 be said to walk without even a limp. She is an excel- 
lent dancer, frequently dancing for a whole evening, and 
but few persons know, when she sits down, that the right 
knee-joint is purposely 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 but simple splint, the patient may get 
well. It also exemplifies in a most emphatic manner the 
advantage 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 re- 



384 THE TBBBAPEUTIC INFLUENCE OF HEST [Lkt. 

minding you that tbe iibBoess may \>e altaorbcd irithoul uty 
hftnu to the patient. Most surgeunehavo seen hip diiieaw 
aaaociateil with the cleareet possible evidence of fluetuatton, 
fi'om a WJiiBiderable oollection, probably, of purulent flniii 
in th« thigh, and have yet witncaaed the apontaneouB i'm- 
np{iearauce of that ductiiatiug swelling. One of the c&bm 
which I have already detailed, and some otheis which I 
shall hereafter adduce, open «p this queBtion — Is it pos- 
sible foi- an abeceM to be absorbed ? I may reply, that I 
liave not the least doubt about it. I have no doubt vbst- 
cver that those portions of the contents of an absoeoa K^cfa 
are not nbsolutely solid can be completely abaorbed. The 
Holid residuum may remain permanently amongst tho 
surrounding Boft imrta, not doui^ or le&ding to any uie- 
chief, unless, perhaps, ihe patient sbould suffer from 
typhus fever, scarlet fever, measles, or any other physical 
or moral cause producing severe constitutional dcpreesioti, 
as wy H^e .'xempUHcd in thi; i:AS<^a of ln.ll.'lt' th^.t ]my<: l-e^i. 
buried in the living liody for many years, without produe- 
ing any detrimentiil effect, until some serious injurj' to the 
general health occurs, nnd then there is a discharge. Some 
years ago I saw ]>rofeBsionally a general officer who fought 
111 l^gy]>t against tlie lirst Napoleon, and who at that tune 
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 lie absorbed without any danger to the patient ; but I 
apprehend that before what may be termed healthy absorp- 
tion of an abBcesa occurs, the pus globules are broken up. 
and then the altered fluid results of the abscess may be 
absorbed without iujiiry to the constitution. The solid 
purta of the absceaa may remain. 

Chronic Ahfces* abforhed. 

In the year Ifi'iO I had a patient under my care at Guy's 
Hospital, in whose fiirearra there was a large chronic 
iiliaceaa. Thinking it a case in which 1 might put the ques- 
tion of absorption of pus to the test, without risk to the 



XV.] AND THE DIAGNOSTIC VALUE OP PAIN. 385 

patient, I passed a fine trocar and canula into it under the 
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 the aperture in the 
skin was carefully closed. The abscess was kept quiet by 
the arm being placed upon a splint. In a few weeks, and 
without any constitutional disturbance, the abscess com- 
pletely disappeared. The patient died some months after- 
wards from disease of the chest, and I looked with interest 
to discover the remains of the old abscess at its former site, 
and there I found some solid cretaceous-looking material, 
which was doubtless the residuum of the abscess, interposed 
between the fascia and the subjacent muscles. Anxious 
to be quite satisfied on this head, I requested my friend, 
Dr. Odling, to undertake the chemical examination of this 
residuum, and here is the result in his own words ; " A 
tough substance, of a yellowish colour, having the appear- 
ance of artificially dried pus. Like the solid residuum of 
pus, it consisted principally of a butyraccous fat, and of 
soluble and insoluble albumen, but also yielded an aque- 
ous extractive, or pyin, and an alcoholic extractive. The 
mineral constituents were chiefly chlorides, sulphates, and 
phosphates of soda and lime, corresponding with the con- 
stituents of the ash of pus." 

I think I could not place a more conclusive case before 
you in answer to the question — Is it possible for an abscess 
to be absorbed ? * The abscess in this case was proved to 

♦ The question whether pus can be absorbed or no has been often 
diBpated, according to the varying phases of our knowledge of pus and 
the process of absorption. From what we now know of the movements 
of living pus-cells, and our power of aiding these by moist-heat (as in 
drawing suppuration towards the surface witli a poultice), we may dis- 
miss the old view that its large size prevented the removal of a pus- 
oell. One undoubted clinical instance of the removal of pus we, 
occasionally, see demonstratecl in the very rapid disappearance of an 
hypopyon, where the pus which has followed on a buppurative corneiiis 
has gravitute<l backwards, through the cornea, into the anterior aqueous 
chamber, and can be there seen to soon disappear. But it must not he 
forgotten that this removal of pus, as pus, takes place under most 
favourable circumntances. The pus-corpuscles are not only closely 
contiguous to richly vascular structures, the blood in which is con- 
stantly beiug renewed, but they lie bathed in a warm fluid which is 

2 C 



360 THE TnERAPEVTIC INFLUENCE OP BEST [U 

(lemonBtration to exist ; pus was cli-awn off, &nd ex&miaad 
microscopically ; all the tiuid portion of it disappearod M 
abaorptiou ; and probably lues of the Bolid reuiduo wunw 
have been found if the patient had lived longer. 

A large Abacetn in Ihe Doriial Region lAgorhed. 

I had under my care a man who bad a very large aliet 
projecting backwards, and atiaociatfd with diseaseil sjiilis 
in the doreat region. This largo abeoess, holding, I aboi" 
think, a pint and a half of fluid, received a distinct imp . 

aive movement from the interior of the chust during ouaf^ 



Erolfibly , ,. ^_^^ 
iri^ oollootioDs of pus whioli Hr. IDIton bu described. That «A 

ctillectiona may. portV front abwi'ptinn of the pits-gernm, portl; kaoi 
the ranki-uliir d;Mii(Ci:r!itioii nf tlie piw-corpnacles. nflcr loiig reet »nd 
jtrotraott.l treiiOueiit ilisaiirK.'nr. ia undoiibtt-d ; bnt wliclhcr" Ihis da- 
appeBKinco is cciinpleU', or wlietlier tlie space in which tlie collectkn 
lay ia Bafely oblil^iateil, JB a very different lualtir. On tlila mibjeot I 
may quote Mr. Sininn (Iii'Ct. un PBtliolo<cy, p. 115} : "In the aurgici] 
trealiueiit of large clironio abscisses, it luod olten to be tried to obtam 
cure without disi'hnrgin" the luntler. by proiiniting (aa was then 
tliongbt) the aVsorption of pua. Blreding. or purging, or vomiting, ot 
aweiiting, or othpT cvarDiitiunB, were hnil n-coursu to. and not in- 
frequently the ttiictunling tumour vntiished. But thia w-na only fora 
time. A large proportiun of the strum had been withdrawn from the 
ciitileuts of the abitcosH. and these liad been redaced t* little beyoitd 
Cells; but. as suoD as Ihe bloo<l had reciivcrnl ita nntuml ennstitution, 
tlicBu cells again exerted their power, and surrounded IhcnisclTes aitti 
their natiin<] iitiuosphere. Accidcnlal cirrumslancis will oitvn aet like 
the treatment to which I have referred, imd will reduce the fluidity of 
pus, Bij timt an abscess apparently vnnislies ; but the cells mny remain 
□uie.-cent for an indefinite t me, and may presently again surround 
tTiempelviB with fluid blastemii, forming again the same onioimt of pua 
OB nt first. The prrfect and pirmanciil ubsorptioji of an abscim — con- 
sisting not only in Ihe removal of its serum, but in the di'struction and 
diuolutinn of its cotpuEcli's, so tlint the part shall retain no tendency 
to the re-K'^'umuiation of !la previous conteals — this. I am perstioileii, 
is amongst the very rarest on^orrences in surgical practice." While 
the remrival of pus, as pus, is ns u clinical fact of great rmrily, it is 
equally certain lliot colh'clions of pus nisy lie, after jiarliBl icnioial, a 
mere i-iipnt moTluuia ainonpst the surr<iunding tissues, and aftiT long 
yciiriJ, from wiine local i'>jury or general deterioration of healtli, lake on 
Hgnin H iicrnit'iniia vitality. Si'e the chapter on Itcsiduid Alisces^es in 
fSir J. Pugit's Clin. Lect. and Essays,— [En,] 



XV.3 AND THE DIAGNOSTIC VALUE OP PAIN. 387 

ing or a full inspiration. By rest in bed for several months 
the spine disease was cured ; and by blistering and rest 
the abscess subsided — in fact, was gradually absorbed. 
July 18t>2 : This patient is now in Guy's Hospital, suffer- 
ing from an accidental injury to his foot. There is not the 
slightest indication of the foi*mer dorsal abscess, nor of any- 
thing wrong about the spine. 

If it be asked — What are the conditions of an abscess 
asBOciated with hip-joint disease which recommend or jus- 
tify the making an opening into it by the surgeon ? I 
should say, with all reasonable submission to the expe- 
rience which I see before me — If the abscess be enlarging 
very rapidly, and Nature seems incompetent, from her 
feebleness (a bad indication), to make a successful effort to 
limit it by a natural barrier, the opening may be made, 
and half, or more, of the pus be drawn off (without 
squeezing the abscess). The opening should be imme- 
diately and carefully closed up, lest the outpouring of the 
fluid may be continuous, and a drain of pus be produced 
00 as to affect the general health. The abscess should be 
subsequently supported by plaster or bandage, in order to 
keep it at rest. 

If the walls of the abscess become inflamed, hot, and 
painful, with great febrile and constitutional disturbance, — 
or if the abscess contain air (resonant on percussion), from 
decomposition, mixed with the fluid, the opening ought to 
be made large enough, and at the most depending part of 
the abscess, to allow gravitation to determine at once the 
evacuation of the whole of the fluid in the abscess. Sub- 
sequently the walls of the abscess should be kept in contact 
for the purpose of inducing, by ]>res8uro and rest, mutual 
adhesion, and of limiting the extent of surface capable of 
discharging too abundantly pus, serum, or lymph, wliich 
would diminish both the quality and quantity of the blood, 
and so deteriorate the general health. 

I felt myself bound to return to this subject of abscess 
associated with diseased joints, 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 

2 c 2 



383 THE THERAPEUTIC INFLUESCE OF BEST [Lsci. 

have now adduced may be a slight contribution towards a 
rigbt determi nation on tbia subject. 

OigeatB of the Left Bip-Joint (^Sero/uloug f) ; good Anekjilom; 
large Ab»ees» abtorhed. 

J, W. P came under ray care in 1852 : he waa then 

nine years of age. The drswijig before you repreaents the 
patient as ho was in I8G1. The disease came on without any 
known accident. He Lad 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 wm 
under treatment at home, getting daily worse, until his 
admission intoGuy'8Ho6pital,Feb.2nd, 1862. Hisgeneral 
health was then very bad; constitutional disturbance ex- 
cessive ; thigh flexed and addncted ; foot turned inwards ; 
dreadful pain in the hip, and some pain at the knee. Con* 
siiiiTiiblc difFiiBod gruRrnl cwdling oxietod, mid oxtuntivQ 
fluctiintion, inoet distinct at tlie nppur 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 applying a long 
straight wooden splint, extending from the foot to the arm- 
pit ; giving him 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 sybsidenco of tlio general constitutional disturb- 
ance were so marked, tliat it was not thought necessary 
to adopt any new measure ; the splint, occasionally read- 
justed, was worn Tin interruptedly for four months. At the 
endof that time, his friends, seeing him apparently so well, 
begged that he might be allowed to go to their home, at 
Bexley Heath, for change of air. Ho went there, and came 
back in about sis weeks, rather worse, not having been 
sufficiently nourished, nor kept so quiet as he ought to 
have been. Wlien he retumed to Guy's, the straight splint 
was reappHetl, and kept on during three months longer ; 
after that he had a leathern splint (like Fig. G4) made, so as 
to embrace the pelvis, thigh, and knee, and he was allowed 
to got up. He wore this splintduring the next year until 



XV.) 



Ain> THE DtAGNOBTIC VALUE OP PAIN. 



he was too big for it. The diseased limb was then in good 
poeitioQ, but a little ahorter than the other ; the abecesa 
and all other local indications of disease were gone. I 
feel confident that if I had ventured to open the abecesa, I 
should have made a starting-point of deterioration in his 
health which would have led to his death. I feel as con- 




fident as experience and reSection can make me, that 
that would nave been the resnlt. On looking at the 
drawing (Fig. 75), you see very strong evidence of a former 
most serioufily diseased condition of the right hip-joint. 
From the time he left Guy's he moved about with hia 
cmtches, in ^ood health and growing fast, doing nothing 
beyond attending to school during nearly three years, when 
he found he could walk very well without his artificial 
support. 1 saw this lad repeatedly, and watched hia pro- 



3'JO THE THERAPEUTIC INFLUENCE OF BEST [LlC7. 

preM with great satiflfaction. Oiitlie24thof Marcli, IMl. 
tlio pati^ut called upoii mo in k<^>^1 health ; he had uot 
been really ill since he left Guy b. He couJd walk seven 
miles easily with a thick-«oled and high-heeled shoe. The 
growth of the left limh had not kept pace with that of the 
right. The left half of the pelvis, measured from the 
median line to the posterior or to the anterior saperior 
spinous process, was not so broad by three-quarters of aa 
inch as the right. Here is a point worth hearing in mind, 
oapaciallyin reference to females nnder like circnmatAOoes 
— whether with hip-joint disease there may not be some 
deformity or want of aymmotry in the two sidee of thft I 
pelvis (see p. 320)." I think wo have distinct ovidenov 1 
that it is so ; it was well marked in this case. The left j 
posterior superior spinous process was nearly threo-qnarten 1 
of an inch above the transverse level of the right ; the left | 
side of the pelvis was altogether higher on the left than 
on the right side ; and he Biiid he had himself uotiLvd tlmt 
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 iu takiug the measurements, so as to comjiaro with 
accuracy the relative length of the two lower limbs. The 
patient should lie flat on his back on a hrm mattress, with 
the legs extended and parallel. The jwint of the anterior 

* I hnve not be«n able hitherto b> find that this Enbject hac been 
worlied out by nriters on obstctrica. Dr. Itnmcs (Obs. Trs. vol. ii.) 
doBcriLes a Bymmetripallj distorted peWiB in u piilient ret. Iwenty, the 
result of uniquatlen^lh of the leiTB, thelvft leg beingone inch siiorteT 
thnn the H|;lit, from a fnicture of the nnkle when the patient yiaa two 
years old. " In this case it is eleiir that the main work of supporling 
the body, nnil of luooraotion, was thrown upon the sound right log. 
The mueclea connecting the right polvis with the riulit leg aseumed a 
more active development, and wrought a corresponding davelopment 
of tho l>onea to which tiiey were attached. Concurrently vitA tbil 
■timulated growth of Ihu right pelvis and leg, the left pelvis, althoagEi 
not undergoing a process of atrophy, yet uuderwent a oompanilivuly 
slow development. The result was a fuiiy, perhaps an excessively 
developed right half of tbe pelvis, a contnipted left Imlf, a narrowing 
of Ihe con^'ugate diameter, an oblique distortion of the brim, and a 

a via cavity shallower on the left than on the right side." Tlio 
brmitf here described would appear to be very much what one 
would eipect to meet witli in the pelvis of a palieut, who in early life 
had suffered and recovered from liiBcnse of tho hip-joint. 8eo notea 
pp. 317,417.— [Ed,] 



XVJ AND THE DIAGNOSTIC VALUE OP PAIN. 391 

superior spine of each os innominatum should be felt for, 
and the overlying skin marked very accurately, for the 
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 inner 
side of the patella, down to a transverse ridge which can be 
felt upon the inner surface of the internal malleolus, and 
just above its tip. By noting the following measurements, 
it will be seen that there is defective development in each 
segment or portion of the lower limb on the diseased side. 
Measured from the anterior superior spinous process of the 
ilium to the lower part of the inner malleolus, the length 
is as follows : — 

Right sido, Ivofl Plde. Difference, 

lucbes. Inches. inches. 

Femur 19 . . 17| . . 1^ 

Tibia 14 . . 13^ . . 0* 

Length of foot . . 11 . . 10 . . 1 
Right patella larger than left. 

Here, then, is a case of hip-joint disease, very severe in 
character, very enduring, cured by " rest," and the abscess 
absorbed, llic patient, when I saw him last, was perfectly 
well. Ho was to be found at Beckenham, selling books for 
Messrs. Smith and Co. at the railway station. 

In all the cases of hip 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, wo are likely to give the patient an inconvenient 
limb, in consequence of the limb being fixed in a straighter 
position than the other, and that this would necessarily 
interfere with progression ; and perhaps it would be so if 
the limb retained its proper length. But it is a fact that 
the diseased limb does not grow quite so fast as the other ; 
hence it is always a little the shorter. And again, although 
a straight splint 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, 
therefore, acquiesce in the view of some surgeons, that it 
is better to put on a splint which makes the hip-joint per- 



3y2 THE THERAPEUTIC ISFLOENCE OF REST [Uoi. 

niaDently somewhat flexed, I believe, on the whole, t 
Btroight splint 18 the beet. 

Diseated Hip-Joint, with Siippnralitm of the Le/i Side ; rvrtA 
by Four Xontht' Seel ; Absecgg absorbed. 

■\\'Uliaro T , aged eighteen, was admitted on the 30th 

of Septemlxir, 1861. He is a clerk in a printing-offioa 
Tiiree months ago, when in good health, he slipped dova 
several steps, but did not faJX He etrainod his left hip 
Beverely. immediately became lame, and on the following} 
A&y could not etand. He iiad been lame and oonficed tA 
the house and to his bed up to the time he came to Out's 
Hospital, except when on two occosiona he was taken int. 
cab to difibrent hospitals, where he was ordered lotion^ ' 
blisterfi, aqd medicines. On admission, the thigh was fixed, 
addncted, and flexed towanls the abdomen ; the hip-joint 
was oxtrenicly piiinful on moving- it in tht sHjiLteKt di;f^(C 
(>r 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 paiu 
in the hip-joint ; so did striking the sole of the foot, or 
pushing the limb upwards from the knee-joint ; great 
starting and jumping of the left leg, especially on going 
off to sleep. 'Full diet. 

Oct. 8tli. 18fil. — 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 now and then. 

In ft fortnight the pain and jumping of the limb had 
subsided gradually, and in two months all pain was gone ; 
he was quite comfortable, and eould move himself in bed 
without pain. 

Jan. Slid, 1962.— The splint was taken off to^ay; the 
limb can now be moved and handled without causing any 
[win in the hiji-joint, whilst formerly it caused exquisite 
pain ; no pain on pressing the trochanter major, or tapping 
the heel or knee ; no swelling over the joint anteriorly. 
On attempting flexion of the femur, the pelvis moves with 
it, indicating anchylosis. The limb appears longer than 
the sound one (although in reality it is a quarter of an 



XVJ AND THE DIAGNOSTIC VALUE OF PAIN. 393 

inch shorter), on account of the obliquity of the pelvis. 
There is also flattening of the nates on the affected side. 

Feb. 3rd. — There is now no pain whatever in the hip ; he 
can walk very gently about the ward without the aid of 
either crutches or stick, and feels perfectly well in health. 

4th. — The patient left the hospital to-day, with direc- 
tions to be c€U'eful that his exercise in walking does not 
cause a return of pain in his hip. 

This is important advice, for the new structures — the me- 
dium of consolidation — will not bear rude concussion or 
straining. Here is a drawing of his actual condition at 
the end of February, 1862 (Fig. 76). 

I saw this patient in 1863 ; ho was wearing a leathern 
splint, and taking very moderate or limited exercise. 
Being an intelligent lad, of a literary turn, and connected 
with the printing business, be used to occupy himself with 
reading at home, and taking very carefully adjusted exer- 
cise ; the union between the acetabulum and the femur not 
being, at that time, perfectly consolidated. 

DisecLsed Hip-Joint ^supposed to he Gonorrhceal in origin; Abscess 
opened by Nature ; portions of Bone extruded by Granu- 
lations ; cured by Best^ with permanent Anchylosis. 

F. P , aged twenty- two. Early in the spring of 

1859, his health being previously quite good, he had 
gonorrhoea, which ran its usual course and left him. In 
June he had severe pains down the inner side of the 
right thigh, and the inner side of and within the knee- 
joint ; these were attributed to rheumatism, and a phy- 
sician who was consulted gave his opinion that it was 
gonorrhceal rheumatism in the knee and hip. However, 
the pains became increasingly severe, in spite of abun- 
dant medicine, blisters, leeches, &c. The 13th of July, 
1859, was the fii*st day on which he remembers having any 
pains whatever in the hip-joint, and, although they were 
slight, he was obliged to use a stick to get about the house. 
The anti-gonorrhoeal treatment was continued until the 
24th of August, when Mr. El win, a surgeon in my neigh- 
bourhood, saw him for the first time. "He then had 
extreme pain in his hip-joint ; the slightest movement — 



39+ 



THE THERArEOTIC INFUJENCE OP BEST [Lect. 



even a person ■waiting BcroBB the room — appeared to shako 
him, and cansod him great agony in his hip." This it 
Mr. Elwiu'e own statemest. " His diseased leg wm ap- 
parently three or four inoht* shorter than tho other, frma 
the femur being flexed and adducted, and the knee-joint 
flexed. There wan the fluctuating swelling of an absccm 
in tho groin." I saw the patient, in consultation, on tho 




let of Septerahor, 1859, and recommended the application 
of a long straight wooden splint, absolute quiet in tho 
recumlient position, good diet, and the twelfth of a grain 
of bichhiride of mercury twice a day in some bitter infusion. 
Tho only known iniury the patient could connect with his 
hip dispaso resulted from a eudden and violent effort he 
had made in swimming, which produced at the time some 



XV.] AND THE DIAGNOSTIC VALUE OP PAIN. 395 

pain in the right groin and hip. The straight splint was 
applied immediately. I saw 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 thi^h ; both the swelling in the 
groin and the fluctuation had nearly disappeared. He was 
recommended to keep recumbent a few weeks longer, but 
without the splint, except at night ; and thenceforward to 
use great caution in walking 

In such cases I think it is better, when a patient is 
improving, to put the splint on at night, especially in the 
case of children ; because the involuntary 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 a small bed-sore on his sacrum. 

In January 1860 he could walk about well with his 
crutches. He passed the summer and autumn of that year 
at Swanage, getting out of doors occasionally, and resting 
the joint at other times by lying down. During his stay 
at the sea-side an abscess appeared in the thigh, and 
opened spontaneously by ulceration. Several portions of 
bono have come away at intervals through three sinuses 
since March 1860. When I saw him in February 1861, 
his health was excellent, he was free from pain, was able 
to walk a distance of two miles, and could stand about all 
day. Ho can now (1862) walk ten miles without pain or 
weakness in his right leg. I have some of the portions of 
the bone which came out of the apertures in the three 
sinuses. The anchylosis is now perfect. 

This case, I believe, supports very decidedly the view 
which I have expressed as to the great value of ** rest " in 
the treatment of disease of the hip-joint. 



^^^^HB^ 


i 




■ 


■ 


l^d 


396 THE 


THEBArELTIC INFLUENCE 


OF REST 


[Ltrt. 






LECTtJKE XVI. 




' I* 


HIP-JOINT DISEASE ; SO KHOWS ACC1DKNT ; BEQCEL TO BOABLVT tTTEBi ■ 
CUB£0 BY AN0HYLO81S, AFTEH A FKW UONTnB OF EMT— LOCAL V 

ARISE rno« cauviofSLy usuealtht btbucti-res errrBHiHO bapid 

UBTiraiOBATION FBOM THf EVTBCT Of THE OOSBnTDTlOSil. PIS- 

KECRDSIS or ACDTABtlLCll, CCRED BT BlCaT— BUSIOINT DISBASI; 
AKCfiTLOStS, TtlTH TmOH SOMEWHAT BBMT— OAStB GUtDLATIKO BIT- ■ 
JOIKT mSKAlE Dtn TO DCFIOIENT NEBVOUa rarLt'KlICB ; TIUCATMBBT— ■ 
CCnvED aACBDH, CAUB1N0 DUTLSINO BYHFTDM8 OF BIP-JOmT DISEA«I ^ 



Pursuing tlie subject of hip-joint dieeaBe, I purposely 
Bolect the next case for your consideration, because it vras 
apparent!}' associated 'U'ith scarlatiua as a cause. I think 
it must have fallen to tlio lot of almost oveiy surgeon to 
sec disease of the joints or disease of the hones occurring 
as oue of the important eeqiielEe of scarlet fever. It ap- 
pears, BS far as I can ascertain, that the cause of that 
association has not hitherto received its proper or true 
inteipretation. I will not pretend tliat the cause wliich I 
shall offer is the only one (according to many, these sequeliB 
have a pyeemic origin), but it is one that long ago occurred 
to mj' mind, and to which I have frequently referred in my 
hospital teaching. 

Wq)-Joint Dieense ; no frnoicn Acd^ml ; Sequel to Scarlet 
Feeer; cured hi/ Anchylosis, after a few mtrntha of Rett. 
A young geiitlcinan, aged fourteen, a tolerably healthy 

lad, had a scveiii and prolonged attaek of scarlet fever, at 



XVIJ AND THE DIAGNOSTIC VALUE OP PAIN. 397 



the Bluecoat School, in the winter of 1859. As he was 
recovering from the fever, or soon afterwards, he com- 
plained of pain in his left knee, and became lame, 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 any im- 

¥U. 77. 





provomont in his condition. As his general health was at 
that time not good, he was sent home for change of air, 
and I saw him at my own house on February luth, 1860. 
He had then all the local indications of acute disease in his 
left hip-joint — viz. intense pain in his knee and hip-joint 
on attempting to bear any weight upon the pointed toe, or 
on making any attempt to move the hip-joint ; but none 
in the knee on movement of that joint only. The thigh 



393 THE THEBAPEUTIO ISFLUENCE OF HEST [Lb 

was flexed, and the foot tHmed downwanla and Inwari 
with a Htrong tendency on the part of the head of the feian 
to dislocation backwards. Obscure fltictuattoD conld tb 
felt deeply seated behind the trochanter major under tin 
gluteal mUBclea. Three dftys afterwards I went to 1^1 
home, and applied the splint here delineated (Fig. VT) M 
the left leg and pelvis, in iprder to prevent hie movinij tUl 
limb. He was directed to take a dose of castor oil or 3 
confection of eeniia occasionally, and one-sixteenth of g 
firain of bichloride of mercury, with one drachm of tinctingi 
of bark, twice a day. At his residence, near Highgate, ] 
waa placed in a Email but airy room on a hair mattnn , 
and not allowed to get np for anj' pnipoBo, Within ft 
fortnight he waa nearly free fnim pain Iwtn day and nighlj 
whereas, before the application of the splint, hia ni^A 
were dreadful to himself, aa well aa to hia father mf 
mother, who heard hia expresaiona of distreas. 

Dnring the three following months the p.itient remained 
nnint<Truotedly In bed, with the limb securely bandaged 
to the aiilint. When the seycrity of the symptoms had 
subsided, I waa iiarticnl.irly struck with the rapid and 
marfccil improvement which occurred in this case, when 
measTired by the extreme simplicity of the treatment 
adopted. There was no other surgeon in attcnilancc, and 
I saw liim only once a mouth, and then merely for the 

(urpoBC of readjusting the s|>Iint, In the latter end of 
lav 18C0 all the symptonia of active disease were absent, 
antf the deep sub-gluteal fluctuation had disappeared ; 
anchylosia had taken place between the femur and aceta- 
bulum, with the limb and foot iii a good jiosition ; the 
pelvis moved with the femur, and the length of the left 
limb waa the same as that of the other side, without either 
inversion or eversion of the foot. On taking him out of 
bed. at the expiration of four months, ho found he could 
bear acme weight upon the lame leg. From this time he 
waa allowed to get iip daily, and move carefully about 
with the sup]x>rt of crutches. In June I860 he went to 
Margate, and remained there 'intil the end of September, 
being the whole time in excellent health, and free from 
p.iin. Tie lived out of doors the greater imrt of the day. 
walking with the aid of his crutches, but usually bore 



XVL] AND THE DIAGNOSTIC VALUE OP PAIN. 399 

more or less weight upon his lame leg ; and he sometimes 
walked short distances with the support of one crutch and 
the arm of his mother. On his return home he continued 
bis walking exercise, with daily increasing strength in 
his leg, using his crutch for security against accident. 
The general health was perfect (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. Somehow his crutch 
became entangled between his legs and a hamper, forcing 
bis left leg behind the right one, and ho fell helplessly 
upon the floor. Unfortunately, he fell upon his left leg, 
striking his left knee, and 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 ecchymosed and swollen, and the 
hip near the trochanter major was very painful 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 up and resume his walking 
exercise. 

In the early part of 1861 he found that the neighbour- 
hood of the trochanter major had become enlarged. I saw 
him at my house on March lOth : he was in very little 
pain ; he could bear 8ome weight upon the left limb, but 
less than when he came from Margate. On examining 
him I found a large abscess behind the trochanter major, 
with a very thin covering of slightly reddened skin at one 
part ; considerable increase in size of the upper third of 
tbe thigh-bone ; little or no pain at the hip-joint itself, but 
tenderness on pressing or grasping the trochanteric epi- 
physis and adjoining portion of the shaft of the femur. 
His general health was good. Two days afterwards I 
opened the abscess, and let out nearly a pint of unhealthy 
pus mixed with some clotted blood and some curdy matter, 
but it was not decomposed, or offensive to the smell. The 
abscess was at once completely emptied, and nicely adjusted 
pressure was made by a thick pad of lint and a bandage 
round the pelvis, so as to coapt the outer and inner sur- 
faces of the abscess ; the lancet aperture was left open, and 



400 THE THERAPEUTIC INFLUENCE OF REST 

ho wftB deeiietl to Ue quietly in bed. Little (X)n§titational'| 
disturbance followed the opening of the abscees. I eaw J 
him tigaia in a fortnight ; he was welt in health ; i 
most exceliont ; the walk of tlie abscess had : 
throughout nearly four-fifiliB of its extent ; and the di»- 1 
charge waa chiefly serous, emnll in ([uantity, and mixed >f 




with but little pus. The enlargement of the shaft of the 
bono near the trochanter major was con si durable, and 
slight pain was complained of on direct pressure. 

I saw no more of this iwiticnt until Januaiy loth of 
the year 18C2. He was then seventeen years of age, and 
could walk five or six miles easily without pain. There 
was scarcely any lameness, and here is a drawing of his 
actual condition (Fig. 78). This is a good case, which not 



XVL] AKD THE DIAGNOSTIO VALUlB OP PAIN. 401 

only ilhistrates ihe advantage of treating hip-joint disease 
by ** meohanical rest " — as a very simple but successful 
means for cure — but also carries with it another important 
indication; namely, that the injury which he received 
later on to the trochanter major did not lead to any 
aeoondary deterioration at the hip-joint itself, showing the 
perfection of the repair which had there taken place. The 
case also clearly points out the advantage of accurately 
coapting the walls of a large abscess after it has been opened. 

1 now avail myself of this case to introduce one or two 
remarks which bear upon it. 

I think it may be fairly stated that unhealthy structures 
suffer rapid deterioration from the depressing influence 
or effect of any severe constitutional disturbance, such as 
occurs in scarlatina, measles, erysipelas, small-pox, and 
similar diseases. And herein lies the interpretation which 
I would, with all deference, submit to you in regard to 
these cases of local disease, apparently associated with 
and resulting from, the development of scarlatina, measles, 
small-pox, or erysipelas ; namely, that at the time, or pre- 
vious to the occurrence, of this depressed constitutional 
condition — a condition, in all probability, of blood-poison 
— those parts which subsequently assume a diseased con- 
dition were not in a healthy state. I will now place before 
you two cases which tend to sustain this view, and which 
are to my mind satisfactory instances of this clews of cases. 

Necrosis of Left Tibia and Anchylosis of Ankle-joint consequent 
upon Scarlatina and previous Local Injury, 

The following drawing (Fig. 79) represents the legs of a 
patient who had scarlatina, and, as a sequel, necrosis of 
nearly the whole of the shaft of the left tibia between the 
upper and lower epiphyses, leaving the knee-joint unim- 
plioated, but involving the ankle-joint, which has become 
anchylosed. The shaft of the tibia has been reproduced 
by Nature. 

The history of the case is very short. The patient was 
at school in Scotland, and Dr. White, of Athol Place, 
Perth, has obligingly forwarded to me these brief notes : 
— " The epidemic of scarlatina at Glenalmond School 

2 D 



402 THE THERAPEUTIC INFLUESCK OP BEST [Lect, 

bogan tho last week of September, and G wae sent 

into ho8])itaI on the 6th October with a slight sore throat 
Hiid other precursory symptoms of an attack. lathisoon* 
rlition, but with no eruption, he continued till the 12tt, 
C>]tober, when tho throat affection left him, and he fint 
complained of pain and swelling above the interasl mal* 
leoluB of tho left ankle. In a day or two it asBumed tha 




cliavactcr of a diffused inflammation of the cellular tissue, 
associated with severe constitntional disturbance, and the 
liical mischief rapidly extended upwards to tho knee, fol- 
lowed by extensive suppuration and sloughing of integu- 
ments over the tibia, exposing the denuded bone. About 
fiio 22nd of October the throat affection again appeared, 
iictompanied Ity an eruption and other symptoms of 
scarlatina ; the efflorescence fwhich was dusky and livid) 
began to fade in three or four days, and desquamation 
followed, as in onliuary cases. On the 23rd November ho 
loft Glenalraond for London," 



XVI.] AND THE DIAGNOSTIC VALXJB OF PAIN. 403 

Now it appeared, upon inquiry of this young gentleman, 
that during the summer he had felt at times an aching 
pain in his left leg, which he thought was due to a 
blow from a cricket-ball. When he was at all tired, it 
ached so much that he could hardly walk, but still there 
was no appearance of injury. Here, then, was a patient, 
under the influence of blood-poison in the form of scar- 
latina, which never developed itself thoroughly or com- 
pletely, but seemed to concentrate all its morbid influence 
— upon what part? Why, upon the part which was 
recognised by the patient as being at the time of the occur- 
rence of the scarlatina in a depressed condition vitally, and 
perhaps structurally also, for he had suffered pain in it 
after ordinary exercise ; therefore there was an indication of 
something wrong. The lad was brought to London, and 
when I first saw him his general health and his leg were in 
a most deplorable condition. The whole of the tibia, from 
the lower epiphysis upwards to the 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 cedematous swelling about 
the foot. 

Judging by the history of the case, it was associated 
with some local injury previous to the scarlatina. Not- 
withstanding the very low condition of his health, and the 
great extent of local mischief, we (Mr. CoUambell and 
myself) thought, considering his age, that we might, 
perhaps, by time, good feeding, and careful professional 
attendance, enable >iature to repair the injury, and renew 
the destroyed soft textures and bone. His leg and foot, 
swollen and painful, were placed upon an iron splint, 
provided with a screw behind the knee, so that we might 
gradually straighten the flexed knee-joint, and the whole 
limb was swung under an iron cradle. He was in exces- 
sively bad health, and his life was, doubtless, threatened. 
However, by great perseverance, excellent nursing, and un- 
remitting domestic care on the part of those in the hous^, 
he arrived at the state you see represented here (Fig. 79). 
The whole of the middle part of the tibia became sepa- 
rated, and 1 removed it in several portions ; new l>one was 
thrown out, and all the soft parts healed over, except at 

2 D 2 



ilj-t THE TIIEKAPEDTIC ISFLUENCE OF EEST [Lkt. 

the point iudicatcd in the drawing, which was the out- 
let of a BiDUB poseiug under the teudooB of the exteDSon 
over the ankle-joint, and probably connected witli diseased 
bone, which, hiwever, I could not discover. Fifteen 
months after his Bcarlatma, he entered my room walking 
with oriitcheB, but bearing some little weight upon his leg, 
:Lnd he found that he could stand upon the diseased leg 
with the aid of a little snpport. When last heard of ( 187H ) 
he was a clergyman, doing active duly in the ueighbonr- 
hood of London, and able to walk five or ten milea without 
any difBculty. The tibia has been thoroughly and firmly 
restored. 

This case displays the wonderful repftrative [Wwera of 
Nature at an early period of human life, and, I think. 
justifies the interpretation which I have affixed to it — via. 
that hia leg was in a deteriorated condition, as regards the 
Imne, at the time when the acarlatina occurred ; and that 
the dei)ret!8iiig inlinr.Rv ..f tluit ILx-l-p.-ison lo-l to ih,- 
death of the bono. 

Diteaie nf the Lower Jam conneqiient upon Scarhlina anil 
prciioug Local Injury. 

Here is another instance, which carries with it the same 
kind of historj-, and I think the eamo interpivtation. 

A young gentleman, aged fourteen, remcmln?red that he 
had a blow on the right side of the lower jaw with a 
hockey stick in March 1857. Ho had previously been in 
his ordinary health. After tho blow ho had occasional 
pains in tho jaw, but nothing important occurred. In four 
or five weeks, ho did not exactly know which, he went 
home to Uj'denham to sec his brothers and sisters, who at 
that time had scarlet fever. He stayed at home a fortnight, 
and then returned to school at filackheath. In a few daj's 
he became poorly- — feverish and depressed, with a very 
slight sure throat. The lower jaw then, for the first time, 
licgan to swell and to be very painful. 1 saw him at 
Sydenham, with Mr Corbould, early in June 1857, about 
three months after the blow, and six weeks after the expo- 
sure to scarlatina. Tho lower jaw was then enormously 
ssvollun every tooth on the riglit side was loose, and could 



XVlJ AND THE DIAGNOSTIC VALUE OF PAIN. 405 

have been easily taken from the jaw by the fingers alone. 
I'he incisors, the canines, and the bicuspids, on the left side, 
were all more or less loose. The whole jaw was painful 
and tender on pressure, from ostitis and periostitis. There 
was subsequent suppuration, resulting in several small 
abscesses, which I opened, and from one of them 1 removed 
a thin plate of the lower jaw. 

The explanation of the case appears to be this : — The 
boy has a blow, not a severe one, upon his lower jaw ; he 
has occasionally slight pains in it ; no swelling, no evidence 
of local inflammation manifests itself; he goes home, comes 
within the influence of scarlatina, or a blood-poison, returns 
to a healthy spot at Blackheath, 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 tolerably good air, abun- 
dance of fluid nourishment, and scrupulous domestic care, 
and ultimately regains perfect health. 

The subject of ** rest " is well exemplified in this case. 
We found all his teeth loose, and felt certain that if we 
were not very careful to prevent their disturbance, they 
would fall out of themselves. 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 administered, 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 exaggera- 
tion, 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 evciything else he is perfectly 
well." Now, here are three cases. 1 could adduce many 
others equally illustrative, which I think display in a 
striking manner the depressing influence 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. 



4KG- THE TUEBAPEDTIC INFLUENCE OF REST [Lkt. 

Cate of DueoBed Bip-jotnl. villi Necrunii of Acrlabul uin, 
eureil hy Real. 

The next caeo of hip-joint disease is one complicated 
with dieeaeo of the BCetabnluiu ; and that is it« sped«) 
feature, A delicate, pale, unhealthy-looking young gen- 
tleman, agod fifteen, in the spring of 184ti, after taking 
a long walk. Buffered much pain and some enelliug in 
bi» right hip-joint. He was then in Edinburgh, and was 
ko^Jt in bed during three months by his surgeon's advice, 
his thigh l«ing stj^pped np with some irrit«ting plaster 
spread upon leather. Slowly recovering tromthw attack, 
he continued well until August 1847, when over-eiertion 
lironght on his hip-joint symptoms again more aeverely 
than in 1646, and he remained at home in London, nnder 
the care of an hospital surgeon, alternately keeping and 
(juitting his bed at short intervals, so that the joint had 
not the advantftgo of aiutiiiut'd rust-, until tlii.' fiid uf mil. 
when, notwithstanding numerous leeches, lotions, strong 
comiter-irrilants, and abundance of medicine, all his hip- 
joiut symptoms bccaiuo much worse. As to leeches, he 
said to me, " I have had upwards of 1,200 applied to my 
liip in the course of a few mouths !" The loss of blood by 
1,200 leeches may be estimated at about 300 ounces. This 
is pretty well for a delicate lad suffering from Jiip-joint 
disease. He told me he had taken " ])ailfulB of horrid 
medicine." The loss of blood, the physic, and the coiuiter- 
irritation reduced his strength, and brought on loss of 
appetite, want of sleep, with jumping and starting pains 
in the limb, to such an extent that ho was com{>elled from 
sheer exhaustion to keep flat upon his back, and so 
remain uninterruptedly at rest ujxm his bed ; and from 
that time he began to improve in every respect. 

Here, then, was a case of " forced rest " against the 
judgment and discretion of the medical attendants — forced 
rest compelled by direct feebleness on the jiart of Nature ; 
and from that time the patient began to improve. He 
continued in bed until the summer of 1849, nearly eighteen 
mouths. The blistering and couuter-irritauta that were 
applied were, according to his own account, something 
awful. Even when exhausted in bed Ids surgeon would 



XVL] AND THE DIAGNOSTIO VALUE OF PAIN. 407 

not let him alone, but still applied blisters, setons, and 
oounter-irritants. A large abscess made its appearance in 
the spring of 1849, just above Poupart's ligament, near 
the anterior superior 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 sneezing, 
or by taking a full breath, indicating an intimate associa- 
tion 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 (I 
never saw a man so white — I might almost say translucent 
— as 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 opening of this latter abscess I 
passed a 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 the bowels, when it would gush out. 
There was scarcely any pain in the hip-joint. 1 ascertained 
by careful but painless examination, although he was in 
great fear the whole time, that the thigh-bone and the 
anterior part of 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 his lying any 
longer in bed, he was daily dressed, laid upon a couch, and, 
as soon as the weather and his own extreme feebleness 
permitted, he was 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 doors, sitting in a Bath chair in the garden, or being 
dragged about in a small hand-carriage. From the time 
of my first visit he left off all medicine except cod-liver 
oil and steel wine, and took porter, wine, meat, &c., in 
abundance. In 1851, amongst other efforts, he went to the 
Exhibition, resting on his crutches ; and in 1852 he was 
employed in a public office, where he has been constantly 
occupied ever since. 

On March 21st, 1861, he called on me in good health, well 



408 TUE THERAPEDTIC INFLDENCE OF BEST [Lecl 

wivuruJ with firm flesh. He belongs to a rifle corjie, goes 
thruugh the drill, and can walk ten or twelve nule« with- 
uut pain ; but the exertion uf walking beyond that distanoe 
brings on fatigue, which be attributes to his stiff hip-joint. 
Several small portiona of cancellated bony stracturo have 
been extruded from the upper abscess at throe or foar dif- 
ferent times, but none during the last four years. The 
ainus from the intm-pelvio abscess does not remain closed 
for more than thi-ee or foiir months at a time, when a little 
pain and ftilneBS ooour under the closed aperture. This 
boon opens of itself, or he himself opens it. About a tea- 
spoonful of pus escapes, and in a day or two nothing but a 
thin watery fluid uozes out, and then it remains cloecd 
during another three or four montha. ^ w alks aomewhat 
tamely, dipping the ] " " " - - — - 

touches the gtonod 

upright upon the BO __ ._. 

alxmt an inch and a half or two inches from the ground. 
The head of the femur in this caee is a little anterior in 
position to where it ouglit to be. That explains a slight 
fulness below I'uupart's ligament wliich imjiedes the easy 
return of the blood, anil produces a varicose condition of 
his superficial veins. The muscles of the damaged leg are 
oxceediujily well developed, but not quite so much so ae on 
the sound side. 

] tliink I might fairly refer to this case as one of 
diseased hip-joint eonipiicated with disease of the aceta- 
bulum, not jilaced under very favourable circumstances as 
regards professional treatment, and, consequently, not as 
regards rest. Yet, in spite of all, so strong have been the 
energetic efibrts made by Nature, that the patient is, in his 
actual condition, happy and comfortable ; equal lo all the 
duties of the office in wliich he is employed, capable of 
taking exercise, and able to form part of a volunteer 

Hip'joint Digeate; Anchyhidt, teith tiie Thigh wmeiehal btnt. 

The next is a case of hip-joint disease, with anchylosis. 
The patient was sent up to me for the purpose of reducing, 
if poBsiblo, the hip-joint deformitj-. The drawing before 



XVI.] 



Aim THE DUQNOBTIC VALUE OF PAIN. 



409 



you repTOsenta the state ofthe patient whea be came tinder 
my care at the hospital. The bent condition of the Umb 
waa all he had to complain of. During the coarse of the 
hip disease he had never been kept at rest on his bed, but 
allowed to get about daUy upon his cmtohes. The course 
of the di&ease had been slow, and it« result was anchyloaia 




of the thigh-bone to the aoetabulum. In November 1855 
chloroform was administered, and poArerful attempts were 
made to straighten the leg ; but our eSbrts, 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 he was admitted. With respect to this 
application of force to disturb anchylosed jointe, it is not 



410 THE THERAPEUTIC INFXUENCE OF BEST [L«t. 

my intention to do more ttan esprefla a doubt as to the 
propriety of it in many cases, especially in iiip-joint disea^. 
The hip-joint is remarkalily simple in its constructioai 
The adaptation of the convex he^ of the thigh-bone to tba 
concave or cup-like cavity of the acetabulum allows of 
easy coaptation, and this is one of the conditions which 
contribute to quiet and jterfect consotidadon of the opposed 
bony surfaces. 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 forc« I 
thought jnatiGable, and it failed to improve the position of 
the thigh-bone. 

I saw a distressing case of this kind some y^ars ago. I 
had attended the daughter of agrocer, suffering&om severe 
hip-joint disease, in toe Kent Road, and had taken a grc«t 
deal of trouble with the patient in order to obtain anchy- 
losis of the hip-joint, and fortunately succeeded. I liit 
sight of thu young girl for buiiio tinii-. wlii^n tli.' Lite Dr. 

Barlow said to me, " 1 wish you would call at Mr. 's ; 

his daughter is now very ill, and she wishes to see you." 
I called, and as soon an she saw me she buret into tears, 
and said, " I am sure soon to die, aud I am anxious to 
express to you my deep regret that I did not follow your 
advice. When I left your care I had a stiff hip-joint, and 
you advised me to be satisfied with that state. Following 
the advice of friends, I went to Mr. — • , who said he 
could cure my stiff joint and make it movable." This 
gentleman employed a great deal of force in order to 
disturb or break down the bony union ; fresh mischief was 
set up, which resulted iu large suppuration, so extensive as 
to resist all subsequcut 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 history of a case which I consider 
exceedingly melancholy. The jiatient had a useful, pain- 
less, but stiff hip-joint. My surgical successor assumed the 
power of correcting Nature, and rendering the limp flexible 
and movable ; yet it turned out in the end that his efforts 
only resulted in the jmtient's death. 



X\L2 AND THE DIAGNOSTIC VALUE OF PAIN. 411 

Cases of Lameness in Children, due, perhaps, to deficient Nervous 
Influence, simulating Hip Disease. 

No doubt it happens to most consulting surgeons to see 
cases of lameness in children (in some instances both lower 
extremities being affected, in others only one), which are 
only to be diagnosed by the law of exclusion, as not being 
explicable by any recognised 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 evidenced by the wasting of 
the limb and the retarded growth of the muscles and of 
the bones. This leads to want of power in the limb, and 
deficient precision of step, and thus to unsteady gait ; but 
the limb is not flexed or adducted, nor is there usually any 
distinct pain when the patient walks, which he does limp- 
ing 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 limb is, as a rule, strikingly defective in 
warmth, I have found that th ebest method of treatment is 
to endeavour 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 of 
liquor ammonias to the oil. During the night the limb 
should be surrounded by cotton wool, and during the day 
with flannel or any similar material. 

Should the ankle or knee show any tendency to yield 
laterally, the most simple mechanical apparatus should be 
used, so as not to confine or make pressure upon the muscles. 
Walking exercise short of fatigue should, as far as is 
possible, be daily persevered in.* 

* Cases (akin to those of which Mr. Hilton is speaking), where a 
lower extremity is affected with infantile paralysis, are oc^^asionally 
thought to be due to hip-joint disease. On the diagnosis between the 
two, Mr. Holmes (System of Surgery, vol. y. p. 848) speaks as follows: 
— *'The hip-joint is less easily under observation, and the morbid 
sensibility which acoompunies some of these cases of paralysis gives 
more resemblance to hip disease on first handling the limb ; but the 
distinotion is usually easy to make. Paralysis generally affects a 



+12 THE TQERAPEUTIC IKFLCESCE OF BEST [Lkl-T 

Tjijihua Ferer folUneed («/ Parali/ms of the Left Leg ; Jfeowwry 
riiueh (ttWerf 6^ ruiiEitni; the Limb irilh Sperm Oil, and ntt- 
sequently wilh Sjierm Oil and Liquor Ammonia. 

A little girl, aged eiz. haviog previr>usly liad good hcaltli, 
was seized with seTere fever (with brain disturbance during 
aljout a forttiiglit), from whicli she reoovered gradually. 
The left leg and foot, however, remained ehruukeD, with 
^i-eatly diminifihed pctwer, and inability un the part of 
the patient to direct the foot with precision. The limb was 
always cold eicept when ramie wai-m with artificial heat; 
viiriouB kinda of friction and electricity had been tried 
during many months, but without any improvement. 
When I was oonsultod in this case I advised that apenn 
oil (liquor ammoui» was added afterworda) should be well g 
niljbed into the limb night aud morning, and lamb's-wooL 
stuckings worn. 

Dy th™- nifiiTis tJiP liml) wns nmii.:> wanu, am! nir.iiitaiiw4 
so. Niithini^i'lst' was done. I have seen this patient since 
several tiiiiis, the last occasion being April 187C. She 
CHU now wulk and nin witli precision, the ranscularity of 
lliu limb is much increased, and its warmth well sustained. 



i 



Hip-joliii Sjimptonis ; Jiiint Di«<'iise Kiisppcled, the real Cavie 
beinij Cerebral, 
Here is a case where the indications were more precise. 
A young hidy aged seven, in August 1801, being then and 
previously in good health, was residing at the sea-side, 
and, after plaj'ing tind amusing herself during several 
lionrs upon thu beach on a bright sunny day, had a sudden 
chill, then bocanio hot and feverish, had violent headache 
accompanied by groat lieat of head, and for a day or two 
wiiH deliriouB. She was confined to her bed from ten to 
fimrloen duys, wben, on attempting to walk, it was dis- 

RvaX jifirt <iT tli<! whr>le of the loner linili : hip disease only causes toes 
of movenu-nt of llie pnrt nJE'cteil. In the former, po8»iTe notion ia 
■iiBy Rnil raiide^ no pnlii, or not niorp llian nny other motinn ; in the 
Intterlhcinint is t-tiff. nn<l nn attempt ti move it causes Bcute Boffer- 
ing; ; flnally. in pnrilTsis there \i no wiiBt[ng of the biittock unless the 
wholHliiiiti ii vnBie'd, nor is the pOditioD of the trochanter erer 
nlterc'l." — [Kd.] 



XVL] AND THE DIAGNOSTIC VALUE OP PAIN. 413 

covered that she was lame in the 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 particulars of this case. I was 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 all ; no pain upon carefully mani- 
pulating the hip-joint ; no special local tenderness upon 
applying pressure below Poupart's ligament over the hip- 
joint, where there is always a degree of more or less 
tenderness, especially in children, this being a rather 
sensitive part. There was no indication of anything 
wrong in the hip. The child was treated by tonics. On 
January 6th, 1862, the patient walked into my room, in 
every respect improved — less lame, the limb being in- 
creased in size, and maintaining its temperature nearly as 
well as its fellow. On June 4th, 1862, I had the follow- 
ing note : — " The patient is now greatly improved." 

Case of a Curved Sacrum causing some of the " Outlyiing 

Symptoms " of Hip-joint Disease. 

Here is another case where hip-joint disease was simu- 
lated by a structural disturbance which had taken place in 
the sacrum, or the last lumbar vertebra. The history of the 

case is briefly this : — T. J. H , aged nine, residing at 

Gillingham, Kent, was admitted into Luke ward on the 
29th of September, 1859, under my care. He was sup- 

Eosed to be suffering from long-standing disease of the left 
ip-joint. His mother gave us a history of his having had 
measles four years ago, and that since that time his left 
leg had always been weaker than the right. Twelve 
months after this he fell from a wall six feet high upon his 
left knee, which became much swollen and very painful, 
and it continued to pain him for some time. Soon after 
this the hip-joint of the same side was supposed to have 
become affected, causing him to walk with difficulty, and 
to rest on the right leg to ease his left hip. A short time 
after the pain of the hip commenced, he observed that the 
left leg was becoming contracted and shorter than the right, 
so that when he stood upright he rested with the great toe 



XVL] AND THE DIAGNOSTIC VALUE OF PAIN. 415 

side, and comparing it with the other, it appeared that 
they were each of the same length. There was nothing 
wrong to be detected in the hip-joint itself, which 1 exa- 
mined with care. As there was no definite remedy to be 
adopted in this case, the patient was sent away from the 
hospital in the condition which you see represented in the 
two drawings (Figs. 81 and 82) placed before you. 

Malposition of both Hip-joints — Congenital, 

There are other kinds of cases which simulate hip- 
joint or spinal disease ; one of these is certainly that of 
congenital malposition of the hip-joint. Such cases are 
rare — at least as far as I know. 1 have here sketches 
(Figs. 83 and 84) of two patients, both presenting con- 
genital malpositions of the hip-joints, which are situated 
posterior to their normal or natural position; and this 
abnormal position necessitates, that the erect position may 
be maintained, a remarkably curved condition of the spine. 
This curve of the spine, and 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 counter- 
poise the malposition of the hip-joints. This instance 
(Fig. 83) came under my notice on the 25th of May, 1852. 
I had never seen a case like it before. The girl was then 
four years old. Her gait wap very extraordinary, utterly 
unlike the awkward modes of progression which we see 
dependent upon disetise of the hip-joint or spine, the 
shoulders 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 being certain of the matter, I requested the advice of 
Sir B. Brodie, whose experience I thought might help me. 
We took the patient up to his house, and he said, " 1 think 
I have seen a case exactly like it. I remember 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 



XVL] AND THE DIAGNOSTIO VALUE OP PAIN. 417 

or parturition.* Sir Benjamin Brodie said, "The only 
answer I can give is, that this lady had had one child : 
that is my sole experience in the matter." That, I believe, 
was considered satisfactory by the mother. The child is 
reported to me as growing up in perfectly good health, but 
retaining her remarkable gait. I saw tbis patient again 
in July 1862. She was in excellent health. The same 
characteristic gait was observable, and the same deformities 

* An elabomto paper on this subject (Das Becken bei angeborentr 
doppeUeitiger Huftgelenksluxation) will be found by H. Ernst Sassman, 
Arch, fiir Gynaakol. Bd. v. The foUowiug are amongst the abnormaliiies 
met with in the pelvis of a woman, let. 19, the subject of congenital 
dislocation of both hips:— Sacrum more horizontal than usual, and 
more concave, coccyx united to sacrum almost at a right angle, ilia very 
steep, cavity of true pelvis not narrowed in any direction, transverse 
diameter of pelvic outlet enormously enlarged, the antero-posterior 
mnch diminished, pubic arch extraordinarily wide, ischial tuberosities 
widely apart, pelvis supported upon femurs at a marked slope from 
behind forwards, and from ab)ve downwards. 8ome of the above 
alterations are thus brought about. As soon aH the child begins to 
stand and walk about, the lumbar lordosis (see Figs, above, 83 and 84) 
increases rapidly, and causes the inclination of the pelvis, tilting the 
sacrum up and the pubes down. By this displacement of the sacrum 
increased tension is thrown up^n the posterior parts of the sacro-iliac 
ligaments, the hinder portions of the ossa innominata are also drawn 
together, which would make the anterior portions gape widely ; but 
this is prevented by the pubic symphysis ; and so the soft bones, fixed 
behind and in fiont, curve outwards in the centre. This excessive 
widening of the pelvic brim would be prevented by the upward and 
inward pressure of the femurs through theacetabula; but owing to the 
dislocation of these bones this pressure in wanting. The widening of 
the pelvic outlet is brought about by the pressure of the displaced 
femurs on the false pelvis acting on the ossa innominata as levers, 
driving the upper part in and the lower out A greater agent in 
widening the outlet is muscular action ; thus, the femurs not being in 
the acetabula, the pelvis by its weight siuks and is, as it were, slung 
upon the heads of the femurs by the muscles around their necks: 
these being attached to the u^chial spines and tuberosities draw these 
parts outwards and upwards. The abnormal inclination forwards and 
downwards of the pelvis upon tho femurs is aided by the excessive 
tension which is thrown upon the ilio-psose muscles and the ilio- femoral 
ligaments, owing to the displacement upwards and backwards of the 
heads of tlie femurs. As to pre^ancy and delivery, there is greater 
discomfort than usual during the former, owing to the displacement 
forwards of the uterus, and during this periotl the peculiarity of the 
giiit is incraised ; during pregnancy the chief cause of delay is tho 
horizontal position of the uterus : but on the whole the prognosis is 
scarcely worse than in normal pelves, — [Ed.] 

2 E 



^A&V V/AAA.1.V4. A'^'M. CA&V 



r 



the spine, it throws the chihl's i 
lurwjinls thut the ehihl falls (h)\vi 
walk.'' 'J'he child was afterward 
spinal apf^aratus on. This turn 
congenitally malplaoed hip-joint 
treatment could cure a case of 1 
in opposition to Nature, and, as a 
surgeon. The mechanical meaa 
obviously useless, and after a time, 
apparatus was given up. The chi 
the peculiar gait (see Fig. 84). 

Some time ago, happening to be i 
maker*s room, he told me of his wa 
a case of anterior curvature of the 
I looked at the child ; it had the pec 
gait of malplaoed hip-joints, and 
compensatory to the error loci of tl 
cause of the deformity had been ove 
attempt was made to correct the cu 

A fourth case has come under n 
dislocation of the hip-joints. I wai 
consulting surgeon in the West-en 
case a medical man had, for no leaf 
using spinal apparatus and futile i 
hips. 



Congenital Deficiency of Develonm 



/>■•»< 



XVI.] AKD THE DIAGNOSTIC VALUE OP PAIN. 419 

which is often overlooked, and which simulates disease of 
the hip-joint, in some cases by inducing lameness, in others 
by causing lateral curvature of the spine, marked by a 
want of symmetry in the height of the two shoulders. 
The explanation of the above lies in a want of due and 
symmetrical development of the two lower limbs as 
regards their length, a fact which can only be recognised 
by careful measurements. I may add that I have seen so 
many of these cases, that I am persuaded that they occur 
not infrequently, and that they are usually overlooked. 
Thus I have seen many patients wearing spinal supports, 
in order to correct a lateral curvature, when the deformity 
might have, and has been subsequently, corrected by 
placing within the shoe or boot a piece of cork thick 
enough to compensate for the shortness of the less deve- 
loped limb. Half an inch, or indeed a quarter of an inch, 
of difference in the length of the two limbs is quite suffi- 
cient to generate some of the outlying sjonptoms of hip 
disease, viz. a limp, and also pain (which is usually felt in 
the hip) after fatiguing exercise. 

The following is a case in point. About eighteen years 
ago I was consulted by an anxious mother who had noticed 
for some time a little limp or lameness in her daughter's 
walking, and ^ad recently observed that her left shoulder 
was a little lower than the right. This want of symmetry 
in the 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 mechanical sup- 
port 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 half 
an inch the shorter of the two.* The patient having been 

♦ American surgeons, amoiigs>t theii^ Dr. Hjimiltou of New York, 
Dr. Cox of Philadelphia, Dr. Wight of Brooklyn, have of late years 
insisted upon this fiict. The conclusions of the lust named, of evident 
importance in practice (espeiially on the other side of the Atlantic, 
where actions for malpractice are not uncommon), are well summed 
up as follows in the Lon. Med. RcwOrd, May 1878. Amongst them 

2 E 2 



»7li''V., 1.11V »»l 



KliouMors (lisiij^pcared at once, i 
the Banie method of treatment ha\ 
em])loye(l. 

In the next case, the fact that o: 
half an inch shorter than its fello 
planation of the commencing ad 
which apparently began in the eti 



«re — 1. The greater nnmber of normal lo 
length. 2. The left lower limb is oftener 1 
limb. 3. The probable average natural ine^ 
about one quarter of an inch, perhaps a litt 
probable average accidental inequality of 1 
treatment of fracture of the femur, id about 

5. The facts of development and the facta < 

6. There will be one case in ten— or eleir 
limbs of equal length after treatment of frao 
¥rill be accidental inequality in the rest, tl 
every 100 or 200 cases, the lower limb who 
well treated will be somewhat longer than it 
ratio is not surely fixed as yet 8. One sat 
gation after fracture of the femur may be • 
surgical service of a large hospittil in a period < 
10. It is impossible for the sui-geon to makelir 

after fracture of the femur 12. C 

the standard of length for its associate Urn 
standard of a lower limb of which the femui 
limb itself before injury. 14. In cases of d 
inequnlity, it is important to measure other o( 
of the same body, which may afford valuable 
treatment. 15. So far as we now lmn«r u :- «^ 
tli#* f*»*»'^*' ' — 



XVI.] Ain) THE DIAGNOSTIC VALUE OF PAIN. 421 

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 con- 
tinuous. When I was consulted in 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, &c., I advised 
that a splint should be applied, and the patient kept lying 
down. After awhile, when the above symptoms had dis- 
appeared, she was permitted to go about wearing a cork 
sole on the left foot. There has since been no return of the 
pain ; in fact, in the words of Mr. A. R. Martin, the medical 
attendant, the patient may be considered cured. 

Diseases of the Sacro-iliac Joint and the neighbouring Bones. 

Before leaving the neighbourhood of the hip-joint, I 
would 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. 56, 
page 216) will remind you of the powerful ligaments which 
hold the sacrum in its due relation to the os innominatum 
on each side ; strong ligamentous tissues are interposed 
between the lateral aspect of the sacrum and the inner 
and posterior part of the os innominatum. 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 ligaments which fix them together, without 
perceiving that great strength is a part of their natural 
function. If any disease should occur at the sacro-iliao 
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 transferred 
through the medium of the spine to the sacrum, and thence 
produce pressure upon the articular structures of the joint, 
which would, if diseased, induce pain. Nor pould the 
patient stand upright without great pain. Remembering 
the relations of nerves to that joint, one would say that 
sacro-iliao disease might manifest itself by pain, taking 



422 THE THERAPEUTIC INFLUENCE OP REST [Lect. 

the course of the distribution of the obturator nerve, which 
passes just over the fnmt of the joint. (Vide Fig. 39, page 
1218.) The gjQRt sciatic nerve might, from its doeer 
proximity to tlie joint, and its sending nerves to it, indnce 
rijmote symptoms of pain in the hip- or in the knee-joint, 
or the l)ack part of the calf. There is also the superior 
gluteal ners-e lying close to this joint, which supplies the 
deep glutei muscles and the tensor vaginse femoris, and 
that nerve might lead to spasm or wasting of those musdee. 
The psoas magnus is lying close at hand, and, under the 
influence of irritation, it would be 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 comfort, 
pain in the knee, pain in the leg, wasting of the gluteal 
region, or flattening of the muscles (these are the out- 
lying s.vmptoms of hip-joint disease), these symptoniB 
de})ending entirely upon the disease of the sacro-iliac 
articulation. 

I think it will lie 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 sacrum, and between the 
sacrum and the upper part of the os innominatum in some 
cases. If wo were to treat this question with a skeleton 
only before us, wo might presume that the local symptoms 
wotild be precise enough ; but when these deep parts are 
clothed with soft structures, there is a great difficulty in 
making an exact pressure, as, for example, upon the upper 
part of the sacro-iliac joint so as to isolate it from the 
sacrum, or the sacrum from the last lumbar vertebra. 
Hence it will be necessary for me, in treating this part of 
my subject, to group together the morbid conditions of 
this neighbourhood. I shall endeavour to point out the 
distinguishing marks ; but for all practical purposes we 
might identify them all as forming a little group. 

Case of Disease of the last Lumbar Vertebra emulating Hip- 
joint Disease. 

On the 28th of Januaiy, 1860, a little child was brought 
to me, supposed to be suffering from diseased hip-joint. A 



X\T[.] AND THE DIAGNOSTIC VALUE OF PAIN. 423 

physician sent this note with the patient : " The little child 
I send to you came before me for supposed disease of the 
back, but it seems to me to be an affection of the hip-joint. 
I have, therefore, advised the friends to take your opinion." 
The patient, a delicate child, had had 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 in the hip, knee, and thigh, was very lame, 
and suffered intensely upon making any attempt to walk. 
Considerable constitutional disturbance prevailed. On 
examination I found the hip-joint free from pain ; that is, 
on movement of the hip-joint — isolated movement — the 
patient experienced no pain, nor was there the slightest 
evidence of any local heat at the hip-joint. Although there 
was no pain in the left hip-joint, she presented all the 
"outlying symptoms" of disease in that joint— lameness, 
pain in 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 on the left side. But on 
pressing the os innominatum towards the sacrum she com- 
plained 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 articula- 
tion. Some increase of heat was to be felt in this neigh- 
bourhood by placing the palm of the hand upon it, and by 
comparing the temperature of the corresponding parts on 
the opposite side. Thus the case was made out to be dis- 
ease between the lower lumbar vertebra, sacrum, 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 had fallen upon 
the ice, but the fall produced 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. 
The case was to be treated simply by mechanical rest, and 
the 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 a fortnight. In 
two months, in direct opposition to my previous strongly 



424 THE THEBAPEDTIC INFLUENCE OF REST [LbCt. 

oxpraBsecl wisbea (as she upjiuareMl to be in every respect 
so well), she was allowi^ by Lor pai-euts to get up and 
wulk about, and mxiu ufturwards UDiucnBUred exercise was 

111 a few weeks the lameness and all tbe other uatoward 
sj-uiptoms were again apparent, with oocasional shivering. 
'I'heHO ayniptoniB oontiunetl uncontrolled, and she was 
allowed to be moving about the house until she was brovght 
til luo in the early port of June IBIiO. She was then 
ttcoginpanied by the Eunily surgeon, who said he was ex- 
cessively sorry to see these nice quiet people, good patients, 
am! so on, so distreeeed about their poor scrofulous little 
child, with a diseased spine, and a large ahsoess fomiiug: 
adding confidentially to myself, that although the oaso was 
utterly hopeless as regards the treatment, etill be thought 
it right to bring the case for me to see, ae I had seen it 
before. An abscess could now he distinotly felt, deeply 
sejitt-il iijion thr inniT .uiii ].nsUTiiir put .^f'tho ilium, on 
its pelvic aspect, near the sacrum and last lumbar Tertebra ; 
and there was some increase of heat and abnormal firmnesa 
of tlie surrounding aoft parts. A hemlock poultice with 
bread was ordered to bo applied over the abscess, and the 
recumbent supine position to be again resumed, and con- 
tinued without intermission. The mother was now willing 
to carry out this plan of " rcdt " carefully, and for any 
extent of time. The child was to take the air daily, 
weather permitting, in a little four-wheeled carriage. The 
diet was to be good, but not stimulating. It was intended 
that the patient should go to the sea-side for the remainder 
of the summer, 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 pus, 
serum, shreds of lymph, and more solid caseous material 
were discharged. The health remained good. 

Now. hei'e is a child sufi'ering severely as regards health, 
kept lying in bed, securing the parts from disturbance, 
and, after seven mouths' persistent rest in the recumbent 
position, her health has gradually improved ; and the 



XYI.1 AND THE DIAGNOSTIC VALUE OF PAIN. 425 

expression that her health remained perfectly good is not 
exaggerated. The abscess by degrees ceased to discharge, 
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 respect 
well, except that there was a little weeping of thin fluid 
from the mouth of the sinus of the abscess ; there was no 
pain anywhere. The fourth and fifth lumbar vertebrsa 
seem firmly consolidated, and do not yield like the other 
vertebne on bending the spine. The discharge ceased in 
February 18G1, when she was brought to me, at my 
request. She is now, and has been since January 1861, 
in good health. The last lumbar vertebra projects back- 
wards a little, but not abruptly. She runs about with 
the other children, up and down stairs, and stoops to pick 
up anything oflf the floor. Sept. 9th, 1862. — The mother 
writes to me thus: "You will be pleased to hear that 
mv little daughter is quite well, and has not felt the 
slightest retiim 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 by parents and by the 
surgeon in attendance ; but, in spite of that, the child is 
now perfectly well, without a single drawback. In addi- 
tion, I think it shows conclusively the value of mechanical 
rest in the treatment of cases of this kind. 

Severe Disease of Spine, close to Pelms, cured by Rest. 

In the summer of 1851, Miss A fell down some 

steps and bruised her back in the lumbar region. This was 
soon followed by pain and some tenderness at the part, as 
well a§ some pain in the legs. The pain and weakness in 
the back increased, with some loss of power in the lower 
extremities, 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 surgeons 
and physicians, all of whom advised tonic plans of treat- 
ment, change of air, exercise, and counter-irritation. One 
surgeon treated her most energetically for neuralgia. These 
varied kinds of treatment were pursued with irregularity. 



420 THE TIIEKAPEUTIC INFtUEKCE OF IlEST [LecT. 

ami without any benefit to the patieDt, iip to the time 
when I saw this lady in 1B54, nearly three yeara from the 
lieginninp of her eymptamB. She was then emaciated and 
weak, had a frequent and irritating cough, with hecticaod. 
diatressed expression and rapid pnlee ; also her health wae 
reported to mc aa very greatly deteriorated, and still getting 
worse. She oould walk but a very short distance, and that 
with difficulty. She had pains and cramps, and diminished 
Benaihility in both lege, and she could not stand upright 
without snpiiort : both legs were somewhat wasted. The 
fourth and fifth Inmbar rertebrse were painful on prossurfc 
and slightly projecting barkwards ; pressure upon them 
producing a severe pricJcing sensation down the left leg, in 
the course of the branches of the aut«rior craral nerre. 
Deep in the loin on the right side the fluctuation of ab 
abscess conid bo detected, extending towards the crest (fi 
the right ilinm. Tlie abscess was opened ; her health gave 
wiiy. ami the lui.lly .iiip.-iired to be on Iht- vltv virgc- of 
the grave. I then had her placed on one of Alderman's 
Iieda. and removed in an invalid carriage to Brighton. She 
remained on the couch uninterruptedly, never quitting it, 
except for the purposes of personal cleanliness, during five 
months, and then she was lifted horizontally ofi' the bed on 
to a coTich or sofa, and put Iwck when the lied was ready 
for lier. Her health gradually and quickly improved ; and 
at tlic expiration of a few months all the pain in both legs, 
and the pricking aensation in the left, had diBap]>eared. and 
Iroth legs were improved in sisto and power. She continued 
reeurabent until the discliargo had coflsed. At the expira- 
tion of fifteen months she could etjind upright without 
pain. and. after a few days' trial, with confidence in hereolf. 
I'aking walking exercise with cnitches. she gradually got 
well. When last I saw this patient she was in perfectly 
good health, with not a single drawback in respect to her 
condition. 

Thifl case. then, shows the Vithie of rest. I am quite 
confident that had not the i)atient been compelled to lie 
down, and had not great care been taken of her, she would 
have died. 



^ 



XVI.] AND THE DIAGNOSTIC VALUE OF PAIN. 427 

Case of Disease between tlie Sacrum and Ilium ^ with intense 
Pain in the Leg cm the same side of the Body, 

This case is of much interest — in one respect especially, 
because I was enabled by the recognition of the course of 
the nerves to the leg to ascertain the real character of the 
case, the true position of the cause of the symptoms, and 
thence to deduce the proper plan of treatment. The details 
are not very long. 

On November 23rd, 1861, I was requested to see, with 
Mr. Barnes, of Chelsea, a young gentleman who was suf- 
fering, and had been suiferinj^ for some considerable time, 
from intense pain in the calf of his right leg. The thigh 
was slightly flexed, and ho was unable to walk or stand 
upon the limb. He was sitting upon a couch, the limb 
every now and then jumping involuntarily, causing him 
to cry out with pain. This occurred several times while 
I was in the room. He 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 April 24th, 1860, the lad slipped down two staira, 
and struck the lower part of his back, but no direct injury 
was suspected. He soon became lame in the right leg, and, 
in attempting to walk, his foot turned somewhat inwards. 
He continued lame and weak in the right leg for nearly 
three months, after which time he gradually resumed the 
natural occupations of his period of life. He had repeated 
attacks of lameness arising f lom slight casual accidents. 
In February 1861, whilst bowling his hoop, he trod unex- 
pectedly, and with force, upon a stone, and sprained his 
foot ; and from that time he became again very lame, and 
went about on crutches. In the early part of October 
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 leg was very great day and 
night, depriving him of sleep, and disturbing his general 
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 



42S THE TUEHAPErtTIC INFtUENCE OP REST [LiA 

carafully, from the adiUtional pain and spHSni wliioh wert 
iudnoc'il by it. and fiuding nothing wroug about the koM 
or hip-joiiit, e&snn to the ooncinsiou that probalily thert 
i[ii;;ht be deep abscess near the biick part of tho tibi^ 
ttnd that the tibia itself might bo diaea^ed. He direutv* 
ihe tiei'motit to be adapted to such a view of the caBt^ 
aud ordered a belladouiia ploBter to cover the leg. TlW: 
night fullowiug this visit tu the eurgeoii was paeaed ia 
^tvatly ineiMaiied pain, with uranips aud twitching uk 
tliu right limb. After teu days, there being no allevia' 
tion of the severe aj'tuptome, the opinion of anothw 
hoHpitiU. surgeon was aoiiglit. He saw the patiunt Ift 
bed, and exaiuiued hiin carefully ; but 1 believe he gaiF* 
no intelligible or satisfactory oi'iniun aa to the cauee «r 
the paiuful ayiuptoms. He directed the patient tu b« 
kept quiet on a couch or bed, the knee-joint and leg iA 
bo supported by a splint, and tho knee to be cover«i 
with t-uttijii wuoi. 

I hojM this statement will not iiu]>Iy anytliing like 
sclf-laudation. I only mention the fat^ta in detail f<.ir the 

{iur[io80 of ])ointing out the method of proceeding which 
oil tu a right interpretation of the sym]>tume. 

No iniprovoraeut occurring, I was desired to sec this 
suflering patient, and I went to him with the expectation 
of doubtful benefit to be derived from my examination, 
considering the eminence of the two surgeons who had 

S receded me, and from whose suggestions no good had been 
erivod. Ifuunda very intelligentladsittiugupun a sofa, 
with his right log lying ou its outer side, supjiorted by 
pillows. Tho pulse <]uiekened, but with little febrile 
excitement ; the tongue was not much furred ; tho thigh 
slightly flexed, and not to be straightened without pain. 
There was most severe i)aiu in the leg, which was every 
now and then, at two or three minutes' interval, suddenly 
and intensely iiicreaBod so as to make him cry out. The 
back part of the calf of tho leg was very Bensitive, both on 
supei^cial aud deep pret^uro, the muscles of the part being 
in a state of sthenic contraction and quivering, but there 
was no marked increase of temperature at the part, nor any 
distinct fluctuation. By steady and continued pressure 
uiwn the calf of the leg, tlie pain was not increased, and I 



XVI.] AND THE DIAGNOSTIC VALUE OF PAIN. 429 

thought the spasmodic condition of the muscles seemed to 
subside. 

These local symptoms, with their natural suggestions, 
excluded anything like local disease in the neighbourhood 
of the posterior part of the tibia, or within the calf of the 
leg, where the pain was expressed. The mnscles 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 knee or hip-joint when the ex- 
amination was confined 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, because he could not bear any weight 
upon his right leg, and recent experience has shown that 
the pain had been greatly aggravated by making such an 
attempt. I thought it was clear that the real pathological 
cause 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 it — namely, increase of temperature. The 
nervous supply to the deep and superficial muscles of the 
leg, and to the overlying skin, being derived from the great 
sciatic nerve, suggested to my mind the belief that the 
cause, whatever it might be, would be found anatomically 
associated with that nerve, to the exclusion of the anterior 
crural and obturator nerves. 

These considerations induced me to examine the struc- 
tures near to which the great sciatic nerve travels towards 
its distribution. The patient being gently turned over on 
his stomach, I pressed with my thumb upon the junction 
of the sacrum with the ilium, and near to the last lumbar 
vertebra, on the right side, and he immediately screamed 
out that I gave him the pain in his leg. On making a like 
degree of local pressure on the corresponding part on the 
opposite side, no pain was induced at the point of pressure 
or in the leg ; by repeating the pressure on the right side 
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 the obvious and first remedy 
was to give rest to the joint. That could be obtained only 



430 TUE TUEKAFECTIC INFLUESCE OF REST [LsuR 

liy the pationt lying flut upon the back uuiutermptedly, 
(iiid by the applioation of a long straight epliut to the Itg 
mill pulviH, ao UB to proveut any diaturbaiiL-ii ; the recnm- 
\ti:nt and supine position to be strictly imuiitaineii during 
two montlia. The epliitt was applied iannodiately by Mr. 
liiirues. He had no luedidne — not a drop. The patient 
was nut allowed to turu in his bed, or to ait up fur any 
imrpiifie i and in a fortnight all tlie painful symptoms hax.! 
aulisided, so that he was quito comfortable in 

I did not see this patient aguiu until two mouths after 
luy providUB visit, I found him happy, free from pain, 
liealth and appetite good, complaining only of a little liea4r 
ache from hu head being too low. I turned him on to hW 
left side, and examined his right sacra-iliac joijit by direqfcj 
pressure ; but it did not produce any pain, either at tW 
part or In the leg. Thus mechanical rest had aided Nature 
to repair the misuhief, wliatevur it niij^ht luivf lioi-n. Cuu- 
sideriug tliat he had been more or leas lame since April 
1800, it seemed unreaBonabte to suppose that the diseuscil 
structure of the sacro-iliac joint could be repaired in so 
short a time as two months ; Jienco it was arranged that 
tho same plan of niechaiiical rest should be persevered in 
for one or two months lunger. 

The diagnosis, in this case, was cstabliahed ebieHy 
through the medium of a recognition of the anatomical 
course of tlic great sciatic nerve wliich supplied the part 
where tho pain and is))aam were expressed. In tliat re- 
spect the CiiBC is irnportant and of striking interest. The 
patient's health, I am liappy to say, was in the end per- 
fectly restored. 



I 



XVnj Ain) THE DIAGNOSTIC VALUE OF PAIN. 431 



LECTURE XVTT. 

aACRO-lLIAO DISEASE IN A BOY AGED FIVE, OURED BY MECHANICAL 
EE8T — 8ACK0-1L1A0 DISEASE IN A MAN OF FOBTY-TWO, CURED BY 
BEHT — SACRO-ILIAC DISEASE IN THE LEFT SIDE AFTER PARTURITION; 
SUPPURATION WITHIN THE PELVIS, ABSCEi»S ABSORBED, CUBED BY 
REST — DISEASE OF THE SACRO-COCCYOEAL JOINT, FROM INJURY, CURED 
BY REST — INFLAMMATION OF THE COCCYGEAL JOINTS, FROM INJURY, 
CUBED BY REST — PAIN IN THE POSTERIOR POUTION OF THE COCCYX 
IN HYSTERICAL CASES, EXPLANATION OF— CASE OF NON-DEVELOP- 
MENT OF BOTH PATELLA UP TO TliE AGE OF THREE AND A HALF 
YEARS— DISEASE OF KNEE-JOINT (.SCROFl LOl S ?) TREATED BY 31E- 
CUANICAL liEaT, CURED BY FIRM BoNY CONSOLIDATION — DISEASED 
KNEE-JOINT, FROM INJURY, WITH PARTIAL CARIEd OR NECRObI;} OF 
THE PATELLA, CURED BY REST — TRAIMATIC DISLOCATION OF THE 
TIBIA, TREATED BY REST AND AI'PLICATION OP COLD — WOUNDS PEXE- 
IRATING THE KNEE-JOINT TREATED BY COLD AND REST — DISEASE 
BEl'WEEN IHE SHAFT AND LOWER EPIPHYSIS OF THE FEMUR — DIbEASB 
OF knee-joint; BICEFS divided and limb STRAIGHTENED — OLD 
DISEASE OF knee-joint; FLLXORS DIVIDED— TREATMENT OF U^OSE 
CARTILAGE IN KNEE-JOINT BY REST. 

Is my last lecture I alluded to cases of disease occurring 
between the sacrum and the ilium, and I mentioned two 
or three instances which were cured by rest. I shall now 
detail some similar cases, not only because they are com- 
paratively rare, but because the real seat of disease is so 
frequently overlooked ; while, if the diagnosis be once cor- 
rectly made, the treatment is exceedingly simple. All this 
is in accordance with the general impression in the pro- 
fession, that nine- tenths of uur success in practice depends 
upon accurate diagnosis. Some surgeons are disposed to 
think that acute or chronic diseases between the sacrum 
and the ilium, if of a serious character, are almost incur- 
able, and are hence disposed to pay but little attention 
to their treatment, except in palliation of the symptoms. 
I think we have clear clinical and pathological evidence 



432 THE THERAPEUTIC IHFLDESCE OF BEST [1 
tliat they are actually cnraHe ty tho employment of prapfi 

SdCTo-iliae DUeage in a But/ aged Jive, cured hy Merkaitiedt 
Sett. 

For the pnrpoee of showing that these caees occur at a 
agee. and in both Bexes, I shall have occasion fifst to alluj 
to a young gentleman whom I saw on October 2yth, 185! 
with Mr. Taylor, of the Kent Road. The child was thoi' 
five years old. Ho had been increasingly lamo in the I^ 
Ifg for about a month, from some obscure cause. He wi»' 
BTiffering from much coiigtitutional disturbance, rest^ 
badly at niglit, and wao unable to sit, walk, or etauS 
without pain in his left leg. Up to the time of my vii^ 
he had been allowed to move about as well hb he ooul^ 
having been treated medically since the first appearance (•< 
his symptoms. Hiw left thi^h was a little flt-\fd, the l">dy 
somewhat bent forwards, and he could ni.>t lx)iii' ftiiy WL=ight 
on that side. The case, then, might be one of hip, spine, 
Sttcro-iliac, or possibly cerebral disease. On placing him 
in tho recumbent position upon hie back, it became evi- 
dent, by carefidly manipulating the hip-joint alone, that 
there was nothing wrong about it. The spine presented 
nothing abnormid on direct pressure, nor in appearance ; 
but. on striking the sole of the foot upwards, he had pain 
in the neighbourhood of his left hip. Pressing tho left 08 
innominatum towards the sacrum, or pressing the sacrum 
itself forwards, and exerting, with tho thumb, defined 
pressTire over the poaierior ])art of the left sacro-iliac 
articulation, gave him considerable pain. Thus the case 
seemed to be made out to be disease between the sacrum 
and ilium. On inquiry, it was thought possible that 
some local injurj-, which would explain his sj-mptonis, 
might have originated in a fall which the little patient 
had whilst trying to drag a branch off a tree, sonie short 
time before the lameness manifested itself. 

A belladonna plaster spread upon leather was placed 
npon his liaok and hip, and it was arranged that lie was 
not to move from his recumbent position for any purpose 
whatever. With that understanding, neither splint nor 
mechanical appliance was made use of. fiimple means 



XYIL] AND THE DIAGNOSTIC VALUE OP PAIN. 433 

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 general 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. I wrote 
to Mr. Taylor in April 1860, to ask him about the case, 
and he replied, "The recumbent position was enforced 
strictly for three months, and the boy has perfectly re- 
covered — 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 sacro-iliac 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 constant tendency to wedge its way between the 
ossa innominata, and press upon those structures which 
constitute the soft part of the sacro-iliac synchondrosis. 

Case of Sacro-iliac Disease in a Man aged Forty-two, cured by 

Mechanical Rest, 

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 frequently necessaiy for 
him to lift heavy weights, and he thought he might have 
strained the parts in some way, although he could not defi- 
nitely fix the time or manner of the accident. The pain, 
which was at first only intermittent and comparatively 
slight (coming on only after exertion), gradually 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 

2 F 



+34 THE TlIEltAPEDTIC rUFLUENCB Or BEST [Tj^- 

itdmiasioii into Guy's ho hoA been treated for TlieumatiMn, 
soiatica, and hip-joint dieeaee. On odmiBBion. it was found, 
by careful exaiuiiiation, that tho setit of the greatest pain 
correajionded with the right sacro-iliao eyiichond«i«i*I 
PreBBiire Tipon the Bacnim or iliiim in such direptiim as to 
disturb the saorci-iliac synch ondruBiB gave rise to great 
pain, ae did also premture applied directly over the join* 
between tho Bacrum and the os iuDOiDinatntn. On the other 
hand, the pelvia Iwing steadied, the hip-joint could be moved 
about and manipulated in any way ^^^thout producing pain,' 
HO long as the movement did uot affect the aacro-iliao eyn- 
(.-hondroBis. At tiiuee thoi'u was pain about the glntesl 
region ; there was never pain in or about the knee. Tho 
pationt could not lie on fain right side ^thout pain, wm 
unable to atand or to walk ft-ithout very great pain, «od th« 
attempt to stand prodnoed yielding in the lower part of ths 
back ; but there was neither ehortening nor lengthening 
of the limb, nor any luarkud alti^riitum ii. Hk^ ct.ntour of 
the gluteal region. The [latient had had neither shiverini; 
nor any other symptoois of irritative fever. Ho was orders! 
to keep his bed, and remain absolutely at rest u]H)n his buck. 
I will not trouble you with the minor details. About twv 
months afterwarils, in February 1858, he was furnished 
with a strong pelvic belt of leatfier, providwl with buckles 
and straps, and so contrived and padded as firmly to em- 
brace and steady the pelvic bones, and prevent, as fur as 
possible, movement of tho sacro-iliac joint. The patii^ut 
remained recumbent iu led until the beginning of April 
(four uiimths), when he was i>ermitted to sit up in Kh), 
which he did without pain. In a few daj's be got up 
(wearing the belt), walked slowly about with the aid of ii 
stick, and with scarcely any pain at all. From this timi- 
he steadily impi-ovcd, and at tho expiration of five months 
ho left the hospital, i-etnruing to Lis occupation throe weeks 
after wfirds. The time spent in n-st was therefore six 
moKthtj. I reipiested the patient to call upon me in li^Cl. 
niid ln" ilid BO in March. Ho could then carrj- two cwt. 
without difficulty, inid had dono so during the last tw<. 
years, but he still liihl great store by tho i)elvic leather 
belt, wliifh pivo him more comfort and a greater sense of 
Heeuiitv than aiivthiiigelse, and the tighter it was Btriip[K.'d 
the iijo'i-e COLLI tbrtiil.le it w.as to bim. 



XVn.] AKD THE BIAGNOSTIO VALUK OF PAIN. 435 

This man presented clear evidence that he had disease 
between the sacrum and the ilium, from which he had 
snffered during six months previously 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 ultimately made with success. The advantage 
of the circular belt no doubt consisted in its maintaining 
the diseased parts in forced coaptation, for I believe the 
man has now anchylosis between the sacrum and the ilium. 



Sacro-iliac Disease in the Left Side after Parturition ;* 
Suppuration within the Pelvis; Abscess absorbed; cured 
by Mechanical Reft. 

In 1853 I saw a lady, aged twenty-four. After a tedious 

* In certain cases disease of this articulation seems to occur during 
the process of parturition, purticulurly wiiero the child itself, or the 
oephidic diameters especially, are of unusual size. Thus a c&se of 
laceration of the right sacro-iliuc synrhoiulrosis id rerorded by Dr. 
Scanzoni (Zerieissung der recten Synohondrobid sacro-iliaca wahrend 
derGeburt. Schmidt's Jalirb. ix. 1859). Here very severe pain was felt 
after delivery in the joint, and down the thigh as far as the knee, 
followed, by undoubted crepitation, the opening of an abscess near 
Foupart's ligament, and, by means of a probe introduced here, the 
detection of bare l)one in the articulation. In Professor Esnuirch's 
monograph, On the Use of Cold in 8uro:ery, will be found a case of a 
patient who, after delivery ** with great difficulty of a very large child," 
suffered from indammation of the right sacro-iliac joiut, and was cured 
by rest and tlie application of ice. 

It is well known how much attention was fonnerly, especially towards 
the end of the lust centurj', directed to the question whether the sacro- 
iliuc joint yields, to any important extent, in parturition. Whether ihe 
auricular surfaces of the sacrum and ilium are united by a single piece 
uf cartilage, or, as is ()erhaps more common in the female, by two pieces 
aliglitly separated by a chink lined by a more or less perfect synovial 
membrane, it is obvious that a very severe strain must l3e thrown upon 
this articulation when an unusually lar^e or well-ossified fetal heaa is 
delayed before escaping under the pubio arch and through the outlet 
of the pelvis, and so is enabled to extend forcibly the sacro-cocoygeal 
carve, tending to thrust the lower part of the sacrum backwards, and 
BO to force forwards the wide base of this bono between the ossa 
innominata, separating these, and thus placing an amount of tension 
on the sacro-iliac joints and their posterior ligaments, which, if long 
conttoaed, may bet up iuftammatory mischief here. — [Ed]. 

2 F 2 



43(} THE THERAPEUTIC INFLUENCE OF BEST [Lki^ 

and severe, but natural labour, sho had been deliverod 
on April 17tli, 1853. of a healthy and stniag child. Sbft 
roniained in bod, and evcrj'thing went uu well for two oE 
three weeks, when, on moving abruptly iu bod and tuniin|^ 
quickly on lier side, aho felt pain for the first time in ' ~^ 
loft hip. It was not thou severe, but gradually incrcc 
in severity, piuticulariy on attempting to stand or wa]l({ 
Siho had at the same time obstinate constipation of tb% 
iKiwelfi. She oontinued lame, suffering h«m pain in ih/tl 
hip and on the inner side of the knee, restless nights, wi^t 
profuse perspiration, and depressed general health- Sl^t 
took quinine, eulpburio acid, and other tonics, and hadtib 
belladonna plaster applied to the gluteal region. On Jting 
25th, seven weeks after her oonhnument, I saw this lady^ 
in consultation with Mr. Sinclair, of Halstead. There watt 
some difSculty in making out the scat of the disease. £ 
found her reclining with her right side upon a couch, to 
and from which shi; \vua currit'ii by bor husljiiiid, as (-he 
could neither stand nor walk without pain in the left hip- 
joint and knee. The left limb was shorter than the right, 
liecause the leg could not bo perfectly straightened, and 
the thigh was a little bent upon the abdomen and slightly 
adduuted, (These are very much the outlying symptoms 
of hip-joint disease.) She was really iu extremely bad 
health ; her nights were sleepless, her appetite gone, she 
was always in pain, with symptoms of commencing hectic 
On attempting to stand, it was impossible for her to bear 
the slightest weight on the left leg without agonizing pain. 
The buttock was flattened on the left side, and when the 
solo of the foot was stmck 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 
experienced in it by flcKion. rotation inwards or outwanls, 
nor on pressure in front of the joint ; at least, there was not 
more tenderness than is usual in that situation. It was 
plain, therefore, that the hip-joint must lie excluded from 
sitspiciou. On pressing the ossa inuominata towards each 
other, thus compressing the sacro-iliac articulation, the pain 
in that joint and in the hip and knee on the left side was 
; and on examining the back, and pressing upon 



XYH] AND THE DIAGNOSTIC VALUE OP PAIN. 437 

the posterior part of the left Bacro-iliac joint, great pain 
was felt near the point of pressure. On accurately measur- 
ing the two limbs, it was shown that the apparent shorten- 
ing of the leg depended on the slight elevation of the left 
aide 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 
swelling towards the left sacro-iliac joint, and pressure upon 
the supposed abscess 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 rest to the sacro-iliac 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 the 
pelvis posteriorly and laterally, including the hip-joints. 
She was not allowed to move from her position in bed and 
upon her back for any purpose. Some saline febrifuge 
was to be taken 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 bella- 
donna 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 straight, and lies flat upon 
the bed by the side of the other leg. A pelvic circular belt 
was applied, and constantly worn. 

It was plain that this lady had a long illness before her. 
As she had been of extremely delicate health at all times, 
as her residence at that 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 lodgings 
opposite the sea, without being moved from the horizontal 
position. She returned from Brighton in October 1854 
qtiite well ; indeed she had been so for some considerable 
time previously. 



439 THE THEBAPEUTIO INFLtlENCB OF REST [Lew- 

In the spring of 1865 aho wiia able to take any retwon- 
aLlo walking cxeroiae without pain or ineonveuience. tod 
was considered cured of her eacro-iliiu; disettso ; she hSft 
renminod in that respect qiiito ■well. I might add that 
the abBceHs entirely disappeared. She never pasned any. 
purulent fluid from the rectum ; henoe w* laay infer that , 
tho nhacess wae absorbed. Several BU])orficiaI abscee«eir 
formed in the left leg below tho knee, and wore opened, . 
giving isBne to unhealthy pus. 1 tliink it is in accoixtanoB ' 
with tho eupcrienoe of most aorgeooB, that when purulent 
absorption haa taken plare, if the person be not very 
healthy, the BQOondary ahsoeBses, which may ]>erfaap6 bff ' 
tho conaequonoo of that absorption. havQ, generally speak* 
ing. unhealthy and offensive pns within them. I haT» 
ncitioed it repeatedly ; and it becomes a ii&|)p7 provision 
ou the part of Nature when ahie selects thoae parts of tha 
boJy where the Hocondary abseesB may be ootnpn,ra lively 
harm loss. 

This lady wore a belt embracing tho pelvis during nearly 
the whole period of hor residence at Brighton, and took 
cod-liver oil and steel wine aomewhat irreguhiriy. The 
only therajwutio agent efficiently eniployod was local 
mechanicnl rest to the saoro-iliac syiichondroais. and that 
princijile was most completely and satisfactorily carried 
out. Since that time she has had no children. 

In the following year she had disease in her right knee- 
joint which becamo much swollen. She thought it was 
brought on by trying to save the left leg in walking. This 
was a tedious thing, but she got over it by a]>plying a 
aplint to tho joint, and so giving it rest, and by spending 
a SHmmor in Wales. In .7anuaiy 1801 I saw her again. 
She was in excollont health ; indeed I never saw her look- 
ing ao well. 

These .ire all the cases of sacro-iliac disease which I think 
it necessary to adduce (they are not all which I might 
have placed before you) to show how this disease may iio 
diagnosed ; and that, when once clearly diagnosed, the 
treatment is one of cKtromo simplicity. Wo must give rest 
to tho joint by the recumbent position, and aid anchylosis 
through the medium of close coaptation of tho opposite 
surfaces of the bonca by a pelvic belt. 



XVU-] AND THE DIAONOBTIC VALUE OP PAIS. 43fl 

Before quitting the neighbourhood of the pelvis, I would 
niake a few remarks od aome cases of diseasu of the sacro- 
coccygeal articulation: but first let me refer you to this 
diagram, showing the sacral nerves pausing over the pos- 
terior surface of tho sacrniu, and spreading their branches 
over the lower part of the sacrum and coccyx (Fig. 85). 




J.K 



e. Tubr'ntKr of itchluin. d. Greater ucro-KliIlc llgamFtii. t, Lesur ucro^ 
•ctalk llgBDwnt, with pudic nsrve lyinB npon lu poBUrlor iiBpwI. r. Sphincter, 

i, TniiBvcmis pcrliutl. it ^Erector pcnLa- i, Accelerator uriDQ- 
1, Pudic nerve croBiiog antoriot Bacro-Bci«tic ligament, and dividing 
into broncbes, toniB to Ihe aphiiicler ani und lower part of Hie 
rBotum. part of which perforate the mnscular fibres in order to 
reacli the mucouB membrane of tb« rectum; otlierg In tlie muicif* 
ae«n in the fore-part of tbe sketch. 2, Posterior branchei of the 
Recond, tliird, and fonrth sacral nerves proceeding to the posterior 
aspect of the coccyx. 3, Sacro-coccyseal neiru distributed over 
the apei of the ooccji and adJHoent &ofl parts. 

In tho sketch (Fig. 86) you may seo tho attachment 



THE THERAPEUTIC IKFLLENCE OF REST [Lot. 

3 gluteus niaximuB to the coccyx. It must be 
18 that if the sacro-coccygeid joint or the cocgrx 
be inflamed, and the glutcua maximuB be used to 
xtfiut in the act of eleTfttJng the body from the 




sitting posture, or in sitting down, or in rapid progression, 
the coccyx or sacro- coccygeal articulation must bo 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 mazinitis. Then notice the mus- 
cular association of the posterior part of the external 
sphincter of the anus in this drawing (Fig. 85, f) ; its fixed 
point is at the apox of the coccyx. During defecation, this 
muBclo and the levator ani contracting would tend to disturb 
or displace the coccyx, and pull it away from the sacrum. 



XVnj AND THE DIAGNOSTIC VALUE OP PAIN. 441 

Some of the symptoms of which such patients generally 
complain are thus explained. 



Disease of the Sacro-coccygeaX Joint, from Injury ; cured by 

Best. 

I saw the young woman, to whose case I am about to 
refer, on the 2nd of April, 1860, and she gave me this 
history. Ten months before she fell upon the comer 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 care- 
fully, but she could not run or walk rapidly, and she 
experienced great pain in going up-stairs, or upon sitting 
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-coccy- 
geal articulation. 

For treatment, she was directed to lie down as much as 
possible, to take the twentieth of a grain of bichloride 
of mercury, and a drachm each of tincture of rhubarb and 
tincture of bark two or three times a day, and to keep the 
intestinal evacuations soft with confection of senna. 

She continued lying down until April 20th (eighteen 
days), when I saw her again, and she was in every respect 
l^etter. She then went home to lie down a month longer. 
After the lapse of that time she was so much relieved from 
all her symptoms 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 sacrum, and she suf- 
fered no important inconvenience unless she happened to 
sit abruptly upon a hard flat surface ; then the angle of 
union between the coccyx and sacrum was painful. The 
pointed end of the coccyx annoyed the rectum somewhat, 
Dut she was getting accustomed to that. In 1861 she 



iM it \ nil I ;ni\ ('xireiuc an mil <»n iiie ] 
aiitl to take cavu that no linMt anion: 
shall 1)0 iv<{nir('<l I'ortliL* ])nr])Ose (.iMct 
should be kt'jit 8(^f't, and the ])atient j 
a largo amount of fluid iiourishmei 
absorbod, and leaves very little fecal 
the chief indications in the treatmei 
they all relate to the subject of mechan 
of which is the secret of the sucoc 
cases. 

Inflammation of the. Coccygeal Joints^ J 

Rest, 

^The last case of this kind to which 
following : — In consultation with th 
I saw a young lady, aged sixteen, in 
. She had slipped down the steps of th< 

( frost of the preceding winter. She \ 

region, but said she did not strike h< 
sequently felt the local pain. Soon 
pain in defecation, in assuming the < 
attempting to walk. At the period of 
in every respect in good health; bi 
about six months — she had suffered 
constipated bowels, and loss of appel 
general health anything but good, an< 
losing flesh. Her easiest posture wai 



\ 



XVH] AND THE DIAGNOSTIO VALUE OP PAIN. 443 

a recumbent position upon a hair mattress, and not allowed 
to get up at all during the first eight weeks. At the expira- 
tion of that time it was found that nearly all the local 
symptoms had disappeared. She then took gentle, limited, 
and carefully-watched exercise (partly at the sea-side), and 
ultimately got quite well. I saw her father on February 
25th, 1860, and he reported to me that his daughter had 
been, and was then, quite well, except a slight disposition 
to be coustipated. 

I had intended, if this patient had not been relieved by 
rest, to have put a bistoury under the skin and cellular 
tissue, and detached the external sphincter from the coccyx. 
I did this operation some years ago in the case of an 
hospital patient, who had suifered from the same kind of 
injury and had the same local symptoms. 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 have since that 
time seen several such cases quite as severe, which have 
done well by time, and perseverance in the method of treat- 
ment by rest alone. 

Surgeons are consulted by persons who have great pain 
and tenderness in walking, some pain in defecation and in 
sitting, and pain about the posterior part of the coccyx. 
This kind of case occurs more especially 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 cir- 
cumstance, — 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 inflammation. 
Such patients scarcely ever, or rarely, receive any benefit 
from remaining in the recumbent position. The explana- 
tion of the symptoms is this: — You will remember that 
there are numerous sacral nerves spread over the posterior 
surface of the sacrum and coccyx, and that they are in 
intimate structural communication with the anterior sacral 
nerves, which join with the hypogastric plexus of the 
sympathetic within the pelvis, and thence proceed to the 
uterus and ovaries. There is pain and sensitiveness in the 
skin and over the sacrum and coccyx, difficulty in walk^ 



cw<l to the kiifnvioiiit. for the pni^H 
value (iii.l tniv ivhition of " mofh:n.i 
in tho injiuios mid ilisi'asce -.it tin 
would Bolioit your attention to an in 
derelopment of the patelln until thi 
age. 

One of Non-development of both PateH 
and a hdfjfeart. 
This child (a female) waa bom in 1 
of gestation — the mother says with on 
BO aa to rest upon the cheat, where ai 
and an abscess sulwequently formed, 
deformity in any of the mother's pn 
ohildran. I saw the child at Guy b 
months old. Her legs below the kn 
lated into any position, backwards, f< 
without pain. She could flex the 1 
patella or distinct ligamentnm patel 
careful examination, be discoTered bj 
hospital, or by myself, in either knee 
AsUey Cooper examined this child's 1 
reBolt ; but he assnred the mother tha* 
walk well after a few years, for he ha 
and the child ultimately walked well 
made of the patient by Canton in 18 
one foot, turned nnwardn T* n-n"! 



XVnj AND THE DIAGNOSTIC VALUE OF PAIN. 446 

it turned out to be the eame child. There were no patellad 
at that time — not a rudiment to be felt ; and I saw the 
child walking about the room, bearing its weight upon 
the condyles of the thigh-bones, with the legs turned for- 
wards, the feet in the air, the soles of the feet presenting 
directly upwards, and the child hugging one foot, ana 
sucking one of its own great toes. The mother assured 
me that the child used to go to sleep in that way. She 
could not stand upright by herself on her feet, but moved 
about upon the posterior surface of the condyles of the thigh- 
bones. I advised the parents to place forms around the 
room, so that she might rest her hands upon them, and in 
that way begin to employ the legs as organs of support 
and progression. This plan was carried out, and the child 
was not allowed to walk as hitherto, nor to pull her legs 
directly upwards towards the face, which she was very fond 
of doing. The legs were from this time kept quite strai ght 
when in bed or lying down. When three and a half years 
old she had no patellae, but at about four years very small 
ones, like peas, manifested themselves, resting in a rudi- 
mentary ligamentum patellae, which Mr. Owen, of Finchin- 
field, then or soon afterwards recognised.* From that 
time she began to be safer on her legs, and when she was 
about five years old she could walk, supporting herself by 
two short walking-sticks. Afterwards she walked increas- 
ingly well, but not safely ; for the legs used frequently to 
give way under her, and she would fall down. At between 
six and seven years of age I examined the patient. She 
could walk uprightly, but not with perfect steadiness. Each 

* A rodimentary patella lias been noticed at the third month ; it 
remains cartilaginous up to about the third year, when ossification 
commences usually by a single nucleus. To meet the increasing 
strain upon the bone, ossification should be complete about puberty. 
A somewhat similar case will be found recorded by Mr. Godlee, Clin. 
800. Trs., vol. X. Here the left knee only was alfected, and the 
patella, though small, was present. The congenital dislocation for- 
wards in this case appears to have been due to a constant spasmodic 
action of the extensors of tlie knee. " Mechanical rest " was made use 
of euriy (the child was only seven weeks old), and successfully, by 
means of an apparatus which prevented dislocation forwards or late- 
rally, aided by an ac(!umulator worn behind the knee to aid the flexors 
in overcoming the extensors. — [Ed.] 



Pi 



I 

i 

.1 



•« 



J 

■ ^ 



])art of tlic (lay. The ])atelljL' are ^ 
and in ^^ood nosition ; indred, on 
notliinj:; peculiar ]H'e8ents itself, bu 
suddenly conios down upon her fee 
she is apt to faU. I saw nothing p 
of walking when in my room. 

Here is a case, then, where " mec 
starting-point of the freedom of a 
deformity. If she had been allo'v 
upon the condyles of the femur, it \ 
followed that the strong crucial \ 
employed to maintain the bones in t 
each other, and to oppose inordinate 
have been so stretched that it would 
impossibility to render the joint sei 
ing the erect posture, or in aiding p: 

Disease of Knee-joint (Scrofulous ?) trea 

cured by firm Bony Cons 

F. L was nine years of age "v 

knee commenced swelling without ol 
out much pain ; for a few days lotio 
applied, and he was kept in bed. 
treatment, as he was not only not im] 
tenderness, and swelling were incre 

of DhathnTll. bmnorTif \\\m +rw f»io ir» 1 



XVIL] AND THE DIAGNOSTIC VALUE OF PAIN. 447 

within the joint ; no rough pressure or movement of the 
joint could be borne ; the knee was flexed, and could not 
be straightened without inducing extreme pain. His father 
had a portion of deal gouged out so as to make a deep 
trough, in which the child's leg was placed. The edges 
of the trough were higher than the prominence of the 
patella ; the two long bones forming the joint were kept 
straight, and the edges of the splint prevented the bed- 
clothes from touching the leg at night. Steady pressure 
upon the joint, by strapping it with soap plaster, and per- 
fect rest to the joint by the splint, with attention to his 
general health, were continued during several months, 
when, finding the joint diminished in size, less painful, 
and still slightly movable, a thick leathern 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 six- 
teen months he was not allowed to make the slightest 
attempt to bear any weight upon his leg. He was carried 
about in the arms of his mother, or placed in a little car- 
riage, and drawn out daily when the weather permitted. 
Then he began to get about very cautiously on crutches. 
His general health was very bad, but the knee was dimi- 
nishing in size. From that time the limb became more 
sightly and more useful. He was taken into Wales to the 
sea-side, and he had all the advantages that good air, 
domestic comfort, and extreme care against injury could 
provide. After staying there some months he was brought 
to town by sea, and I then saw him. There was obviously 
defined fluctuation above the knee, as well as in the pop- 
liteal region ; the patella was firmly fixed to the front 
of the femur, and the tibia was partly united to the 
condyles. The abscesses did not communicate with each 
other, so far as could be ascertained. His health was 
better than formerly, but he was still very feeble and deli- 
oate-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 



448 THE THBAPEUTIO ISFLUENCE OF REST [Lkt. 

by aea to Pembroko for the winter, and in a few months 
tho popliteal abecees broke, and tbe one abovt) the patella 
was opened by the 8urge(m as soon as the skin coveriiig . 




Ibui [be Lefl, and tbc ligUl fool 1> pot bo fullf ijevelopnl u tbc U'ft. 

the abBcesa became verj- tliiu. The purulent discharge was 
not excessive, the walls of the abscesB did not inflame, and 
the joint remained free from furtlier implication. In the 
spring his health had much imjii-oved, and tho discharge 
from the sinuses soon cijased. Findins he could bear some 
weight on hie leg without pain, he took (with hie crutches) 
a gradually increasing extent of exercise during the next 



XVn.] AND THE DIAGNOSTIC VALUE OF PAIN. 449 

two years, when the crutches and leathern splint were put 
aside. He was then 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 his leg reached 
the condition represented in this drawing, which was 
made on the 20th of June, 1861. In April 1861, the 
report respecting him is this : " He is now in his nine- 
teenth year, can take almost any amount of walking exer- 
cise, enters into the sports of his college, plays at cricket, 
is strong, and pulls well in a boat. The knee is firmly 
anchylosed, his general health excellent, and his lameness 
scarcely perceptible." By such careful but simple manage- 
ment, and the use of the leathern splints (which he regards 
as a sort of trophy, and says he will never part with), he 
ultimately recovered. 

Diseased Knee-joint^ from Injury ^ with partial Caries or 
Necrosis of the Patella ; cured hy Mechanical Rest. 

The next case is one of diseased knee-joint, depending 
upon, or associated with, necrosis of the patella. Surgeons 
will admit that disease of the interior of the knee-joint, 
connected with a necrosed or carious condition of the 
patella, usually involves a considerable amount of risk to 
the joint. Of the few cases of this kind which I have 
seen, amputation has been required in order to save the 
patient's life in three instances. 

This young gentleman, J. M , aged six years, a highly 

strumous lad, although ofhealthy parents, fell upon some 
pebbles or gravel, and struck his knee-joint, in the early 
part of May 1857. He was afterwards seen 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, 1857. 
He then had suppuration external to the knee-joint, and 
effusion of inflammatory fluid into the interior of the joint. 
He had strumous ophthalmia, some ulcers upon the cornea 
and at the margins of the eyelids, and his general health 
was exceedingly bad. 

Here was an important and serious complication of an 
external abscess connected with disease of the patella and 

2 G 



l»au-iiii, auu LiiL'iu loii a iiecroseu ( 
the boTU'. 

Tlic removal <»f the fluid from tl 
fluctuation within tlio knee-joint l 
whole of tho joint was hot, swolle 
ing groat gentleness in moving th( 
leathern splint was applied to tl 
half of tho thigh and upper half 
knee. The splint was worn day a] 
poultice to the wound. The genei 
first of alkalies and bitters, and sub 
and cod-liver oil, together with good 
wore the splint uninterruptedly duri 
abscess was slow in healing ; exube 
projecting from the wound over the 
• i persistence of some deep-seated loct 

'ii unhealthy bone. These granulatio 

{. ! the skin-level by nitrate of silver. ' 

tion, swelling, and puffiness of th< 
sided, and in a few more months he < 
out difficulty, but with the joint sti 
In March 1858 he had a seconc 
knee, which brought on fresh subac 
matory action within the joint, asso 
}j stitutional disturbance. Soon after 

again ; the knee had become flexed, 
1 1 a tendency to become dislocated bac 



• t 

I 

■Ii 



XVIL] AVD THE DIAGNOSTIC VALUE OF PAIN. 461 

thickening, and some heat about the joint. He was taken 
to the sea-Bide, where he remained till the middle of 
October. At that time I again saw him. All the joint 
83rmptoms had nearly disappeared. The splint had been 
worn nninterniptedly ; 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 exa- 
mined the knee to-day. He can do anything he likes 
with it, and can move it in any direction. There is no de- 
formity 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 surrounding skin, and is 
adherent to the bone. 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 
extraordinary^ one. I used to think if he got off with a stiff 
joint he would be ver^^ fortunate ; for, if you remember, 
the head of the tibia was inclined to be displaced back- 
wards. But here he is, and to see him walk you would 
imagine that he never could have had the serious disease 
of the knee-joint he had." 

This patient certainly did present the appearance of 
what is termed a scrofulous and strumous constitution, as 
evidenced by his bad general health, enlarged glands in his 
neck, and ulceration of the cornea and eyelids. I might 
add to these facts by noting that the disease of the patella 
was brought on by a comparatively slight accident. Yet 
he is now perfectly well. It is probetble that small portions 
of carious bone may have been extruded with the purulent 
discharge, but none have been seen. 

The next case to which I will allude is 

A Case of Traumatic Dislocation of the Tibia forwards and 
outwards, treated by Best and the persistent application of 
Cold. 

It is to this latter circumstance I would take the liberty 

2 o 2 



lliir.l, au.l a ilinl.«:iitiuii of tlio k-ft 
%v:,i:U. '[■h,■^■.■^vM■.lU■.i]■uol■nv^lM^ 
the anU'riur and ontur part of tbo 
projection forward of the head of 1 
of its upper eurfaoe oould be distu 
the integuments. The patella an< 
dined obliquely forwarda, and the 
quite lax ; u^xin the baok of the 1 
felt tto two rounded prominenoea 
femur, and the tendons of the flexort 
formed tense cords on the lateral bi 
mosis existed on the outer and Ion 
and the injured limb was somewhat 
Chloroforxa having been adniiniat«n 
relaxed ; extension and oounter-e 



accompanied by a alight snap, and 
flumed its natural appearanoe. A oc 
woa put upon the ba^ of the limb, i 
te the middle of the thigh. A bladd 
constantly applied to uie knee for 
nights without intenniBsion, in ord 
temperature of the knee, the result 
during this period no symptom of lo 
observed. On November 26th thn » 



?Vn.] AND THE DIAGNOSTIC VALUE OF PAIN. 463 

tho only medicines, slight aperients occasionally, and ten 
grains of Dover's powder to procure sleep. He got quickly 
well. 

This man had dislocation of the tibia, and must have 
torn all the internal and most of the external ligaments 
of the joint. During seventeen days and nights the joint 
was never allowed to got warm, and he had not a single 
bad symptom, except on one occasion, when, for the pur- 
pose of observation, the application of the ice was left off 
for a few hours, and then the joint began to get hot and 
painful. 

Permit me to add another case illustrative of the good 
effect of the local application of cold in j)reventing the 
occurrence of inflammation, after a wound in the knee- 
joint. 

A young man came into Guy's having received, a few 
hours before, an incised wound, nearly throe inches long, 
penetrating into the anterior and outer part of his knee- 
joint. The limb was put upon a long straight wooden 
splint, and thus supported, the foot and knee wore elevated, 
80 as 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 irrigation, by 
dropping cold water during twenty-three or twenty-four 
days and nights. The patient had not one bad symptom, 
except when we took away the cold irrigation by way of 
experiment, and then he began almost immediately to 
experience pain, heat, and more swelling within the joint. 
He finally got perfectly well, the joint completely recover- 
ing itself without permanent defect or injury of any kind. 

I cite these two cases, but 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 pre- 
venting or controlling inflammation after traumatic injury. 
The cold should be applied with a spirit of defiance to the 
inflammatory condition, and a fixed determination not to 
permit its occurrence. I feel confident, from what I have 
seen in private and hospital practice, that if we could only 
make proper use of cold locally in cases of accident or 
injury, and employ it eflBciently — ^that is, continuously and 



tliw liiitlidd (jf i>r.>cee<liiiK the tnio 

must ]wti;nt remedy, acting jiowiirf 
the nervouB Byatem, aa 'well as i 
larger blood-TeeaelH, and I mast a^ 
most nnphf Biologically and feel 
oountry." 

I have here a case of tranmatio i 
on which I muat dwell for a few n 

Lacerated and contuted Woitnd lojf 
Supjntratton trilhin and aroa*d 
the Articular Surface of the Sm 
of the Joint; lAnib fixed in a go 
a firm toooden ^lint, lo ituwefi 

William K , engineer, age 

healthy-looking youth, whose leg li 
machinery of a steamer near Do^ 
Guy's Hospital on October 28th, 18l 
the accident), with an extensive '. 
wound over ibe inner condyle of 
portion of the integument had been ] 
wound pasftad under the iutegtime 
the knee-joint. The edges of the 
t<^ther by pins and figure-of-8 
sliehtlv flov-l ■ ■■-"" "■"- • " 



XYEL] AND THE DIAGNOSTIC VALUE OF PAIN. 455 

temperature continues very high. Bowels open ; pulse 
90 to 100. 

30th. — The joint is very hot and painful, with much 
effusion within it. Patient gets no sleep. Pulse 90, full ; 
tongue furred. Pins taken out ; wound suppurating. Two 
grains of opium at night. 

31st. — Patient is flushed; pulse 100, full. Ice to be 
discontinued, and warm poppy fomentations applied to the 
knee, and the limb to be placed on a splint. The bowels 
being costive, aperients were ordered. 

November 2nd. — He is much quieter ; the pain is lessened. 
There is discharge of much healthy pus from the wound. 
Slept four hours during the night ; bowels opened ; pulse 
90. Ordered full diet. Listen's splint apj)lied. 

7th. — Patient is comfortable. The discharge is purulent 
and profuse. Appetite pretty good. 

11th. — Much inflammatory suppuration around the joint ; 
incisions were made above and below the joint to give exit 
thereto. Ordered wine, &c. 

22nd. — Suppuration is extreme, both from within the 
joint and from the soft parts without. Patient is rapidly 
emaciating. Several pieces of bone have come away, one 
of them having a distinct portion of articulating surface 
upon it. 

28th. — Patient does not sleep well, and is getting thinner. 
Ordered opium every night. 

December 1st. — The joint seems thoroughly disorganized. 
It is being straightened gradually upon a wooden splint. 

4th. — Much difficulty is experienced in retaining the 
limb in a proper position, owing to the tendency of the 
tibia to be dislocated backwards and outwards. 

15th. — It has been necessary to " put up *' the limb afresh 
every two or three days. Dislocation of the tibia is with 
much difficulty prevented. The plan now adopted seems 
to answer the purpose. Listen's back splint is applied 
behind, a short splint on the inner side of the thigh, and 
a long splint (interrupted opposite the knee), extending 
from the foot to the armpit, on the outer side of the limb. 
The discharge is much diminished. Patient feeds and 
sleeps well ; pulse 80. 

January 5th, 1862. — Lately there has been an increas- 



L'Oth.— U\.uiia i 



I'VLniary 1 Sih.— After fuur inoii 
pix-'tty firiuly auchylused ; nt> pail 
fixed to the femur ; tiw joint iB T 

March 3rd. — With the exceptioii< 
near the knee, which forttmately 
repairing structures, nothing untc 
this patient, who may now be saic 
log ie nearly an inch shorter than 1 
left the hospital with ashortwoodc 
of the knee, and supporting his wei 

Soon after leaving Guy's he fell, 
his anohylosed knee. He came ags 
pain, heat, and swelling of the knee 
to the back of the limb, which was 
constantly applied to the knee, bo a 
of heat. With these simple means 
dnriug a month, his knee Mcame fr 
swelling; and he again quitted tl 
bearing some weight apon the limb 

This case does my dresaer, Mr. I 
The patient at one time was despe 
been at all disposed to cut off a lim 
that occasion as an opportunity for 
preferred watching nml o^n-i-: — 



XVn.] AHD THE DIAGNOSTIC TALUB OF PAIS. 457 

limb. The bonea dre firmly united to each other, and 
there is nodisplacemeiitof the tibia laterally or posteriorly. 
The biceps was our great opponent, and I threatened to 
cut its tendon asunder; but thinking wo might beat it 
without any cutting, we applied a small firm bag of sand 
over the head of the fibula and under the side splint, bo 
as to press the tibia inwards, and it succeeded. I verily 



Sketch of W. K— 




believe that if the dresser and bouse surgeon had not been 
absolutely determined that displacement of the tibia should 
not occur either backwards or laterally, this man would 
have had a very deformed and almost useless limb, but he 
BOW has one that scarcely offends the eye at all, and which 
will be a very useful member both for support and pro- 
grosBion. 
I venture to append this further remark : I feel quite 



458 THE THBBAFEOTIC INFLUENCE OF REST [Lkt. 

COD Gdont that, provided emrgeons will adopt and foUowoat 
with inflexible detenmsation iiim plan of Becuring "me' 
chaiiioal reet " to iaflatued aud euppuratiiig Joints, they 
will Tory BL'ldom aee much deformity in anch casea. sud very 
rarely be^reqnired to exciae the joint, ur amputate the limb, 
iujury Ui the mGdium of ntiion betwoen the sfa&ft and 
lower epiphysis of the femur ia not very rare ; from what 
I have Been in public and private practice, I think that it 
IB a pflthologioal condition not unfroquently overlooked, 
the local syTOptowis being miBiiiterpretfd, Any injury to 
tho epiphysis itself, or U> the soft tissue uniting it tu the 
Bhaft of the thigh-hone, requires the aid of ueclianical rest 
for its relief or cure ; and here is a caae in point. 

DiieoK hetmeen the Shaft and Loaer EjAphygia of the Femur ; 
Su]ipUTallon ; AhmcffKi opt-ned ; cured by Betl. 

Fanny II . fi^ud ti'ii yciirs, was admittLd into one 

of my wards on April 13th, 1859, AVhen three years old 
she had a fall over the end of a bed, which stunned her. 
When takeu up she could not put her right foot to tho 
ground ; and the knee became flexed, so thiit the groat toe 
was two or throe inches from the ground. In a short 
time, however, she became much improved ; hut her father 
noticed a slight weakness in her walking. On April 21st 
her right leg was very slightly shortened, say a quarter of 
an inch; tho knee-joint ctnild be neither estetided nor 
flexed perfectly. There was pain on pressing a spot one 
inch above the knee-joint both on its outer and inner Bide ; 
the temperature was much increased at both points, and 
some swelling existed there. The upper part of the pop- 
liteal space was hard, full. Lot, and tense ; with pain at 
intervals occurring twice or thrico a day, and lasting about 
ten minutes. A long straight splint was put on the limb, 
extending from the axilla to tho foot ; she was ordered 
one grain of iodide of jxitassium with infusion of bark 
three times a day, and poppy fomentations to tho swollen 
part. 

April 23rd. — The long splint could not he borne, and it 
was removed. 

27th. — No improvement. Tho patient suffers very much. 



XVn.] AND THE DIAGNOSTIC VALUE OF PAIN. 459 

The limb was then placed upon a double inclined iron splint, 
and swnng. Six leeches applied upon each side of the 
knee. Two grains of mercury with chalk and three 
grains of Dover's powder to be taken night and morning, 
and some saline febrifuge during the day. A hemlock 
poultice was applied over the painful part. 

May 9th. — There is distinct fluctuation of an abscess to 
be felt under the vastus intemus, anterior to the tendon of 
the adductor magnus. An opening was made through the 
skin and fascia 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 the abscess, from which about two ounces of healthy 
pub quickly flowed. 

June 7th. — ^A deep sub-muscular abscess was opened on 
the outer side of the knee, and sixteen days subsequently 
another opened of itself in the popliteal space. 

Jidy 20th. — The leg has been at rest, swinging upon the 
iron splint, and the knee can now be perfectly straight- 
ened without pain. There is no distinct swelling, but a 
little general thickening of the lower part of the femur 
immediately above the knee-joint. The wounds have all 
closed. The iron splint is to be left off, and a firm leathern 
splint is to be applied, so as to keep the limb straight and 
the seat of the disease undisturbed. 

This mechanical support was continued through several 
weeks, and during that, and for a long 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, with- 
out any untoward symptom. 

I have no doubt that this was a case of disease between 
the shaft 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 part is not, 
I think, often referred to, but I am convinced that it is not 
of unfrequent occurrence. 

I am anxious to impress upon the profession generally 
my strong conviction that in all cases of accidental injury 
or inflammation of the knee-joint, as well as in every 
disease of this articulation, the knee should be kept unin- 
terruptedly at rest and straight, until its reparation is 



460 THE THERkPEUnC INFLCKNCE OF REST [LeCt. 

complete. I l>elicTe that as sooa as stifGcient importaooe 
IB given to Buch views we shall cease to witnesa thow 
numsroua and ostraordinary deformities alxjiit the knee- 
joint, resulting entirely from the want of mechanicsl 
reBistanco to that mnaoular force, which canses bo oftea 
dislocation of the tibia andfihula outwards and backwaida, 
of which you may find so many specimeiiB iii the metTO> 
politan and other pathological muaeume. A fixed rigid 
Bplint will certainly prevent Buoh deformities— I feel poai- 
tivo about it — provided the splint be sufGciently resisting. 
A gntta-percha splint will not accomplish it, not bcitig 
BufBeiently strong. A firm, padded splint of leather, wood, 
or iron ought to be placed along the posterior and laterJ 
part of the joint ; and I may add that in all such cases it iK 
advifiable that the limb be swung, as in cases of &actnraa 
of the leg. During many years I have Bwung aearly all 
my cnses of acute disenao of the knee-joint, and I have 
found it cimtrihute iiiJiinjiiB^.ly to tliu com'ruil uf tlio piitieut 
Hero are two or three caseB in illustration of the 
deformity which ensues from the non -employment of 
mechanical resistance to diflturbing muscular force, and 
the method of proceeding to lie adopted in order to remedy 
the deformity which may have occurred. 

Case of Dmamd Knee-joint; the Knee fiexed, and the Tibia 
parlially disheatcd backwards ; Ihe Biceps Tendon divided, 
and the Limb straighteaed ; cared by Mechanical Reel. 

A young woman, J. M , when she was two years old, 

had a fall upon her right knee, and suffered afterwards 
from symptoms of acute inflammation of the joint, followed 
by contraction of the ham-string muscles, and extreme 
flexion of the knee. Two abscesBes, one in the popliteal 
region, and one above the knee, were associated with this 
diseased joint. She was not able to walk without crutehe* 
after the accident ; very inconvenient inBtrumentB were 
employed for the ])urpose of putting the leg straight, and 
flhc thinks bLo received more harm than good from their 
application. On March 29th, 1860, she came under my 
care in Guy's Hospital ; she waa then eighteen years old. 
When standing upon the left leg, the heel of the right foot 



XTU.] AKV THE DIAONOSTIO TALUB OF PAIN. 461 

WB8 between four and five inches above the ground. The 
pfttella wftu filed firmly by bone to the femur. Chloroform 
having been given, forcible eiteneion was employed, but 
we could not straighten the limb; the tendon of the biceps 
muscle was therefore divided about one inch above the 
head of the fibula ; forcible exteneion of the knee was 
oontinned, and the limb straightened, after which a straight 
vooden splint was applied to the limb upon its posterior 




aspect. After the operation, ice in a bag was constantly 
applied to the knee, in order to prevent the occurrence of 
any inflammation, and five grains of Dover's powder were 
ordered to be taken at night. On the 13th of April, within 
a fortnight of the forcible extension, her leg was straight, 



41)2 THE TE&BAFBtinO IMFLUBHOE OF REST 

and very comfortalile. The Bpltnt was constantly applied' 
until May 2lBt, and here is tJit; final result. Tbiadrawiiw 
(Fi^. 89) was madti in January 1862, Riid accaratdj] 
repreeents her present condition. Yon will obeerve thaKj 
t.lie ground-planH of this patient's feot present some Qotaliai 
poculiaritiuB ; tlio ri^^ht foot is altogether smaller than thtt 
loft, and its outer portion is but imperfectly developed^ 
whilst the great toe is exceedingly prolonged. This, I 
apprehend, is owing to the period of life at which this wt« 
a compamti%'ely usclesB foot. The great toe has, howeTW^ 
grown most extraordinarily since siie has heon using Uu 
limb. Yon may remember that on a previous occasion 
(Lecture XIII.) I reminded you that wo might divide the^ 
foot, aiiatoraically and physiologically, into twolongitudioti: 
parts — into the outer or strong part, and the Inner ormo»' 
elaetio part, connected, structurally and functionally, with 
the more advunccd pcriiwi of life, when tiw fixit is reijuired 
to be in a state of |>erfection. It secniB that this patient 
formerly used her right foot scarcely at all, and it did not 
grow with the other foot; but soon after the biceps tendon 
was divided and the foot came into active use, the growth 
of the foot has been something marvellous, and cspeciallv 
on its inner side ; hence the prolongation of the great toe 
seen in the giound-plan. The patient is now altout twenty 
years old, niid can take a eousidei-able amount of exercise 
without difficulty. 

In this case I did not find it neccsBary to divide thi' 
tendons of the semi-ten din onus or the sonii-membranosuti 
nmsclos ; these, after the division of tlie biceps, j-ielded tn 
tlie influence of extension. 

Before openkting upon the tendon of tlie biceps muscle, il 
is neeessarj" to bear in mind, iind to ascertain, the exact 
position of the external [xipliteal nen-e. I'revious to the 
adiuinistratioii of the chloroform, there is usually no diffi- 
culty in distinguishing the real characters of the tens<^ 
cords which you may feel passing along the tightened part 
of the popliteal region, as we see it when the knee is much 
bent from old disease of the joint. Tho nerve may then 
l>e recognised by the pain which is induced when pressure 
is made upon it. Its course being ascertained, tho other 
cords must be tho tendons ; and further than that, as far 



XVU.] AND THE DIAGNOSTIC VALUE OF PAIN. 463 

as I have observed, upon closely examining the parts, you 
may trace the individual tendons up towards their respec- 
tive muscles, and so identify them. 

Old-diseased Knee-joint; Knee hent ; Tibia displaced hack- 
wards ; Flexor Tendons divided ; treated hy " Mechanical 
Best:' 

Martha M , aged fourteen, was admitted into Guy's 

Hospital, under my care, in January 1860, suffering from 
the effects of old-diseased right knee-joint. The tibia was 
drawn backwards and upwards, so that she could only just 
touch the ground with the great toe by inclining the 
pelvis to that side. At five years old when quite healthy, 
she had her knee struck by a little hammer; and it 
became chronically inflamed. She had no splints ; and 
although she was under constant professional treatment, 
she continued to get worse during two years, when she 
was taken to a London hospital, with advanced disease in 
the knee-juint. She remained there seventeen weeks in 
bed, and during the latter j)art of the time, she had scarla- 
tina 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 of 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 tlie 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 knee was flexed and the 
tibia displaced backwards, the condyles of the femur pro- 
jecting forwards. 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 mem- 
branous anchylosis between the tibia and femur. Chloro- 
form having been administered, the leg was extended, and 
the tendons of the biceps, semi-tendinosus, semi-mem- 
branosus, and gracilis were divided. 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 



464 THE THKBAPELTia INFLUENCE OF REST [Lbot. 

siiccoBsful, although some tcariag of the tisenca was heard 
during PUr effurts at estensiou. The limb waa then 
bandaged upon a atraight splint ; the tibia, however, ooaW 
not bo brought to its proper position ae regards the femur. 
lu ten days another spliot was applied, with a scren 
attached to it, so that the knee could be gradually extended 




and the tibia advanced until the limb was ucarly in iti) 
present condition. She left the hospital tightetn woeks 
after admission, with the screw spliut upon the leg. As 
soon iis it was found that the limb could bo maintained in 
that improved jiosition by tho patient, a comm<in leathern 
splint was a^ipliud to it, for the purpose of supporting and 
defending the joint. This Icatheni splint woa worn day 
and night for fourteen months, during which time she has 



XVn.] AND THE DIAGNOSTIC VALUE OF PAIN. 4G5 

walked more or less on the lame leg, gradually increasing 
the distance, and going to school daily, with her health 
improving. 

Feb. 7th, 1862. — She can walk two miles without pain 
or much fatigue in the leg ; no heat or swelling in the 
knee. The right leg, properly measured, is quite an inch 
and a quarter shorter than the left 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 " physiological rest " (by division of tendons) is an 
important agent to be employed in correcting some of the 
deformities of diseased knee-joints. The deformities, how- 
ever, might as surely be prevented by the application of 
splints in the early part of their treatment. 

I had intended, if time had permitted, to adduce some 
facts tending to prove that one kind of loose cartilage 
may be absorbed in the knee-joint, by retaining the loose 
cartilage accurately at rest in contact with the same part 
of the synovial membrane during several weeks, and 
employing counter-irritation over it at the same time.* 

♦ In a clinical lecture on loose cartilages in the knee-joint, pub- 
lished in the Guy's Hospital Reports for 1868, Mr. Hilton gives several 
oaaes in which a loose cartilage gradually disappeared when kept 
fixed by strapping, so as to be pressed firmly against the synovial 
membrane. He concludes by saying, " Synovial membrane is merely 
a modification of serous membrane, and as such is endowed witb 
secreting and absorbing powers. You must use this latter function in 
order to get rid of the important disease whicli is now occupying our 
attention. How is fluid in a joint absorbed? By the synovial 
membrane only, and by no otiier means. With clot in a knee-joint 
would you open that joint ? Ot-rtainly not. 'J'he clots of blood will 
undoubtedly be absorbed. Rcoognide, then, this absorbent power of 
synovial membranes, and use it in the cure of loose cartilage.*' For 
a mention of two other cases treated with complete success, see a 
short but interesting paper by Mr. Man by in the Birmingham Med. 
Review, July 1875— {Ed.] 

2 H 



THE THERAPECTIC ISFLDENCE OF REST {LMdt. 



LECTITRE XVIir. 

rriiruous hibeask or both bldow-join«; jow 



In a previoiia lecture I mentioned that, althouj^h Boni 
dieoased juinta may occur iu perBons of a Bcrofuloue con 
stitution, it docs not necessarily follow that the joints ca » 
not rojiair Ihemaclves by time and ojtjwrtunity. Here i 
a drawing (Fig. 93) wliich will [wrtray such joints. 

Slrumoat Disei 



This drawing from nature represents another instance 
of anchylosis of both elbow-joints, occurring lii what is 
termed a scrofulous youth. In spite of this the elbow- 
joints are perfectly anchyloeed — auchyloaed, however, in 
a very unfortunate position, because he could not feed him- 
self except by bending the head towards the left hand, 



XVUI.] AND THE DIAGNOSTIC VALUE OF PAIN. 467 

nor could he dress himself or make any important nee of 
his anus. 

The following IB a brief reference to thie case: — W, S 

was fourteen years of age when he became, some years 
ago, an in-patient of mine at Guy's Hospital. His mother 
stated that he was always an unhealthy child, and that 
when four years old he had small-pox, followed by what 
the doctors called " scrofular abecesaes." Disease began 
simultaneouHly in both elbow-joints. No splints were 
applied in order to determine the direction of the forearms, 
wliich were allowed to keep in the position represented in 




the engraving. Several small pieces of bono hud been 
remoT^ at different periods from both joints. There was 
no pain in either joint, but some thickening remained in 
the Burronnding 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 scrofalous constitution was mani- 
fest in this patient, yet in both joints anchytosia had been 
aooompliBhol. 



468 THE THEBAFBtno INTLUEliICE OP REST 

ITieoe two drawings (Figs. 94 and 95) show the hand 
aud forearm of a young girl agw! eighteen, who came 
tinder lay care in 1962, with extensive dieeaso of the carjiiiB 
and wriBt-joint oi the right side. The cause of the diseow 
was not known. Bnppuratioii amongst the bones had 
occnrred, leaving soveiul discharging ainnees both on the 
anterior and poetflrior aspect of the wrist. It was veiy 
painful, and the bones coold be made to grato upon each 



ng.*4. Fie. 




I 



other ; it probo ilftocted deuudod bono. An huwpital kiiv- 
goon, seeing no probability of wiving the arm, hud arrange*! 
toamputntf it in n d.iyortwo; hut, Vicfore doing so, I wai; 
consulted, and, as the girl wns in tolerable health, I advised 
her not to faibmit to tho operatiim. A k-athem splint wai^ 
monlded upon her hand and ann, so as to keep tho wrisl 
absolntcly at rest. This splint was worn day and night 
dtiring several months, and she was sent to Margate to 



XVUL] AND THE DIAGNOSTIC VALUE OP PAIN. 469 

reside. The pain and discharge soon diminished, the 
sinuses closed, and she got well as regards the wrist, ex- 
cept that the wrist-joint was anchylosed, so that she could 
not bend it, but she could move her fingers and thumb 
with great freedom in 185 5, 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 
structures. 

The following is another illustrative case, with a rather 
curious history : — I saw a lady some years ago who came 
to me with disease of the carpal bones. She had had a 
ganglion on the back of her hand, and slie went to a 
surgeon to have it cured. He proposed to rupture it by 
striking it with a hard leathern-bound book, but his arm 
was not very steady. He tried several times to break or 
burst this ganglion, by striking it with the back of the 
book, but he could not succeed. At length, however, he 
gave her hand a tremendous blow with a larger book, 
which ruptured the ganglion, but the blow led to inflamma- 
tion 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 I saw this lady for the 
first time, with a painful and swollen wrist and hand. 
Two sinuses were dist- barging pus, and a probe introduced 
into them came in contact with bare bone. A leathern 
splint was moulded upon the hand and forearm, so 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 months ; the sinuses closed, and 
although the wrist is stiff, yet she has a very useful hand. 
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 sufficient to intimate the value of " rest " 
as a therapeutic agent in their treatment. 

There is, perhaps, no part of the human body in which 
the beneficial influence of mechanical rest can be established 
80 perfectly, in so many different ways, and in relation to 
so many different accidental lesions, as the neighbourhood 
of the knee-joint ; so that I could easily extend this subject 



470 THE THERAPEDTIC INFLUENCE OF EEST [Lkt. 

aver two or tliree lecturee, ■with appropriate illustiativo 
caeeB ; but the only one to which I will now briefly allade 
in uiie of forciUe sepnration of the lieamontum patoll% from 
the patella. This is a oomparatively rare accident, aitd it 
requiree to be tr«at€id by abwjluto rest to the leg ; to elevate 
the leg and foot so as to relax the estonsor muscles Ij-ing 
iijion the thigh, and at the same time to employ etripa of 
plaster, horeeBhos-ithaped, to pull the patella downwards 
towards the detaclied ligamciitum patellee. A case of this 
kind was admitted under my care at Gny'e Hospital. 

Cate of Sapture of the LigtmetUttm PaUlltE at ike Junction 
of the Ligament with the Patella. 

Eobert B , aged forty, was admitted into Comelitis 

ward on the 12th of October, 1861, with a good deal of 
Hwelling and eccbymoBis over the whole of tlie knee-jfiint, 
and complete iii^OiilitT to lift 1h|. Iri;. Tho jiccmint he 
gave of the accident was, that he was standing on a plank 
which was suddenly tip]>od up, and his heel became fixed 
in a deep groove in tho plank. He was thrown quickly 
first forwards and then backwards with great force, whilst 
his leg was bent under him. He felt something give way 
at tho knee, and from that time he lost the power over his 
leg. When placed in bed, the patella was fonnd entire, 
drawn upwards, and unnaturally movable, esiiecJally in 
the long axis of the limb. There was a strongly marked 
depression immediately below the apes of the patella, into 
which the finger could be thnist almost to the joint, bo 
that the condyles of the femur could be easily felt ; the 
lower end of the patella could bo directed backwards to a 
great extent, or could bo tilted forwards by pressure on its 
npj>er 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 
kneo-joint. A lead lotion was applied over the whole of 
the joint. Wiien the general swelling had subsided, 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 tho upper part of the ligamentum pat«llfe. 

November 17th. — Tho patient was allowed to get up, 
with a short splint extending along the back of the thigh 



XVI IL] AND THE DIAGNOSTIC VALUE OP PAIN. 471- 

and leg, 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 limb by his own efforts. 
He was ordered to continue the use of the short back splint, 
and to get about on crutches. 

On quitting the hospital, although the union of the 
patella to its ligament was tolerably good, yet it was not 
at all equal in strength and firmness to what the patient 
required of it. He ventured to walk about a great deal 
too much upon it, and he soon came back to the hospital 
with the parts inflamed and swollen. Having remained in 
the hospital at rest 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 months before the repair 
wotdd be complete. 

In a former lecture (Lect. XIIT.) I adduced several argu- 
ments and many facts against scrofula being as frequently 
the cause of diseases in the bones and joints as accidental 
and local injury. One of the facts which I adduced in 
support of that opinion was, that in diseases of the tarsus 
the cuboid bone and the os calcis are more frequently 
affected than any other. Almost all the weight seems to 
concentrate itself upon the outer part of the foot ; and I 
apprehend these are some of the reasons why disease of 
the tarsus occurs so frequently on the outer side- It 
receives most of the weight of the \K)dy, and is thus 
rendered liable to all accidents associated with that early 
and indiscreet period of life and of unmeasured exercise — 
childhood. Now, to give rest to the tarsus it is necessary 
that the foot should be elevated and freed from any pres- 
sure. I may now place this subject practically before you 
by referring to a case. 

Case of Disease of the Cuboid and Os Calcis ; Diseased Bone 
removed; New Bone formed; Cure aided by ** Mechanical 
Best." 

On April 2nd, 1856, a gentleman brought his son to 



472 THE THERAPEDTIC INFLUENCE OF REST [UOR 

my house suffering from disease of tho tarsal bon^ of liia i 
right fixit. Ilchaii been several nionthe under professional | 
truatiuent, haviag abundance of medicine, hut aUowod to 1 
get about at home as well as he could, without giving adjT j 
decided rest to tho foot. The cause of tho disease wm j 
supposed to be scrofula, brought on by over-exerlion, vit^ , 
possibly local injury. When I saw this yonug gentlcniau he 
was eleven years old ; not very unhealthy iu appearance, but 
presenting florid ohoeks, thick lips, feeble pulse, oold hand* 
and feet, and enlarged tonsils, 'ITie whole of the right foot 
was swollen, especially the outer side correspoudiiig widi j 
its tarsal and nietatATsal pcHtions. Ulceration, the soqiMl I 
to an abscosB which had opened of itself, existed for about I 
rtne square inch over the cuboid and its articitlations wiA I 
tlie OS calcis and the two outer metatarsal bonee. TittA 
surrounding and overlapping skin was dark and eoage^ted. I 
Poulticea hiul U-ca coutiDued uj, to the tinn- of mv wcing 
him. Uu piissinj; a i>tobe into tlie wound, l.mie ilenu.W 
of periosteum was at once detected, but ho would not allow 
of a close examination of tho part ; and, as the foot was 
swollen and inflamed, I thodght it l«tter to send him home 
to Hammersmith, and place hiin on hie bed with his foot 
and leg elevated, so as to get rid of their congested state. 

I saw him again at his home on the 21st of April. His 
foot had become niiich smaller and less painful ; he had 
more sleep at night, and suffered less pain ; he was already 
improved by " rest." I might extend my remarks with 
respect to the elevation of a limb suffering from a state 
of congestion. It is at least an important point iu treat- 
ment, which appears to be not sufficiently attended to in 
practice. 

After giving chloroform (for he would not allow me to 
touch him otherwise), I explores! the wound ; and finding 
the cuboid necrosed and carious, with disease of its arti- 
culations with the OS calcis, I removed the loose pieces 
of bone, leaving the periosteum and the whole of the 
BuiTounding soft vascular structures undisturbed. The 
whole of the cuboid Ixjne and a portion of tho os calcis 
were removed. The excavation was large and deep. He 
was kept in bod, with his leg raised, until May 9th (fi^-e 
weeks), when his kneo was placed upon a wooden leg, with 



XVm.] AND THE DIAGNOSTIC VALUE OP PAIN. 47^ 

a horizontal rest for his leg, and a footpiece of leather (an 
important addition to this kind of apparatus), to prevent any 
accidental injury or disturbance to the foot itself. Two 
months after his first visit to mo I saw him at my house on 
his way to Margate, much improved both as regards his 
health and his foot : the wound was quiet, and disposed to 
close. He liadhis crutches and wooden leg, which he was 
to use at all times when moving about, under the super- 
vision of his careful and anxious mother, who was dotingly 
fond of him, and much alarmed at her son having been 
thought scrofulous. Iodide of lead ointment was to be 
applied to the feeble wound, and over that a pad of cotton- 
wool. He remained at Margate until the end of September 
1856. During his stay there, suppuration and ulceration 
occurred in the sole of the foot, opposite the diseased bones 
of the dorsum of the foot. He came to me on the 7th of 
October, 1856, at the end of six months. The ulceration 
on the dorsum of his foot was nearly closed, but there was 
still some discharge from the sinus in the sole. Direct 
pressure made over the side of the cuboid, or through the 
fourth and fifth metatarsal bones, gave him some pain, and 
he could not then bear any weight upon the 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 dorsum 
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 was thought to be 
scrofulous. 

Here was a case, then, of disease of the cuboid bone and 
anterior part of the os calcis undoubtedly relieved through 
the medium of " mechanical rest." 

In the summer of 1859, whilst in a state of somnam- 
bulism, 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 he was found by his 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 recovered, and has been well 
ever since. At my request this patient, with his father. 



myeolf. Kdtitu the two outer tix* c 
aro assnciiiti'd aiiatuniically with t 
bono which I kuow was disoaeud, 
growth has been impeded, and the 
oonfiguration of the foot, as regardi 
articulate with the cuboid. At the 
Mae, the spaoe natarally ooonpied 
now perfectly filled up to its prc^ 




sabjaoent oellalar tiesne are per£» 
appears to me that the metataraal t 
^kd the 08 calcia are now anchylosed 
but there ia little nr nn differnnnn in 



XVin.] AND THE DIAQNOSTIO VALUE OP PAM. 475 

tributed BOmething towards the good result obtained in 
this case. 

Com of Diteaseofihe 0» Cains ; Sone removed; Bonereneieed. 
In 1855 I removed nearly the whole of the 08 calcia of 
a yonng patient by making an incision along the outer 
and back part of the foot. I took care to leave the peri- 
oBteum as complete ae I could, and oot to disturb nnneces- 
sarily the surrounding granulating surfaces, and especiaUy 
to gnard against any interference with the epiphysis of the 
OS calcis ; and here (Fig. 97) is roughly depicted the con- 




dition of the foot some time after the operation. I have 
seen the patient since that drawing was made : the foot is 
quite consolidated and healthy, but not so fully developed 
as OQ the left side, although there seems to be almost as 
good an os calcis as in the other foot. It is hard and solid ; 
there is no pain on pressure ; and the bone seems to have 
been perfectly reproduced. If that be true, and the expla- 
nation correct, it is another instance of how highly impor- 
tant it is to avoid any interference with the perioetetim 
and other tissues which surround these necrosed or carious 
portions of bone. 

Ditefue of the Epiphysis of the Os Calcis. 

I must now allude to a morbid condition which I believe 

to be not of very rate oocnmnoe, namely, disease of the 



476 THE THERAI'EUTIC INFLUENCE OF REST [Lwav 

epiphysis of the os oalciB, I have had thb drawing madft 
from nature niorely far the piiipziee of reiuiiiding anatA^. 
iiiistu aod aurgeona of the existence of the opijihysis t<> thfl 
IIS caloi§. Hero (Fig. ?B) is the foot of a patient tiiirtoei^. 




years of age, indicating the precise extent of the epiphysis 
at that period of life. Yon see a thin plate of boue eur- 



XVm.] AKD THE MA0N08TIC VALUE OF PAIN. 



477 



rounded by a temporary cartilage attached to the posterior 
and inferior part of the os calcis, preparatory, no doubt, to 
ita fuller development, the epiphysis having relation to the 
perfection of the foot, giving to it increasod leverage, and 
adding especially to its elasticity. It is worthyof remark 
that the tendo Achillia Ja attached cxcluHively to the 




epiphysis of the heol-bono ; hence it is apparent that if we 
have any disease in the cpiphyais, or in the medium of 
union between it and the body of the bone, we shall find a 
great antagonist to mechanical rest in the tendo Achillia. 
This is the great foe with which we have to contend for the 
purpose of preventing any disturbance of the young bone 
and its epiphysis — that is. to the comparatively soft tissue 
situated between the epiphysis and the body of the os calcis. 
It is necessary, in cases of disease of. or injury to the 
epiphysis of the os calcie, that the patient should keep 
the knee flexed for the purpose of relaxing this tendo 
Achillis, and so giving rest to the injured ( " 
epiphysis. 



478 



THE THEEAPKUTIO INFLUEKCK OF BEST [Ijkt. ] 



This drawing (Fig. 99) repreeentB part of tbo foot i>f k J 
patieut aged niueteeu ; thoro remains but little etmctnnl I 
evidence of an epiphysis to tlio ob culcia, although you tu^ 1 
distinctly recognise a slight indication of it in tho lower \ 
and posterior part of the os calcia ; I may add that the O 




calcis in this foot doos not seem to mo to be nt all wuU 
developed. 

I here prodiico pathological evidence that the epiphysis 
of the OS calctH is sometimes diseased and spontaneoutily 
Boparated, This dried preparation (Fig. 100) is, in fact, 
tho epiphysis of the os calcis separated spontaueously 
from an hos])ital patient of mine aged about nineteen or 
twenty, as the result of injury to the heel, and subsequently 
suppuration. 

Quitting the foot, I ask you to notice a diagram, taken 
from nature (Fig. 101), showing the rough anatomyof the 
cervical muscles on tho right side, and the same part£ 
covered by the fascia on the loft side, with tho thinl and 
fourth cervical nerves descending upon the fascia to the skin 
covering tho clavicle and the anterior part of the chest. Thv 
termiuation of the first intercostal nerve is also seen. 



XVm.] AHD THE DIAQMOSTIO TALDE OP PAIS. 



479 



This Bimpla nervous distribution onglit to remind ua of 
thfl fact, that if a patient complains of pain at this part of 
the cheat, the cause may lie in one of two different direo- 
tione. For, as nothing but these nerves can express the 
pain, it may depend upon disease in the cervical region. 




rhU dnwlni; li Intendal 
•upplytng ;h( 



associate with the third and fourth cervical i 
upon some disease connected with the origin of the upper 
dorsal nerves (near to the upper dorsal vertebr»), or with 
their course towards the sternum. 

The right side of the diagram representsaportion of the 
sternum as well aa a portion of the clavicle cut away so as 
to expose the stemo-clavicular articulation, composed of 
two articular surfaces, one of the sternum and the other of 
the clavicle, and separated by the inten>osed articular diso 
of fibro-cartil^e. It is worthy of notice that the clavicle 



l>,tw.cl. th,- <lavi,l>. ,ii„l Ktvnill 

(kstiu,tioi,,>l„lltlKBurroini.liiij;; 
with itH mobility, is tho expliinal 
of Btemo-claviciilar anchyloBie, ai 
find a pathological Bpecimen illn 
the human subject. Laet buhuiu 
looked over the rich oollection of 
I saw nothing approaching such i 
The next two cases show the ^ 
ment of discaae in the stemc 
Disease of the stemo-clavicnlar 
tively rarely seen in its early staj 
tion showiuc recent inflammatioi 
a patient of mine who died fn 
joint is diseased it is easily dii 
difficult to cure, chiefly on accou) 
is the consequence of its struotun 
tion with the nicchanism of rea 
of the head and of the upper ei 
of the head having refcrenoe to 1 
mastoid. With all these function 
it is a veiy difficult joint to keep i 
now mention three cases of diseae 

due of Diseate of the Righl Stento 
Bnl. 



XVIII] AND THE DIAGNOSTIC VALUE OP PAIN. 481 

edges), about the size of half a crown, just below and in 
front of the joint. A probe could be passed along the 
sinus into the joint, apparently between the interarticular 
cartilage and ^e sternum, and dead or bare bono could be 
there detected. This condition of j(»int had continued for 
nearly a year before his admission, during which time the 
patient had supported his arm constantly in a sling, and 
was allowed to walk about. His health was good, but he 
had great pain in the joint whilst taking a full breath, 
when moving the head, especially 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, wdth 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 purpose of keeping the 
diseased parts in a state of rest. The local symptoms of 
disease — pain, redness, swelling, and discharge — began to 
improve almost immediately after we had fixed his clavicle ; 
and in between five and six weeks a piece of the articular 
surface of the sternum was pushed to the orifice of the 
wound by the granulations, and I removed it with forceps. 
From that time the local symptoms rapidly subsided, and 
the sinus soon afterwards closed ; he was then allowed to 
get up and walk about, still wearing the starch bandage. 
He continued in the hospital several weeks after this period, 
chiefly for the purpose of preventing him from using his 
right arm before the newly repaired structures were per- 
fectly 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 should he not continue 
well. Since then I have not heard of him. 

Disease of the Left Stemchclavicular Joint; Suppuration in 
the Joint ; opened hy Ulceration ; cured hy Best. 

Here is another case of the same kind, but a little more 
interesting in its details — a case of disease in the left 
stemo-clavicular joint, produced by violence. In 1850, a 

2 I 



I iMiiia Jiiil.ni;. 111.' lii-iil)i! ■.\]>]«.-.iT 

Cl.vill,' ^ItJil illtutllr ioillt llOtttVUI 

artk-iiliir til-ro-caitilugi-. Ho Im.l 
sioQal care ul' several Burgeonti du 
names I do not mention, as aome 
The abscess had been opened Ion 
visit to myself ; and as tne ulcerati 
under and behind the stemo-maat 
of his surgeons advised, as a last : 
length of the siuue should be la 
the deeper iwirts, and " compel th 
bottom of the wound." I appreb 
mastoid had been divided, and th 
from the bottom, the cure would 
any compulsion on the part of th' 
fact that he would have given th 
because the 8 temo- mastoid wasooi 
influences. Unwilling to submit t 
the patient sought my opinion. B 
state was simply the result of loot 
that it was curable by long-conti 
adt'ised him to adopt and cany ool 
to laying the siuus open, the ree 
uncertain. 

The patient then told me tb 
Between six and seven months age 



XVra.] AND THE DIAQNOSTIO VALUE OP PAIN. 483 

caught hold of him round the right arm and waist, and 
with great effort succeeded in getting him out of the room ; 
he then threw him right over the baluster down-stairs, 
and so escaped the knife. The coachman was subsequently 
tried, convicted of the robbery, and transported. Im- 
mediately after this struggle the gentJeman found that he 
had damaged his left stemo-clavicular joint. From that 
time the tenderness, &c., to which I have alluded began. 
The stemo-clavicular joint soon became inflamed, and 
then suppurated. The arm was carried in a sling. The 
discharge was considerable, and he suffered a good deal 
of pain on attempting to raise the left arm or take a 
full breath, or cough or sneeze, or turn his head abruptly. 
The skin was red over the joint, and the surrounding 
parts were much swollen. Sir Benjamin Brodie saw the 
patient afterwards with myself, and acquiesced in the 
propriety of attempting to cure him by rest. He thought 
the disease would be cured in that way if we could keep 
the parts sufficiently quiet, but that, as he observed, was 
not an easy matter. We subsequently, however, succeeded 
in accomplishing it tolerably well by the aid of a broad, 
leathern, well-moulded splint, which embraced and fixed 
the whole of his shoulder, including the scapula and the 
upper half of the humerus. The upper arm was further 
fixed in position to the side by a strap and buckle, which 
passed round his chest. The forearm rested in the ordinary 
trough of leather which supported it and the hand. This 
mechanical apparatus had the effect of keeping the sterno- 
clavicular joint nearly, but not quite, at rest. The sterno- 
mastoid had still some little disturbing influence upon the 
diseased joint when he turned his head to the right side, 
or when any muscular exertion required him to make a 
full inspiration. I proposed to fix the left stemo-mastoid 
by putting a bandage or fillet round the head, and fasten- 
ing it to the arm ; but this he said he could not submit to. 
He wore the splint, &c., four or five months uninterruptedly. 
From the first week of local rest to the joint he began to 
be free 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. He continued the use of 
the apparatus for several months afterwards, as any 

2 I 2 



■ •n iui_' ut (iiy loijUt'Bt. His Wh-A 
saye. ■■ get ovtT tlio acciUent " foi 
movementB of the left arm are ni 
two ; he cannot lift it 80 easily, o 
raised, quite bo &eely as on the oth 
whitish, thin-ski lined cicatrix is 
terior part of the sternal end of t 
normal in form ; it is flattened an 
above to below than the oorreep< 
clavicle, and some small-pointed 
bo felt on the upper border of the 
The clavicular portion of the 
atrophied. On closely examinin{ 

Suite obvious that its articular n 
kau on the other side. The ohie 
totonsisteithorinaloeaoftheinte 
or its consolidation with the oU' 
anchyloeie or ligamentous union b 
intorarticular fibro-cartilage. H< 
injury to the stemo-claviculaT arl 
which is complete, and the resnl 
possibly be made by the surge 
(juietude which encourages Nature 

Case ofDueaae of the Bight SlerwH 



XVIIL] AND THE DIAGNOSTIO VALUE OF PAIN. 485 

arm. She had somo considerable pain in the right sterno- 
clavicular articulation immediately. A large abscess formed 
over and behind the joint subsequently, which received 
pulsations from the subclavian artery, leading to the sus- 
picion of aneurism, and on that account I was requested to 
see her. It was clear that there was no eccentric expansion 
in the tumour, but that it was a soft fluctuating swelling, 
probably an abscess, receiving a distinct propulsion from 
behind, where it was in contact with the subclavian artery. 
This relieved the minds of her friends, and the lady went 
into the country. The abscess opened of itself, and dis- 
charged pus abundantly. A splint was applied, and the 
arm was Kept quiet for a short time. I saw the patient 
several times, and with a probe could detect disease of the 
clavicle at its sternal end, extending into and implicating 
the whole of the stemo-clavicular joint, where she suffered 
a great deal of pain. She had subsequently several attacks 
of bronchitis, with cough and expectoration, which dis- 
turbed the joint very much. Ultimately she died, I 
believe of pyaemia, after a few days* severe illness, but I 
oould not succeed in obtaining a post-mortem examination 
of the case. 

Disease between the first and second piece of the Sternum^ cured 

by Best, 

The case to which I will now briefly allude is one of 
great interest — namely, disease between the first and 

second bones of the sternum. This patient, D. J , 

was formerly a medical student. He was twenty-two years 
of age when he first consulted me in March 1853, for 

Eain and uneasiness about the upper and middle part of 
is chest. He stated that for several months he had been 
unable to take the least amount of exercise without con- 
siderable pain and difficulty of breathing; any attempt 
even at gentle motion, as in walking, fiill breathing, 
coughing, or indeed the least movement of the head or 
arms, was sufficient to increase his suffering. He had 
constant dull pain in the neighbourhood of the sternum, 
extending towards the lower part of the back of his neck, 
and between his shoulders, wkich during damp weather 
was of the most severe and gnawing character, accompanied 



486 THB THERAPEDTIO INTLCESCE OF REST [LtcT. 

witli a eeneo of opprefBion aod coDstriction about tlie air-, 
puHNiigoH, a.B though he were being choked. Any attempt 
U) take a Jeep iuspiration produced pain in the emao part, 
FresBure made with the hand npon the frout of the cbetit, 
during expiration was attended with j>ain of the laoat Bcvera-, 
i^nd landnatiug kind. He jumped and started iiihisBleep, 
and was disturbed by frightfnl dreams. Hieappetite hut, 
failed during the last few weeks, but he did not appear to 
havo lost much flesh. He had consulted many eminent 
phyaiciauB and surgeons in town and country, but oould not 
learn from them any dietinot cause of his Buffering. He 
had been leeched and blistcTed over the ohcet and spino^ 
and had paGBed in euooet«ioa through the ordeals of boat- 
ing, cricket, quoits, and gymnastic uxcrcisesi indeed, every. 
pofisible kind of treatment appeared to have been pursnea,! 
but without benefit, and he was now wane than ever, i 
might sav that he had not l>ecn provitiuslv- examined care- 
fully witfi respect to the Bternuui or Bpiiic, The physicians 
and surgeons who saw him were Biitisficd to take his indi- 
catiuns of pain, as he was a professional man. I suppose 
they did not think it worth while to examine the sternum, 
where the real mischief was found. I examined his spine 
very carefully, but could not discover anything wrong 
there. His breathing was regiilarand natural, but limited 
in its extent by pain in his chest ; the heart's action was 
normal. There was acute pain on percussing the chest ; 
and on approaching the middle line in front, the pain, by 
pressure ujion the sternum, was much increased. On 
placing my thumb directly over the junction of the first 
and second bones of the sternum, and exerting slight 
pressure upon that part, the pain was ao intense that he 
nearly fainted. It was evident that the secret of all his 
morbid symptoms lay in this joint,* and indeed there was 
some enlargement and thickening there. Upon close inter- 
rogation as tu the probable cause of all this, ho said he 
could remember three years ago having received, during a 

• Tlie two upper piocca of the iternum are usually ileecribed ae 
unittd bjr cartilage, bony union being m<i gave iu lute old age. Mr. 
Riiington, Med. Chr. Tib., vol. Irii,, haa drawn attention to the faot 
that two forms of joint are found here, tlie amphi-arlhrodial, and the 
arthrodial or gliding variety of the diartbrodial joinL — [Ed.] 



XVIIL] AND THE DIAGNOSTIC VALUE OP PAIN. 487 

sparring contest, a very violent though friendly blow upon 
the part now affected, although it was not until several 
months afterwards that he experienced any severe pain. 
Finding a diseased joint in this patient, and bearing in 
mind the means he had already employed without benefit, 
it appeared to me that everything had failed in conso(iuenoe 
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 rib^, and so in the walls of 
the chest ; to use no exertion of any kind which required 
prolonged or violent respiratioa ; to keep the sterno- 
mastoids relaxed ; not to do anything with the upper ex- 
tremities which would require the 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 de- 
scribing the symptoms 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 cough or talk aloud ; 
he could scarcely do anything without great suffering. 

At the expiration of four months of absolute rest, he had 
so much improved 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. All tenderness of the sternum upon 
any amount of pressure had subsided. In writing to me 
soon afterwards he 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 greatest 
possible care of himself, his recovery was prolonged by 
getting up too early. In January 18G0, 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 five London and two provincial 
hospital surgeons, and three London hospital physicianA, 



488 THE TiIEBA,rEDnC INFLUENCE OP BEST IXht. 

jirevioualj- to my interview -with yon. The boating -wa 
ordered by a phyaician, and other athletic sports hy the 
London Burgoona. and certainly they played the ^ery devil 
with me. I §]iall never forget tagging off t« the Isle Of 
Man for a month to have plenty of rowing. You cSS 
ittmgine my etate on my rotum homo. My condition for i 
many montlis was most intonsa and painful misery. I am 
satisfied that, had I not followed your adviee, nothing shcart 
of an opening and exfoliation, and God only knows what, 
would have been the result." 

This case \nil be aatififactory, I think, aa pointing out 
the importance of examining the part where the pain was 
coniplfuned of, while, at the same time, it displays the value 
and importance of mechanioal rest in cases of this hind. 

Before couolnding those loctnreB on the therapentio' 
influence of rest in its relation to the treatmsnt of diseased . 
joints, I am desirons of placing before yon a familiar illnft- 
tratinn nf tin? inoxplicablo piiid wliich iiriHCB fnim due rest. 

exertion. 

Two perwjns start upon a pedestrian tour, and after 
walking a certain uumlxir of miles, feeling fatigued, they 
seek relief by lying down and going to sleep. After a 
repose of an hour or two, with perfect rest of mind and 
Ixfdy, but especially of body, they rise invigorated, "giants 
refreshed," and proceed on their journey with renewed 
sti-ongth, and apparently without the slightest incon- 
venience. Now, what have they olitained during the period 
of repose ? Anything or nothing ? No food has been 
taken, and therefore no strength has Iwen obtained by 
the addition of any now material to the system. The 
hyixithesis is. that the various enfeebled structures have 



had time and opportunity- by rest to beeomo invigorated 
by selecting and appropriating to themselves, in the form 
of nutrition, new material from tho cajiillary circulation, 
which is proceeding within or near them. 

Let us. for the piirjiose of pursuing the inquiry, modify 
tho illustration by the BUpjx>sition that, although both 
pedestrians are much fatignol by walking, only one of 
them takes his rest, and that the other proceeds on his 
jonniey, notwithstanding his fatigue. 



XVinj AND THE DIAONOSTIO VALUE OP PAIK. 489 

The one continues walking, and, after going some con- 
siderable distance, at length arrives at his much-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 con- 
dition, or possibly of an inflammation of the ankle, knee, 
or hip-joint. Wnat has occurred in the one case, and not 
in the other ? The one, wearied by his exertions, lies down 
and takes his rest, and suffers no harm ; the other, while 
still under the influence of fatigue, continues his journey, 
and he is the subject of a joint^inflammation. What, I 
ask, has really happened to him who suffers ? We must 
assume that there has been in his case a temporary physio- 
logical exhaustion of the various structures which have 
been especially concerned in walking. We may presume 
that the synovial membrane no longer secretes its proper 
lubricating fluid ; that the elasticity of the articular car- 
tilage 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 unsteadi- 
ness of gait; and that the muscles being wearied and 
fatigued, the person has not had the advantage of that 
muscular adjustment which would have secured his joints 
from the ill effects of any jar or sudden concussion as he 
walked. 

The influence of this latter condition (which we may, I 
think, term ** muscular adjustment ") you will recognise at 
once, when I remind you of what often happens when 
walking in the dark. If you abruptly meet with a little 
descent of only two or three inches, and your foot comes 
down unexpectedly without your having pre-arranged or 
nicely adjusted your muscular force, the patella may be 
broken, perhaps, or the whole body receives a momentary 
shock from the rapid transit of the vibration through it. 
The influence of the shock is felt even in the brain, in- 
ducing temporary confusion » and causing sometimes a slight 
stinging, electric-like sensation upon the face throughout 
the distribution of the sensitive part of the fifth nerve — 
sometimes, indeed, the tongue is bitten. 

Whence this sudden discord in the action of the various 



4i'0 THE TUEBAPECTIC INFLUENCE OK REST [Licr. 

stmctnreB hitherto employed in httnuoaiouB co-weiation,. 
which permite this rude and h&reh cuncussiun of Uie wluile 
framo from bi) hidoII an error in progreeeion ? 'I'he btinea,. 
the synovial luemhranea, the articular cartilage, the lig»- 
raonta, ore all in a state of integrity. The only peouljarity. 
is, that the iiniacle§ have been taken by Burprieo.and havft) 
not had the opportunity of giviiip liuvt aid iu the fall which > 
they would othurwise have done, nud bo preserved thft' 
person from the coucuasion from which he has aufiered, bat i 
which he would have cscnpud hud he been aware of tha 
sudden deeoent. or had he be«n alive to the ourrect meaeur&- 
Rteiit of the distance. 

Allow me to put before yon another illostratiun of ths 
same state. You may see a man, full of confidence in him- 
self, .jump from a height of two or threeTards, alight upaa, 
his feet, and walk away unhurt ; while another personal 
or the samp jicrmm nt another period, timid and afraid, or 
without a fiwil inirpiim;. fulls Huddi'uly iui.l Tii<u\i"jclcdly, 
or jumjw unilor the influence of fear ut doubt, a com- 
paratively nhort distance, not maintaining his muntiil equi- 
librium, " !<»ics his head," as it ia called, and comes down 
upon his feet, cunfuBcs liis brain by the ohock, and perhaps 
sustains a fracture or dishx^tiou at hits ankle, a broken 
leg or thigh. 

What has Iteen the cause of these different results? 
Simply tliat the one who luid his niind " always about him," 
his nervous centres alive to his ini]H:m1ing necessities or 
requirements, has had the advantage of keeping up and 
controlling: his muscular adjustment, s.) iis to prevent any 
shake to the brain or serifms injury to any of the bones 
or joints. This seems to me to lie tlie resiilt of instinctive 
muscular adjustment. 

Now, to go back to the apjilication of this rather long 
digression. The jK-destrian who walked on at the time 
when his friend stayed l>ehind for the purpose of repose, 
proceeded on his journey in a state of fatigue and must^ular 
oxhauBfion, so that the joints had not, during the jx-'rioii of 
their prolonged exercise in walking, tlie advantage of mus- 
cular adjustment to modify the eft'ecta of concussion upon 
the joints and ligaments. Under such circuni stances, the 
joints become the subjects of violent concussion or vibra- 



XVinJ AND THE DIAGNOSTIC VALUE OP PAIN. 491 

tion, vascular congestion, and then inflammation. There 
is no apparent or recognisable lesion of structure ; but the 
pliability or elasticity of the foot is gone, and the joint is 
stiff, and will not bear concussion. The elasticity of the 
articular cartilage, however, is only temporarily diminished, 
for the renewed capability of bearing weight and concus- 
sion 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 conges- 
tion, and thus allowing them by " rest " to return to their 
natural and vigorous condition. Ought not this typical 
expression of Nature's high appreciation of rest to form a 
safe guide and direction for the surgeon in many of the 
cases to which his attention may be called ? I say, Yes ! 
Is it so regarded, or is such a physiological line of thought 
and action manifested so often as it ought to be by the 
surgeon in his recommendations or his practice? I say 
decidedly. No ! 

I have indicated to you that accidents and disease of 
joints occur from over-walking and over-straining, from 
rude progression, from some twist, muscular fatigue, or 
some other casualty. The drawings (Figs. 102, 103, 104, 
and 105) have reference to this point. 

Case of severe Inflammation of Might AMe-joint and Foot, fol- 
lowed hy Suppuration ; complete Dislocation of the Foot ; 
cured hy Rest. 

This drawing (Fig. 102) represents the right foot of 

H. B , who at sixteen years of age was admitted under 

my care at Guy's Hospital on March 26th, 1855. He was 
previously quite well, but fatigued, when he determined to 
walk from Southwark to Enfield on the morning of March 
21st, 1855, although he had pain in his foot when he 
reached Gracechurch Street on his way. When he arrived 



492 TEE THKHAPEUTIC INFLUENCE OF BEST 

at Enfield liis foot and ankle were swollen. He e 
dtwre all day, and in the evening went to tho railway ■ 
rie, t«i. 




Btation, enpportcd by two men. At night he could not 
bear the slightest weight upon his foot, and the ankle was 



XVin.] AND THE DIAGNOSTIO VALUE OF PAIN. 493 

much swollen. Cold lotions were applied to the painful 
and swollen parts, and some medicine given. He came 
to Guy's Hospital on the 26th, five days after the attack, 
Buffering most severely with acute inflammation within 
the ankle-joint, and at the outer side of the foot over 
the 06 calcis and cuboid bone. Leeches were applied 
abundantly, and poppy fomentations. The leg was ele- 
vated upon a pillow, and supported laterally by sand-bags. 
Extensive suppuration took place near the external mal- 
leolus. This was opened in a fortnight from the accident* 
The integuments were disposed to slough. Hemlock poul- 
tices were applied. A week after this opening was made, 
some ulceration of the skin occurred, and the foot became 
completely dislocated inwards from the tibia, so as to 
expose to view the top of the astragalus, as well as the 
articular surfaces of the tibia and fibula. 

Here I might add, as a matter of interest, that this boy's 
ankle-joint being completely exposed to view, I took occa- 
sion to touch with my finger the exposed, inflamed, and 
partially ulcerated articular cartilage. He felt no pain ; 
but when I pressed hard upon either the articular surface 
of the astragalus or the tibia, it gave him a great deal of 
pain ; clearly indicating that the pain was not associated 
with simple ulceration of the cartilage, but had reference 
to the deep pressure upon the subjacent parts. 

Chloroform was inhaled, and I reduced the dislocation ; 
but thinking it safer for the patient, I divided his tendo 
Achillis, for the purpose of preventing any displacement 
by the action of tne gastrocnemii, which were frequently 
in a state of spasm. Splints were then applied, and the 
diseased leg was swung. He remained in Guy's nearly 
eleven months, and then went out for six weeks, when he 
returned because his foot had become swollen, red, and 
painful, from improperly using it; in fact, the new or 
repairing young bone was not at that time equal to the 
claims and exigencies which had been thrown upon it. 
Subsequently he had frequently slight attacks of inflam- 
mation in his foot from over-exertion in standing or walk- 
ing. He used to say, "I only come to the hospital to 
lie up ; " and he availed himself of the privilege rather 
frequently. His mother, getting quite tired of these 



494 THE THEHAPECTIC INFLUENCE OF BEST [Lxit. 

repoftted Imspital viBits, wiahod me to take off his leg ; but 
I preferri^d to wait tmd aeo the result of N&ture'§ offorta M 
repair. 

Well, here is the remilt (Fig. 102). Three or four piecoe 
of dead bone came away troni the oe calcis, and probably 
the cuboid. I aav him in May 1861. He oonsiders that 
hia foot and leg have been well for three yoara. H© can 
walk any roaeonablo dietance, and atando at his work — hat 
and cap making — not unfrequently for fifteen hoorv a day. 
'I'hia is a good oaae fairly repn!8ciiting bloodleea, conserva- 
tive surgery, and indicating that although a great amount 
of local injury may occur Be the reault of over- fatigue, it (s 
capable of being entirely recovered from. 

Tho next case is one of great interest. 

Injurv to the tofl Strveture uttUing the Shaft of lie Tibia to iti 

hnrcr Epiphj^h. fi'lhir.-^ h.j Ofiitix owrf S'lh-pf^ftt.-il 
SHi>p>iraliiin ; D<?iith in I'lrelve D<iiii'. 

A youii}; gi^ntleman, eighteen years of age, tolerably 
healthy, and living at Islington, was always active and 
fleet of foot. On Friday, Jan. 10th. 1802. ho 'ran two milts 
right off to a friend's house, and, after resting for a short 
tiiue, lie ran back two uUIcb home, but sufl'ered no known 
inconvcuicuce fron) that exertion, (hi the Sunday evening 
following, ri'tuniing from chapel, wearing a very narrow, 
liigh-hoelod boot, ami, walking at the eilgo of the pave- 
ment, his left foot turned inwards with a sudden jerk or 
twisting seuRiitiou, and lie exclaimed to his sister, who was 
with hiui, "Dhl I have twisted my fi«)t; 1 never had 
such a dreadful wrench before.'' lie walked home. and. 
exeoptini^ at the time of the strain, he felt but little of the 
injury during tli.at evening or night. Ho walked to bin 
buainesB — ten minutes' walk from his own home— on Mon- 
day morning, when the jmin in his leg near the ankle 
became m great that ho could not remain, and he ivtumed 
home ; he lim]ied, and could 8<;arcely bear any weight on 
his foot. His mother fomeuted bis ankle, used hartshorn 
and oil to it, apjdied vinegar, and gave him an ajwrienf. 
She nursed bim through Tucs-Iay. 'Wednesday, and Thurs- 
day, wlieii bis BTirgeon was culled in about m"id-duy. The 



XVIIIJ AND THE DIAGNOSTIC VALUE OF PAIN. 496 

patient could not then bear any handling of his ankle ; he 
cried with pain, which he referred to about two inches 
above the internal malleolus and across the tibia in a 
straight lino ; there was some swelling at that part, but no 
ecchymosis or other discoloration. The pain on pressure, 
with a doubtful crepitus, made it appear probable that it 
might be a simple fracture of the tibia. The pain continu- 
ing on 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 that he had sustained some injury 
to the epiphysis; for upon close examination I found 
the ankle-joint free from mischief. A little careful manipu- 
lation enabled me to isolate the injury to the tibia, and 
I told Dr. BillingliTirst that I believed the soft parts 
between the shaft and the lower epiphysis of the tibia were 
injured. At that time the patient was suflfering extreme 
pain, and he had a small collection of pus deep in the leg 
at the inner and back part of the tibia. I did not again 
see this patient alive. Five or six days afterwards he died 
with what was thought to be typhoid fever. 

By chance, on the day before the funeral, I heard of his 
death. I immediately wrote to his relations, and obtained 
permission to make an examination of the leg. I went to 
the house early on the following morning ; the hearse was 
at the door, so that I had only time to unscrew the coffin 
and examine the leg. I found the soft parts around the 
injured bone, external to the periosteum, infiltrated with 
serum, but there was no evidence of any laceration of these 
structures ; no bruised appearance, no extravasation of 
blood. The periosteum was separated from the inner, 
anterior, and posterior parts of the lower portion of the 
tibia by a considerable collection of pus, wiiich was con- 
fined in its position by the periosteum. The lowest part 
of this collection of pus corresponded with the injury to 
the epiphysis depicted at d. Fig. 105. The fibula was not 
injured, nor was the interosseous ligament between it and 
the tibia. No suppuration nor any evidence of inflam- 
matory condition within the ankle-joint existed. I took 
away this bit of the tibia, and it fairly remunerated me 
for my trouble. These drawings (Figs. 101 and 105) wore 



496 The therapeutic iitfluenoe op rest [Lect. 

made frr.ni the preparation on the samo day that the pieoo 
of bone was obtained. This praparation is a longitndinal 




In Blrncldre (curri»|ioiidini! wllh c. Fig. IIN). upon nlilth llie urtiu-lcnoi it allll 
Ainily Bx«d. c, Sn-tlon ct c|il|ib]'Hti, InBnmcd. d, Sn-ti.iu of lUe ivR mrdium 

dM>«y«l, l«vlng«E«p™i.tlniKiu»'BiirJ.'Fi|i. 1U9. 
FlE- IM. Kilenul wrliiiv of the uiae poitloii of Itbia. a. PDrlLon of Iht tlbii 
ihprirfd of tl> pprUntram bi «il>-|Krli sle«l siinrnrjllon. fc. Inner D>iiUaiiiM. 

eplphjiii (u the timti of bone, rf, SeM vt injury lo thr niediuin of union 
between the e|-ii>bj^«lE( aiuI 'linn, leqvingE n foii*<iiti-rabLp flap or cavity between 
tbeiu. r, Orwive Tir tbe tetidun uf the tLttlalis poAtLcus muv le. 

section of the tibia, showing tho iuflamtiiatory condition 
of tho whole intt-rior of the shaft of the bone, and also of 



XVIII.] AND THE DIAGNOSTIC VALUE OF PAIN. 497 

the epiphysis. There is, as you may seo, a distinct gap 
from inflammatory softening and absorption, or laceration, 
between the shaft of the tibia and its lower epiphysis. 
This is precisely the spot where the boy had the first sense 
of injur^^ on the Sunday evening ; it was near to that spot 
that he complained of pain when Dr. Billinghnrst first saw 
him. In this instance we have distinct evidence of an 
injury having occurred from violence to the soft structurejf 
between the shaft and epiphysis of the tibia, followed by 
death — I believe from pya3mia — twelve days after the 
accident. 

These lectures, from the mode of their delivery, have 
been of necessity fragmentary. Their object has been 
to establish a j)rinciple; and how difficult a matter 
of attainment this is in medical science we need not be 
reminded. 

I have herein endeavoured to show that ** Eest is a most 
important therapeutic agent in the cure of accidents and 
surgical diseases." To illustrate the varied applications 
of this principle, I first surveyed, 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 knowledge of the anatomy and physiology 
of the different parts which he may be called upon to 
treat. 

I have also endeavoured to impress upon you the fact, 
" that every pain has its distinct and pregnant signification^ if 
we will but carefully search for itJ^ To the extent of my 
present opportunity I have striven, by the agency of a 
more precise nervous anatomy, to unravel and render 

Satent the meaning of pains which have been so often 
escribed as anomalous or obscure. From the pain which 
follows the intrusion of a particle of dust on to the con- 
junctiva, and the closure of the eyelid for the security of 
rest, up to the most formidable diseases we have to treat — 

2 K 



THE THEKAPEUTIC INPLUE^-CE OF BEST. 



i 



(laiii the monitor, and rest the cure, are Btarting-pomte for 
cciiitouipltttion which should ever be present to the mind of 
thu tmrgeou in reference to his troatment. Feeliug that 
I have, at most, advanced but one short step towards the 
object of every scientific surgeon, I trust I have neither 
dogmatized nor spoken presninptuoualy. A like idea was 
doubtless present to the mind of Dr. Darwin when he 
wrote the preface to his " Zoonomia." " A theory," he 
says, " foiiuilod on Nature, that should bind together the 
BCEttterod facts of medical knowledge, and converge into 
lino point of view the laws of organic life, would thus on 
nittiiy accounts contribute to the interests of eooiety. It 
would capacitate men of moderate abilities to practise the 
urt of healing with real advantage to the puhQc, it would 
unable eveiy man of literary attainments to distiugmsh 
the genuine disciples of medicine from those of bo^tfuiU 
effrontery or of wily address, and would teaoh manldud iw 
some important situafiuiis thf- knowlod^fi of theiiisi;lvt-ii," 
I may also adopt his (juotation from L'icoro, changed into 
the past tense, liecausc it so exactly expresses my feelings : — 
" Hfec, ut ix)tui, explicavi ; wee tamen, ut Pythius Apollo, 
ccrta Tit sint, et fixa (juse dixi ; sed ut honmnculus nnus 
ex mtiltis, probabiliorft conjectiira ae']nous." 



i 



INDEX. 



Abdominal musoles, contraction 
of, from peritonitis, 247. 

■ NBBYES, cutaneoas dis- 
tribution of, 246, 250. 

AiisOESS, absorption of, 378, 885; 
lowest part of, depends upon posi- 
tion of patient, 125 ; siu-face coap- 
taUon of, equivalent to rest, 123 ; 
not to be disturbed by daily 
squeezing, 124 ; structure of, 124. 

, axillary, 129; cervical, 

133, 143 ; facial, 147 ; sub-fasoial, 
128; iliac, 136; orbital, 133; 
popliteal, 146; post-pharyngeal, 
135 ; psoas, 94 ; sub-gluteal, 137 ; 
sub-mammary, 125 ; sub-occipital, 
139, 142 ; under temporal fascia, 
125. 

OPENING OF, must be at 



its lowest part, 123 ; to give rest 
to its walls, 123 ; deferred in iiip- 
joint disease, 383 ; in disease of 
epi[)hysis of femur, 458 ; pro- 
priety of, in diseased joints, 383, 
385; ulterior object of, 122; 
danger of, by knife, 129 : method 
of, by forceps and director, 130. 

Absorption of callus after giving 
rest to bone, 265 ; of lymph after 
pericarditis, 263 ; by serous mem- 
oranes, 264 ; of abscesses, 378, 385. 

Acetabulum, necrosis of, 406. 

Amebican burgeons, on congenital 
inequality of the lower limbs, 
419. 

AN.fi8THFnos, local cutaneous ap- 
plication of, in abdominal dis- 
ease, 248; to branch of fifth 
nerve, 185 ; to intercostal nerves. 



256 ; for diseased joints, 183, 
230; for pleurisy, 259; for peri- 
carditis, 261 ; for diseased bladder, 
185. 

Anal ulckb, painful, mode of giving 
rest to, 295, 297 ; bleeding, cured 
by division of sphincter, 303. 

Anchylosed femur, attempts to 
alter position of, 409. 

Anchylosis of ankle-joint, 401 ; 
elbow-joint, 466; hip-joint, 358, 
362, 368, 369, 381, 396; knee- 
joint, 826, 327, 454 ; sterno-cluvi- 
cular joint, 480, 484; scaphoid 
and astragalus, 825; temporo- 
maxillary joint, 114. 

Aneurism cured by rest, 63 ; caus- 
ing pain in the cutaneous distri- 
bution of fourth an 1 fifth dorsal 
nerves, 89. 

Anki^-joint, anchylosis of, 401 ; 
inflammation of, with suppura- 
tion and dislocation, cured by 
rest, 491. 

Anterior crural nerve, distribu- 
tion of, 213, 214, 215, 224. 

Anus, artificial, afibrding physio- 
logi uil rest, 304 ; distribution of 
nerves to, 282, 286, 291, 295. 

Aorta, disease of, associated with 
cutaneous pain, 87, 257. 

Arachnoid, internal and external, 
description of, 22, 23; use of 
fluid between, 22, 23. 

Arm, mu8culo-cut£kneous nerve of, 
distribution, 186; injury to, 191 ; 
pressure of exostosis on, 192. 

Arterial distribution, law of, 292, 
293, 294. 

2 K 2 



500 



INDEX. 



A0TIUQAL1T8, injniy to, horn a jump, 

318 ; anchylosis of, 324. 
Atlas, exfoliation of bone from, in 

feyphilis, 112; dislocation and 

anchylosis of, 114. 
AvDiTOBT CAKAL, excoriation of, 

depending on diseased molar 

tooth, 211. 
Axel key and Gustaf Betzius, on 

the structure of the pia mater, 

25. 
Axillary abscess, 129. 

Barnes. Dr., on distortion of the 
pelvis from inequalitj of the legs, 
owing to old fracture, 390. 

Bed-^ore penetrating into vertebral 
canal, 370. 

Bell, Sir C, case of fistula cured 
by rest, 126. 

Bent arm after venesection, reason 
of, 190. 

Bladder, irritable mucous mem- 
brane of, method of relieving, 
272 ; varying behaviour towards 
calculi, 65. 

• dilatation of the neck of, 

as a means of giving physiolo- 
gical rest, 272 ; tubercular disease 
of, simulating stone, 66. 

Brain, anterior portion of, most 
liable to injurv ttom blow at back 
of head, 29 ; chronic affections of, 
often the result of local injury, 
57 ; loses its congested state 
when quiescent, 51, 52 ; not con- 
gested during sleep, 51, 52 ; dis- 
ease of, producing symptoms of 
hip-joint disease, 412 ; quiescence 
of, and circulation influenced by 
the cerebro-spinal fluid, 30 ; me- 
chanical means for securing rest 
in, after congestion by work, 18, 
19 ; rest of, exemplifled, 8 ; use of 
the lateral ventricles of, 18, 19, 
30 ; laceration of, 53 ; lesions of, 
treated by mechanical rest, 55, 
56. 

, coNcrssiON OP, should be 

treated with lon^ rest, 55, 56; 
sudden deaths a long time after, 
57 ; analogous to bruises in other 



parts of the body, 56 ; prododsg 
molecular disturbance of its gob- 
stance, 53 ; rest absolutely oe- 
cessary to produce repair aflsr, 
56; danger of using stimalsots 
after, 55 ; value of tl e applicatkm 
of ice, 56 ; influence of food sod 
stimulants on, 55. 

Breast, physiological rest to, 127. 

Bright, Dr., on sub-oocipital pain, 
95. 

Bruce, Mr., on the degeneratiTe 
changes in cartilage, 3i2t. 

Bullet injubt to musculo-cvts- 
neous nerve, effects of, 191. 

Burns, contraotkm after, one csose 
of, 245. 

Bursa on taberoaitj of ischium 
producing pain idong infenor 
pudendal nerve, 243. 

Bl^lin, Mr., a case of anchvloiis 
of knee after long-continued rest, 
322. 

Buzzard, Dr., on pains around the 
trunk in syphilitic spinal menin- 
gitis, 93. 

Cadge, Mb., on varying behaviour 
of bladder to calculi, 65. 

Callbndbr, Mr., on the hyper- 
distension of abscesses with car- 
bolized water, 123. 

Callus absorbed aiter rest had been 
given to a bone, 265 ; means at 
securing rest to a fracture, 6S, 
265. 

Canceb involving sacral and ob- 
turator nerves, 220. 

of rectum painless, 2^. 

Capillaries, mode of giving rest 
to, 491. 

Capsule, elastic functions of, 12; 
of kidney, 15; of liver, 12; of 
spleen, 14 ; of testicle, 15. 

Carbuncle followed by sloughing, 
after-treatment ctf, 145. 

Cartilages loose in jcmits, treat- 
ment of, by rest, 465. 

Cause of frequency of ulcers just 
above ankle, 216. 

Cerebro - SPINAL FLUID in the 
ventricles, 18 ; physiology of, IS, 



INDEX. 



501 



25y 80; forms a wAter-be<l for 
base of the braiD, 25 ; advantage 
of distinguishing tlie portions of 
the brain separated by this fluid 
from the bones, 29 ; specific 
gravity of, 29; influence of, on 
tile Corpus striatum and thala- 
mus nervi optici, 30; analogy of, 
to eapsuhir apparatus of viscera, 
19; influence on the eirculnti(»n 
of the brain, 30, 31 ; obtained 
from a patient after fracture of 
skull, 32; relfttion of, to spina 
bifida, 33;' function of, in the 
fcetal brain, 44, 45. 

Cerebro-sfinal orENiNO, use of, 
and description, 18, 23 ; occlusion 
of, 37, 39, 40 ; occlusion of, asso- 
ciated with spina bifida, 39 ; 
occlusion of, causing internal 
hydrocephalus, 38; occlusion of, 
in a gentleman thiity-four years 
of age, 45. 

Cervical abscess, 133, 134, 143. 
■ NERVES, third and fourth, 

distribution of, 479. 

VERTEBRA, fifth, sixth, 



' ' # 

seventh, case of injury to, and 
recovery from, 116. 

Children when ill waste more 
rapidly than adults, 6. 

Chinese lady's foot, showing that 
forced rest does nut deteriorate 
the structure of joints, 323. 

Chordee, origin of diflcrent, at 
difleront times, 279. 

Circumflex nerve, distribution of, 
168. 

Clock, floral, an instance of rest 
in plants, 6. 

Coagulaulb lymph, function of, in 
producing rest, 68; value of, in 
wounds of serous membranes, 
68; influence of, on inflamed 
mucous membranes, 69 ; detached 
after performing its office, 70; 
absorption of, atter inflammation, 
69; danger of disturbing, in 
wounds of serous membianes, 
68. 

CoLO.v, pressure of, on kidney, 15 ; 
disease of, associated witli pain 



in knee-joint, 220; obstructed, 
treated by artiflcial anus, 304. 

Congestion of secreting organs re- 
lieved by their tubular outlets, 12. 

Conjunctiva, injure<l, cured by 
physiological rest, 268. 

Cooper Forster, Mr., case of sub- 
pectoral abscess cureil by rest, 
J 26. 

CoBPrs STRIATUM, effect of cerebro- 
spinal fluid on, 19, 30. 

CuSTO-VERTEBRAL JOINTS, disease 
of, very rsire, 313 ; action of, in 
r&spiration, and rest of, 315. 

Crucial ligaments, aetiou of, 282. 

Cuboid bone, diseatio of, cured by 
rest, 471. 

Curved sacrum,, causing outlying 
symptoms of hip disease, 413. 

Cy^TITI8, chronic*, means of pro- 
curing physiological rcbt in cases 
of, 272. 

Davip, M., observations on rest, 
151. 

Deficiency of development, con- 
genittU, of one lower extremity 
mistaken for spinal disease, 419; 
a cause of early hip-joint disease, 
420. 

Delay in opening an abscess 
about knee-joint, danger of, 127. 

Deltoid, wasting of, after injury 
to circumflex nerve, 186. 

Development of pelvis may be 
dwarfed in long-standing oases 
of hip-joint disease, 347; after 
amputation of thigh, 347. 

Diaphragm, influence of, on the 
liver, 12; nervous dirtribution 
to, 182, 253; and pericardium, 
nervous distribution to, analogous 
to that of a joint, 253. 

Dislocation of hip-joints, con- 
genital, 415. 

Distribution of Nerves. See 
Nerves, Distribution of. 

Dorsal nerve, first, distribution of, 
479. 

Dorsum ilh, dislocation of femur 
on to, reduced, anchylosis, 359, 
360, 866, 867. 



DcKCAir, Db. H., iWlDitiMi uad 

varietius of m^uimanK, 281. 
DrnHAH. Mu. A., conditiui of Imin 
durini; ilecp, SO, SI. 

Eab, I'xtenal, distribullon of netvea 
to. 76. 

Earackb oBsociatnl with tootli' 
nche.TS; nmociKtedwIthdimsaed 

lOll^F, 78 ; BBBI>FUltcd WiUl Eliff- 

Tieas of jnw, 78 ; pRxluoal by 
(-nlnrged oerrleal glund near 
aiirirulHT branoli nf xeeand and 
third oervioa! nartea. 61. 

Earlubt BTvltoira of hip disease, 
221. 

Elbow-joiht, niUBCuI&-cntitiN<nu 
nerve, di«iihntion to, 186. 1&2; 
anrbylosii of, 4GG ; acToiHiIouB 
diBPSBC of, 466. 

EMBLETON.Dn.ouHlimiMor-ttppMn. 



8^. 
Eprrnvsis, dim 



of, fc'ir 



■ S'lO' 



Fox. Db. C, cm e*r«<ni^)i. 7T: « 

otiirr nmiii-eticitu between filb 
and VBgna, 78. 

GAKoncKE. H cnae of, ttrmi preasme 

1 the tlbar nerve, 200. 
GxseKtiijts r.AKOLioK, ^roKtl) in- 

Tnldn^, its tffmta, 208. 
Gddlik, SIh., on roneenilsl dielo- 

calion forwnnU of flie knee. 446. 
ULlssoit'e ctPSL'LB. fnortioD (t, 12. 

GLmAL ABSOCS, 137. 

IsTBiatiK KXDVBS, di^ibo- 

tion tif, 289 ; superioT. 235 : p«in 
nlnng ii]f«rinr padeDdal branch 
of. produced by bnm on tubeto- 
Bit? of ischium, 243. 

OosoRRHiSA. ehoidw aAer, cnnN 
of, 278 : joint-trouble* (pjKmie!) 
Bft«T, 310, 393. 

OnANruTiOHB, pftinfol, node of 

■ - '1.1^, 149. 



Gmti 



B .-i.pply lo 



a heard and fill in dtsoascd 
, renaon of, 326. 



Fw B. istn 

FOTH D 



INDEX. 



503 



distinguishing 1)etween an irri- 
tuhle and inflamed uIccTt 71. 

Henle, Profe:<80r, epithet used by, 
to sub-arachnoid tissue, 25. 

Hebnia, danger of pui gativos after, 
63; value of rest in cases of, 
G3. 

HiP-JOiNT. anchylosis of, 358, 3G2, 
869; congenital malposition of, 
415; dLitribution of nerves to, 
214, 833. 

, DISEASE OP, associated 

with pain in knee-joint, 334 ; not 
necessarily scrofuioud, 331 ; has 
nothing special in its character, 
330 ; characteritttic symptoms do 
not show themselves till tiie dis- 
ease has advanced, 331 ; import- 
ance of early diagnosis of, 331 ; 
diagnosis of, 336 ; value of rest 
in cases of, 341 ; method of dis- 
tinguishing symptoms of, from 
those of sacro-iliac disease, 343 ; 
oared by rest in same patient 
where the shoulder-joint was 
destroyed for want of rest, 344 ; 
splint for, 346, 351 ; case of, cured 
by five montlis' rest, 349; of 
twelve months* duration, cured 
by seven months' rest, 350; in 
scrofulous patient cured by rest, 
353 ; limb straightened and splint 
applied, curetl by rest, 359 ; with 
dislocation of right femur, dt-ath 
from pytemia, 367; scrofulous, 
treated by rest, 372 ; in phthisical 
patient, cured by anchylosis, 375 ; 
bony anchylosis, opening of ab- 
scess deferred, recovery, 381 ; 
scfofulous, cured by anchylosis, 
abscei>s absorbed, 888 ; with sup- 
puration of left side, cured oy 
four months* rest, 392 ; supposed 
to be gonorrhoeal, cured by rest, 
893 ; sequel to scarlet fever, cured 
by rest, with anchylosis, 396 ; 
with necrosis of acetabulum, 
cured by rest, 406; cases simu- 
lating, 411, 412, 415; symptoms 
of, produced by curved sacrum, 
413; symptoms of, caused by 
cerebral disease, 412 ; simulated 



by disease of the last lumbar 
vertebra, 422. 

Holmes, Dr. O. W., on beneficial 
effects of riding upon the liver, 
12. 

Mb. T., on spina bifida, 

33; on a case of early hip 
disease, 222 ; on the diagnosis 
between infantile paralysis of 
lower lunb and hip disease, 411. 

HoM(EOPATHY and hydropathy 
often get the credit where rest 
effects the cure, 75. 

Hood, Dr., letter on the effects c>f 
overwork producing insanity, 
which is cured by rest, 9. 

HiOHUNGs Jackson, Dr., on the 
ophthalmoscopic condition of the 
retina during sleep, 51. 

HuLKE, Mb., on exostoses from first 
rib, 201. 

Hunter, John, views of, on growth 
and rest in plants, 5. 

Hutchinson, Mb, J., on distribution 
of nerves to fingers, 194; on 
c«iuse of unilaterally furred 
tongue, 206. 

Hydrocephalvs, diffused and ex- 
ternal, 37; internal, caused by 
closure of the iter a tertio ad 
quartum ventriculum, 38; in- 
ternal, fluid of, drawn off by 
puncture of anterior fontanelle, 
40. 

Htoid bone, arteries to, 292. 

Utpe&ssthesia, area of, after frac- 
tured spine, 73, 74. 

Htstebical fains in hip- or knee- 
joint, explanation of, z26 ; afl!bc- 
tionsof sacro-ooccygeal joint, how 
to distinguish, 443; contraction 
of abdominal muscles, how to 
dihtinguish from that of perito- 
nitis, 250. 

Ice, application of^ to traumatic 
dislocation of tibia, 451 ; applica- 
tion of, to lacerated wound, into 
knee-joint, 454. 

Iliac Abscsss, 136. 

Ilium and sacrum, disease between, 
cured by rest, 427, 482, 435. 



504 I8DKX. 1 


l.Vr*NriLB PARAUTSM •fftcting 




lowpi limb, diBgnoiis of, ttom 


light aido of l.t-art. 15. 


liipdiwasc. 411. 


KMEtJOtST, absecas oTcr tluvW) 


lNFLAllHAT10!f. loRlI bcM » trUS Ul- 


anoliyioMB of; 312, 326. «t; 


dication ol, 70. 


flexed, 171: gmtipiug of suada 




of, 83. 


217. 224; l&vomted WOOtul IB*, 


IsTEBOOOTAt, NBETES, disttibutioD 


treiiled by cold and reat. Ul; 


of, 250, 25& 




iNTEffiN.!. MAXILLARY- ARMBI, di* 


to. 230: uenro diatrUwlial W 


tribuliOD of. 293. 




InTKRNAL BirHBXOCB HBBTK, cUstrl' 




butioQ of, -lis. il6. 




IKTRA-ABTICCLAH DTeMnnt ill Mllts, 


■tod with apinnl dtaoa^ »•; 


175. 




InKiTATTON Mused hy elone in 


ofooIon.22U: pniJi in. tttsodatoJ 




with di»ttW! of bip-joiut. 220. 


B child. 7. 


, KbKxw kI loK ihI to b luBi in hv 




128; di«ai«eof, pi-udnciiiirdi«lo«»- 


Jadmdice produoed by ctmgwted 


ti(Mi.2a2; traitod hf divuionof 


liver, iftor funwd nigt, 18. 




Jaw, loww. diMMe of, foilowJng 


Ml, «6 1 with nennuiti of p.1.11* 


soarUtiHa. 40*. 


cur^ b)- Test, 419 : with flei.'d 




i..i!ir, l.ii.l.,ii3 divided, ci,R-<ll.T 



HeriBation 'iu, 32« : those lenat 
auhjetl to DVc'rwotk least liable to 
dtBcaa-, H13. 



■ : ri. ivei„llu,.uOT,4ll. 
1,1 .1 ■. ■., .li,-MiiBO uf joints of, 323; 
|iliy-ir.,l..siCTl ft-Bt nlTordwi to 
iimtmaB iiicmbranej of, by nitrate 
of silver, 271; law of uerronB 
di*fnliiitiim In, '£M, 271; en Be of 
uypliilji.i' .i.^.^nMiTiC. iwcnlj-L-igiit 



KiDSET, cSbcts of nviTHork on, 1 
eloalic [-apBule of, l,i; i^ftVet 
pressure of tlie euloii uii, 15. 

Kiso. Db. W.. Ml i>tovii,i„tig 



INDEX. 



505 



15 ; congestion of, produced by re- 
cumbent position, and effeotSf 13. 

Lymph, value of the cffuBiun of, as 
a splint to secure rest, 67, 98; 
effusion of, in pericarditis, cause 
of, 263; Nature's intention in 
the effusion of, in pericarditis 
and croup, 2t)3; absorption of, 
after pericarditis, 263. 

Lymphatics, absorption by, may 
explain enlarged gland and pain, 
79, 81. 

Maoendie, M., on ccrobro-spinal 
a])crture, 23; on collections of 
cerebro-spinal fluid, 25; on de- 
velopment of footul brain, 45. 

Marttn, Dr., on infra-mammary 
pain, 83. 

Median nebye, effect of pressure 
on, 199. 

Measuring uovfER limbs, mctliod 
of, 390. 

Monro, foramen of, 18, 31. 

MoxoN, Dr., on external hydro- 
cephalus, 37; on closure of the 
cerebro-spinal opening, 39 ; on la- 
ceration of tlic fourth ventricle, 53. 

Mucous membranes, nervous asso- 
ciation of, with muscles acting 
upon them, 245; nervous asso- 
ciation of, in sore throat, 270; 
influence of purgative medicines 
on, 271 ; of irritable bladder, 
method of relieving, 272 ; of 
rectum, nerve distribution to, 
281, 286; of urethra, 274; of 
vagina, 280. 

Muscles, grouping of, aeconling to 
their nervous supply, 181; pre- 
cision of nervous supply to, 179 ; 
supply to muscles of leg, 223; 
contraction of, after bums, oause 
of. 245. 

Muscular adjustment described, 
489, 490. 

MusciLO spiral nerve, distribu- 
tion of, 179, 180. 

Nature, power of, in self-repara- 
tion, 3 ; employs rest as a curative 
agent, 3; the reparative power 



of, a principle of guidanoe for the 
surgeon, 67 ; treatment of, for 
severe injuries, 65 ; treatment of, 
for a foreign body iu the con- 
junctiva, 62; constant tendency 
of, to repair injuries, 62, 70; 
intention of, in effusing l^mph 
in pericarditis and croup, 264. 

Necrosis of acetabulum, 406; of 
tibia, 401; of patella, 449. 

Nerves, flfth cerebral, irritation of, 
producing puin in the auditory 
caniil, 78; filth pair, irritation of, 
by diseased tooth, 78; pain in 
the cutaneous distribution of 
fourth and flfth dorsal, caused by 
aneurism, 89 ; the same that sup- 
ply the joints supply also the 
muscles moving the joint and the 
skin over the insertions of the 
muscles, 168, 169; precision of 
supply of, to the muscles, 179 ; 
meaian, effect of, pressure on, 
199 ; ulnar, effect of pressure on, 
200 ; obturator, effect of pressure 
on, 220; of mucous membranes, 
their association with musoles 
acting upon them, 245, 274 ; 
glut^d, pressure on, producing 
pain in penis, 242 ; eluteal, pain 
along, produced by bursa on tu- 
berosity of ischium, 243. 

, DISTRIBUTION OP, tO 681, a 

means of diagnosing disease, 76 ; 
fltlh pair, causing association of 
diseased tongue with auricular 
pains, 78 ; second cervical to the 
external ear, 77 ; fifth to the ex- 
ternal ear, 77 ; fifth to scalp, 82 ; 
occipital to scalp, 82; to the 
elbow, 186 ; to the fingers, 193 ; 
to the toes, 195; to the thumb, 
196; to tho wrist, 198; of an- 
terior crural to the hip-joint, 215 ; 
from sacral plexus to hip-jouit, 
334 ; of the obturator, to the hip- 
joint. 215, 333; to the knee, 217, 
224 ; to the larynx, 271 ; to the 
diaphragm, 182, 254 ; to the peri- 
cardium, 255 ; to the anus, 289 ; 
abdominal, 246 ; second cervical, 
77, 82 ; third cervical, 77, 479 ; 



s*^s 



,'"«»i,sr""' "Mw „, / 

n ""' ■» WWoh," i?*"™ of u,„ 



INDEX. 



607 



Peritonitis, why it produces oon- 
tmction of ao<lonntial muscles, 
247 ; latent form of, 247. 

PSRONEAh OR EXTEKNAL HOPLITEAL 

NEKVE, distribution of, 229. 

Phuenic nerve, distribution of, 182, 
255. 

Plants, growth of, a result of rest, 
5; physiological rest of, in hot 
countries, 5. 

Pleurisy, why associated with cuta- 
neous fmins, 256 ,* value of local 
application of anaesthetics in, 259; 
ueccaiity for res.t in the treatment 
of, 2<J0 ; causing gymmetricitl cu- 
taneous pains, 252. 

Pneumogastuic nerve, laceration 
of, 53 ; presaure on, by blood clot, 
35. 

Popliteal abscfss, 146. 

post-pharyngeal abscess, 112, 
185; bone extrudcKl from, 112. 

Precision of nervous supply to 
muticlos, 179. 

Pregnancy, 8ymi)toms of, produced 
by anal ulcer, 800. 

Prostate glanp, ulceration of, 
producing symptoms of st<mo, 65. 

Purgatives, danger of, after hernia, 
63 ; constant use of, injudicious, 
272. 

Pressure, useful in treating? sinuses 
and varicocele, 160, 161; intra- 
articular, 175. 

PuDic NERVES, distribution of, 242, 
274, 280. 

Pus, absorption of, 385. 

Py^^iia and pyieniic joint-troubles 
after fevers, 311. 

QuAiN, Mr , arterial supply to 
rectum, 291 ; case of painful 
ulcer, 152. 

Ra3ISKill, Dr., on sub-occipital 
pain, 96. 

Rectum, cancer of, painless, 282; 
iiiben8ibility of, 282 ; distribution 
of nerves to mucous p.iembrano 
of, 286, 289; arterial distribution 
to, 291 ; ulcer of, 284 ; ulcer of, 



associated with enlarged glands, 
294. 

Bbctum, its relation to uterine dis- 
orders, 801. 

Recurrent laryngeal nerve, dis- 
tribution of, 238. 

Repair, primordial power of struc- 
tures to repair themselves, 4 ; a 
repetition of growth, 6 ; maxi- 
mum of, co-equal with minimum 
of disturbance, 8 ; associated with 
defective sleep in the old, 8. 

Rest the first curative agent of 
Nature, 3 ; to injured parts sug- 
gested by pain, 4; and growth 
inseparably connected, 5; and 
growth in plants, John Hunter's 
views regarding, 5; vegetable, 
the floral clock an instance of, 6 ; 
physiological, of plants in hot 
countries, 5; necessary for the 
pirniuction of animal food, 6; 
and sleep the normal condition of 
hcidthy infants, 6; of the brain, 
exemplification of, 8; effect of, 
in curing insanity produced by 
overwork, 9 ; and work, alterna- 
tion of, necessary to secure the 
health of the viscera, 10; Nature's 
plan for sustaining health, 52; 
concussion of the brain treated 
by, 56 ; concussions of tho spine 
treated by, 57 ; aneurism cured 
by, 63 ; value of, in hernia, 68 ; 
given to tho larynx in laryngitis 
by tracheotomy, 64; to injured 
brain by trephining, 65 ; ulcer of 
tongue cui-ed by, 80; given to 
eyes by making a ceiling green 
when the patient must be m the 
recumbent position, 107; ab- 
scesses open^ to secure, to their 
walls. 123 ; sinuses cured by, 188; 
physiological method of treating 
irritable ulcers by, 147 ; observa- 
tions on, by M. David, 154 ; phy- 
siological, cose of intolerance of 
light cui«d by, 165 ; physiologi- 
cal, proiluoed by the cutaneous 
application of anassthetics, 185; 
necessity for, in pleurisy, 260; 
physiological, in relation to peri- 



cufliUA, 3G3: fiwclUng of joints 
a [ticaiu for eoauring, 205; to 
n froctartMi 1-onc eMurod by 
mtluH, 865; tlicmMiitia iiiia- 
Slice o^ indicateit % Natura in 
injuries of tlio eye, W8 : [ihysio- 
loginl, injury to' tbi) aoiijunctiva 
ci